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qualitative research methods in mental health and psychotherapy

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qualitative research methods in mental health and psychotherapy

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Qualitative research methods in mental health and psychotherapy: a guide for students and practitioners edited by david harper & andrew r. thompson. wiley-blackwell. 2011. £29.99 (pb). 272 pp. isbn: 978-0470663707.

Published online by Cambridge University Press:  02 January 2018

qualitative research methods in mental health and psychotherapy

This is a very useful book that introduces qualitative research in mental health contexts for those wishing to better understand the approaches behind papers they read. It is also a source of specific guidance for those considering doing their own research.

The structure of the book, across and within chapters, is cleverly designed to promote effective use of appropriate methods. There are three sections. The first introduces the basic tenets; the second includes chapters on each of a range of approaches, and the third addresses research quality and future directions. This works well. In particular, it sets the various qualitative approaches in the wider mental health context. This will help students and trainees to gain an appreciation of the underpinning and implications of the different traditions and so make an informed choice of method to address their particular research question.

The editors have drawn together contributions from many experienced researchers with genuine expertise, leading to generally high-quality contributions covering many of the main approaches. Within the chapters on approaches, the consistency of a uniform set of straightforward, practical headings makes each easy to follow, and allows quick comparison between methods. In addition to the more obvious ‘how to’ content, particular sections that are valuable include those on the type of questions each method best suits and on service user involvement. My only disappointment was the lack of coverage of some of the less verbally focused qualitative methods such as ethnography and participant observation. The integrative chapters contain some of the major highlights of the book, including the thoughtful set of recommendations for ethical practice in chapter 3, the material on asking the right questions in chapter 5, and the considered and balanced overview on judging quality in chapter 16.

In a field that at times feels dominated by obfuscating jargon and a cult-like zeal, the editors have produced an accessible, illuminating text that will be of great value to those wishing to gain an introduction to this essential and developing area of mental health research.

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  • Volume 200, Issue 5
  • Jan Oyebode (a1)
  • DOI: https://doi.org/10.1192/bjp.bp.112.108746

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  • DOI: 10.5860/choice.49-2986
  • Corpus ID: 268104602

Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners

  • David J. Harper , Andrew R. Thompson
  • Published 1 August 2011

21 References

Giving voice and making sense in interpretative phenomenological analysis.

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  • Published: 29 April 2022

Positive mental health in psychotherapy: a qualitative study from psychotherapists’ perspectives

  • Sherilyn Chang 1 ,
  • Rajeswari Sambasivam 1 ,
  • Esmond Seow 1 ,
  • Mythily Subramaniam 1 ,
  • Hanita Ashok Assudani 2 ,
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  • Sharon Huixian Lu 2 &
  • Janhavi Ajit Vaingankar 1  

BMC Psychology volume  10 , Article number:  111 ( 2022 ) Cite this article

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There is growing evidence in the literature on the use of positive mental health (PMH) interventions among clinical samples. This qualitative study aims to explore the definitions of PMH from psychotherapists’ perspectives, and to examine views and attitudes related to the construct.

Focus group discussions were conducted with psychotherapists at a tertiary psychiatric institute. Focus group sessions were transcribed verbatim and transcripts were analyzed using an inductive thematic approach.

Five themes related to psychotherapists’ definition of PMH were identified: (1) acceptance; (2) normal functioning and thriving in life; (3) resilience; (4) positive overall evaluation of life; (5) absence of negative emotions and presence of positive emotion states. Themes related to views and attitudes towards PMH were: (1) novel and valuable for psychotherapy; (2) reservations with terminology; (3) factors influencing PMH.

PMH in psychotherapy is a multidimensional concept that means more than symptom management and distress reduction in clients. There is potential value for its application in psychotherapy practice, though some concerns need to be addressed before it can be well integrated.

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Introduction

Positive mental health (PMH) reflects a state of mental wellbeing that goes beyond the mere absence of psychopathology. It encompasses emotional and psychological wellbeing, and functioning in psychological, social and societal domains [ 1 ]. In relation to emotional wellbeing, Diener et al.’s definition on subjective wellbeing is often drawn upon as it looks at an individual’s overall evaluation of their life and emotional experiences such as life satisfaction, positive affect and negative affect [ 2 ]. This is also seen as the hedonic approach to wellbeing that focuses on pleasure attainment and pain avoidance [ 3 ]. In contrast, the eudemonic approach ‘focuses on meaning and self-realization and defines wellbeing in terms of the degree to which a person is fully functioning’ [ 4 ]. A closely related concept of psychological wellbeing has been conceptualized as consisting of six dimensions: autonomy, environmental mastery, personal growth, purpose in life, positive relations with others, and self-acceptance [ 5 ]. In addition to emotional and psychological wellbeing, Keyes also considers social wellbeing as essential in identifying a thriving individual as flourishing [ 6 ]. Some studies have also identified spirituality (related to religious beliefs and practices) as an important domain of PMH [ 7 , 8 ].

Traditionally psychotherapy, and also clinical care in general, focus on alleviating symptoms and are largely aimed at correcting deficits resulting from disruption of normal functioning [ 9 , 10 ]. There have been calls to shift away from this deficit-based view of mental health to promoting wellbeing, and to evaluate both PMH dimensions and psychopathology when providing psychotherapy and in conducting research [ 1 , 11 , 12 ]. Distinct psychotherapeutic interventions that are theoretically grounded in positive psychology, a scientific field that studies contributing factors of human flourishing and optimal function [ 13 ], explicitly targets wellbeing outcomes. Some examples include therapies such as the wellbeing therapy [ 14 ] and positive psychotherapy [ 15 ]. Other non-positive psychology approaches such as mindfulness-based interventions and gratitude-promoting exercises have also been incorporated into traditional psychotherapies to enhance wellbeing.

Several studies have examined the effectiveness of PMH interventions in improving outcomes among clinical samples. A meta-analysis by Goldberg et al. reported equivalent efficacy of mindfulness-based interventions to first-line, evidence-based psychological and psychiatric treatments in symptoms reduction, with effects most consistent for depression, pain, smoking and addictions [ 16 ]. In another meta-analysis examining the effects of positive psychology interventions on wellbeing and distress, the authors found small effect sizes for such interventions on improving wellbeing and depression, and moderate improvements for anxiety among clinical samples [ 17 ]. A recently published article by Jankowski et al. provided a comprehensive review of the various types of interventions in psychotherapy to promote wellbeing and the efficacy of these treatments [ 11 ]. The authors found support for these approaches in enhancing wellbeing and urged ‘researchers and psychotherapists to continue to integrate symptom reduction and wellbeing promotion into psychotherapy approaches aimed at fostering client flourishing’. Given that ‘good outcomes’ of psychotherapy constituted more than symptom alleviation and included outcomes such as with gaining acceptance and self-understanding, alongside developing a sense of mastery and self-compassion [ 18 ], there is value in exploring the application of PMH interventions in psychotherapy.

To date there has been no study that has examined the concept of PMH among psychotherapists and to understand their attitudes towards a PMH based approach in psychotherapy. As a step towards exploring ways in which PMH interventions can be incorporated into psychotherapy practice, it is imperative to first understand the concept of PMH from the point of view of psychotherapists in clinical settings. This could provide insights into the attitudes of psychotherapists towards PMH and identify potential challenges and difficulties in integrating PMH interventions into psychotherapy in a clinical setting. The present qualitative study thus aims to explore the definitions of PMH from psychotherapists’ perspectives and its application in their practice, and to examine their views related to the concept of PMH.

Study design and setting

A qualitative study was conducted at a tertiary psychiatric hospital in Singapore and data collection took place between April and November 2019. This study used an interpretivist approach to gain an in-depth understanding of psychotherapists’ definitions and views of PMH, and this enabled an understanding of psychotherapy practices from the practitioners’ perspectives to yield clinical applications and inform future research. The Consolidated Criteria for Reporting Qualitative Research (COREQ; Additional file 1 : Appendix A) was used to guide the reporting of this study [ 19 ].

Study sample

Participants for this study were professionals who provided psychotherapy to individuals with mental health issues at private or public institutions in Singapore. Purposive sampling was adopted to ensure appropriate representation of psychotherapists by work experience. Psychotherapists were invited to participate in the research study through connections from personal network and also via word of mouth (none of the recruited participants were personally acquainted with study team members who were present during the interview), and were contacted through phone calls and emails to provide them with further details of the study. Inclusion criteria for the study were individuals aged 21 years and above, experienced in providing psychotherapy to people with mental health problems at public or private institutes, and able to provide consent. The study was approved by the institutional ethics committee and all participants had provided written informed consent prior to their participation. This study was conducted in accordance with the Declaration of Helsinki.

Qualitative data was collected during focus group discussions (FGDs) conducted with psychotherapists. Each FGD session lasted between 1.5–2 h, had 4–6 participants, and was facilitated by a female senior researcher (JV), who has a background in epidemiology (MSc) and is trained in qualitative research methodologies and has domain expertise in the area of mental wellbeing. Study team members (RS, ES or SC), who were researchers with bachelor degrees in psychology and had prior experience in conducting qualitative research, were present during the session as a note taker. Participants completed a short questionnaire that collected information pertaining to their sociodemographic background and clinical experience. As part of icebreaking activity before the FGD began, all participants and study members who were present briefly introduced themselves regarding their work and personal interests. An interview guide was used during the FGDs to facilitate discussion (see Table 1 for brief guide). This interview guide was developed with inputs from clinicians and psychologists from the study team to set the questions in the context of psychotherapy. Participants were first presented with an overarching question on what PMH means to them in their practice, and were then given time to pen down their thoughts on cue cards. These cards served as aids to facilitate subsequent discussion. As far as possible, the discussions followed the experiences of the participants and clarifications were sought when needed. Participants were also encouraged to share their opinions on the viewpoints raised by other participants during the discussions. Recruitment of participants and FGDs continued until repetition of themes occurred and no new information was evident (i.e. data saturation achieved). All the FGDs were audiotaped and transcribed verbatim for analysis. Quality checks on the transcripts were performed; after which the transcripts were anonymized to safeguard the participants’ identity.

Thematic data analysis was conducted to analyze the data where common underlying themes were identified inductively from the data [ 20 ]. NVivo software (Version 11) was used to code and organize the data. One transcript each was assigned to three study team members (JV, SC, ES) who read through the respective transcript repeatedly and thoroughly to familiarize themselves with the content. Each team member noted meaningful content in the transcript to generate codes inductively which were later combined to form emergent themes. Study team members then gathered to discuss the codes and themes obtained, and a list of preliminary themes was identified. This was used to code the remaining transcripts, and new codes and themes were created to capture any new content that emerged. After all transcripts were reviewed, various themes were combined to produce higher-order themes. Any disagreements between team members were resolved through discussions to reach consensus.

Lincoln and Guba’s criteria to assess the trustworthiness of a study looks at credibility, transferability, dependability and confirmability [ 21 ], and these criteria can be applied in conducting thematic analysis [ 22 ]. In terms of data accuracy, all FGD sessions were audio-recorded and transcribed verbatim by a team member; study team members (other than the person who transcribed the interview) performed checks on the transcripts to ensure its quality and accuracy. Raw audio recordings and verbatim transcripts were stored in well-organized archives until verification was completed, and records of observation notes, coded transcripts and discussion notes were kept to provide an audit trail of the code generation process and serves to provide dependability and confirmability. Findings were reviewed by members in the study team which included researchers and also psychotherapists and this addresses credibility of the study. Detailed descriptions of the research process and in reporting of results can provide information to other researchers on the transferability of findings in another study population.

A total of 7 FGDs were conducted with 38 participants for the study. The participants’ age ranged between 27 and 63 years, were mostly females (84.2%), of Chinese ethnicity (81.6%), and the majority had obtained a post-graduate degree (94.7%; Table 2 ). All participants had received formal training in varied psychotherapy modalities including cognitive behavioral therapy, positive behavioral management, exposure and response prevention, eye movement desensitization and reprocessing, acceptance and commitment therapy, schema-focused therapy, emotion focused therapy, solution focused brief therapy, psychodynamic therapy, dialectical behavioral therapy, mindfulness-based therapy etc. For the majority of participants, their clientele comprised adults presenting with mental disorders including mood disorders and anxiety disorders. Others worked with children and adolescents with childhood disorders, elderly population with dementia, or individuals who needed life coaching.

Thematic analysis of the qualitative data identified five themes pertaining to psychotherapists’ definition of PMH: (1) acceptance; (2) normal functioning and thriving in life; (3) resilience; (4) positive overall evaluation of life; (5) absence of negative emotions and presence of positive emotion states. Their views on the concept of PMH could be examined from the following three themes: (1) novel and valuable for psychotherapy; (2) reservations with terminology; (3) factors influencing PMH. Figure  1 a, b present the coding trees derived from the coding process with the subthemes and themes shown. The following section describes the themes in further details and salient quotes that underscore the essence of the theme are presented.

figure 1

a Coding tree of themes identified in the coding process pertaining to psychotherapists’ definition of PMH. b Coding tree of themes identified in the coding process pertaining to psychotherapists’ views on the concept of PMH

Definitions of positive mental health

(1) Acceptance

This was a common theme discussed by participants from various FGDs. PMH was defined as having the ability to accept things that happened in life and acknowledging the outcomes that resulted. Acceptance was in relation to not just negative events, but also acceptance of ‘difficult emotions’ and where one is in life.

It’s about accepting where you are in life and… as well as… growing in that journey to acceptance and being at peace with that. – FGD 3 Same way like you were talking about ACT (Acceptance and Commitment Therapy) just now, it’s accepting it, even if they just accept what has happened to them, I think it’s already positive mental health. – FGD 7

In a related note, a participant described PMH as having contentment in life and described how acceptance of situation contributed to contentment.

Positive mental health to me is finding content, which is a bit like peace, whatever the circumstance… a lot of it is perception, how you see certain things, like certain circumstances that you might not be able to control. So I mean modifying or coming to terms with what I can accept and what I can change. I think that helps; gives me contentment and peace. – FGD 6

(2) Normal functioning and thriving in life

For the participants, having PMH was defined as being able to function normally. At the individual level, a functioning person was described as someone leading a balanced and healthy lifestyle, and able to manage stress and not be overwhelmed by it. The idea of optimal functioning pertained to various aspects in life including occupation, relationship with others, and being an active and contributing member of the society.

PMH is not about like the mental condition. It is about, you know, how we make these conditions and maybe other life issues not to interfere with our life. So it’s about living that life, you know, despite all the obstacles and difficulties. – FGD 3

Some participants moved beyond the notion of basic psychosocial functioning to describe PMH in terms of thriving which encompassed the idea of growth.

I wrote it (PMH) as the ability to thrive in very stressful environment [be]cause I think the way I see PMH is not just the absence of mental health issues but [it] is also the ability to kind of progress and really to be able to kind of expand on your own potential. – FGD 4 … they (clients) are kind of bootstrapped. They are self-corrective. They may come to you with a presenting problem, but if you just drop a few hints along the way, a bit of psycho-edu[cation] here, a bit of coaching there, they are able to extrapolate that to other problems independently on their own. So I think that’s also important. It’s not just where you are now, it’s whether you have the capacity to adapt and grow. – FGD 6

(3) Resilience

In defining PMH, the concept of resilience was frequently brought up by participants and it at times co-occurred alongside the theme on functioning. Yet this is a distinct theme from functioning in that rather than focusing on outcomes, it describes a trait or skillset that promotes wellbeing.

I would see it (PMH) as resilience, the ability to deal with challenges and the ability to function. – FGD 1 Okay for me positive mental health is being able to cope with the demands and challenges of life. So it’s a bit like mental resilience… sometimes you have negative emotions and being able to cope with that or cope with the demands. – FGD 2

Resilience was often described by participants as a trait that would help their clients to ‘bounce back’ from adversities, and also as a coping resource to support normal functioning in spite of challenges. One participant discussed how having emotional resilience can aid distressed clients to self-regulate by learning to not internalize events that occurred around them.

(4) Positive overall evaluation of life

The keywords in this theme were ‘quality of life’, ‘good life’, ‘fulfilled life’ and ‘life satisfaction’. Definitions captured in this theme described the concept of PMH as an all-encompassing, overall evaluation of one’s life that generated a broad sense of wellness or a feeling of ‘good living’.

Good living, like you’re not just alive; but you are living well, so living well… I think it’s defined differently by different people. So to person A living well might be ‘I’m a able to look after my grandkids’, that’s living well… to summarize it’s the person’s own idea of a good life, a good quality of life. – FGD 1

While elaborating the concepts of life fulfillment and the ideal life in the context of PMH, keywords such as ‘goals’, ‘values’, ‘purpose’, ‘meaningful’ and ‘aspirations’ were often mentioned and participants described these as constituents of a ‘good life’.

… a feeling of living a life that is consistent with one’s values… If someone values career, then he is living a life that is working towards that. If my value is family, I’m living a life that allows me to spend time with my family in a way that I consider meaningful. – FGD 5 Positive mental health is leveraging on people’s needs and values to bring them closer to their fulfilment… To me, fulfilment is living their own values, living their lives according to their own values. And being able to meet their needs. – FGD 6

(5) Absence of negative emotions and presence of positive emotion states

This theme relates to the emotional state of an individual and the definitions of PMH encompassed the absence of distress and the presence of positive emotions. PMH was defined as the removal of mental illness symptoms or distress, and also it meant experiencing positive emotions and state such as ‘happiness’, ‘hope’ and ‘joy’.

Freedom in mind, having peace, having calm. And there is no mental illness or distress and managing with difficulties. – FGD 4 I’ve written that firstly, positive mental health is being hopeful and laughing often. – FGD 5

Views on the concept of PMH

(1) Novel and valuable for psychotherapy

For some participants, PMH was a novel concept which could be defined in various ways by different individuals. For one participant, it gave the ‘impression of mindfulness’ which is the ‘third wave of therapy at the moment’, and some participants compared it to positive psychology.

So I think positive mental health is a new change, so it’s like a new science where you hear a lot of people saying that oh it’s important, it’s crucial but the research out there is very limited to back up all this evidence, but we do see the trends of positive mental health is emerging too. – FGD 2

Participants generally agreed on the importance of individuals to have PMH, with one participant stating it as ‘our birth right’, and another participant citing it to be ‘imperative for a healthy society’. A number of participants acknowledged the roles that they could potentially play as psychotherapists in introducing PMH concepts to their clients, as evident from the following quotes:

Like traditionally the way therapy was created was for like to remove disorder. That’s why I think the newer age therapists are saying that we really need to go further where there’s this idea of growth. I think that’s where the newer age therapists try to incorporate it as part of therapy. – FGD 4 I think for me they (PMH-based interventions) definitely have a space in psychotherapy and they help to balance out between always talking about problems as compared to, well, talking about what were you like before all the problems and what would it be like without the problems. So it balances out the conversation a little bit as compared to every time you come in we talk about your difficulties. – FGD 5

Not all participants, however, concurred with the relevance and significance of PMH, particularly in the context of clinical setting and the profile of clientele that they saw.

I think positive psychology is not that much used in our setting maybe because we have quite a lot of patients in quite severe conditions and talking about positive psychology is like… we are at this level and then you are talking about positive psychology. So maybe in our setting, clinical setting, we don’t really talk about positive psychology and I find that it’s more of a marketing thing… like it’s great and we are doing these classes in school and all that but I think there are other things that are more important to be done. – FGD 2

(2) Reservations with the terminology

A number of participants expressed reservations with the term ‘positive’ that was being used, either with respect to ‘positive mental health’ or ‘positive psychology’. To some participants, such usage implied that clients have to strive towards a positive state all the time, which is ‘not natural’ and ‘an impossible setup’ for them, when instead a simple improvement or progression could in fact be thought of as ‘positive’.

Because from clinical psychology background, it’s about treating mental illness. So it’s like if they (clients) can reach a neutral level or it may be back to baseline, then it’s something the patient may know to achieve, so positive means it sounds to me like up there (pointing to higher level). That you know even myself cannot be completely happy all the time. – FGD 3 The word ‘positive’ here is very misleading. And it’s exaggerating people’s expectations… it’s like wherever you are, if things get in anyway slightly better… that’s already positive. It need not necessary be like you have to have ten steps of growth, not really. – FGD 7

Some participants felt that this terminology carries a connotation and dichotomizes mental health either into the positive or negative realm, and that did not accurately reflect the entirety of what mental health should be in their psychotherapy practice.

I guess one of the main core tenets of psychotherapy is to bring flexibility and balance in the ideas or the perspective that we share about ourselves and other people. So I guess with a connotation, where you kind of put ‘positive’ in front of a word, it doesn’t sit really well in a lot of practices that we do encourage in psychotherapy. – FGD 1 When you term it as positive it becomes very dichotomous, very off-putting… when [what] we want to talk is more about adaptability, workability, more neutral rather than there’s a negative or positive connotation. – FGD 1

They suggested alternative terms such as ‘mental wellness’, ‘positive living’, or sticking to words that were used by their clients, for instance ‘better life’ if that was what the client explicitly stated.

(3) Factors influencing PMH

Participants described several factors that could influence PMH and these were broadly classified into three categories: individual level, interpersonal level, and community and social cultural level. At the individual level, it was about clients’ personality and them having basic self-care which included things like exercise, proper sleep hygiene and healthy coping mechanism. For some participants, it was also about the clients having goals and purpose in life that could motivate them and which contribute to better wellbeing.

I think the other is having that sense of meaning and purpose, so feeling that I have meaningful visions, pursuits or meaningful job that I can contribute meaningfully to my system and the society at large. – FGD 3

At the interpersonal level, participants discussed interpersonal relationship with others that could influence PMH. This included support received from family, friends, or a significant other who provided the feeling of being ‘connected’ with others. A couple of participants noted the impact of mismatched values or misaligned expectations in relationships with others could have on the individuals.

But I think the other part is in the relationship with their significant other, the manner of how these values are transmitted or being talked about. Sometimes it can cause a lot of distress when they have different values. That’s where they have a lot of conflicts, especially when mental illness comes into the system which is a new thing, it can actually distraught the whole thing. – FGD 3

In terms of factors at the community level and social cultural level, a number of participants described how addressing stigma could be a step forward in improving PMH. One way to do so could be to reframe the idea of PMH:

But I was just wondering like why can’t PMH be same as growth and development so not assuming that you have a problem, but you just want to be resilient or be with some more resources. – FGD 4

Participants also suggested creating awareness and improving mental health literacy, particularly amongst the youth and within the school setting.

We are so driven by academic literacy that that’s pretty much all we know right, to achieve and strive, achieve and strive. And if we don’t get it then we fail. But there’s no emotional literacy and acceptance in that that is being taught in schools. – FGD 1

This was an exploratory study conducted to understand psychotherapists’ definitions of PMH and their views of this construct and its application in their clinical practice. From the findings reported in this study, it was observed that PMH was a multidimensional concept and while defined in varied manners, four main themes emerged from this qualitative inquiry. These themes identified are in many ways reflective of the conceptualizations of PMH and wellbeing in the current literature.

PMH in psychotherapy for the participants meant clients are able to alleviate distress and experience positive emotions. Considering that many of the study participants worked in clinical setting with clients who sought treatment for mood and anxiety disorders, it is expected that reducing distress would be a component described. This theme is in line with the hedonic traditions of mental health where the focus is on feeling well [ 23 ]. The hedonic approach also looks at life satisfaction which concurred with the theme on positive overall evaluation of life that was identified in this study. The theme on normal functioning and thriving in life identified in this study is reflective of the eudemonic viewpoint in which the focus is on functioning well psychologically and socially [ 24 ], and parallels could also be drawn with Ryff’s and Keyes’s concept of personal growth [ 5 ].

It was unclear at first glance if the theme on resilience accorded well with the hedonic and eudemonic traditions of conceptualizing PMH. A recent systematic review identified ‘growth’, ‘personal resources’ and ‘social resources’ as conceptualizations of resilience within adult mental health research [ 25 ]. In this sense it is comparable with Ryff’s and Keyes’s dimensions of personal growth and environmental mastery [ 5 ] where in the former individuals seeks development as a person, and in the latter being able to tap into individual and surrounding resources. Nevertheless, several authors have also suggested to include definitions of PMH that encompassed skills and coping strategies to achieve wellbeing [ 8 , 26 , 27 ]. Vaillant also proposed a cross-cultural definition of PMH that included viewing mental health as resilience [ 28 ]. Furthermore, this might be a pertinent concept for our study participants in the context of psychotherapy as clients are usually distressed and are seeking help to resolve their issues and return to normality, or to ‘bounce back’.

Results from this study showed that psychotherapists in our study, whose self-reported primary psychotherapeutic orientation was not amongst those in the fourth wave of psychotherapies (value- and virtue-oriented approaches such as positive psychology interventions, loving-kindness and compassion meditation and spiritually informed therapies; see [ 9 ]), generally see the value and potential in introducing PMH to their clients. However, PMH being novel and a ‘new science’ for some participants, unfamiliarity with it might act as a barrier for application in clinical settings. For one, some participants raised a point on the limitation of its use among clients presenting with more severe conditions. At this point, it might be worth highlighting that studies have been conducted among clinical samples which included patients with major depressive disorder and schizophrenia, and they provided preliminary evidence on the effectiveness of wellbeing interventions in improving wellbeing and reducing distress [ 11 , 17 , 29 ], with effects comparable with those of conventional cognitive behavioral therapy [ 30 ]. A qualitative study conducted among service users with psychosis to investigate their experience of positive psychotherapy also reported promising results. Feedback given was generally positive and participants provided instances of how the intervention supported them in making significant changes to their work and life domains [ 31 ]. In all, these studies lend support for the application of PMH interventions and incorporating them into psychotherapy practice.

Perhaps then the question to contemplate on is when or at which stage of therapy should interventions with elements of PMH be introduced to clients. Some therapists believed that while meaning in life is an underlying issue for all problems, it is not appropriate to address this with all clients in therapy. Client’s readiness and also presence of other pressing issues are factors to be considered [ 32 ]. In a similar vein, McNulty and Fincham noted that the effects of wellbeing traits and processes (e.g. optimism, positivity) are contextual based [ 33 ]; the interaction between a person’s characteristics and the social environment influences how these play out in either promoting or compromising wellbeing. Thus, psychotherapists would need to consider the circumstances in which to initiate PMH interventions, and future studies can seek to examine such factors that could potentially influence the effectiveness of these interventions.

Another finding worth discussing is that a number of participants were skeptical towards the use of the word ‘positive’. It is hard to discern if this reservation among our study participants is attributable to their background in clinical psychology and hence, the focus on deficits, or the unfamiliarity with PMH construct. The contention being that this terminology creates a dichotomy which is not an accurate nor ideal portrayal of mental health, and working towards a positive state all the time is not inherently desirable nor achievable. This echoes the argument by McNulty and Fincham that because psychological traits and processes have to be best understood in context [ 33 ], it would be prudent to avoid labeling them as positive or negative. However, as some authors have noted, these could be some common misconceptions surrounding positive psychological interventions [ 34 , 35 ]. Rather, practitioners and researchers of PMH are advocating for a more balanced focus between illness and wellness. What this suggests is not replacing conventional psychotherapy modalities with PMH interventions, but instead complementing or supplementing the existing treatment options with them.

There are some limitations of this study to be noted. Firstly, some of the participants were acquainted with each other in the FGD session and that could potentially introduce participant bias in a way that their responses reflected the group’s sentiment rather than their own personal opinions. This was minimized by setting the scene from the beginning of the session where participants were explicitly informed that this was an exploratory study and there were no right or wrong answers to begin with. Participants were consistently asked if they agreed or disagreed with what was mentioned, and were encouraged to express their personal opinion in relation to the point raised. Secondly, the large majority of the participants were from public health institutions; only three participants were employed in private practice and one had experience in both. It is possible that differences in work practices and views exists between psychotherapists in public versus private setting, and this could limit the generalizability of the study findings.

With the growing evidence and support for PMH and wellbeing interventions in the literature, it is an opportune time to explore service providers’ perspectives and views towards the use of these interventions in psychotherapy. This study found that the concept of PMH carried multiple meanings for psychotherapists in their practice that meant more than reduction of distress and alleviation of symptoms. It was generally agreed that PMH is an important concept and has a place in psychotherapy for clients, though some concerns may need to be addressed before it is introduced to them. Findings generated from this study provided valuable insights to understanding potential facilitators and barriers in integrating PMH interventions into psychotherapy.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to requirements mandated by the institutional review board (IRB) and funders, but may be available from the corresponding author on reasonable request. Access may be granted subject to the IRB and the research collaborative agreement guidelines.

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This study was supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (NMRC/CG/M002/2017).

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JAV, RS, ES, HAA, GCYT and SHXL designed the interview guide, approached and consented research participants. The project was supervised by MS. JAV and SC conducted interviews with the participants. Analysis of data was performed by SC, JAV and ES, and the first draft of the manuscript was written by SC. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

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Chang, S., Sambasivam, R., Seow, E. et al. Positive mental health in psychotherapy: a qualitative study from psychotherapists’ perspectives. BMC Psychol 10 , 111 (2022). https://doi.org/10.1186/s40359-022-00816-6

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Article Contents

Introduction, challenging some common methodological assumptions about online qualitative surveys, ten practical tips for designing, implementing and analysing online qualitative surveys, acknowledgements, conflict of interest statement, data availability, ethical approval.

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Methodological and practical guidance for designing and conducting online qualitative surveys in public health

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Samantha L Thomas, Hannah Pitt, Simone McCarthy, Grace Arnot, Marita Hennessy, Methodological and practical guidance for designing and conducting online qualitative surveys in public health, Health Promotion International , Volume 39, Issue 3, June 2024, daae061, https://doi.org/10.1093/heapro/daae061

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Online qualitative surveys—those surveys that prioritise qualitative questions and interpretivist values—have rich potential for researchers, particularly in new or emerging areas of public health. However, there is limited discussion about the practical development and methodological implications of such surveys, particularly for public health researchers. This poses challenges for researchers, funders, ethics committees, and peer reviewers in assessing the rigour and robustness of such research, and in deciding the appropriateness of the method for answering different research questions. Drawing and extending on the work of other researchers, as well as our own experiences of conducting online qualitative surveys with young people and adults, we describe the processes associated with developing and implementing online qualitative surveys and writing up online qualitative survey data. We provide practical examples and lessons learned about question development, the importance of rigorous piloting strategies, use of novel techniques to prompt detailed responses from participants, and decisions that are made about data preparation and interpretation. We consider reviewer comments, and some ethical considerations of this type of qualitative research for both participants and researchers. We provide a range of practical strategies to improve trustworthiness in decision-making and data interpretation—including the importance of using theory. Rigorous online qualitative surveys that are grounded in qualitative interpretivist values offer a range of unique benefits for public health researchers, knowledge users, and research participants.

Public health researchers are increasingly using online qualitative surveys.

There is still limited practical and methodological information about the design and implementation of these studies.

Building on Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) , we reflect on the methodological and practical lessons we have learnt from our own experience with conducting online qualitative surveys.

We provide guidance and practical examples about the design, implementation and analysis processes.

We argue that online qualitative surveys have rich potential for public health researchers and can be an empowering and engaging way to include diverse populations in qualitative research.

Public health researchers mostly engage in experiential (interpretive) qualitative approaches ( Braun and Clarke, 2013 ). These approaches are ‘centred on the exploration of participants’ subjective experiences and sense-making’ [( Braun and Clarke, 2021c ), p. 39]. Given the strong focus in public health on social justice, power and inequality, researchers proactively use the findings from these qualitative studies—often in collaboration with lived experience experts and others who are impacted by key decisions ( Reed et al ., 2024 )—to advocate for changes to public health policy and practice. There is also an important level of theoretical, methodological and empirical reflection that is part of the public health researcher’s role. For example, as qualitative researchers actively construct and interpret meaning from data, they constantly challenge their assumptions, their way of knowing and their way of ‘doing’ research ( Braun and Clarke, 2024 ). This reflexive practice also includes considering how to develop more inclusive opportunities for people to participate in research and to share their opinions and experiences about the issues that matter to them.

While in-depth interviews and focus groups provide rich and detailed narratives that are central to understanding people’s lives, these forms of data collection may sometimes create practical barriers for both researchers and participants. For example, they can be time consuming, and the power dynamics associated with face-to-face interviews (even in online settings) may make them less accessible for groups that are marginalized or stigmatized ( Edwards and Holland, 2020 ). While some population subgroups (and contexts) may suit (or require) face-to-face qualitative data collection approaches, others may lend themselves to different forms of data collection. Young people, for example, may be keen to be civically involved in research about the issues that matter to them, such as the climate crisis, but they may find it more convenient and comfortable using anonymized digital technologies to do so ( Arnot et al ., 2024b ). As such, part of our reflexive practice as public health researchers must be to explore, and be open to, a range of qualitative methodological approaches that could be more convenient, less intimidating and more engaging for a diverse range of population subgroups. This includes thinking about pragmatic ways of operationalizing qualitative data collection methods. How can we develop methods and engagement strategies that enable us to gain insights from a diverse range of participants about new issues or phenomenon that may pose threats to public health, or look at existing issues in new ways?

Advancements in online data collection methods have also created new options for researchers and participants about how they can be involved in qualitative studies ( Hensen et al ., 2021 ; Chen, 2023 ; Fan et al ., 2024 ). Online qualitative surveys—those surveys that prioritize qualitative values and questions—have rich potential for qualitative researchers. Braun and Clarke (2013 , p. 135) state that qualitative surveys:

…consist of a series of open-ended questions about a topic, and participants type or hand-write their responses to each question. They are self-administered; a researcher-administered qualitative survey would basically be an interview.

While these types of studies are increasingly utilized in public health, researchers have highlighted that there is still relatively limited discussion about the methodological and practical implications of these surveys ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). This poses challenges for qualitative public health researchers, funders, ethics committees and peer reviewers in assessing the purpose, rigour and contribution of such research, and in deciding the appropriateness of the method for answering different research questions.

Using examples from online qualitative surveys that we have been involved in, this article discusses a range of methodological and practical lessons learnt from developing, implementing and analysing data from these types of surveys. While we do not claim to have all the answers, we aim to develop and extend on the methodological and practical guidance from Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) about the potential for online qualitative surveys. This includes how they can provide a rigorous ‘wide-angle picture’ [( Toerien and Wilkinson, 2004 ), p. 70] from a diverse range of participants about contemporary public health phenomena.

Figure 1 aims to develop and extend on the key points made by Braun and Clarke (2013) , Terry and Braun (2017) and Braun et al . (2021) , which provide the methodological and empirical foundation for our article.

: Methodological considerations in conducting online qualitative surveys.

: Methodological considerations in conducting online qualitative surveys.

Harnessing interpretivist approaches and qualitative values in online qualitative surveys

Online qualitative surveys take many forms. They may be fully qualitative or qualitative dominant—mostly qualitative with some quantitative questions ( Terry and Braun, 2017 ). There are also many different ways of conducting these studies—from using a smaller number of questions that engage specific population groups or knowledge users in understanding detailed experiences  ( Hennessy and O’Donoghue, 2024 ), to a larger number of questions (which may use market research panel providers to recruit participants), that seek broader opinions and attitudes about public health issues ( Marko et al ., 2022a ; McCarthy et al ., 2023 ; Arnot et al ., 2024a ). However, based on our experiences of applying for grant funding and conducting, publishing and presenting these studies, there are still clear misconceptions and uncertainties about these types of  surveys.

One of the concerns raised about online qualitative surveys is how they are situated within broader qualitative values and approaches. This includes whether they can provide empirically innovative, rigorous, rich and theoretically grounded qualitative contributions to knowledge. Our experience is that online qualitative surveys have the most potential when they harness the values of interpretivist ‘Big Q’ approaches to collect information from a diverse range of participants about their experiences, opinions and practices ( Braun et al ., 2021 ). The distinction between positivist (small q) and interpretivist (Big Q) approaches to online qualitative surveys is an important one that requires some initial methodological reflection, particularly in considering the (largely unhelpful) critiques that are made about the rigour and usefulness of these surveys. These critiques often overlook the theoretical underpinnings and qualitative values inherent in such surveys. For example, while there may be a tendency to think of surveys and survey data as atheoretical and descriptive, the use of theory is central in informing online qualitative surveys. For example, Varpio and Ellaway (2021 , p. 343) explain that theory can ‘offer explanations and detailed premises that we can wrestle with, agree with, disagree with, reject and/or accept’. This includes the research design, the approach to data collection and analysis, the interpretation of findings and the conclusions that are drawn. Theory is also important in helping researchers to engage in reflexive practice. The use of theory is essential in progressing online qualitative surveys beyond description and towards in-depth interpretation and explanations—thus facilitating a deeper understanding of the studied phenomenon ( Collins and Stockton, 2018 ; Jamie and Rathbone, 2022 ).

Considering the assumptions that online qualitative surveys can only collect ‘thin’ data

The main assumptions about online qualitative surveys are that they can only collect ‘thin’ textual data, and that they are not flexible enough as a data collection tool for researchers to prompt or ask follow-up questions or to co-create detailed and rich data with participants ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ; Braun et al ., 2021 ). While we acknowledge that the type of data that is collected in these types of studies is different from those in in-depth interview studies, these surveys may be a more accessible and engaging way to collect rich insights from a diverse range of participants who may otherwise not participate in qualitative research ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). Despite this, peer reviewers can question the depth of information that may be collected in these studies. Assumptions about large but ‘thin’ datasets may also mean that researchers, funders and reviewers take (and perhaps expect) a more positivist approach to the design and analytical processes associated with these surveys. For example, the multiple topics and questions, larger sample sizes, and the generally smaller textual responses that online qualitative surveys generate may lead researchers to approach these surveys using more descriptive and atheoretical paradigms. This approach may focus on ‘measuring’ phenomena, using variables, developing thinner analytical description and adding numerical values to the number of responses for different categories or themes.

We have found that assumptions can also impact the review processes associated with these types of studies, receiving critiques from those with both positivist and interpretivist positions. Positivist critiques focus on matters associated with whether the samples are ‘representative’, and the flaws associated with ‘self-selecting convenience’ samples. Critiques from interpretivist colleagues question why such large sample sizes are needed for qualitative studies, seeing surveys as a less rigorous method for gaining rich and meaningful data. For example, we have had reviewers query the scope and depth of the analysis of the data that we present from these studies because they are concerned that the type of data collected lacks depth and does not fully contextualize and explain how participants think about issues. We have also had reviewers request that we should return to the study to collect quantitative data to supplement the qualitative findings of the survey. They also question how ‘representative’ the samples are of population groups. These comments, of course, are not unique to online qualitative surveys but do highlight the difficulty that reviewers may have in placing and situating these types of studies in broader qualitative approaches. With this in mind, we have also found that some reviewers can ask for additional information to justify both the use of online qualitative surveys and why we have chosen these over other qualitative approaches. For example, reviewers have asked us to justify why we have chosen an online qualitative survey and also to explain what we may have missed out on by not conducting in-depth interviews or quantitative or mixed methods surveys instead.

Requests for ‘numbers’ and ‘strategies to minimize bias’

While there is now a general understanding that attributing ‘numbers’ to qualitative data is largely unhelpful and inappropriate ( Chowdhury, 2015 ), there may be expectations that the larger sample sizes associated with online qualitative surveys enable researchers to provide numerical indicators of data. Rather than focusing on the ‘artfully interpretive’ techniques used to analyse and construct themes from the data ( Finlay, 2021 ), we have found that reviewers often ask us to provide numerical information about how many people provided different responses to different questions (or constructed themes), and the number at which ‘saturation’ was determined. Reviewer feedback that we have received about analytical processes has asked for detailed explanations about why attempts to ‘minimize bias’ (including calculations of inter-rater reliability and replicability of data quality) were not used. This demonstrates that peer reviewers may misinterpret the interpretivist values that guide online qualitative surveys, asking for information that is essentially ‘meaningless’ in qualitative paradigms in which researchers’ subjectivity ‘sculpts’ the knowledge that is produced ( Braun and Clarke, 2021a ).

The benefits and limitations of online qualitative surveys for participants, researchers and knowledge users

As well as a ‘wide-angle picture’ [( Toerien and Wilkinson, 2004 ), p. 70] on phenomenon, online qualitative surveys can also: (i) generate both rich and focused data about perceptions and practices, and (ii) have multiple participatory and practical advantages—including helping to overcome barriers to research participation ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ). For researchers , online qualitative surveys can be a more cost-effective alternative ( Braun and Clarke, 2013 ; Terry and Braun, 2017 )—they are generally more time-efficient and less labour-intensive (particularly if working with market research companies to recruit panels). They are also able to reach a broad range of participants—such as those who are geographically dispersed ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ), and those who may not have internet connectivity that is reliable enough to complete online interviews (a common issue for individuals living in regional or rural settings) ( de Villiers et al ., 2022 ). We are also more able to engage young people in qualitative research through online surveys, perhaps partly due to extensive panel company databases but also because they may be a more accessible and familiar way for young people to participate in research. The ability to quickly investigate new public health threats from the perspective of lived experience can also provide important information for researchers, providing justification for new areas of research focus, including setting agendas and advocating for the need for funding (or policy attention). Collecting data from a diverse range of participants—including from those who hold views that we may see as less ‘politically acceptable’, or inconsistent with our own public health reasoning about health and equity—is important in situating and contextualizing community attitudes towards particular issues.

For participants , benefits include having a degree of autonomy and control over their participation, including completing the survey at a time and place that suits them, and the anonymous nature of participation (that may be helpful for people from highly stigmatized groups). Participants can take time to reflect on their responses or complete the survey, and may feel more able to ‘talk back’ to the researcher about the framing of questions or the purpose of the research ( Braun et al ., 2021 ). We would also add that a benefit of these types of studies is that participants can also drop out of the study easily if the survey does not interest them or meet their expectations—something that we think might be more onerous or uncomfortable for participants in an interview or focus group.

For knowledge users, including advocates, service providers and decision-makers, qualitative research provides an important form of evidence, and the ‘wide-angle picture' [( Toerien and Wilkinson, 2004 ), p. 70] on issues from a diverse range of individuals in a community or population can be a powerful advocacy tool. Online qualitative surveys can also provide rapid insights into how changes to policy and practice may impact population subgroups in different ways.

There are, of course, some limitations associated with online qualitative surveys ( Braun et al ., 2021 ; Marko et al ., 2022b ). For example, there is no ability to engage individuals in a ‘traditional’ conversation or to prompt or probe meaning in the interactive ways that we are familiar with in interview studies. There is less ability to refine the questions that we ask participants in an iterative way throughout a study based on participant responses (particularly when working with market research panel companies). There may also be barriers associated with written literacy, access to digital technologies and stable internet connections ( Braun et al ., 2021 ). They may also not be the most suitable for individuals who have different ways of ‘knowing, being and doing’ qualitative research—including Indigenous populations [( Kennedy et al ., 2022 ), p. 1]. All of these factors should be taken into consideration when deciding whether online qualitative surveys are an appropriate way of collecting data. Finally, while these types of surveys can collect data quickly ( Marko et al ., 2022b ), there can also be additional decision-making processes related to data preparation and inclusion that can be time-consuming.

There are a range of practical considerations that can improve the rigour, trustworthiness and quality of online qualitative survey data. Again, developing and expanding on ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al ., 2021 ), Figure 2 gives an overview of some key practical considerations associated with the design, implementation and analysis of these surveys. We would also note that before starting your survey design, you should be aware that people may use different types of technology to complete the survey, and in different spaces. For example, we cannot assume that people will be sitting in front of a computer or laptop at home or in the office, with people more likely to complete surveys on a mobile phone, perhaps on a train or bus on the way to work or school.

: Top ten practical tips for conducting online qualitative surveys.

: Top ten practical tips for conducting online qualitative surveys.

Survey design

Creating an appropriate and accessible structure

The first step in designing an online qualitative survey is to plan the structure of your survey. This step is important because the structure influences the way that participants interact with and participate through the survey. The survey structure helps to create an ‘environment’ that helps participants to share their perspectives, prompt their views and develop their ideas ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ). Similar to an interview study, the structure of the survey guides participants from one set of questions (and topics) to the next. It is important to consider the ordering of topics to enable participants to complete a survey that has a logical flow, introduces participants to concepts and allows them to develop their depth of responses.

Before participants start the survey, we provide a clear and simple lay language summary of the survey. Because many individuals will be familiar with completing quantitative surveys, we include a welcoming statement and reiterate the qualitative nature of the survey, stating that their answers can be about their own experiences:

Thank you for agreeing to take part in this survey about [topic] . This survey involves writing responses to questions rather than checking boxes.

We then clearly reiterate the purpose of the survey, providing a short description of the topic that we are investigating. We state that we do not seek to collect any data that is identifiable, that we are interested in participants perspectives, that there are no right or wrong answers, and that participants can withdraw from the survey at any time without giving a reason.

Similar to Braun et al . (2021) , we start our surveys with questions about demographic and related characteristics (which we often call ‘ participant/general characteristics ’). These can be discrete choice questions, but can also utilize open text—for example, in relation to gender identity. We have found that there is always a temptation with surveys to ask many questions about the demographic characteristics of participants. However, we caution that too many questions can be intrusive for participants and can take away valuable time from open-text questions, which are the core focus of the survey. We recommend asking participant characteristic and demographic questions that situate and contextualize the sample ( Elliott et al ., 1999 ).

We generally start the open-text sections of these surveys by asking broad introductory questions about the topic. This might include questions such as: ‘Please describe the main reasons you drink alcohol ’, and ‘W hat do you think are the main impacts of climate change on the world? ’ We have found that these types of questions get participants used to responding to open-text questions relevant to the study’s research questions and aims. For each new topic of investigation (which are based on our theoretical concepts and overall study aims and research questions), we provide a short explanation about what we will ask participants. We also use tools and text to signpost participant progress through the survey. This can be a valuable way to avoid high attrition rates where participants exit the survey because they are getting fatigued and are unclear when the survey will end:

Great! We are just over half-way through the survey.

We ask more detailed questions that are more aligned with our theoretical concepts in the middle of the survey. For example, we may start with broad questions about a harmful industry and their products (such as gambling, vaping or alcohol) and then in the middle of the survey ask more detailed questions about the commercial determinants of health and the specific tactics that these industries use (for example, about product design, political tactics, public relations strategies or how these practices may influence health and equity). In relation to these more complex questions, it is particularly important that we reiterate that there are no wrong answers and try to include encouraging text throughout the survey:

There are no right or wrong answers—we are curious to hear your opinions .

We always try to end the survey on a positive. While these types of questions depend on the study, we try to ask questions which enable participants to reflect on what could be done to address or improve an issue. This might include their attitudes about policy, or what they would say to those in positions of power:

What do you think should be done to protect young people from sports betting advertising on social media? If there was one thing that could be done to prevent young people from being exposed to the risks associated with alcohol, cigarettes, vaping, or gambling, what would it be? If you could say one thing to politicians about climate change, what would it be?

Finally, we ask participants if there is anything we have missed or if they have anything else to add, sometimes referred to as a ‘clean-up’ question ( Braun and Clarke, 2013 ). The following provides a few examples of how we have framed these questions in some of our studies:

Is there anything you would like to say about alcohol, cigarettes, vaping, and gambling products that we have not covered? Is there anything we haven’t asked you about the advertising of alcohol to women that you would like us to know?

Considering the impact of the length of the survey on responses

The length of the survey (both the number of questions and the time it takes an individual to complete the survey) is guided by a range of methodological and practical considerations and will vary between studies ( Braun and Clarke, 2013 ). Many factors will influence completion times. We try to give individuals a guide at the start of the survey about how long we think it will take to complete the survey (for example, between 20 and 30 minutes). We highlight that it may take people a little longer or shorter and that people are able to leave their browser open or save the survey and come back to finish it later. For our first few online qualitative surveys, we found that we asked lots of questions because we felt less in control of being able to prompt or ask follow-up questions from participants. However, we have learned that less is more! Asking too many questions may lead to more survey dropouts, and may significantly reduce the textual quality of the information that you receive from participants ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ). This includes considering how the survey questions might lead to repetition, which may be annoying for participants, leading to responses such as ‘like I’ve already said’ , ‘I’ve already answered that’ or ‘see above’ .

Providing clear and simple guidance

When designing an online qualitative survey, we try to think of ways to make participation in the survey engaging. We do not want individuals to feel that we are ‘mining’ them for data. Rather we want to demonstrate that we are genuinely interested in their perspectives and views. We use a range of mechanisms to do this. Because there is no opportunity to verbally explain or clarify concepts to participants, there is a particular need to ensure that the language used is clear and accessible ( Braun and Clarke, 2013 ; Terry and Clarke, 2017 ). If language or concepts are complex, you are more likely to receive ‘I don’t know’ responses to your questions. We need to remember that participants have a range of written and comprehension skills, and inclusive and accessible language is important. We also never try to assume a level of knowledge about an issue (unless we have specifically asked for participants who are aware and engaged in an issue—such as women who drink alcohol) ( Pitt et al ., 2023 ). This includes avoiding highly technical or academic language and not making assumptions that the individuals completing the survey will understand concepts in the same way that researchers do ( Braun and Clarke, 2013 ). Clearly explaining concepts or using text or images to prompt memories can help to overcome this:

Some big corporations (such as the tobacco, vaping, alcohol, junk food, or gambling industries) sponsor women's sporting teams or clubs, or other events. You might see sponsor logos on sporting uniforms, or at sporting grounds, or sponsoring a concert or arts event.

At all times, we try to centre the language that we use with the population from which we are seeking responses. Advisory groups can be particularly helpful in framing language for different population subgroups. We often use colloquial language, even if it might not be seen as the ‘correct’ academic language or terminology. Where possible, we also try to define theoretical concepts in a clear and easy to understand way. For example, in our study investigating parent perceptions of the impact of harmful products on young people, we tried to clearly define ‘normalization’:

In this section we ask you about some of the perceived health impacts of the above products on young people. We also ask you about the normalisation of these products for young people. When we talk about normalisation, we are thinking about the range of factors that might make these products more acceptable for young people to use. These factors might include individual factors, such as young people being attracted to risk, the influence of family or peers, the accessibility and availability of these products, or the way the industry advertises and promotes these products.

Using innovative approaches to improve accessibility and prompt responses

Online qualitative surveys can include features beyond traditional question-and-answer formats ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ). For example, we often use a range of photo elicitation techniques (using images or videos) to make surveys more accessible to participate in, address different levels of literacy, and overcome the assumption that we are not able to ‘prompt’ responses. These types of visual methodologies enable a collaborative and creative research experience by asking the participant to reflect on aspects of the visual materials, such as symbolic representations, and discuss these in relation to the research objectives ( Glaw et al ., 2017 ). The combination of visual images and clear descriptions helps to provide a focus for responses about different issues, as well as prompting nuanced information such as participant memories and emotions ( Glaw et al ., 2017 ). We use different types of visuals in our studies, such as photographs (including of the public health issues we’re investigating); screenshots from websites and social media posts (including newspaper headlines) and videos (including short videos from social media sites such as TikTok) ( Arnot et al ., 2024b ). For example, when talking about government responses to the climate crisis, we used a photograph of former Australian Prime Minister Scott Morrison holding a piece of coal in the Australian parliament to prompt participants’ thinking about the government’s relationship with fossil fuels and to provide a focal point for their answer. However, we would caution against using any images that may be confronting for participants or deliberately provocative. The purpose of using visuals must always be in the interests of the participants—to clarify, prompt and reflect on concepts. Ethics committees should carefully review the images used in surveys to ensure that they have a clear purpose and are unlikely to cause any discomfort.

Survey implementation

Thinking carefully about your criteria for recruitment

Determining the sample size of online qualitative studies is not an exact science. The sample sizes for recent studies have ranged from n = 46 in a study about pregnancy loss ( Hennessy and O’Donoghue, 2024 ), to n = 511 in a study with young people about the climate crisis ( Arnot et al ., 2023b ). We follow ‘rules of thumb’ [( Braun and Clarke, 2021b ), p. 211] which try to balance the needs of the research and data richness with key practical considerations (such as funding and time constraints), funder expectations, discipline-specific norms and our knowledge and experience of designing and implementing online qualitative surveys. However, we have found that peer reviewers expect much more justification of sample sizes than they do for other types of qualitative research. Robust justification of sample sizes are often needed to prevent any ‘concerns’ that reviewers may raise. Our response to these reviews often reiterates that our focus (as with all qualitative research) is not to produce a ‘generalisable’ or ‘representative’ sample but to recruit participants who will help to provide ‘rich, complex and textured data’ [( Terry and Braun, 2017 ), p. 15] about an issue. Instead of focusing on data saturation, a contested concept which is incongruent with reflexive thematic analysis in particular ( Braun and Clarke, 2021b ), we find it useful to consider information power to determine the sample size for these surveys ( Malterud et al ., 2016 ). Information power prioritizes the adequacy, quality and variability of the data collected over the number of participants.

Recruitment for online qualitative surveys can be influenced by a range of factors. Monetary and time constraints will impact the size and, if using market research company panels, the specificity of participant quotas. Recruitment strategies must be developed to ensure that the data provides enough information to answer the research questions of the study. For our research purposes, we often try to ensure that participants with a range of socio-demographic characteristics are invited to participate in the sample. We set soft quotas for age, gender and geographic location to ensure some diversity. We have found that some population subgroups may also be recruited more easily than others—although this may depend on the topic of the survey. For example, we have found that quotas for women and those living in metropolitan areas may fill more quickly. In these scenarios, the research team must weigh up the timelines associated with recruitment and data collection (e.g. How long do we want to run data collection for? How much of our budget can be spent on achieving a more equally split sample? Are quotas necessary?) versus the purpose and goals of the research (i.e. to generate ideas rather than data representativeness), and the study-specific aims and research questions.

There are, of course, concerns about not being able to ‘see’ the people that are completing these surveys. There is an increasing focus in the academic literature on ‘false’ respondents, particularly in quantitative online surveys ( Levi et al ., 2021 ; Wang et al ., 2023 ). This will be an important ongoing discussion for qualitative researchers, and we do not claim to have the answers for how to overcome these issues. For example, some individuals may say that they meet the inclusion criteria to access the survey, while others may not understand or misinterpret the inclusion criteria. There is also a level of discomfort about who and how we judge who may be a ‘legitimate’ participant or not. However, we can talk practically about some of the strategies that we use to ensure the rigour of data. For example, we find that screening questions can provide a ‘double-check’ in relation to inclusion criteria and can also help with ensuring that there is consistency between the information an individual provides about how they meet the inclusion criteria and subsequent responses. For example, in a recent survey of parents of young people, a participant stated that they were 18 years old and were a parent to a 16-year-old and 15-year-old. Their overall responses were inconsistent with being a parent of children these ages. Similarly, in our gambling studies, people may tick that they have gambled in the last year but then in subsequent questions say they have not gambled at all. This highlights the importance of checking data across all questions, although it should be noted that time and cost constraints associated with comprehensively scanning the data for such responses are not always feasible and can result in overlooking these participants.

Ensuring that there are strategies to create agency and engage participants in the research

One of the benefits of online qualitative surveys compared to traditional quantitative surveys is the scope for participants to explain their answers and to disagree with the research team’s position. An indication that participants are feeling able to do this is when they are asked for any additional comments at the end of the survey. For example, in a survey about women’s attitudes towards alcohol marketing, the following participant concluded the survey by writing: ‘I think you have covered everything. I think that you need to stop shaming women for having fun’. Other participants demonstrate their engagement and interest in the survey by reaffirming the perspectives they have shared throughout the survey. For example, in a study with young people on climate, participants responded at the end that ‘it’s one of the few things I actually care about’ , while another commented on the quality of the survey questions, stating, ‘I think this survey did a great job with probing questions to prompt all the thoughts I have on it’ .

We also think that online qualitative surveys may lead to less social desirability in participants’ responses. Participants seem less wary about communicating less politically correct opinions than they may do in a face-to-face interview. For example, at times, participants communicate attitudes that may not align with public health values (e.g. supporting personal responsibility, anti-nanny state, and neoliberal ideologies of health and wellbeing), that we rarely see communicated to us in in-depth interview or focus group studies. We would argue that these perspectives are valuable for public health researchers because they capture a different community voice that may not otherwise be represented in research. This may show where there is a lack of support for health interventions and policy reforms and may indicate where further awareness-raising needs to occur. These types of responses also contribute to reflexive practice by challenging our assumptions and positions about how we think people should think or feel about responses to particular public health issues. Examples of such responses from our surveys include:

"Like I have already said, if you try to hide it you will only make it more attractive. This nanny-state attitude of the elite drives me crazy. People must be allowed to decide for themselves."

Ethical issues for participants and researchers

Researchers should also be aware that some of the ethical issues associated with online qualitative surveys may be different from those in in-depth interviews—and it is important that these are explained in any ethical consideration of the study. Providing a clear and simply worded Plain Language Statement (in written or video form) is important in establishing informed consent and willingness to participate. While participants are given information about who to contact if they have further questions about the study, this may be an extra step for participants, and they may not feel as able to ask for clarification about the study. Because of this, we try to provide multiple examples of the types of questions that we will ask, as well as providing downloadable support details (for example, for mental health support lines). A positive aspect of surveys is that participants are able to easily ignore recruitment notices to participate in the study. They are also able to stop the survey at any time by exiting out of the browser if they feel discomfort without having to give a reason in person to a researcher.

While the anonymous nature of the survey may be empowering for some participants ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al. , 2021 ), it can also make it difficult for researchers to ascertain if people need any further support after completing the survey. Participants may also fill in surveys with someone else and may be influenced about how they should respond to questions (with the exception of some studies in which people may require assistance from someone to type their responses). Because of the above, some researchers, ethics committees and funders may be more cautious about using these studies for highly sensitive subjects. However, we would argue that the important point is that the studies follow ethical principles and take the lack of direct contact with participants into the ethical considerations of the study. It is also important to ensure that platforms used to collect survey data are trusted and secure. Here, we would argue that universities have an obligation to investigate and, where possible, approve survey providers to ensure that researchers are using platforms that meet rigorous standards for data and privacy.

It is also important to note that there may be responses from participants that may be challenging ( Terry and Braun, 2017 ; Braun and Clarke, 2021 ). Online spaces are rife with trolling due to their anonymous nature, and online surveys are not immune to this behaviour. Naturally, this leads to some silly responses—‘ Deakin University is responsible for all of this ’, but researchers should also be aware that the anonymity of surveys can (although in our experience not often) lead to responses that may cause discomfort for the researchers. For example, when asked if participants had anything else to add to a climate survey ( Arnot et al ., 2024c ), one responded ‘ nope, but you sure asked a lot of dumbass questions’ . Just as with interview-based studies, there must be processes built into the research for debriefing—particularly for students and early career researchers—as well as clear decisions about whether to include or exclude these types of responses when preparing the dataset for analysis and in writing up the results from the survey.

The importance of piloting the survey

Because of the lack of ability to explain and clarify concepts, piloting is particularly important ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ; Braun et al. , 2021 ) to ensure that: (i) the technical aspects of the survey work as intended; (ii) the survey is eliciting quality responses (with limited ‘nonsensical’ responses such as random characters); (iii) the survey responses indicate comprehension of the survey questions; and (vi) there is not a substantial number of people who ‘drop-out’ of the study. Typically, we pilot our survey with 10% of the intended sample size. After piloting, we often change question wording, particularly to address questions that elicit very small text responses, the length of the survey and sometimes refine definitions or language to ensure increased comprehension. Researchers should remember that changes to the survey questions may need to be reviewed by ethics committees before launching the full survey. It is important to build in time for piloting and the revision of the survey to ensure you get this right as once you launch the full survey, there is no going back!

Survey analysis and write-up

Preparing the dataset

Once launching the full survey, the quality of data and types of responses you receive in these types of surveys can vary. There is very limited transparency around how the dataset was prepared (more familiar to some as ‘data cleaning’) in published papers, including the decisions about which (if any) participants (or indeed responses) were excluded from the dataset and why. Nonsensical responses can be common—and can take a range of forms ( Figure 3 ). These can include random numbers or letters, a chunk of text that has been copied and pasted from elsewhere, predictive text or even repeat emojis. In one study, we had a participant quote the script of The Bee Movie in response to questions.

: Visual examples of nonsensical responses in online qualitative surveys.

: Visual examples of nonsensical responses in online qualitative surveys.

Part of our familiarization with the dataset [Phase One in Braun and Clarke’s reflexive approach to thematic analysis ( Braun and Clarke, 2013 ; Braun et al ., 2021 )] includes preparing the dataset for analysis. We use this phase to help make decisions about what to include and exclude from the final dataset. While a row of emojis in the data file can easily be spotted and removed from the dataset, sometimes responses can look robust until you read, become familiar and engage with the data. For example, when asked about what they thought about collective climate action ( Arnot et al ., 2023a , 2024c ), some participants entered random yet related terms such as ‘ plastic ’, or repeated similar phrases across multiple questions:

“ why do we need paper straws ”, “ paper straws are terrible ”, “ papers straws are bad for you ”, “ paper straws are gross .”

Participants can also provide comprehensive answers for the first few questions and then nonsensical responses for the rest, which may also be due to question fatigue [( Braun and Clarke, 2013 ), p. 138]. Therefore, it is important to closely go through each participant’s response to ensure they have attempted to provide bone-fide responses. For example, in one of our young people and climate surveys ( Arnot et al ., 2023a , 2024c ), one participant responded genuinely to the first half of the survey before their quality dropped dramatically:

“I can’t even be bothered to read that question ”, “ why so many questions ”, “ bro too many sections. ”

Some market research panel providers may complete an initial quality screen of data. However, this does not replace the need for the research teams’ own data preparation processes. Researchers should ensure they are checking that responses are coherent—for example, not giving information that contradicts or is not credible. In our more recent studies, we have increasingly seen responses cut and pasted from ChatGPT and other AI tools—providing a new challenge in assessing the quality of responses. If you are seeing these types of responses, it might be an opportunity to think about the style and suitability of the questions being asked. For example, the use of AI tools might suggest that people are finding it difficult to answer questions or may feel that they have to present a ‘correct’ answer. We would also note that because of the volume of data in these surveys, the preparation of data involves multiple members of the team. In many cases, decisions need to be made about participants who may not have provided authentic responses across the survey. The research team should make clear in any paper their decisions about their choices to include or exclude participants from the study. There is a careful balancing act that can require assessing the quality of the participants’ responses across the whole dataset to determine if the overall quality of responses contributes to the research.

Navigating the volume of data and writing up results

Finally, discussions about how to navigate the volume of data that these types of studies produce could be a standalone paper. In general, principles of reflexive practices apply to the analysis of data from these studies. However, as a starting point, here are a few considerations when approaching these datasets.

We would argue that online qualitative surveys lend themselves to some types of analytical approaches over others—for example, reflexive thematic analysis, as compared to grounded theory or interpretive phenomenological analysis (though it can be used with these) ( Braun and Clarke, 2013 ; Terry and Braun, 2017 ).

While initial familiarization, coding and analysis can focus on specific questions and associated responses, it is important to analyse the dataset as a whole (or as clusters associated with particular topics) as participants may provide relevant data to a topic under multiple questions ( Terry and Braun, 2017 ). We initially focus our coding on specific questions or a group of survey questions under a topic of investigation. Once we have developed and constructed preliminary themes from the data associated with these clusters of questions, we then move to looking at responses across the dataset as we review themes further.

Researchers should think carefully about how to manage the data—which may not be available as ‘individual participant transcripts’ but rather as a ‘whole’ dataset in an Excel spreadsheet. Some may prefer qualitative data analysis software (QDAS) to manage and navigate data. However, many of us find that Excel (and particularly the use of labelled Tabs) is useful in grouping data and moving from codes to constructing themes.

As with all rigorous qualitative research, coding and theme development should be guided by the research questions. A clear record of decision-making about analytical choices (and being reflexive about these) should be kept. In any write-up, we would recommend that researchers are clear about which survey questions they used in the analysis [researchers could consider providing a supplementary file of some or all of the survey questions—see, for example Hennessy and O’Donoghue (2024) ].

In writing up the results, researchers should still seek to present a rich description of the data, as demonstrated in the presentation of results in the following papers ( Marko et al ., 2022a , 2022b ; McCarthy et al ., 2023 ; Pitt et al ., 2023 ; Hennessy and O’Donoghue, 2024 ). We have found the use of tables with additional examples of quotes as they relate to themes and subthemes can be a practical way of providing the reader with further examples of the data, particularly when constrained by journal word count limits [see, for example, Table 2 in Arnot et al ., (2024c) ]. However, these tables do not replace a full and complete presentation of the interpretation of the data.

This article offers methodological reflections and practical guidance around online qualitative survey design, implementation and analysis. While online qualitative surveys engage participants in a different type of conversation, they have design features that enable the collection of rich data. We recognize that we have much to learn and that while no survey of ours has been perfect, each new experience with developing and conducting online qualitative surveys has brought new understandings and lessons for future studies. In recognizing that we are learning, we also feel that our experience to date could be valuable for progressing the conversation about the rigour of online qualitative surveys and maximizing this method for public health gains.

H.P. is funded through a VicHealth Postdoctoral Research Fellowship. S.M. is funded through a Deakin University Faculty of Health Deans Postdoctoral Fellowship. G.A. is funded by an Australian Government Research Training Program Scholarship. M.H. is funded through an Irish Research Council Government of Ireland Postdoctoral Fellowship Award [GOIPD/2023/1168].

The pregnancy loss study was funded by the Irish Research Council through its New Foundations Awards and in partnership with the Irish Hospice Foundation as civil society partner [NF/2021/27123063].

S.T. is Editor in Chief of Health Promotion International, H.P. is a member of the Editorial Board of Health Promotion International, S.M. and G.A. are Social Media Coordinators for Health Promotion International, M.H. is an Associate Editor for Health Promotion International. They were not involved in the review process or in any decision-making on the manuscript.

The data used in this study are not available.

Ethical approval for studies conducted by Deakin University include the climate crisis (HEAG-H 55_2020, HEAG-H 162_2021); parents perceptions of harmful industries on young people (HEAG-H 158_2022); women and alcohol marketing (HEAG-H 123_2022) and gambling (HEAG 227_2020).

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Positive mental health in psychotherapy: a qualitative study from psychotherapists’ perspectives

Sherilyn chang.

1 Research Division, Institute of Mental Health, Singapore, Singapore

Rajeswari Sambasivam

Esmond seow, mythily subramaniam, hanita ashok assudani.

2 Department of Psychology, Institute of Mental Health, Singapore, Singapore

Geoffrey Chern-Yee Tan

3 Department of Mood and Anxiety, Institute of Mental Health, Singapore, Singapore

4 Singapore Institute of Clinical Sciences, A*STAR, Singapore, Singapore

Sharon Huixian Lu

Janhavi ajit vaingankar, associated data.

The datasets generated and/or analyzed during the current study are not publicly available due to requirements mandated by the institutional review board (IRB) and funders, but may be available from the corresponding author on reasonable request. Access may be granted subject to the IRB and the research collaborative agreement guidelines.

There is growing evidence in the literature on the use of positive mental health (PMH) interventions among clinical samples. This qualitative study aims to explore the definitions of PMH from psychotherapists’ perspectives, and to examine views and attitudes related to the construct.

Focus group discussions were conducted with psychotherapists at a tertiary psychiatric institute. Focus group sessions were transcribed verbatim and transcripts were analyzed using an inductive thematic approach.

Five themes related to psychotherapists’ definition of PMH were identified: (1) acceptance; (2) normal functioning and thriving in life; (3) resilience; (4) positive overall evaluation of life; (5) absence of negative emotions and presence of positive emotion states. Themes related to views and attitudes towards PMH were: (1) novel and valuable for psychotherapy; (2) reservations with terminology; (3) factors influencing PMH.

PMH in psychotherapy is a multidimensional concept that means more than symptom management and distress reduction in clients. There is potential value for its application in psychotherapy practice, though some concerns need to be addressed before it can be well integrated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00816-6.

Introduction

Positive mental health (PMH) reflects a state of mental wellbeing that goes beyond the mere absence of psychopathology. It encompasses emotional and psychological wellbeing, and functioning in psychological, social and societal domains [ 1 ]. In relation to emotional wellbeing, Diener et al.’s definition on subjective wellbeing is often drawn upon as it looks at an individual’s overall evaluation of their life and emotional experiences such as life satisfaction, positive affect and negative affect [ 2 ]. This is also seen as the hedonic approach to wellbeing that focuses on pleasure attainment and pain avoidance [ 3 ]. In contrast, the eudemonic approach ‘focuses on meaning and self-realization and defines wellbeing in terms of the degree to which a person is fully functioning’ [ 4 ]. A closely related concept of psychological wellbeing has been conceptualized as consisting of six dimensions: autonomy, environmental mastery, personal growth, purpose in life, positive relations with others, and self-acceptance [ 5 ]. In addition to emotional and psychological wellbeing, Keyes also considers social wellbeing as essential in identifying a thriving individual as flourishing [ 6 ]. Some studies have also identified spirituality (related to religious beliefs and practices) as an important domain of PMH [ 7 , 8 ].

Traditionally psychotherapy, and also clinical care in general, focus on alleviating symptoms and are largely aimed at correcting deficits resulting from disruption of normal functioning [ 9 , 10 ]. There have been calls to shift away from this deficit-based view of mental health to promoting wellbeing, and to evaluate both PMH dimensions and psychopathology when providing psychotherapy and in conducting research [ 1 , 11 , 12 ]. Distinct psychotherapeutic interventions that are theoretically grounded in positive psychology, a scientific field that studies contributing factors of human flourishing and optimal function [ 13 ], explicitly targets wellbeing outcomes. Some examples include therapies such as the wellbeing therapy [ 14 ] and positive psychotherapy [ 15 ]. Other non-positive psychology approaches such as mindfulness-based interventions and gratitude-promoting exercises have also been incorporated into traditional psychotherapies to enhance wellbeing.

Several studies have examined the effectiveness of PMH interventions in improving outcomes among clinical samples. A meta-analysis by Goldberg et al. reported equivalent efficacy of mindfulness-based interventions to first-line, evidence-based psychological and psychiatric treatments in symptoms reduction, with effects most consistent for depression, pain, smoking and addictions [ 16 ]. In another meta-analysis examining the effects of positive psychology interventions on wellbeing and distress, the authors found small effect sizes for such interventions on improving wellbeing and depression, and moderate improvements for anxiety among clinical samples [ 17 ]. A recently published article by Jankowski et al. provided a comprehensive review of the various types of interventions in psychotherapy to promote wellbeing and the efficacy of these treatments [ 11 ]. The authors found support for these approaches in enhancing wellbeing and urged ‘researchers and psychotherapists to continue to integrate symptom reduction and wellbeing promotion into psychotherapy approaches aimed at fostering client flourishing’. Given that ‘good outcomes’ of psychotherapy constituted more than symptom alleviation and included outcomes such as with gaining acceptance and self-understanding, alongside developing a sense of mastery and self-compassion [ 18 ], there is value in exploring the application of PMH interventions in psychotherapy.

To date there has been no study that has examined the concept of PMH among psychotherapists and to understand their attitudes towards a PMH based approach in psychotherapy. As a step towards exploring ways in which PMH interventions can be incorporated into psychotherapy practice, it is imperative to first understand the concept of PMH from the point of view of psychotherapists in clinical settings. This could provide insights into the attitudes of psychotherapists towards PMH and identify potential challenges and difficulties in integrating PMH interventions into psychotherapy in a clinical setting. The present qualitative study thus aims to explore the definitions of PMH from psychotherapists’ perspectives and its application in their practice, and to examine their views related to the concept of PMH.

Study design and setting

A qualitative study was conducted at a tertiary psychiatric hospital in Singapore and data collection took place between April and November 2019. This study used an interpretivist approach to gain an in-depth understanding of psychotherapists’ definitions and views of PMH, and this enabled an understanding of psychotherapy practices from the practitioners’ perspectives to yield clinical applications and inform future research. The Consolidated Criteria for Reporting Qualitative Research (COREQ; Additional file 1 : Appendix A) was used to guide the reporting of this study [ 19 ].

Study sample

Participants for this study were professionals who provided psychotherapy to individuals with mental health issues at private or public institutions in Singapore. Purposive sampling was adopted to ensure appropriate representation of psychotherapists by work experience. Psychotherapists were invited to participate in the research study through connections from personal network and also via word of mouth (none of the recruited participants were personally acquainted with study team members who were present during the interview), and were contacted through phone calls and emails to provide them with further details of the study. Inclusion criteria for the study were individuals aged 21 years and above, experienced in providing psychotherapy to people with mental health problems at public or private institutes, and able to provide consent. The study was approved by the institutional ethics committee and all participants had provided written informed consent prior to their participation. This study was conducted in accordance with the Declaration of Helsinki.

Qualitative data was collected during focus group discussions (FGDs) conducted with psychotherapists. Each FGD session lasted between 1.5–2 h, had 4–6 participants, and was facilitated by a female senior researcher (JV), who has a background in epidemiology (MSc) and is trained in qualitative research methodologies and has domain expertise in the area of mental wellbeing. Study team members (RS, ES or SC), who were researchers with bachelor degrees in psychology and had prior experience in conducting qualitative research, were present during the session as a note taker. Participants completed a short questionnaire that collected information pertaining to their sociodemographic background and clinical experience. As part of icebreaking activity before the FGD began, all participants and study members who were present briefly introduced themselves regarding their work and personal interests. An interview guide was used during the FGDs to facilitate discussion (see Table ​ Table1 1 for brief guide). This interview guide was developed with inputs from clinicians and psychologists from the study team to set the questions in the context of psychotherapy. Participants were first presented with an overarching question on what PMH means to them in their practice, and were then given time to pen down their thoughts on cue cards. These cards served as aids to facilitate subsequent discussion. As far as possible, the discussions followed the experiences of the participants and clarifications were sought when needed. Participants were also encouraged to share their opinions on the viewpoints raised by other participants during the discussions. Recruitment of participants and FGDs continued until repetition of themes occurred and no new information was evident (i.e. data saturation achieved). All the FGDs were audiotaped and transcribed verbatim for analysis. Quality checks on the transcripts were performed; after which the transcripts were anonymized to safeguard the participants’ identity.

Brief guide of questions and probes used

What does PMH mean to you in psychotherapy practice?

When you say [construct], what are the things that you are thinking of? Can you give me some examples? How do you apply that in your practice?

How would you define [construct]?

Why do you think [construct] is PMH? How do you think [construct] helps in PMH?

What are the factors that promote PMH or psychological wellbeing?

How do you think that would be a factor in a person’s mental health?

Thematic data analysis was conducted to analyze the data where common underlying themes were identified inductively from the data [ 20 ]. NVivo software (Version 11) was used to code and organize the data. One transcript each was assigned to three study team members (JV, SC, ES) who read through the respective transcript repeatedly and thoroughly to familiarize themselves with the content. Each team member noted meaningful content in the transcript to generate codes inductively which were later combined to form emergent themes. Study team members then gathered to discuss the codes and themes obtained, and a list of preliminary themes was identified. This was used to code the remaining transcripts, and new codes and themes were created to capture any new content that emerged. After all transcripts were reviewed, various themes were combined to produce higher-order themes. Any disagreements between team members were resolved through discussions to reach consensus.

Lincoln and Guba’s criteria to assess the trustworthiness of a study looks at credibility, transferability, dependability and confirmability [ 21 ], and these criteria can be applied in conducting thematic analysis [ 22 ]. In terms of data accuracy, all FGD sessions were audio-recorded and transcribed verbatim by a team member; study team members (other than the person who transcribed the interview) performed checks on the transcripts to ensure its quality and accuracy. Raw audio recordings and verbatim transcripts were stored in well-organized archives until verification was completed, and records of observation notes, coded transcripts and discussion notes were kept to provide an audit trail of the code generation process and serves to provide dependability and confirmability. Findings were reviewed by members in the study team which included researchers and also psychotherapists and this addresses credibility of the study. Detailed descriptions of the research process and in reporting of results can provide information to other researchers on the transferability of findings in another study population.

A total of 7 FGDs were conducted with 38 participants for the study. The participants’ age ranged between 27 and 63 years, were mostly females (84.2%), of Chinese ethnicity (81.6%), and the majority had obtained a post-graduate degree (94.7%; Table ​ Table2). 2 ). All participants had received formal training in varied psychotherapy modalities including cognitive behavioral therapy, positive behavioral management, exposure and response prevention, eye movement desensitization and reprocessing, acceptance and commitment therapy, schema-focused therapy, emotion focused therapy, solution focused brief therapy, psychodynamic therapy, dialectical behavioral therapy, mindfulness-based therapy etc. For the majority of participants, their clientele comprised adults presenting with mental disorders including mood disorders and anxiety disorders. Others worked with children and adolescents with childhood disorders, elderly population with dementia, or individuals who needed life coaching.

Sociodemographic profile of participants (n = 38)

n
Age (mean)35.7
Female32
Male6
Chinese31
Indian4
Others3
University degree2
Postgraduate degree36
Public institution34
Private practice3
Both1

Thematic analysis of the qualitative data identified five themes pertaining to psychotherapists’ definition of PMH: (1) acceptance; (2) normal functioning and thriving in life; (3) resilience; (4) positive overall evaluation of life; (5) absence of negative emotions and presence of positive emotion states. Their views on the concept of PMH could be examined from the following three themes: (1) novel and valuable for psychotherapy; (2) reservations with terminology; (3) factors influencing PMH. Figure  1 a, b present the coding trees derived from the coding process with the subthemes and themes shown. The following section describes the themes in further details and salient quotes that underscore the essence of the theme are presented.

An external file that holds a picture, illustration, etc.
Object name is 40359_2022_816_Fig1_HTML.jpg

a Coding tree of themes identified in the coding process pertaining to psychotherapists’ definition of PMH. b Coding tree of themes identified in the coding process pertaining to psychotherapists’ views on the concept of PMH

Definitions of positive mental health

(1) Acceptance

This was a common theme discussed by participants from various FGDs. PMH was defined as having the ability to accept things that happened in life and acknowledging the outcomes that resulted. Acceptance was in relation to not just negative events, but also acceptance of ‘difficult emotions’ and where one is in life.

It’s about accepting where you are in life and… as well as… growing in that journey to acceptance and being at peace with that. – FGD 3 Same way like you were talking about ACT (Acceptance and Commitment Therapy) just now, it’s accepting it, even if they just accept what has happened to them, I think it’s already positive mental health. – FGD 7

In a related note, a participant described PMH as having contentment in life and described how acceptance of situation contributed to contentment.

Positive mental health to me is finding content, which is a bit like peace, whatever the circumstance… a lot of it is perception, how you see certain things, like certain circumstances that you might not be able to control. So I mean modifying or coming to terms with what I can accept and what I can change. I think that helps; gives me contentment and peace. – FGD 6

(2) Normal functioning and thriving in life

For the participants, having PMH was defined as being able to function normally. At the individual level, a functioning person was described as someone leading a balanced and healthy lifestyle, and able to manage stress and not be overwhelmed by it. The idea of optimal functioning pertained to various aspects in life including occupation, relationship with others, and being an active and contributing member of the society.

PMH is not about like the mental condition. It is about, you know, how we make these conditions and maybe other life issues not to interfere with our life. So it’s about living that life, you know, despite all the obstacles and difficulties. – FGD 3

Some participants moved beyond the notion of basic psychosocial functioning to describe PMH in terms of thriving which encompassed the idea of growth.

I wrote it (PMH) as the ability to thrive in very stressful environment [be]cause I think the way I see PMH is not just the absence of mental health issues but [it] is also the ability to kind of progress and really to be able to kind of expand on your own potential. – FGD 4 … they (clients) are kind of bootstrapped. They are self-corrective. They may come to you with a presenting problem, but if you just drop a few hints along the way, a bit of psycho-edu[cation] here, a bit of coaching there, they are able to extrapolate that to other problems independently on their own. So I think that’s also important. It’s not just where you are now, it’s whether you have the capacity to adapt and grow. – FGD 6

(3) Resilience

In defining PMH, the concept of resilience was frequently brought up by participants and it at times co-occurred alongside the theme on functioning. Yet this is a distinct theme from functioning in that rather than focusing on outcomes, it describes a trait or skillset that promotes wellbeing.

I would see it (PMH) as resilience, the ability to deal with challenges and the ability to function. – FGD 1 Okay for me positive mental health is being able to cope with the demands and challenges of life. So it’s a bit like mental resilience… sometimes you have negative emotions and being able to cope with that or cope with the demands. – FGD 2

Resilience was often described by participants as a trait that would help their clients to ‘bounce back’ from adversities, and also as a coping resource to support normal functioning in spite of challenges. One participant discussed how having emotional resilience can aid distressed clients to self-regulate by learning to not internalize events that occurred around them.

(4) Positive overall evaluation of life

The keywords in this theme were ‘quality of life’, ‘good life’, ‘fulfilled life’ and ‘life satisfaction’. Definitions captured in this theme described the concept of PMH as an all-encompassing, overall evaluation of one’s life that generated a broad sense of wellness or a feeling of ‘good living’.

Good living, like you’re not just alive; but you are living well, so living well… I think it’s defined differently by different people. So to person A living well might be ‘I’m a able to look after my grandkids’, that’s living well… to summarize it’s the person’s own idea of a good life, a good quality of life. – FGD 1

While elaborating the concepts of life fulfillment and the ideal life in the context of PMH, keywords such as ‘goals’, ‘values’, ‘purpose’, ‘meaningful’ and ‘aspirations’ were often mentioned and participants described these as constituents of a ‘good life’.

… a feeling of living a life that is consistent with one’s values… If someone values career, then he is living a life that is working towards that. If my value is family, I’m living a life that allows me to spend time with my family in a way that I consider meaningful. – FGD 5 Positive mental health is leveraging on people’s needs and values to bring them closer to their fulfilment… To me, fulfilment is living their own values, living their lives according to their own values. And being able to meet their needs. – FGD 6

(5) Absence of negative emotions and presence of positive emotion states

This theme relates to the emotional state of an individual and the definitions of PMH encompassed the absence of distress and the presence of positive emotions. PMH was defined as the removal of mental illness symptoms or distress, and also it meant experiencing positive emotions and state such as ‘happiness’, ‘hope’ and ‘joy’.

Freedom in mind, having peace, having calm. And there is no mental illness or distress and managing with difficulties. – FGD 4 I’ve written that firstly, positive mental health is being hopeful and laughing often. – FGD 5

Views on the concept of PMH

(1) Novel and valuable for psychotherapy

For some participants, PMH was a novel concept which could be defined in various ways by different individuals. For one participant, it gave the ‘impression of mindfulness’ which is the ‘third wave of therapy at the moment’, and some participants compared it to positive psychology.

So I think positive mental health is a new change, so it’s like a new science where you hear a lot of people saying that oh it’s important, it’s crucial but the research out there is very limited to back up all this evidence, but we do see the trends of positive mental health is emerging too. – FGD 2

Participants generally agreed on the importance of individuals to have PMH, with one participant stating it as ‘our birth right’, and another participant citing it to be ‘imperative for a healthy society’. A number of participants acknowledged the roles that they could potentially play as psychotherapists in introducing PMH concepts to their clients, as evident from the following quotes:

Like traditionally the way therapy was created was for like to remove disorder. That’s why I think the newer age therapists are saying that we really need to go further where there’s this idea of growth. I think that’s where the newer age therapists try to incorporate it as part of therapy. – FGD 4 I think for me they (PMH-based interventions) definitely have a space in psychotherapy and they help to balance out between always talking about problems as compared to, well, talking about what were you like before all the problems and what would it be like without the problems. So it balances out the conversation a little bit as compared to every time you come in we talk about your difficulties. – FGD 5

Not all participants, however, concurred with the relevance and significance of PMH, particularly in the context of clinical setting and the profile of clientele that they saw.

I think positive psychology is not that much used in our setting maybe because we have quite a lot of patients in quite severe conditions and talking about positive psychology is like… we are at this level and then you are talking about positive psychology. So maybe in our setting, clinical setting, we don’t really talk about positive psychology and I find that it’s more of a marketing thing… like it’s great and we are doing these classes in school and all that but I think there are other things that are more important to be done. – FGD 2

(2) Reservations with the terminology

A number of participants expressed reservations with the term ‘positive’ that was being used, either with respect to ‘positive mental health’ or ‘positive psychology’. To some participants, such usage implied that clients have to strive towards a positive state all the time, which is ‘not natural’ and ‘an impossible setup’ for them, when instead a simple improvement or progression could in fact be thought of as ‘positive’.

Because from clinical psychology background, it’s about treating mental illness. So it’s like if they (clients) can reach a neutral level or it may be back to baseline, then it’s something the patient may know to achieve, so positive means it sounds to me like up there (pointing to higher level). That you know even myself cannot be completely happy all the time. – FGD 3 The word ‘positive’ here is very misleading. And it’s exaggerating people’s expectations… it’s like wherever you are, if things get in anyway slightly better… that’s already positive. It need not necessary be like you have to have ten steps of growth, not really. – FGD 7

Some participants felt that this terminology carries a connotation and dichotomizes mental health either into the positive or negative realm, and that did not accurately reflect the entirety of what mental health should be in their psychotherapy practice.

I guess one of the main core tenets of psychotherapy is to bring flexibility and balance in the ideas or the perspective that we share about ourselves and other people. So I guess with a connotation, where you kind of put ‘positive’ in front of a word, it doesn’t sit really well in a lot of practices that we do encourage in psychotherapy. – FGD 1 When you term it as positive it becomes very dichotomous, very off-putting… when [what] we want to talk is more about adaptability, workability, more neutral rather than there’s a negative or positive connotation. – FGD 1

They suggested alternative terms such as ‘mental wellness’, ‘positive living’, or sticking to words that were used by their clients, for instance ‘better life’ if that was what the client explicitly stated.

(3) Factors influencing PMH

Participants described several factors that could influence PMH and these were broadly classified into three categories: individual level, interpersonal level, and community and social cultural level. At the individual level, it was about clients’ personality and them having basic self-care which included things like exercise, proper sleep hygiene and healthy coping mechanism. For some participants, it was also about the clients having goals and purpose in life that could motivate them and which contribute to better wellbeing.

I think the other is having that sense of meaning and purpose, so feeling that I have meaningful visions, pursuits or meaningful job that I can contribute meaningfully to my system and the society at large. – FGD 3

At the interpersonal level, participants discussed interpersonal relationship with others that could influence PMH. This included support received from family, friends, or a significant other who provided the feeling of being ‘connected’ with others. A couple of participants noted the impact of mismatched values or misaligned expectations in relationships with others could have on the individuals.

But I think the other part is in the relationship with their significant other, the manner of how these values are transmitted or being talked about. Sometimes it can cause a lot of distress when they have different values. That’s where they have a lot of conflicts, especially when mental illness comes into the system which is a new thing, it can actually distraught the whole thing. – FGD 3

In terms of factors at the community level and social cultural level, a number of participants described how addressing stigma could be a step forward in improving PMH. One way to do so could be to reframe the idea of PMH:

But I was just wondering like why can’t PMH be same as growth and development so not assuming that you have a problem, but you just want to be resilient or be with some more resources. – FGD 4

Participants also suggested creating awareness and improving mental health literacy, particularly amongst the youth and within the school setting.

We are so driven by academic literacy that that’s pretty much all we know right, to achieve and strive, achieve and strive. And if we don’t get it then we fail. But there’s no emotional literacy and acceptance in that that is being taught in schools. – FGD 1

This was an exploratory study conducted to understand psychotherapists’ definitions of PMH and their views of this construct and its application in their clinical practice. From the findings reported in this study, it was observed that PMH was a multidimensional concept and while defined in varied manners, four main themes emerged from this qualitative inquiry. These themes identified are in many ways reflective of the conceptualizations of PMH and wellbeing in the current literature.

PMH in psychotherapy for the participants meant clients are able to alleviate distress and experience positive emotions. Considering that many of the study participants worked in clinical setting with clients who sought treatment for mood and anxiety disorders, it is expected that reducing distress would be a component described. This theme is in line with the hedonic traditions of mental health where the focus is on feeling well [ 23 ]. The hedonic approach also looks at life satisfaction which concurred with the theme on positive overall evaluation of life that was identified in this study. The theme on normal functioning and thriving in life identified in this study is reflective of the eudemonic viewpoint in which the focus is on functioning well psychologically and socially [ 24 ], and parallels could also be drawn with Ryff’s and Keyes’s concept of personal growth [ 5 ].

It was unclear at first glance if the theme on resilience accorded well with the hedonic and eudemonic traditions of conceptualizing PMH. A recent systematic review identified ‘growth’, ‘personal resources’ and ‘social resources’ as conceptualizations of resilience within adult mental health research [ 25 ]. In this sense it is comparable with Ryff’s and Keyes’s dimensions of personal growth and environmental mastery [ 5 ] where in the former individuals seeks development as a person, and in the latter being able to tap into individual and surrounding resources. Nevertheless, several authors have also suggested to include definitions of PMH that encompassed skills and coping strategies to achieve wellbeing [ 8 , 26 , 27 ]. Vaillant also proposed a cross-cultural definition of PMH that included viewing mental health as resilience [ 28 ]. Furthermore, this might be a pertinent concept for our study participants in the context of psychotherapy as clients are usually distressed and are seeking help to resolve their issues and return to normality, or to ‘bounce back’.

Results from this study showed that psychotherapists in our study, whose self-reported primary psychotherapeutic orientation was not amongst those in the fourth wave of psychotherapies (value- and virtue-oriented approaches such as positive psychology interventions, loving-kindness and compassion meditation and spiritually informed therapies; see [ 9 ]), generally see the value and potential in introducing PMH to their clients. However, PMH being novel and a ‘new science’ for some participants, unfamiliarity with it might act as a barrier for application in clinical settings. For one, some participants raised a point on the limitation of its use among clients presenting with more severe conditions. At this point, it might be worth highlighting that studies have been conducted among clinical samples which included patients with major depressive disorder and schizophrenia, and they provided preliminary evidence on the effectiveness of wellbeing interventions in improving wellbeing and reducing distress [ 11 , 17 , 29 ], with effects comparable with those of conventional cognitive behavioral therapy [ 30 ]. A qualitative study conducted among service users with psychosis to investigate their experience of positive psychotherapy also reported promising results. Feedback given was generally positive and participants provided instances of how the intervention supported them in making significant changes to their work and life domains [ 31 ]. In all, these studies lend support for the application of PMH interventions and incorporating them into psychotherapy practice.

Perhaps then the question to contemplate on is when or at which stage of therapy should interventions with elements of PMH be introduced to clients. Some therapists believed that while meaning in life is an underlying issue for all problems, it is not appropriate to address this with all clients in therapy. Client’s readiness and also presence of other pressing issues are factors to be considered [ 32 ]. In a similar vein, McNulty and Fincham noted that the effects of wellbeing traits and processes (e.g. optimism, positivity) are contextual based [ 33 ]; the interaction between a person’s characteristics and the social environment influences how these play out in either promoting or compromising wellbeing. Thus, psychotherapists would need to consider the circumstances in which to initiate PMH interventions, and future studies can seek to examine such factors that could potentially influence the effectiveness of these interventions.

Another finding worth discussing is that a number of participants were skeptical towards the use of the word ‘positive’. It is hard to discern if this reservation among our study participants is attributable to their background in clinical psychology and hence, the focus on deficits, or the unfamiliarity with PMH construct. The contention being that this terminology creates a dichotomy which is not an accurate nor ideal portrayal of mental health, and working towards a positive state all the time is not inherently desirable nor achievable. This echoes the argument by McNulty and Fincham that because psychological traits and processes have to be best understood in context [ 33 ], it would be prudent to avoid labeling them as positive or negative. However, as some authors have noted, these could be some common misconceptions surrounding positive psychological interventions [ 34 , 35 ]. Rather, practitioners and researchers of PMH are advocating for a more balanced focus between illness and wellness. What this suggests is not replacing conventional psychotherapy modalities with PMH interventions, but instead complementing or supplementing the existing treatment options with them.

There are some limitations of this study to be noted. Firstly, some of the participants were acquainted with each other in the FGD session and that could potentially introduce participant bias in a way that their responses reflected the group’s sentiment rather than their own personal opinions. This was minimized by setting the scene from the beginning of the session where participants were explicitly informed that this was an exploratory study and there were no right or wrong answers to begin with. Participants were consistently asked if they agreed or disagreed with what was mentioned, and were encouraged to express their personal opinion in relation to the point raised. Secondly, the large majority of the participants were from public health institutions; only three participants were employed in private practice and one had experience in both. It is possible that differences in work practices and views exists between psychotherapists in public versus private setting, and this could limit the generalizability of the study findings.

With the growing evidence and support for PMH and wellbeing interventions in the literature, it is an opportune time to explore service providers’ perspectives and views towards the use of these interventions in psychotherapy. This study found that the concept of PMH carried multiple meanings for psychotherapists in their practice that meant more than reduction of distress and alleviation of symptoms. It was generally agreed that PMH is an important concept and has a place in psychotherapy for clients, though some concerns may need to be addressed before it is introduced to them. Findings generated from this study provided valuable insights to understanding potential facilitators and barriers in integrating PMH interventions into psychotherapy.

Acknowledgements

Not applicable.

Author contributions

JAV, RS, ES, HAA, GCYT and SHXL designed the interview guide, approached and consented research participants. The project was supervised by MS. JAV and SC conducted interviews with the participants. Analysis of data was performed by SC, JAV and ES, and the first draft of the manuscript was written by SC. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

This study was supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (NMRC/CG/M002/2017).

Availability of data and materials

Declarations.

The study was approved by the institutional ethics committee (National Healthcare Group Domain Specific Review Board; DSRB Ref No.: 2018/00870). All participants had provided written informed consent prior to their participation. This study was conducted in accordance with the Declaration of Helsinki.

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Open Access

Peer-reviewed

Research Article

Barriers, facilitators and proposed solutions to equitable mental health financing and service delivery for the Lebanese populations and displaced Syrians in Lebanon: Findings from a qualitative study

Roles Data curation, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation Research and Development Department, War Child Holland, Beirut, Lebanon

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Roles Formal analysis, Investigation, Validation, Writing – review & editing

Roles Formal analysis, Investigation, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Writing – review & editing

Affiliation Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom

Roles Methodology, Resources, Writing – review & editing

Roles Conceptualization, Funding acquisition, Writing – review & editing

Affiliation Higher Institute of Public Health (ISSP), Saint Joseph University of Beirut, Beirut, Lebanon

Roles Writing – review & editing

Roles Conceptualization, Funding acquisition, Validation, Writing – review & editing

¶ ‡ REC and NSS are joint senior authors on this work.

Affiliations Department of Psychiatry, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon, National Mental Health Programme, Ministry of Public Health, Beirut, Lebanon

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

  • Rozane El Masri, 
  • Sandy Chaar, 
  • Joseph Elias, 
  • Bassel Meksassi, 
  • Rayane Ali, 
  • Bayard Roberts, 
  • Felicity L. Brown, 
  • Michele Kosremelli Asmar, 
  • Martin McKee, 

PLOS

  • Published: June 28, 2024
  • https://doi.org/10.1371/journal.pgph.0003318
  • Reader Comments

Table 1

Forcibly displaced populations experience an increased burden of mental illness. Scaling up mental health (MH) services places new resource demands on health systems in crises-affected settings and raises questions about how to provide equitable MH services for refugee and host populations. Our study investigates barriers, facilitators, and proposed solutions to MH financing and access for Lebanese populations and Syrian refugees in Lebanon, a protracted crisis setting. We collected qualitative data via 73 interviews and 3 focus group discussions. Participants were purposively selected from: (i) national, United Nations and NGO stakeholders; (ii) frontline MH service providers; (iii) insurance company representatives; (iv) Lebanese and Syrian adults and parents of children aged 12–17 years using MH services. Data were analysed using inductive and deductive approaches. Our results highlight challenges facing Lebanon’s system of financing MH care in the face of ongoing multiple crises, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and their impact on sustainability of services. The built environment presents additional challenges to individuals trying to navigate, access and use existing MH services, and the social environment and service provider factors enable or hinder individuals accessing MH care. Registered Syrian refugees have better financial coverage to secondary MH care than Lebanese populations. However, given the economic crisis, both populations are facing similar challenges in paying for and accessing MH care at primary health care (PHC) level. Multiple crises in Lebanon have exacerbated challenges in financing MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon’s health financing system, working with government and external donors to equitably and efficiently finance and scale up MH care with a focus on PHC, and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations.

Citation: El Masri R, Chaar S, Elias J, Meksassi B, Ali R, Roberts B, et al. (2024) Barriers, facilitators and proposed solutions to equitable mental health financing and service delivery for the Lebanese populations and displaced Syrians in Lebanon: Findings from a qualitative study. PLOS Glob Public Health 4(6): e0003318. https://doi.org/10.1371/journal.pgph.0003318

Editor: Parvati Singh, The Ohio State University, UNITED STATES

Received: January 29, 2024; Accepted: May 15, 2024; Published: June 28, 2024

Copyright: © 2024 El Masri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: We are not able to provide data as they were not collected with the permission (from the participants or IRBs) to make available publicly. For any queries, please contact the London School of Hygiene and Tropical Medicine's ethical review committee at [email protected] and reference study approval number 22766.

Funding: This research was funded by UK Research and Innovation as part of UKRI Collective Fund Award UKRI GCRF Development-based approaches to protracted displacement, via grant number ES/T00424X/1 to all co-authors (REL, FLB, JE, BM, RA, SC, MM, MKA, BR, REC, NSS). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The United Nations High Commissioner for Refugees (UNHCR) estimated that, in 2022, around 110 million persons had been forcibly displaced by war, of which 36.5 million were refugees outside their home country [ 1 ]. The global burden of mental illness among those displaced reflects their experiences of conflict, persecution, and human rights violations as well as the unstable environments in which they find themselves [ 2 , 3 ]. Current guidelines for humanitarian settings recommend an inter-sectoral approach to mental health and psychosocial support (MHPSS) services, including integration of MHPSS considerations into basic services, strengthening community and family support, providing non-specialised mental health (MH) care, and offering specialised services [ 4 ]. This approach can be challenging as it requires coordination and prioritisation across different sectors, each with their own financial processes [ 5 , 6 ]. Moreover, scaling up MH services places new resource demands on already strained health systems in crises-affected settings, including enhanced administration and governance arrangements, additional human resources, upgraded infrastructure, increased access to medicines and strengthened surveillance systems [ 7 – 9 ]. Financing these costs and overcoming access barriers is thus a major concern for countries moving towards universal health coverage, and even more so for countries hosting large numbers of displaced populations. The Inter-Agency Standing Committee (IASC), the main global coordinating mechanism and technical body for MHPSS, therefore recommends creating MHPSS technical working groups at national level to oversee the necessary collaboration and optimise resource utilisation [ 5 , 10 ].

The Lebanese context

Lebanon has a long history of armed conflict and political turmoil, and has been impacted by regional wars and other crises. It hosts approximately 1.5 million Syrian refugees, 795,322 of whom are registered with UNHCR [ 11 ], with a further 487,000 Palestinian refugees [ 1 ]. This refugee population constitutes roughly one-fourth of Lebanon’s total population. The situation of Syrian refugees in Lebanon is dire and there is a lack of official recognition of their status. Since 2015, the Lebanese authorities have implemented restrictive measures, including a work ban, border closures, and stringent residency regulations [ 12 , 13 ]. This legal and administrative limbo poses practical challenges in accessing education, employment, and healthcare [ 14 ]. The situation is further complicated by escalating tensions between Syrian refugees and Lebanese communities, as well as rhetoric from Lebanese politicians attributing unemployment, instability, and diseases to refugees [ 13 , 15 ].

Since 2019 the country has faced even more economic, political, financial, social and health crises. The progressive devaluation of the currency, rampant inflation, and capital flight were soon joined by the COVID-19 pandemic and, in August 2020, the Beirut Blast and its aftermath. Following the conclusion of previous President’s term in October 2022, the parliament has been unable to elect a new president, adding to the complex political and economic crisis the country has been struggling with for the last four years. These crises have placed additional stress on all sectors of society, especially the under-resourced public infrastructures and services. The currency devaluation of the Lebanese pound (LBP) by 90% since late 2019 has led the World Bank to redesignate the country as Lower Middle income since July 2022 [ 15 ]. These recent crises have further increased unemployment, exacerbated poverty, and the availability of services in the country for both host and refugee communities, with implications for MH [ 16 , 17 ]. A nationally representative survey of Syrian refugees in Lebanon in 2022 found that 90% of families needed support to meet their basic survival needs [ 16 ], and 80% of the Lebanese population is estimated to be living below the relative poverty line in March 2023 [ 18 ].

Overview of the Lebanese health system

Universal health coverage is at the heart of the vision for the health system in Lebanon [ 19 ]. Yet as of today, the Lebanese health system, a public-private partnership, is nowhere close to achieving this goal. There are multiple sources of funding and channels of delivery depending on which group people belong to, i.e. refugee, migrant or host population, creating many gaps [ 14 ]. Lebanon has historically received external aid to support Syrian and Palestinian refugees, but since the economic crisis, the international community is increasingly providing large amounts of humanitarian assistance to vulnerable Lebanese as well, and to prop up public institutions including health care, public education, social assistance, and security. In 2022, UN agencies alone provided $300 million in assistance to or through Lebanon’s public institutions, which is a quarter of Lebanon’s annual public spending [ 20 ].

Even though Lebanon has a very high number of health insurance operators, the majority of the population cannot afford to pay for full coverage [ 21 ]. Almost 50% of the Lebanese population are enrolled with the National Social Security Fund (NSSF), Lebanon’s social insurance system for employees, or other governmental (i.e. civil servants cooperative and military) schemes [ 21 ]. However the NSSF has been recording a deficit for several years. In principle, those outside these schemes are entitled to coverage by the Ministry of Public Health (MoPH) for secondary and tertiary care at both public and private institutions, as a funder of last resort. In practice, the actual coverage provided by public funds is negligible due to the depreciation of the Lebanese currency since the start of the economic crisis. For example, the NSSF can only cover around 10% of health care costs due to NSSF only covering fees in LBP based on lower exchange rates. Consequently, service users have resorted to private insurance companies or paying out-of-pocket, with such payments increasing from 33.1% in 2018 to over 85% in 2022 [ 22 ]. Palestinian refugees have health care coverage from the United Nations Relief and Work Agency for Palestinian refugees (UNRWA) [ 23 , 24 ], while registered Syrian refugees are covered by UNHCR for secondary and tertiary care [ 14 , 25 ].

The MOPH also provides in-kind support to a national network of primary health care centres (PHCs) across Lebanon that are operated by a mix of local and international non-governmental and faith-based organisations [ 26 , 27 ]. These PHCs offer consultations with medical specialists at reduced or no cost, as well as medicines for chronic illness and vaccines, which are funded by the MOPH [ 23 ]. It is estimated that 68% of PHCs in the MOPH network are owned by NGOs while 80% of hospitals belong to the private sector [ 28 ]. The strong presence of the private sector in service delivery has led to a relative oversupply of hospital beds and technology, and while there is an oversupply of physicians, there is a shortage of nurses [ 29 , 30 ].

The ongoing crises in Lebanon have also heavily impacted the populations’ access to essential medications. Despite spending more than 25% of healthcare expenditure on pharmaceuticals, stocks of drugs have dropped by 50% since the beginning of the economic crisis, leaving more than 70% of the Lebanese population without access to critical medications [ 22 ].

MHPSS system and financing in Lebanon

It is estimated that 90% of individuals needing MH services are left untreated [ 31 ]. This treatment gap can be attributed to several factors, including insufficient financial resources, the societal stigma attached to mental illness, a scarcity of qualified MH providers, and misdiagnosis [ 32 , 33 ]. MHPSS services are delivered through multiple sectors in Lebanon, including health, education, child protection and protection. In 2014 the MOPH launched the National Mental Health Program (NMHP), supported by WHO, UNICEF, and International Medical Corps (IMC). It aims to reform the MH system in Lebanon as a whole, including improvement and scaling-up of primary care-level MH services by implementing the World Health Organization’s Mental Health Gap Action Programme (mhGAP) in PHCs, addressing treatment gaps, reducing stigma, and enhancing the capacity of health professionals [ 32 , 34 – 36 ]. As part of the establishment of NMHP, a Lebanese MHPSS Taskforce was also established alongside the establishment of the NMHP, with the mission of ensuring an effective, coordinated response to the MHPSS needs of individuals in Lebanon and aligning services with the national MH strategy [ 34 ].

Despite these reforms, Lebanon’s healthcare system, including MH provision, continues to be dominated by the private sector, focused largely on hospitals [ 37 ]. To rebalance this, the MOPH and NMHP have partnered with NGOs to expand the network of PHCs, and has been piloting an integrated package of MH care in select PHCs [ 31 , 38 , 39 ]. This integration of MH into PHCs has been challenging due to the fragmentation of the Lebanese health system and the absence of a unified PHC model, although since 2021, the integration of a package of mental services into PHCs is being piloted and is in the process of being costed. However, the dominance of the private sector limits the effectiveness and reach of PHCs.

MHPSS financing arrangements in Lebanon are similar to those in other humanitarian settings where funding priorities are decided based on the organisations leading the response, in this case through the Lebanon Crisis Response plan [ 17 ]. The available funds are clearly inadequate to meet the needs [ 32 , 36 ]. MH accounts for only 5% of the overall health budget of the MOPH and that is mainly for long-term inpatient care in private hospitals [ 40 ]. Against a background of limited financial government commitment, the search for alternative sources of funding has been elusive, a situation exacerbated by the political and economic crises. A global review of MH funding allocation observed that international donors rarely aligned funds disbursed for MH with needs [ 41 ]. Additionally, more work is needed to understand the challenges associated with the current model of MH service delivery available at the PHCs associated with the NGOs, as these services continue to be piloted and scaled up.

In Lebanon, the last comprehensive study on MH financing was published in 2014 [ 42 ], and it only considered the Lebanese population and not Syrian refugees. There have been some studies of MH service provision [ 36 ], but again, none so far have looked at MH service provision or access from the perspectives of both the Lebanese population and Syrian refugees, taking account of the impact of the Syrian crisis on Lebanon, or the collective views of MH actors in both the national and humanitarian health systems in Lebanon. Furthermore, it is known that beyond financial considerations and availability of services, a wide variety of factors, including those at the society, family and individual levels influence individual service usage [ 43 ]. Accordingly, our study aims to investigate barriers, facilitators, and proposed solutions to MH financing and access for both Lebanese populations and Syrian refugees, with a focus on the MH system in Lebanon. Through this study, we aim to address a critical gap in the existing literature and to provide relevant policy, programmatic and research-relevant recommendations for key MH actors in both national health and humanitarian systems globally as well as in Lebanon.

Conceptual framework

The conceptual framework underpinning our study is that proposed by Ryvicker (2018), applying a behavioural-ecological perspective on healthcare access and navigation [ 43 ]. This builds on previous concepts of navigating health care [ 44 ], expanding upon their environmental dimensions. Given the challenges with MH funding in Lebanon, we aim to explore the impact on individuals more broadly and to explore how the funding situation interacts with other factors influencing MH service access. Ryvicker’s framework theorises that healthcare navigation is an ecologically informed process not only because of the spatial distribution of health services and resources (including financing), but because of the spatial distribution of individual and environmental factors that influence individual decision-making, behaviour and available resources (including financing) with respect to service use.

Study setting

This study was conducted in Lebanon, mainly the Beirut and Mount Lebanon (BML) governorates, urban settings that include almost around 50% of the population [ 45 ]. This region hosts around 29% of the most deprived groups in the Lebanese population, 22% of registered Syrian refugees, 22% of the poorest Palestinian refugees, 14% of the poorest Palestinian refugees from Syria, and the majority of refugees from countries other than Syria [ 45 , 46 ].

Study participants

We conducted 73 interviews and 3 focus group discussions ( Table 1 ). Participants were purposively selected from the following groups between 1 November 2022 and 24 February 2023: (i) national stakeholders including governmental MH authorities, insurance company representatives, UN, donor and NGO staff working in MHPSS policy and management of MH programming; (ii) frontline MH service providers in both public and private sectors; (iii) insurance company representatives; (iv) Lebanese and displaced Syrian parents of children aged 12–17 year using MH services; (v) Lebanese and displaced Syrian adults accessing MH care. We drew our samples from the following sources, using snowball sampling: (i) MHPSS task force members; (ii) government and partner programmes; (ii) community representatives and groups; (iii) MH service providers. We purposively sampled Lebanese and displaced Syrian parents of children aged 12–17 years and adults accessing at least one the following types of care in BML governorates: (i) individual or group psychosocial support at the community level from specialised NGOs providing services at the community level but not as part of the PHC network; (ii) non-specialised mental services for moderate or severe depression, anxiety and/or PTSD at the PHC level; (iii) specialised services for moderate or severe depression, anxiety and/or PTSD at the PHC levels (by a psychiatrist or a psychologist); (iv) care for moderate or severe depression, anxiety and/or PTSD from specialised NGOs providing MH services at the community level but not as part of the PHC network; and (v) care for moderate or severe depression, anxiety and/or PTSD in private facilities. We ensured that we had a balanced gender mix.

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Table 1 provides an overview of the number of interviews and focus groups we conducted with each respondent group.

Data collection tools and processes

Key informant interviews were carried out by a team of Lebanese researchers (REM, JE, BM, RA, SC) working in a Lebanon-based International NGO working in child protection, education, and MHPSS, as well as one academic from a UK university (NSS). All had prior experience in conducting qualitative research and received five days of training on MH access and financing, qualitative research and research ethics for this project.

Interview topic guides were informed by the Ryvicker conceptual framework ( Fig 1 ), and designed to answer the research question, which concerned barriers and facilitators to accessing equitable MH services for Syrians and Lebanese and were adapted to the situations of different groups. Interviews with service users and caregivers adopted a narrative approach, in which the participant is asked to tell their story of navigating and accessing the services, with subsequent probes as needed to explore health care seeking and financing in relation to MH services. Narrative interviewing gives the participant control over how they share their stories, allowing a relaxed and unstructured approach that can elicit depth and, at times, more accurate information than obtained in a structured interview [ 47 , 48 ]. This contributes to dismantling power hierarchies linking the researcher and participant [ 49 , 50 ]. With national stakeholders and service providers, a semi-structured format was used. All topic guides were tested and piloted with study team members with experience in MHPSS programmes with Lebanese and displaced Syrians and refined accordingly, and with service users.

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Interviews were conducted by one researcher, primarily in person at the healthcare facility that the service user/caregiver parent usually attends, their houses, or the stakeholder’s office. Participants were also offered the option of remote interviews, some conducted over Zoom. Interviews were conducted in English or Arabic, depending on the participants’ preference. All interviews were audio-recorded, and lasted between 45 and 90 minutes.

Data analysis

The interviews were transcribed verbatim in English and from Arabic to English. Quality checks were conducted for all the transcripts by REM. Data were coded using an inductive and deductive approach based on the framework method [ 47 ], with a coding framework developed including themes based on the Ryvicker conceptual framework ( Fig 1 ) on healthcare access and navigation (2018). Dedoose software was used for coding the data. Six Authors (NSS, REM, JE, BM, RA, SC) coded the data in pairs and used collaborative coding approach [ 48 ] to analyse, define and refine the codes where they held group meetings for that purpose. During these meetings, each pairs’ coding was checked with the team of authors and key themes of each transcripts were identified and discussed collaboratively. Data saturation was reached, with later transcripts not generating new codes.

We invited all study participants to feedback sessions to enable them to reflect on emerging findings and provide feedback. Involving target populations in the data interpretation and synthesis stage is recommended when implementing a decolonial and participatory approach to research in forced displacement settings [ 49 ]. Group meetings for national stakeholders, facility managers and service providers took place over Zoom or MS Teams, with findings shared via email for their feedback if they were unable to join the group meetings. Feedback sessions with service users were held individually via Zoom or a WhatsApp call. We also used short video recordings followed by discussion on WhatsApp with participants as needed, as this method has been noted as highly feasible in Lebanon [ 50 ].

Ethics approval and consent to participate

Ethical approval was obtained from Saint Joseph University in Beirut (ref: USJ-2020-224, 19/01/2021), and the London School of Hygiene and Tropical Medicine in London (ref: 22766, 13/01/2021). Participants were provided with a Participant Information Sheet detailing the aim and scope of the study, and written informed consent was then obtained from participants prior to conducting interviews and focus groups. All identifying information in the transcripts was anonymised and numerical codes were assigned to each transcript. All participants provided written informed consent to take part in the research, conducted by researchers prior to commencement.

We present the enablers, barriers and proposed solutions to MH financing and services for Syrian refugees and Lebanese populations in Lebanon. We found that the multiple crises that Lebanon has been facing–economic, political, COVID-19, and the Beirut blast–all influence how MH services are financed, delivered to and accessed by Syrian refugees and the Lebanese population. We organise our findings according to seven themes that mostly follow our conceptual framework: (1) healthcare environment; (2) built environment; (3) healthcare navigation; (4) provider factors; (5) social environment; (6) gender norms; and (7) individual characteristics. Overviews of the barriers and enablers are presented in Table 2 , and proposed solutions from study participants are presented in Table 3 .

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Healthcare environment

Health financing..

Participants highlighted several challenges to promoting equity, effectiveness, and efficiency of the health financing system, each hindering delivery of MH services and increasing dependence on external aid. Participants acknowledged how the fragmentation of the health financing system, with different ministries and institutions making decisions on health expenditure and implementing social health protection schemes (pooling and purchasing). Their overlapping mandates hinder effective operations, as reflected in the numerous social health protection pools covering different population groups while leaving a large share of the population uncovered. Some participants saw a lack of political commitment to reform, with one participant from government noting the “little interest among politicians to allocate money for primary health care in general and in particular [to mental health]” (male Lebanese MOPH stakeholder).

It was also widely recognised that, especially since start of the economic crisis, gaps in the coverage of social health insurance funds–namely MOPH and NSSF–have worsened due to the drastic currency devaluation. Importantly, private health insurance schemes do not explicitly cover MH services. Furthermore, while public funding mechanisms and private insurance cover the Lebanese population, they exclude Syrian refugees. However, since the economic crisis, some participants perceived that hospitals are less willing to admit Lebanese patients, as they are reliant on reimbursement by the MoPH or NSSF and this funding is often very limited or unavailable. Consequently, they “prefer to take… private patients or those covered by UNRWA or UNHCR that they would be paid in USD” (female Lebanese UN staff) which reportedly further exacerbated the gap in financial coverage between Syrians and Lebanese populations. One Lebanese service user highlighted how inpatient MH care was unaffordable: “They [MOPH] should pay at least 80% . Because no one can afford the whole cost . And I want to get into rehab , so I discovered something , that the ministry doesn’t cover anything anymore these days . And I can’t afford this much” (female Lebanese MH service user). In contrast, Syrian refugees registered with UNHCR have 90% of the cost of secondary and tertiary MH care covered, and pay the same subsidised or no consultation fees when accessing MH services via NGOs or PHCs. Challenges with the fragmented funding arrangements were highlighted by a female Lebanese UN programme manager: “…Now the access to [health] care is more favouring for the Syrian refugee population versus Lebanese because they [Syrian refugees] have a coverage of 100% or 90% coverage from the UNHCR and MH is considered in their SOPs [Standard Operating Procedures] to be fully covered… I think 10% of the [Lebanese] population has private insurance … they can maybe access private facilities, the other [Lebanese] population… are [needing to be covered] at the last resort by the Ministry of Public Health.”

Despite these challenges, participants were encouraged by how the MOPH and NMHP are starting to integrate standardized packages of MH services into PHCs which serve all populations and are “pushing and highlighting the importance of it” (female Lebanese NGO staff). However, it was largely acknowledged that progress on scaling up MH services within and across Lebanon’s PHC network has been “a challenge on the ground” due to lack of resources and PHCs struggling to meet demand for the services they provide: “So because they [PHCs] are very overwhelmed , there isn’t enough staffing on the PHC level . So , it’s [MH] not one of their priorities . And it’s sometimes a challenge to ensure their commitment” (female Lebanese NGO staff).

Lack of resources means that service providers are “mainly relying on humanitarian funds… which are now currently decreasing , day by day” (Female Lebanese UN staff). This creates a short-term project-based culture. One participant noted: “But their [MOPH] funds are limited . It’s mostly international funds and NGO funds who are running these [MH] services” (female Lebanese NGO staff).

Participants also noted how the lack of MOPH funding for hospital level MH services impacted its availability “because very few hospitals they have psychiatric care” (female Lebanese NGO staff). Even when psychiatric care was available in hospitals, it is often very under-resourced and unable to meet demand.

Populations under increasing financial pressure.

This increased cost of private MH services and the effects of crises have forced many Lebanese service users to seek free or subsidised services at facilities that historically served Syrian refugees or low-income Lebanese: “Yes , all [MH services in] the private sector become very expensive , so there are more Lebanese that are benefiting from services through PHCs , either health services or MH services . ” ((female Lebanese NGO staff). The increasing number of Lebanese people seeking primary health care level MH services has imposed more pressure on PHCs and NGOs at a time when they are already facing shortages of staff, medications, fuel, and electricity. Consequently, patients face long waits for treatment and some face catastrophic spending on private MH care: “I honestly was looking for an NGO [including PHCs] , because they told me others are very expensive if I wanted to go to a private clinic . The range varied between $20–100 . And I don’t know anyone who is willing to pay $100 for a session . So , one can have second thoughts [to access MH care] because of the high cost” (male Lebanese service user). Another female Lebanese service user explained: “I just told you in the NGO I know that there is a very long waiting list , and there are a lot of people waiting , including my mother , where I included her name a long time ago , around a year ago , and her name hasn’t come out yet , because I know there are only 2 psychologists in this NGO . ”

Participants who could access NGO services saw them positively. As a Lebanese service user explained: “Thankfully they [NGOs] are providing everything to the people who have MH issues . We pay for transportation , but the other things , like the doctor’s fees and the tests , are either free of charge or cheap” (female Lebanese service user).

Delivery systems

Participants described how MH services provided by NGOs under the auspices of the MOPH were unable to meet demand. A PHC manager noted the challenges posed by the large influx of Syrian refugees since 2011: "They [Syrian refugees] started coming in bigger number . […] We were in 2011 , monthly 500 people [accessing services at the PHC] , now we are around 11 or 12 thousand monthly” (female Lebanese PHC manager). Lebanese individuals have increased needs since the Beirut Blast, further lengthening waiting lists at PHCs: "The Syrians at the beginning they were huge in number . Our numbers are shifted now . We were mostly Syrians and very little , very few Lebanese . [Now] We are almost equal and sometimes Lebanese … more than the Syrians” (female Lebanese PHC manager). Moreover, the absence of dedicated rooms for MH sessions in healthcare facilities further impeded access, with participants expressing concern about privacy and stigma.

Participants reported acute shortages of medications, including psychotropics. This is partly due to the devaluation of the Lebanese currency, as well problems with distribution and storage of the medications due to lack of electricity and fuel. As one Lebanese service user noted: “…my medicines are not available , and I can’t have them because of their high prices… For example , I am without my meds for 27 days” (female Lebanese service user). Another female Lebanese MH service user said:” And the medications , most importantly . Meaning when I will find the medication expensive , I might be forced to stop it . ” A female Syrian service user mentioned reducing medication doses without consulting health providers because of the cost of procuring medication from Syria that was unavailable when she tried to buy it in Lebanon: “My brother sent me some medications from Syria , but the medicine there is very expensive , and he didn’t have a lot of money . Since there are no medications , I started to adapt . Instead of having two tablets per day , I started taking one . Then I started taking only half a pill . Then , a pill every 2–3 days . ”

Access was also hindered by limited information on services: “Of course as long as there is a trusted site that has this information regarding the existence of these services , in which areas , for what purpose , then you would know better how to make the decision , and not to call to find a therapist , but perhaps there would be more information about the specialty . This helps in making the decision more efficiently , when we know the specialty of the doctor , then we would know what we want to treat specifically . If we want to compare therapies , we might think that we are going to see a general practitioner” (female Lebanese service user).

There were particular challenges related to the shortage of health workers, with many psychologists and psychiatrists moving overseas. One female Lebanese UN staff member noted that this is: “really now a major problem in the country … I think we used to have like 70 active psychiatrists , now we don’t have 30 . These 30 are mostly taken by the work that’s taking place in NGOs [who run PHCs] and you barely have , you know , a psychiatrist that has a bit of time to provide services [in these PHCs] or to provide training—and they have their private clinics . ”

This shortage overburdened existing staff: "everyone is overloaded … Each social worker , I would say here is following up on an average of 300 active patients . " (female Lebanese NGO staff). It also restricted choice: “And most of the therapists are women . I asked to see a male therapist , but there wasn’t any” (male Lebanese service user).

There was a wide gap between what MH cadres can earn working for international NGOs compared with the national health system. Recognising that the MHPSS taskforce has a workstream trying to harmonise fees, participants recommended that work should also be done by relevant stakeholders on allocating and standardising specific payments and allocation of funds for NGOs and MH specialists nationally, to avoid competition over resources among NGOs.

Built environment

Even when service users can obtain free or subsidised MH services in the public sector, the increased cost of transportation poses a significant barrier: “I had financial problems here in Beirut , where I couldn’t afford to always come and go to the centre [providing MH services] . The [MH] services here are almost free , as they only charge 15 , 000LL for the session . But I couldn’t attend [them]” (female Syrian service user). Another male Lebanese service user elaborated: “Regarding the services , they asked me if I was able to go to the centre . I told them I couldn’t . The main reason was because the location of the centre was far away , and I didn’t have any means of transportation , and financially . Gas costs a lot . ”

Both Syrian and Lebanese service users, especially those residing in distant towns or villages, grappled with geographical barriers and transportation fees, with MH services concentrated in Beirut. One male Lebanese NGO staff member explained that: “…some people in some areas need maybe to change maybe 3 buses maybe to reach , they are coming from a very far area , and walk maybe more time… so that they can save some money so that they can come . ” This was also described by participants from underrepresented areas: “You can’t find [MH] services everywhere , you can find most of them in Beirut if you want , so the person living far away won’t find this service distributed all over Lebanon . So if this service was found on a certain platform or website , that shows the specialty of every doctor and the location of every doctor and the prices , then the person would be better capable of making a more appropriate decision for themselves” (female Lebanese service user).

These problems were especially severe for elderly people and individuals with disabilities accessing MH care: “Regarding elderly , they can’t go out of the house because of the lack of electricity [needed for elevators] and such” (female Lebanese PHC manager). This facility manager noted how this could be eased if PHCs and NGOs providing MH services to “ talk to the notary and see how many geriatrics we have in a certain area and provide a team to perform home visits for them . ”

Healthcare navigation

Service users reported multiple, often ad hoc pathways to finding and accessing mental health services, including acquaintances, extended family members, NGOs and PHCs, as well as the UNHCR for Syrian refugees. Yet several participants also reported challenges, as a Lebanese father of a child accessing MH services noted: “As a matter of fact I wanted to seek help before , …but I didn’t know where to go . ”

Participants noted the importance of social networks: “Yes , I remembered something you asked me about . You asked me how I was able to access therapy . I know a lot of people . Because of that , I was able to reach [NGO providing MH Hotline services] , and eventually to [NGO providing current services he is receiving] clinic . It would’ve been super hard for me to reach the clinic if I hadn’t known these people” (female Lebanese service user).

The flexibility of scheduling and service delivery was also identified as a key facilitator of access although unavailability of internet access and electricity posed a problem: “The remote areas in Lebanon … even though the NMHP is working on a programme , which I was a part of . It’s called Step by Step . These things help us reach remote areas . But you need internet to benefit from this . There are some people living in rural areas who don’t have access to the internet , even though they are few in numbers , as I believe the majority of people have internet access now . Or they have a slow connection . That would bring us back to the problem . I think the people of Bekaa , the far north , the south , the areas away from the cities need such services . We need more awareness sessions and outreach in order to ameliorate this challenge” (female Lebanese NGO staff).

Participants argued that more convenient appointment times and innovative service delivery, such as in-person and virtual sessions, would make it easier for them, especially those in work. Remote modalities of service delivery also made reaching people with disabilities easier: “With the remote modality , it’s , it’s much easier , much easier now [to reach people with disabilities] . We can provide remote consultations for people who have access problems or mobility problems . ” (female Lebanese NGO manager). Many employers refused their staff time to attend services or recuperate: “I told my boss that I wanted to take a week off , so I can rest . He refused . That’s when I took the 5 pills and a beer” (male Syrian service user). Additionally, some participants, such as a Lebanese schoolteacher, expressed frustration at the unavailability of therapy sessions at convenient times.

Participants also recognised how a "major gap is the referral from the primary level to secondary level , to a specialized psychiatrist . This remains you know , a major problem… after primary [mental] health care , you know the conditions that should be dealt with at the higher… more specialised level” (male Lebanese MOPH stakeholder).

Service provider factors

Participants saw service providers’ attitudes as both a barrier and facilitator to access. For instance, some perceived providers as only focused on making a diagnosis: “That’s why I wasn’t comfortable with the first psychiatrist . She only needed a diagnosis . ” (female Lebanese service user) . Additionally , lack of attendance from service provider was exemplified with them missing their appointment with the service user : “And sometimes the specialist won’t attend , which is bothersome for the patient , as they are paying transportation to be there” (female Lebanese PHC manager).

Participants also felt upset by a lack of compassion and professionalism by providers: “ She [MH service provider] made me feel really offended . I did not like her approach at all . I was kind of I felt like I was repeating the same information . There wasn’t any compassion . There wasn’t any really useful information , anything that I didn’t know myself one time , it was only like two or three sessions . One of the times she had told me at the end ‘how much you fear to be like your mother’ . To me [this was] totally inappropriate” (female Lebanese service user).

Many expressed concern about the pressures facing providers: One service provider said that: “The burnout between employees is faster now . When I was an intern , before the conflict , I didn’t see that much tiredness among service providers” (female NGO staff member), with a service user noting: “like they [MH service providers] need therapy as well I’m sure , you know ! ” (male Lebanese service user).

At the same time, we found that service providers who build rapport and display empathy enabled and enhanced service users’ access. One Syrian service user said: “It was great . She [service provider] promised me to speak with the centre and to issue a medical document for me , and to find a way for me to contact the UN . She took my issue more seriously , and she gave me hope . She made me feel that someone is standing next to me . This made me feel better” (male Syrian service user). Respecting confidentiality was another important quality in a service provider, as noted by a Lebanese service user: “They were friendly with me . And they were very confidential . For example , my mother called them to ask about me , without me knowing , they didn’t give her any information . And they check up on me” (female Lebanese service user).

Service users perceived NGO social workers, a key MHPSS cadre, as supportive, assisting them to navigate the system and providing a patient-centric approach, considering their preferences in scheduling appointments and determining treatment modalities. One female Lebanese service user noted: “The social worker there helps me as well , she comforts me as I told you , as she sometimes helps me to organize the time and such . ”

Participants also agreed that when providers set expectations for therapy improved interactions: “She [service provider] told me I would be uncomfortable talking to her at first . I told her that I speak about everything sometimes . And I want everyone to leave me alone . I don’t tell my family what is happening with me . She assured me that everything we talk about will be confidential . But speaking about your issues will make you relax , after a few sessions . Honestly , I felt comfortable with her . She made me feel better” (male Syrian service user).

Social environment

MH stigma was reported by both Lebanese and Syrian populations. Participants felt that Syrians are becoming more aware of MH problems and accepting of services, in parallel with attitudes also shifting in Lebanese society. For example, one male PHC manager noted that “at the beginning of their refuge , we didn’t have many Syrians asking about MH . They started to be aware about MH after 2017 , where we started to see Syrians asking about MH . They used to have many misconceptions about MH . A person may be abused because they have a MH problem . ” Several respondents were optimistic that change is happening, albeit slowly, noting that Lebanese populations, in particular men, have become more willing to accept care since the Beirut blast. Additionally, participants felt that more awareness campaigns would help to reduce stigma, especially among with younger generations.

Participants saw stigma and lack of support from partners, family members, friends and community members, impacted care seeking, calling for greater awareness raising. Stigmatisation was noted as a barrier to accessibility, with some individuals fearing societal repercussions or being labelled as "crazy" for seeking treatment for MH issues. For example, a female Syrian service user explained: “First of all , people feel ashamed of this issue , as if it is a shame if someone is going to a psychologist , they think that this person is crazy and abnormal… there is lots of ignorance on this subject . So , a lot of people hide that they are being treated psychologically or being treated secretly without telling anyone , even my husband in the beginning he did not accept anyone to know not at all . ” A male Lebanese NGO staff member explained that having MH services delivered within PHCs may reduce stigma related to MH care: “This is why our [MH] services they’re based in primary healthcare centres , so we don’t have a centre for MH alone , to avoid stigma and to normalize more the idea that someone is coming to take the service he is taking it as if it’s any other service , he is entering a PHC like they see a paediatrician , a gynaecologist a dentist , they can see also MH services . ”

Partners, family members and friends were thus both a barrier and facilitator to accessing MH care. For example, a female Lebanese service user described feeling abandoned and hated by her husband and family due to her symptoms. She spent seven months at her parents’ house and her husband eventually let her return to their home, but she felt unsupported by him and other family members. In other instances, family support, particularly from partners, significantly influenced the decision-making process, emphasising the interconnectedness of MH within familial dynamics. For example, a female Syrian service user explained: “My husband also he is receiving psychological treatment as me and he encouraged me a lot because he knew how this issue has facilitated things for him and helped him continue his life and to co-exist with his situation that he is living with and how to accept things that he was not accepting before , and how he can deal with details that used to make a block for him and stops there . ” Interestingly, one participant mentioned how having MH services normalised in the family enables access to MH services: “My aunt knows I see a psychologist , because she sees a psychologist as well . So , I think she understands this , and she gets upset when I don’t take my meds , because I get bored of taking meds all the time” (female Lebanese service user). Participants also described how friends can also play a crucial role in accessing MH services: “I didn’t know I had a problem … but after I got more exposure to the world , especially to my friend , she told me that I might need to go see someone and this thing is not entirely normal and such . And after I started going , I started to discover that this is true” (female Lebanese service user).

For many, the impact of MH issues on their family was also a motivator for seeking support. One female Lebanese service user said that her "first motive to get treated" was to be able to be there for her children, as she did not want them to see her in a sick condition. Another female Syrian service user highlighted the role of family in providing motivation for her to get better mentally, saying "my family is preventing that" when discussing thoughts of ending her life . She also expressed a desire to get better to be able to raise her children : “That was my hope , I was hoping to do something for my family . Let’s see the therapy if it will be successful or not . ”

Gender norms

An emerging theme relates to the influence of gender roles and economic control on the ability to afford MH services, even when they are ostensibly free, as out of pocket payments are sometimes required. Participants reported that gender roles and patriarchal systems can affect women–even those who work as they can be denied money for MH services from their husbands. A female PHC manager explained: “Gender does play a role in how…people seek MH services , how they pay for these services . Of course , we see sometimes households that are headed by men and they don’t see the need for the service . It’s then not possible [for their wives] to pay for MH services . ”

Another gender dynamic was where women reported finding it challenging to find time to access MH services while juggling work and childcare responsibilities. A female Lebanese service user explained: “Like a man has , like ok , his work , but the wife has work and children , everything she has . ” A female Lebanese UN programme manager further noted: “this is the main difference , we see [between men and women] , it’s actually sometimes more challenging for woman to actually access MH services because she has children back at home . ”

On the other hand, participants also noted the influence of notions of masculinity inhibiting men from discussing MH issues or accessing care. For example, a Syrian father of a child seeking MH services said, "I am a man and I can handle it . " Participants also described pressure on men to provide for their families, and working long hours, which often prevents them from accessing MH services. Another male Lebanese service user explained: “In our Eastern community- it is a good thing they established this centre for men only , because the community expects that men can’t cry , as it is prohibited , he can’t express his feeling . Whereas females are looked at as more sensitive . They would stigmatise men if they have a MH issue , unlike women , where they consider it normal for her to cry and such . ”

Individual characteristics

Several individual beliefs emerged as barriers to accessing MH services, with reluctance to take medications, harmful coping mechanisms, lack of knowledge and misconceptions of MH therapy, and other concerns related to service users confidence. In contrast, one enabler was identified which is related to service users’ recognising the positive impact of MH therapy, which has been a common theme across the data.

Harmful coping mechanisms and seeking alternative MH care.

Participants also described how they often turn to harmful coping mechanisms such as drugs and alcohol, which also delayed seeking care. One male Syrian service user participant explained how: “I was trying to drink to feel like I’m fleeing from the anxiety , until I ended having suicidal thoughts due to alcohol and due to anxiety , and the alcohol was increasing it , I was thinking that alcohol is helping me to flee the anxiety . ” Religion was also suggested as an alternative treatment for MH issues by some families, with one female Lebanese service user recounting advice given to her by a sheikh, who did not refer her to further MH services, and simply told her "that I am feeling like that because of the pregnancy , and I wouldn’t feel better until I deliver . "

Misconceptions and lack of knowledge about MH issues and the importance of therapy.

Participants also had several misconceptions and lack of knowledge on MH problems which pushed them away from seeking MH services. One female Lebanese service user mentioned that her beliefs that her MH state is an illness caused solely by pregnancy, pushed her away from therapy. Other Syrian and Lebanese service users expressed their difficulty differentiating depression and sadness, and low expectations of treatment. One service provider mentioned that service users “are not able to differentiate that even believers can get suicidal ideation . ” Additionally, they described how the widespread belief that MH is not important as discouraging individuals from seeking help. Some service users also expressed fear of misdiagnosis: “…Especially when you hear before that there were people who were diagnosed wrongly as if they were experimented with , so you have fear from such an issue and the fear about your future and where you stand and you really need someone to be next to you” (female Lebanese service user).

The importance of awareness campaigns was emphasised, with participants calling for more education on MH. One Lebanese service user said: “I was 19 years old and I stayed 6 years between ups and downs and turning around myself and I didn’t know what I was suffering from until I became 26 , 27 [years of age] and I managed to take the decisions and go [seek MH care]…it is really hard…it took time and I lost years of my life but if I knew [about MH and related services] from the beginning , I wouldn’t have lost anything . But that is the idea , we still need a lot of [MH] awareness or awareness-raising campaigns” (female Lebanese service user).

Concerns related to service users’ own confidence and trust in the MH care process.

Several concerns related to service users’ own confidence in therapy have been identified as barriers to seeking support. One is the fear of seeing the therapist in person: "I would be concerned if I met her face to face . She would know my weaknesses . I’m afraid to see me as weak or unstable" (female Lebanese service user). Additionally, some individuals may find it difficult to talk to their therapist, as a female Syrian service user revealed: "I don’t accept to talk any more about what I am thinking or what is the thing that is making me upset , I can’t , I can’t . " The fear of being judged or misunderstood also prevented some participants from opening up about MH issues: "I used to tell myself that I shouldn’t speak , not to embarrass myself" (male Lebanese service user). For some participants, the lack of safety and security to speak openly is a major concern, as a gay male Syrian service user said: "I was hesitant … My whole tribe has threatened to kill me … I wouldn’t be able to take care of myself . " Finally, readiness of service users to commence and adhere to therapy can also play a role in seeking MH support, as a NGO manager explained: "not everyone feels ready to invest into psychological concerns … It’s not the priority , the priority remains in different areas , different goods , different services . "

Observable positive impact of therapy.

Service users consistently expressed the need to seek help and be followed up by service providers and acknowledged the importance of MH services in helping them deal with their problems: " I don’t know , I don’t have the knowledge how to do it . So I need to seek help to do it" (female Lebanese service user). Additionally, participants who saw the benefits of medications were encouraged to continue therapy, with one participant stating "The most [important] thing I am able to see the effect of is the effect of the medication that is preventing me from entering the vicious cycle . This is helping me" (male Syrian service user). Some participants also viewed their therapist as a helpful friend, which enabled and eased their access to therapy "I consider her as my friend who is helping me , and I should tell her everything" (female Syrian service user).

Proposed solutions to improve MH care financing and access

Participants identified several ways to improve financing and access to care ( Table 3 ). It was widely recognised that more national funding is urgently needed for the NMHP and to fully implement the National MH Strategy. Participants also called on the MOPH and NMHP to invest in PHCs and to reduce the pay gap between MH staff employed by MOPH and local and international NGOs, and to broaden the use of task-sharing to include other cadres of non-specialist providers in primary care level to help decrease the current over-reliance on MH specialists.

Proposals related to financing included formulating a comprehensive policy framework for health financing, guaranteeing social health protection to all; urgently raising funds for the NMHP to fully implement the National MH Strategy; exploring innovative financing mechanisms to supplement humanitarian funding; combining social health insurance funds in the NSSF and MOPH funding (from general taxation) in a single-payer pool, and strengthening implementation of the MOPH and NMHP’s commitments towards strategic health financing mechanisms with a focus on PHC by progressively aligning purchasing methods, at least among public purchasers, moving away from passive fee-for-service mechanisms for secondary and tertiary care and including a strong primary care component which should play the role of gate keeper. A full list of proposed solutions is in Table 3 .

Proposals related to access care included widespread campaigns that go beyond specific MH conditions such as suicide to include broader aspects of MH. This is seen as crucial in helping individuals recognize and address concerns early on, reducing stigma, and promoting a more supportive environment. Some also called on the MOPH, other relevant governmental ministries, UNHCR, and NGOs to publicise the recently published list of free MH services [ 37 ].

A full list of proposals is in Table 3 .

To our knowledge, this is the first study to investigate barriers, facilitators, and proposed solutions to MH service financing and access for both Syrian refugees and the Lebanese populations. Our findings highlighted the challenges in financing Lebanon’s system for MH care, including inequitable coverage, dependence on external humanitarian funds, and risks associated with short-term funding and its impact on the sustainability of services for both populations. Our study further revealed how the built environment presents additional challenges to individuals trying to navigate, access and use the available resources, and how the social environment and provider factors enable or hinder individuals from accessing the MH services they need. We found a perception that Syrian refugees registered with UNHCR have better financial coverage to secondary and tertiary MH care as 90% of the fees are covered by UNHCR but, given the economic crisis, both populations are now facing similar challenges in terms of paying for and accessing MH services.

The barriers described are not unique to MH and are found with other chronic conditions [ 51 ]. They are exacerbated by the economic crisis and currency devaluation, leading public health institutions to favouring patients who can pay in USD. This has implications for social cohesion, while perceptions of preferential treatment may further exacerbate the social tension between refugee and Lebanese populations [ 52 ].

Second, the dependence on external aid and short-term, project-based funding poses a substantial threat to the stability and sustainability of MH programmes. This threat necessitates the establishment of a more robust, long-term financing model [ 53 ], which has also been recommended in Lebanon’s national health strategy [ 54 ], and underpins the imperative for external donors to support and strengthen the national system rather than investing in parallel systems. Moreover, our findings highlight the need for the MOPH to formulate a comprehensive framework for health financing guaranteeing social health protection to all, and in parallel, work on how to reduce fragmentation of the health financing system. It is also critical that MOPH implement its commitments to combining social health insurance funds in the NSSF and MOPH funding into a single-payer pool, in order to maximise efficiency and increase the scope for cross-subsidies to vulnerable populations. This is especially important given that as of March 2023, 80% of Lebanese are reported to be living below the relative poverty line, including around 36% below the extreme poverty line [ 18 ], and in 2022, 90% of Syrian families needed support to meet their basic survival needs [ 16 ]. Going beyond commitments, it is important that this work on reforming the health financing system is done a timely fashion, with accountability mechanisms put in place to monitor progress. However, the stalemate to find a president and make steps towards resolving the current political and economic crisis is a barrier to the government finding sustainable solutions for a number of issues, including that of a better financed health sector.

In addition to the challenges, we also identified important enablers for a sustainable MH care system including the efforts of MOPH and NMHP integrating MH into PHCs. The Primary Health Care Unit successfully defined a set of the essential healthcare services, with the aim to make them financially accessible through subsidised packages for all residents [ 55 ]. This plan has contributed positively to greater equity between Lebanese populations and Syrian refugees at the primary care level, where everyone can access the same services [ 55 ]. Ongoing efforts of the MOPH and NMHP in integrating MH services into more sustainable care models such as the primary care network, though heavily dependent on external aid, would enhance the overall MHPSS response, as has been shown in other humanitarian settings where integration increased communities’ access to these services [ 56 ].

Our participants suggested the need for MOPH to secure dedicated funding to the NMHP given its strategic oversight and leadership in scaling up the MH response in the country. Funding a national structure dedicated to MH, like the NMHP, can also help bridge the gap between the priorities of policymakers and practitioners on the ground, and bring together other sectors working on MHPSS, to coordinate and amplify impact. This recommendation also comes in line with the current MHPSS guidelines [ 4 , 33 ]. Despite the efforts of the NMHP in integrating MH into PHCs and incorporating refugee responses into national strategies, these efforts will be ineffective if the system is not well-resourced [ 57 , 58 ]. For instance, studies have shown that reaching sustainable efforts necessitates endorsement from authorities, encompassing the national government to institutionalise MH care nationwide. This entails the establishment of legal and policy frameworks enabling long-term funding and facilitating the intervention’s growth through the development and the commitment to national guidelines and strategic policy documents [ 59 ]. In Lebanon’s case, this would entail finalising and more importantly, securing funding for its National MH Strategy 2023–2030 [ 38 ].

The shortage of MH specialists and brain drain, and reported lack of compassion from some service providers, emphasise the significant gaps within the healthcare environment which needs to be addressed for more equitable and quality public MH care [ 60 ]. The need for retention of workforce solutions needs to be addressed. These barriers associated with the health system suggests that for an equitable MH care, these context specific characteristics need to be considered in the national efforts [ 61 ]. For instance, the large gap between the demand for MH services and the limited number of MH professionals signals the need for MOPH and MHPSS partners to continue working on implementing and scaling up innovative and efficient approaches to tackle this problem, which include task shifting and incentivising the recruitment and training of MH care providers [ 62 – 66 ]. Our study reported some service users reporting frustration and perceived lack of compassion from MH providers, emphasising the need for better quality care which should be addressed via consistent training packages for all MH providers, with monitoring of tracer quality of care indicators for MH at national level [ 60 , 67 ]. Our study also reported service users noting that MH services are not currently being provided in a way that meet their preferences or understanding of MH challenges, which underscore the importance of providing culturally relevant MH services tailored to both Syrian and Lebanese populations.

Our study also found demand-side barriers to accessing MH care including stigma, lack of support from family, friends and partners, and lack of relevance of MH services, for example not having a choice of gender of service provider when seeking services, as well as services not being offered in a group format. These findings are consistent with recent reviews focused on barriers to seeking care in low-and middle-income countries [ 68 ], and among refugee [ 69 ] and child and adolescent populations [ 70 ]. Addressing these barriers requires comprehensive and inclusive mental health policies and legislations that lead to improvements in MH services, as well as sustainable and culturally adapted MH awareness programmes, including in communities, schools and work settings, that are co-created with target populations.

Our study has several limitations which should be addressed with future research. The self-reported nature of data collected in the key informant interviews and FGDs is a limitation. The sensitive nature of the study topic may have also created reporting bias in the interviews and FGDs, with some service providers, governmental stakeholders, NGO and UN staff not being able to speak freely in fear of making showcasing their services or agencies in a negative light. Despite trying to sample participants from all relevant stakeholder groups, we were unable to interview any participants from NSSF or the MOPH department that is responsible for paying for health services as the “last resort” funder. Additionally, although we aimed to collect data from equal numbers of male and female service users, we found it more challenging to sample males. This led to an uneven number of males and female service users being recruited, which may have led to gender bias in our study results. Finally, this study focused only focused on the health system, while we are aware that MHPSS is an intersectoral issue and responsibility. Future research should assess the provision of MH care through other sectors, such as protection, livelihoods, and education.

Conclusions

Multiple crises in Lebanon have further exacerbated challenges in health system financing for MH care, dependence on external humanitarian funds, and risks and sustainability issues associated with short-term funding. Urgent reforms are needed to Lebanon’s health financing system to equitably and efficiently finance and scale up MH care with a focus on PHCs [ 54 ], and to reduce inequities in MH service coverage between Lebanese and Syrian refugee populations. In particular, external donors should consider channelling humanitarian funding into the national system, rather than into a parallel system. Moreover, there is an urgent need for the government to raise funds for the NMHP and to fully implement the National MH Strategy [ 38 ], while also working on wider health financing reforms by: strengthening implementation of the MOPH’s commitments towards strategic health financing mechanisms with a focus on PHC; combining social health insurance funds in the NSSF and MoPH funding into a single-payer pool; and reducing fragmentation at all levels by strengthening NSSF and fostering a national consensus on how to cover the entire population Lebanon in an equitable way with no or little contributory capacity.

Supporting information

S1 checklist. inclusivity in global research..

https://doi.org/10.1371/journal.pgph.0003318.s001

Acknowledgments

We would like to acknowledge all research participants including displaced Syrians and Lebanese populations who participated in our study. We are also grateful to Michelle Lokot for her feedback on this paper.

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Examining the experiences related to the psychological needs and future perceptions of Turkish adolescents on the basis of reality therapy: a qualitative study

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  • Published: 08 July 2024

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qualitative research methods in mental health and psychotherapy

  • Asiye Dursun   ORCID: orcid.org/0000-0002-4033-0034 1 &
  • Nergis Canbulat   ORCID: orcid.org/0000-0002-1599-3856 2  

This qualitative study investigates adolescents’ perceptions and psychological needs regarding the future in the perspective of reality therapy. Employing a case study design as a qualitative research method, the study reached a total of 181 adolescent participants, including 125 (69.1%) girls and 56 (39.1%) boys. The data obtained from participants were analyzed using thematic analysis by the researchers. As a result of the analysis, their perceptions of the future were categorized into two themes: “Future Perception” and “Future-Oriented WDEP System.” Additionally, it is observed that they formulated various metaphors related to psychological needs. Adolescents’ perceptions of the future encompass both positive emotions, thoughts, and actions, as well as negative expressions. The findings of this research provide insights for developmental experts and mental health professionals in understanding the psychological needs and future perceptions of individuals during the crucial stage of adolescence.

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Introduction

The importance of perception for the future has been emphasized years ago and is considered a phenomenon that needs to be examined. Indeed, without perception, the future cannot be envisaged, and how to behave in the present also remains unknown. In short, when there is no perception and the future cannot be perceived, the world can become a labyrinth where inhabitants lose their sense of direction (Von Foerster, 1972 ). Evaluating the cognitive developments during the transition from childhood to adolescence and the formation of identity, individuals are observed to develop a multi-dimensional time perception that encompasses the past, present, and future (Mello & Worrell, 2014 ). However, adolescents tend to form perceptions more towards the future than the past and the present. Additionally, it is indicated that the perception of the future is an effective structure in different developmental stages (Allemand et al., 2022 ). In adolescence, perceptions of whether there is one or more paths or opportunities for the future differentiate. Therefore, examining future expectations during adolescence becomes crucial for understanding individuals, as research highlights the association of future perception with identity development, hope, and depression during this period (Allemand et al., 2022 ).

Psychological needs are expressed in different ways in different theoretical contexts. However, the satisfaction of psychological needs, emphasized in every developmental stage, increases the likelihood of healthy development and leading a fulfilling life; failure to meet these needs can lead to maladaptive functioning and pathological conditions. Similarly, it is emphasized that psychological needs have individual differences and are related to motivation and self (Deci & Ryan, 2011 ). Moreover, individuals who satisfy their needs are seen to exhibit high levels of self-regulation, perseverance, academic performance, and positive emotions, while controlling their levels of anxiety and achievement-focused success (Vansteenkiste et al., 2004 ). Considering that issues such as self, motivation, healthy development, anxiety, achievement, maladaptive functioning, and satisfaction frequently emerge during adolescence, addressing psychological needs during this period becomes crucial. Therefore, in this study, metaphors are used to explore adolescents’ perceptions regarding the satisfaction and hindrance of psychological needs and what they mean. Different perspectives are presented in detail to shed light on these perceptions.

Future perceptions of adolescents

The adolescent period can be characterized as a transitional phase preparing for adult roles. During this period, adolescents not only prepare for higher education but also make decisions about their future careers. At this juncture, adolescents, faced with tasks such as planning for the future, making choices, and decision-making, are essentially structuring their future expectations. It is observed that the most common future expectation encountered during adolescence tends to focus on career outcomes and educational success (McCabe & Barnett, 2000 ), emphasizing its significance as a crucial construct that needs to be addressed (Turcios Cotto & Milan, 2013 ). Adolescents, while preparing for higher education, are also making decisions about their future careers. At this point, adolescents facing tasks such as future planning, making choices, and decision-making are actually structuring their future expectations. Future expectations, which are expressed as cognitive maps that encompass individuals’ views, interests, and concerns about the future (Yam et al., 2018 ), are also related to emotional states such as self-concept, locus of control, coping strategies, and well-being (Şimşek, 2012 ). Another aspect of future expectations is future perception. Individuals’ perceptions of the future are expressed as the images they create in their consciousness about the future based on their perceptions of the present moment (Yam et al., 2018 ).

The fact that adolescents exhibit a greater orientation towards and engage in more future planning than adults (Prenda & Lachman, 2001 ) suggests the importance of addressing the concept during this developmental period in shaping future developmental stages. Furthermore, the significance of the concept of the future is evident in its impact on adolescents’ behavior, attitudes, and personality formation. Therefore, the examination of concepts such as future perception, anxiety, and expectations that influence individuals’ motivation is emphasized (Aytar & Soylu, 2019 ). In light of all these explanations, understanding how adolescents shape their perceptions of the future can provide insights for professionals working with individuals during this period. The evaluation of future perception and psychological needs is approached within different theoretical frameworks (Daltrey & Langer, 1984 ; Ryan, 1995 ). This study aims to assess adolescents’ perceptions of the future and psychological needs through the perspective of reality therapy.

The relationship between reality therapy, future perception, and psychological needs

When evaluating future perceptions, one can draw upon various theoretical frameworks, and it can be argued that insights from reality therapy’s theoretical explanations can also be beneficial. Glasser ( 2014 ) emphasizes that individuals can control their behaviors, choose for themselves, and underscores the importance of internal control. Furthermore, he anticipates success and happiness in the future when interpersonal relationships are healthy. Glasser also highlights the importance of focusing on the present and the future rather than the past, indicating that using the WDEP system to focus on individuals’ desires and behaviors and planning based on necessary evaluations would be functional. In this process, it is essential to focus on the client’s perceptions. Indeed, perception is a necessary element to plan for the future and evaluate the present (Von Foerster, 1972 ). Therefore, it can be considered that reality therapy provides a theoretical framework to navigate when assessing perceptions of the future.

Moreover, although reality therapy is applicable for professionals working with adolescents in psychology, social work, counseling, classroom teaching, administration, and other disciplines, more research is needed (Wubbolding, 2015 ). Given the known impact of reality therapy on increasing adolescents’ self-efficacy, responsibility, mental well-being, and mental health while reducing anxiety (Jamalabadi et al., 2022 ), it is believed to provide guidance in framing adolescents’ perceptions of the future.

Another focus of the study is adolescents’ perceptions of the four fundamental psychological needs defined within the context of reality therapy (belongingness, power, freedom, and fun). Evaluating the impact of adolescents shaping their future perceptions based on these psychological needs, as well as considering cultural structures reflecting differences in socio-cultural values, underscores the importance of examining psychological needs in the Turkish adolescent sample. Although adolescents’ needs in different cultures are often evaluated in the context of three fundamental psychological needs—autonomy, relatedness, and competence (González-Cutre et al., 2020 ; Fraguela-Vale et al., 2020 ; Liu et al., 2023 ; Vansteenkiste et al., 2020 )—there are few studies that specifically address the dimensions of love-belonging, power, freedom, and fun (Dursun, 2022 ; Harvey & Retter, 2002 ). It is emphasized that psychological needs should be addressed in these four dimensions (Harvey & Retter, 2002 ).

The importance of qualitative assessment of future perception and psychological needs

While there are various quantitative studies examining future perception and psychological needs (Allemand et al., 2022 ; Thomas et al., 2017 ), qualitative research on these topics is rarely encountered (Dursun, 2022 ). However, no study has been found that evaluates the concept of future perception, thought to be related to concepts such as responsibility, decision-making, control focus, psychological needs, and total behavior, within the context of reality therapy. Examining adolescents’ future perceptions in-depth through qualitative research methods is likely to facilitate a better understanding of their emotions, thoughts, and expectations regarding the future. Similarly, exploring their psychological needs can contribute to guiding them towards healthy directions. As a matter of fact, the basic concepts of reality therapy such as making choices, taking responsibility, evaluating the functionality of their own behaviors, making plans and implementing them (Banks, 2009 ) enable adolescents to continue to be successful. It also motivates adolescents to continue making choices that will enable them to take personal responsibility for their future behavior (Mabeus & Rowland, 2016 ). In addition, reality therapy helps adolescents increase their self-confidence and express their own needs without hesitation (Wahyuningsih, 2018 ), and reduces the risk of experiencing hopelessness and identity crisis (Mahmoodi et al., 2013 ). In light of all these explanations, it is thought that it would be appropriate to examine concepts that may be related to adolescents’ future perceptions and psychological needs with the concepts of reality therapy. Because it can be said that experiencing an identity crisis, having a sense of hope and being motivated in future-oriented behaviors will shape the perception of the future. Similarly, it is emphasized that meeting psychological needs is very important for adolescents (Dursun, 2022 ). As stated, one of the important concepts of reality therapy is psychological needs. Consequently, this study is considered important as the first research to investigate adolescents’ future perceptions in the light of reality therapy, focusing on adolescents’ psychological needs in conjunction with evolving and changing life conditions, and utilizing qualitative research methods. Additionally, it is expected that the findings of this study will serve as a foundation and provide data for future research on adolescents’ future perceptions and reality therapy. Lastly, it is believed that the results of this research will offer insights into psychological counseling and guidance services provided to adolescents in schools, particularly in terms of planning their futures and addressing important topics such as psychological needs, responsibility, and control.

Methodology

Participants.

In the research, a convenient sampling method, which is one of the sampling methods in qualitative research, has been used. Convenient or accessible sampling relies on readily available, easily accessible elements (Patton, 2005 ). However, adolescents who are still in the adolescence period, attending formal education, and willingly informed their families about the research, participated in the study. In this context, interviews were conducted with a total of 181 adolescents, with an average age of 15.36, including 125 (69.1%) girls and 56 (39.1%) boys. Care was taken to interview participants from each grade level. Among the participants, 55 (30.4%) were in the 9th grade, 77 (42.5%) in the 10th grade, 26 (14.4%) in the 11th grade, and 23 (12.7%) in the 12th grade. Additionally, an effort was made to reach participants from different types of schools. Indeed, 157 participants (86.7%) attend Anatolian High Schools, 13 (7.2%) attend Social Sciences High Schools, 7 (3.9%) attend Anatolian Imam Hatip High Schools, and 4 (2.2%) attend Vocational High Schools. Their academic averages vary between 41 and 88, with an average of 73.74. Although this study was planned in a qualitative pattern, the reason for the large number of participants is that it was tried to explain the future perceptions and psychological needs of adolescents in the context of maximum diversity sampling. In this way, different situations can be represented and situations can be fully described from multiple perspectives (Henwood, 2014 ). In this study, adolescents of different genders, different grade levels, different school types, and parents with different education levels were included in the study to ensure maximum diversity. Thus, this research, planned in a qualitative pattern, will provide repeatable and convincing results, and the sample will be included in the universe. It has been supported to include all its elements (Creswell, 2013 ).

In the research, ethical approval for the study Scientific Research Publication Ethics Committee. This study was approved by The Humanitarian Sciences Scientific Research and Publication Ethics Committee on 04.04.2022 (ReferenceNo: 2022/11 − 05). The author declare that they have no conflict of interest. Furthermore, an informed consent form and parental consent form were added to the online interview questionnaire. The reason for choosing the online environment to collect data through in-depth interviews in the study is cost and time efficiency (Abidin & de Seta, 2020 ). Adolescents willing to participate in the interviews were informed about the research and provided with a link to the interview questionnaire. Responding to the interview questions in the online environment took an average of 20 min, and the interview data were collected between May and November 2022. Participants no incentives (money, food, gifts, etc.) were provided for participating in the interviews. Due to the large number of participants, numerical ordering was used instead of names.

Validity and reliability studies

In order to enhance the validity and reliability of the research, several measures were taken. To improve validity, the research process and participants (gender, grade level, academic average) were described in detail. Additionally, in the findings section, participant sentences that could serve as examples for codes were presented in detail, including the participant’s gender and grade level information. To ensure reliability in the research, participants were provided with detailed information about the scope of the study, and their voluntary participation was encouraged. Furthermore, the roles of the researchers were predefined, and the process was systematically carried out.

Throughout the research process, including question formulation and analysis, literature-supported procedures were followed, and the research method was thoroughly described. Moreover, one of the measures taken to enhance reliability was seeking expert opinions, as suggested by Creswell ( 2013 ). In this study, opinions were obtained from two experts. Finally, in accordance with Miles and Huberman’s ( 1994 ) formulation, inter-rater reliability is expected to exceed 70%. In this study, reliability was calculated as 86%.

The interview questions included in the interview form prepared by the researchers were grounded in the theoretical foundation of reality therapy. The form underwent modifications after three expert reviews who were knowledgeable about reality therapy and had experience in qualitative question formulation. The questions were designed to delve into adolescents’ future perceptions, starting more broadly and aiming to access both positive and negative aspects of adolescents’ future perceptions. The questions include: (i) How do you imagine your future life? (ii) What are you doing today to achieve your future life? (What are the obstacles, resources, and strengths? ) (iii) When you evaluate what you are doing/not doing today to achieve your future life, what comes to mind? (iv) When you evaluate what you are doing/not doing today to achieve your future life, what advice would you give to yourself? (v) What are your thoughts about the future? (vi) What are your feelings about the future? (vii) What are your beliefs about the future? (viii) How do you meet your psychological needs (love, power, freedom, fun)?.

Coding and analysis

The data analysis in the study employed theoretical thematic analysis to thoroughly organize and describe the data. The process began with the researcher deciphering and repeatedly reading the data, followed by the creation of initial codes, searching for themes, reviewing and creating a thematic map of the themes, and finally, naming and reporting the themes (Braun & Clarke, 2006 ).

In this context, after collecting data from the AD and NC researchers, the process involved rereading the data set multiple times, eliminating unanswered or tangentially answered, and incomplete interview forms from the data mass to reach the final data set for analysis. Subsequently, two researchers simultaneously focused on key terms related to the concepts of reality therapy to perform initial coding. The codes were then categorized and a map was created by AD, which was presented to NC. NC examined the data set in the context of her own code categories, and the process continued with several iterations. Throughout this process, the fundamental concepts of reality therapy were taken into consideration.

Finally, after obtaining the themes, the researchers presented them to experts for their feedback. Following feedback from two experts knowledgeable in reality therapy and qualitative research, the findings were finalized and compiled into a report. The themes, codes, and categories related to adolescents’ future perceptions are presented in Table  1 , while metaphors related to their psychological needs are provided in Table  2 .

Adolescents’ views on future perception

The findings related to adolescents’ future perceptions are presented in Table  1 . These are organized into two main themes: ‘Future Perception’ and ‘Future-Oriented WDEP System.’ Under the theme of Future Perception, six categories were identified, including psychological needs, control, quality world, total behavior, responsibility, and identity formation.

  • Psychological needs

The adolescents who participated in the research mentioned their needs for love-belongingness (f = 162) , fun (f = 157) , freedom (f = 110) , and power (f = 90). Adolescents who perceived the need for love-belongingness as essential, healing, and fundamental expressed meeting this need through environmental resources such as social support and hobbies. They fulfill this need by showing love, feeling valued, meeting the power need through physical, spiritual, verbal, and internal contact. Similarly, the need for fun is met through social contacts and support, hobbies, technology use, showing love, and using humor. Adolescents believe that unhealthy coping mechanisms and lack of awareness or fulfillment hinder meeting the need for fun. Regarding the need for freedom, adolescents meet it through hobbies, taking responsibility, self-control, expression, questioning, and relaxation. However, they find it challenging to satisfy the need for freedom due to reasons such as avoiding responsibility and lack of awareness. Adolescents meet the need for power through hobbies, social support, sports activities, academic efforts, personal development, internal motivation, and taking responsibility. The difficulty in recognizing and defining the need for power makes it challenging for adolescents to satisfy this need. The findings indicate that adolescents engage in different actions to satisfy various psychological needs.

These results highlight the exploration of situations where adolescents cannot meet and satisfy their needs and the need for necessary interventions. Some examples of expressions related to adolescents’ struggles in meeting or satisfying their psychological needs are presented below:

The need for love is important to me. Many things in life pass through love and beauty. I meet my need for love by spending time with my friends and family. [Girl, 10th Grade, Anatolian High School] Fun plays a small part in my life. I spend time with my friends during school breaks, I spend some time on the phone at home, but I love spending time with my mother, going out… [Girl, 9th Grade, Anatolian High School]. In my opinion, freedom is a feature that only exists in birds. There is no freedom in the family; clothing, traveling, reading… And if we are women, of course. The reason for this is the trust between them. [Girl, 12th Grade, Anatolian High School] Power is the meaning of life for me, and I provide the power I need by acting without delay, aware of my position in society, my rank, and what I can do. [Male, 12th Grade, Anatolian High School] The need for love is my raison d’être. It is the best help to start something, I meet my needs in a completely different world by reading books. [Girl, 10th Grade, Anatolian High School] In my opinion, love is necessary for every human being and this need arises from loneliness. I meet my need for love by motivating myself. [Girl, 11th Grade, Anatolian High School] It’s like a painkiller. With hugging… [Girl, 11th Grade, Anatolian High School].

As a result, as can be seen from the statements of the research participants, the psychological needs (Love-belonging, Power, Freedom, Fun) that are fundamental to reality therapy are also effective on their lives. It is particularly noteworthy that their efforts to meet Love-Belongingness and Fun needs are intense. This is clearly seen in the metaphors in which they express their perception of need. Adolescents often compare their Love, Belonging and Fun needs to vital needs such as eating and breathing. In this regard, it can be considered important to focus on meeting these needs and how they are met in preventive and therapeutic studies with adolescents.

Under the category of control, the desire to satisfy psychological needs (f = 84) , effort/dream to achieve goals (f = 74) , positive perception of the future (f = 17) , and negative perceptionsof the future (f = 21) emerged. Adolescents express a desire to control and satisfy their psychological needs, such as being happy and strong in the future, gaining economic power, and meeting the needs for fun and freedom. Additionally, efforts to achieve future goals, such as acquiring a profession, being goal-oriented, and exhibiting perfectionism, indicate a sense of control. Moreover, it is observed that adolescents may have negative perceptions of the future based on a lack of awareness, loneliness, and hopelessness, leading to a feeling of lack of control in this regard. According to reality therapy, gaining internal control is crucial for adolescents. These findings suggest the need to focus on adolescents’ negative perceptions of control and situations where they do not feel in control. In this study examined from the perspective of Reality therapy, the efforts of the participants to gain control over their lives in their statements about the future draw attention. In this respect, it can be said that it is important to provide opportunities for adolescents to feel in control in their future planning and studies on this subject. Some statements expressing adolescents’ feelings related to the control category are provided below:

My biggest dream is that I can express my thoughts freely, that people accept me as I am, and that my thoughts and decisions I make are respected. [Girl, 11th Grade, Vocational High School] It’s like seeing cheerful faces every day, my career being as I expected, and a peaceful life. [Girl, 10th Grade, Anatolian High School] Going to another city or even country for university. [Male, 10th Grade, Anatolian High School] Living a perfect life with family or alone. [Male, 10th Grade, Anatolian High School]

World of quality

In this category, adolescents mentioned positive motivation for the future (f = 100) and negative motivation for the future (f = 39). The quality world is a structure that includes situations, events, people, and perceptions that individuals value. It is effective in meeting and motivating individuals to take action to satisfy their psychological needs. In this context, positive motivation for the future that facilitates adolescents in taking action and satisfying their needs includes positive beliefs about themselves, beliefs about goals, positive beliefs about the environment, spiritual beliefs, and hope. Additionally, it has been found that some adolescents have negative beliefs about themselves and the environment in their quality world. This situation may negatively impact adolescents’ perceptions of the future and lead to a lack of motivation in satisfying their psychological needs. Therefore, there may be a need for interventions addressing the negative perceptions in adolescents’ quality world. Some statements expressing adolescents’ feelings related to the quality world category are provided below:

We will be a happy country, we will leave the difficult days behind. [Girl, 11th Grade, Anatolian High School] I believe that I will be rewarded for my efforts in the future. [Girl, 9th Grade, Vocational High School] Even though I want to be successful, I believe that I will fail when I see my grades. [Girl, 11th Grade, Anatolian High School]

Total behavior pattern

Adolescents’ efforts to achieve future-oriented goals (f = 158) , their emotions about the future (f = 209) , and thoughts about satisfying their psychological needs (f = 32) are evaluated within the pattern of total behavior. Total behavior assesses individuals’ emotions, thoughts, actions, and physiology. In this context, adolescents believe that to reach the lives they envision in the future, they need to be goal-oriented, set goals, be organized, be determined, and have internal control. Additionally, adolescents experiencing hopelessness, feelings of insecurity, and future anxiety believe that meeting economic, motivational, entertainment, power, and time needs is crucial when planning their futures. It is noteworthy that adolescents generally express negative emotions about the future. Adolescents mentioned positive emotions (f = 75), negative emotions (f = 107), and neutral emotions (f = 27) when talking about their future feelings. In positive emotions, they feel happy, hopeful, proud, and peaceful, while in negative emotions, they feel stressed, hopeless, unhappy, excited, sad, anxious, worried, and uneasy. Some adolescents also had difficulty describing and naming their emotions. These findings suggest the importance of paying attention to negative emotions related to future perceptions when working with adolescents. Below are some statements expressing adolescents’ feelings in the total behavior category:

I worked very hard and got the job I wanted… [Girl, 9th Grade, Anatolian High School]. I recommend doing what I want, when I want, without stressing myself too much, so I can be more productive. [Girl, 10th Grade, Anatolian High School] I should take better care of myself, I should plan better… [Girl, 12th Grade, Anatolian High School]. No one can guarantee that they will be with us in 5 years, so we need to chart and evaluate our path accordingly. [Male, 10th Grade, Anatolian High School] Spending more time watching movies and TV series and not worrying so much about the future… [Girl, 10th Grade, Anatolian High School]. I dream motivating dreams for myself and my only wish is to pass the class this year, and if I pass, I want to shine as a different person from everything and everyone for the next 2 years. [Girl, 10th Grade, Anatolian High School] I would say use your time wisely because these times will never come again. Even if you become a very successful and rich person in the future, the only thing you cannot buy is time. [Girl, 12th Grade, Anatolian High School]

Responsibility

Adolescents also mentioned the concept of responsibility for the future in their statements. They stated that there are internal sources (f = 136) and external sources (f = 6) regarding responsibility. While talking about internal resources such as economic, academic, personal development efforts and personal power source, they also stated the importance of external resources such as academic support and social support resources. Responsibility is a very important concept for reality therapy. Similarly, it is very important to be able to take responsibility in terms of both developmental tasks and the career decision-making process during adolescence. It is noteworthy that the participants frequently expressed internal resources. It is thought that it will make it easier to take responsibility since the continuity of internal resources is under the individual’s control compared to external resources.

I’m working too hard. I try new things to discover myself. [Girl, 11th Grade, Anatolian High School] I don’t have a disability, it can’t happen. I am a patient person, my diction is good. I’ll do whatever it takes to get what I want. [Girl, 9th Grade, Anatolian High School] My obstacles are myself, my resources are my books, my strength is my best friend… [Girl, 10th Grade, Anatolian High School]. My resources: My family’s support, highly disciplined and qualified teachers… [Male, 10th Grade, Anatolian High School].

Identity achievement

Adolescents also talked about identity achievement, which is one of the important concepts of reality therapy and adolescence, by talking about successful identity patterns (f = 30) and unsuccessful identity patterns (f = 8) for the future. In their statements, adolescents stated successful identity patterns when talking about concepts such as the desire for control, the acquisition of autonomy, and the desire for social order. They also mentioned unsuccessful identity patterns by including unrealistic expectations and avoiding responsibility. Therefore, according to the research results, it becomes crucial to pay attention to adolescents’ unrealistic expectations and tendencies to avoid responsibility and to intervene as necessary. This way, support can be provided for adolescents to achieve successful identity formation.

I want my feet to be firmly on the ground and to live a life without depending on anyone. [Girl, 12th Grade, Anatolian Imam Hatip High School] I would like to have what I want at my fingertips at any time. [Girl, 10th Grade, Anatolian High School]

Future-oriented emotions

Adolescents’ feelings about the future are categorized under three headings: positive affect (f = 75) , negative affect (f = 107) , and neutral affect (f = 27). Under positive affect, adolescents mentioned feeling hopeful , happy , peaceful , and proud , while also expressing feelings such as hopelessness , anxiety , worry , stress , and unease . Some adolescents also had difficulty describing their emotions. It is noteworthy that adolescents experience negative emotions more frequently than positive emotions. On the basis of reality therapy, attention is paid to the relationship of negative emotions with needs that are not met or are not met in a healthy way.

When I think about my feelings towards the future, I feel hopeful. At least, there are positive feelings inside me for my own future. It’s like everything is going to be really great. [Girl, 9th Grade, Anatolian High School] I feel very sad and scared when I think about not being able to succeed or not reaching my dreams…[Girl, 10th Grade, Anatolian High School]. I don’t know…[Girl, 10th Grade, Anatolian High School].

Four categories were obtained under Future-oriented WDEP system theme in Table  1 . These are wants , doing , evaluation and planning , which are the concepts of reality therapy.

Under this category, adolescents mentioned their expectations of meeting physical (f = 36) and psychological needs for the future (f = 52). They emphasized future economic well-being and physical health in their expectations of meeting physical needs. They also talked about meeting their needs for fun, power and freedom in the future, and their desire to start a family and socialize. When evaluated in the context of future perceptions, wants become highly important as they have the potential to shape the future. This is because wants are qualitative in nature. In this regard, it can be considered that professionals working with adolescents can focus on wants with a perspective of meeting their psychological and physical needs when examining their future perceptions. The wants section could be considered the part where professionals working with adolescents would gain the most information about the perception of the future. This is because adolescents form their wants based on their perceptions of the future. Therefore, considerations could be made for wants such as family, socialization, and meeting needs to be part of adolescents’ perception of the future. Below are some statements expressing adolescents’ wants:

To have a good economic income and to be a happy and healthy person. [Girl, 10th Grade, Anatolian High School] I want to be someone who made my name known. [Girl, 12th Grade, Anatolian Imam Hatip High School] No matter what happens to me, I just need someone to support me. [Girl, 9th Grade, Social Sciences High School] A free life without interference. [Male, 11th Grade, Anatolian High School] A comfortable, fun, non-tiring life [Girl, 10th Grade, Anatolian High School].

Under this category, adolescents have discussed what they do concerning their future-oriented actions. They have mentioned avoidance of responsibility (f = 20) and efforts to achieve their goals (f = 47). Additionally, they have emphasized efforts to achieve their goals when discussing what they do for their future. In their statements, they have mentioned concepts like motivating themselves, setting goals, and making plans. In their expressions, they have talked about inaction, a perception of inadequacy, and procrastination behaviors. These statements reveal a range of attitudes and behaviors among adolescents regarding their actions and aspirations for the future, including both challenges and efforts to reach their goals. In the doing phase, adolescents can gain awareness as they evaluate their own behaviors. Indeed, experiences such as avoiding responsibility, procrastination, and feeling inadequate may arise, negatively impacting their future perceptions. In the context of avoiding responsibility, it becomes crucial for professionals working with adolescents to focus on the adolescents’ current situations and behaviors.

I try to study, try to understand. I’m not doing my best at everything, but I can if I want to, yet I still procrastinate. [Girl, 10th Grade, Anatolian High School] I don’t have many obstacles; my family is supportive. I’ve already started preparing for the university entrance exam. I’ll study all summer, no matter what happens, and I won’t give up. Over the next two years, I plan to study a lot and secure a good major so that I won’t be unemployed. [Girl, 10th Grade, Anatolian High School]

Adolescents’ evaluations of their future can be categorized into three main areas: avoidance of responsibility (f = 87) , efforts to achieve goals (f = 58) and confronting reality (f = 38). They have used concepts representing avoidance behavior such as procrastination, insufficient effort, external locus of control, perception of obstacles, negative self-efficacy beliefs, negative emotions, and neutrality. Regarding their efforts to achieve the goal, they mentioned that they work goal-oriented, have positive efficacy beliefs, need to plan, and internal locus of control. While evaluating their future behavior, they also made statements regarding their awareness that they were facing the truth. Adolescents’ healthy evaluation of their current situation may make it easier for their future perceptions and goals to be more realistic. In this regard, it is important to support adolescents who need evaluation at this stage or who have low self-awareness.

I start studying very late; I prolong my start time, and I check my phone too much. [Boy, 10th Grade, Anatolian High School] I feel like I can’t make it, even if I study, it feels like I can’t survive in this country or achieve a profession in this education system. [Girl, 9th Grade, Anatolian High School] I feel like I can succeed in one way and not in another. I’m in a void. [Boy, 11th Grade, Anatolian High School] I’m making an effort, but I feel exhausted, just like Mac-Ready in the movie ‘The Thing’. [Boy, 10th Grade, Anatolian High School] I believe that if everything I plan goes well, I will hit my target right in the middle. [Girl, 12th Grade, Anatolian High School] I get stressed a lot, I shouldn’t do this, and that’s why I usually lose in the future. I think if I continue like this, I will lose. Mostly, sometimes my self-confidence is shaken. If I do this, I may lose again in the future. [Girl, 10th Grade, Anatolian High School]

Adolescents have shared action-oriented (f = 106) and emotion-focused thoughts (f = 53) regarding their future. In their future plans, they have discussed goal-oriented, family-building, migration, personal growth, economic, and responsibility-oriented behaviors. In addition, their statements included positive expressions such as hopeful future perception, as well as economic anxiety, future anxiety, negative perception of social order and thoughts of uncertainty. It is thought that adolescents’ positive or negative feelings and perceptions about the future may have an impact on their plans. As a matter of fact, emotions are an element related to thoughts and behaviors from a total behavioral perspective. In this respect, negative perceptions and emotions about the future need to be intervened. In addition, it is considered important to raise awareness about the future, which is perceived with unrealistic optimism.

I want to live in South Korea and this is not a dream for two days, I have been thinking about it for about a year and a half and now I am sure that I really want it. [Girl, 9th Grade, Anatolian High School] I want to be advanced in every field, for example, I want to learn different languages, play the guitar and piano, and improve more in painting. And I want to do more sports in the future. [Girl, 11th Grade, Anatolian High School] I hope that animal laws will become stricter and that those who hurt animals, violence, harass and rape women will be punished up to death. [Girl, 10th Grade, Anatolian High School] I don’t know what kind of life I will live, what kind of life is waiting for me, I am definitely worried that if I lose out on this path, I will experience great difficulties. [Male, 11th Grade, Anatolian High School]

Perceptions of adolescents regarding psychological needs

In Table  2 , findings related to metaphors used by adolescents to understand their perceptions of psychological needs are presented. Adolescents used metaphors to express their perceptions of these needs in the psychological needs category. They emphasized the fundamental nature and necessity of all psychological needs, creating metaphors that conveyed meanings such as basic needs and requirements, healing properties like medicine and vitamins for the love-belongingness need. For the power need, they used metaphors conveying the meanings of necessity, struggle, effort, protection, and healing. In expressing the freedom need, adolescents used metaphors like a bird, flying, and self-discovery to highlight relaxation and self-awareness. Regarding the fun need, they discussed its basic and necessary aspects, as well as its motivational properties, using metaphors like going to an amusement park, zest for life, and support. When metaphors are examined, it is seen that psychological needs are very important for adolescents. It is particularly noteworthy that they attach vital importance to the need for love and belonging. Therefore, it is important to understand to what extent psychological needs are necessary for adolescents and to support them in meeting their needs in a healthy way.

Love is a need for me, it is the reason for my existence. It is the best help to start something, and I meet my needs by reading books, entering a whole different world. [Female, 10th grade, Anatolian High School] Power is very important to me. Sometimes, I don’t know how I will do it. I feel like I am in a race. [Male, 12th grade, Anatolian High School] The need for freedom is like the most necessary thing for me to live comfortably in the future. [Female, 10th grade, Anatolian High School] For me, it is one of the body’s greatest needs, and I meet my needs by walking around in friend environments.’ [Male, 12th grade, Anatolian High School].

This study examines the meanings attributed by adolescents to future perceptions and psychological needs within the framework of reality therapy concepts. In this context, six categories were initially identified under the theme of future perception: psychological needs, control, quality world, total behavior pattern, responsibility, and identity achievement. When examining research findings, the importance of psychological needs, one of the fundamental concepts of reality therapy, is frequently emphasized during adolescence. Similarly, needs that are stated to be innate and universal in research (Glasser, 2014 ) are considered as the source of behaviors (Wubbolding, 2015 ). In research findings, adolescents particularly emphasize the significance of the need for love and belongingness, considering it essential and one of the healing and basic needs, also reflected in the metaphors they use. Similarly, in reality therapy, this need is recognized as a fundamental requirement (Wubbolding, 2015 ). Furthermore, during adolescence, which is a transitional period, the degree to which an adolescent satisfies psychological needs from the individuals in their relationships becomes crucial. Indeed, the importance of the need for relationship building during adolescence is emphasized. On the other hand, the need for love and belongingness is known theoretically as one of the most challenging psychological needs to fulfill. This is because it is acknowledged that at least one other person is required to meet this need. Therefore, how this need is met is also crucial. In research findings, adolescents state that they meet their needs for love and belongingness by using environmental resources such as social support and hobbies. Parallel to this, Booker ( 2004 ) emphasizes that the development of a strong sense of belonging is part of adolescence. From this perspective, it is essential for adolescents to meet their need for love and belongingness and to use various sources such as social support and hobbies. This is because the healthy fulfillment of needs in reality therapy is crucial for successful identity formation. According to the research results, adolescents consider the need for entertainment, such as the need for love and belongingness, as a fundamental need. The need for entertainment is known within the framework of reality therapy as the easiest need to fulfill, seen as necessary for increasing and sustaining well-being (Yorgun & Voltan-Acar, 2014 ). When considering adolescents, the need for entertainment is crucial. Adolescents mention that they can meet this need through social contact and support, hobbies, technology use, expressing love, and using humor. However, attention may need to be paid to the positive or negative use of humor in interactions with individuals or environments where the need for entertainment is met. Using dark humor or establishing contact in risky environments while meeting the need for entertainment can be considered unhealthy use. This situation may pose a risk to unsuccessful identity formation and damage the need for freedom. In this context, adolescents, in their metaphors, emphasize that the need for entertainment is fundamental and necessary, providing motivation. Adolescents state that the need for freedom is necessary for the present and future, fundamental, vital, and associated with relaxation. They emphasize this through metaphors. From this perspective, it can be considered that adolescents intensely feel the need for freedom. This is because adolescents under the age of 18 act together with individuals who are responsible for them in terms of financial aspects and the implementation of decisions (Dursun, 2020 ). This may make it difficult to meet this need. In the study, adolescents mentioned that they can meet the need for freedom through hobbies, taking responsibility, self-control, expression, questioning, and relaxation. Another perspective is that situations may arise where the need for freedom conflicts with the need for love and belongingness. While an adolescent satisfies the need for love and belongingness by being part of a group such as family, friend group, religion, etc., it is thought that this situation may make it difficult to meet the need for freedom (Yorgun & Voltan-Acar, 2014 ). However, Glasser emphasizes the importance of not harming others’ needs and taking responsibility when satisfying the need for freedom. In this regard, adolescents’ efforts to control themselves and take responsibility may be an indicator that they are trying to meet their needs successfully. Adolescents believe that they meet the need for power through hobbies, social support, sports activities, academic effort and activities, personal development efforts, internal motivation, and taking responsibility. Attempting to discover one’s internal strength, being able to make decisions by taking one’s responsibility, and building positive relationships with people are important for development and psychological well-being (Yorgun & Voltan-Acar, 2014 ; Wubbolding, 2015 ; Dursun, 2022 ). The research results also show that adolescents meet these needs positively, not by exerting power over others.

One of the strong findings in this study is the ways in which adolescents meet their psychological needs. It is emphasized that discussing adolescents’ future needs and expectations is crucial and significantly contributes to their development (Ege, 2018 ). The indication of how psychological needs in adolescent development are met in this research will serve as a guiding factor for parents, mental health professionals, and social support sources in addressing these needs. Additionally, the evaluation of psychological needs in the context of four fundamental psychological needs—namely, love and belonging, power, freedom, and fun—in this study aims to broaden the relevant literature, emphasizing the necessity of approaching needs from this perspective (Harvey & Retter, 2002 ).

While adolescents strive to meet their psychological needs, the perception of control in adolescents is active, and their quality world is also in the process of renewal (Ünüvar, 2012 ). Adolescents aspire to control future happiness, gain economic power, and meet entertainment and freedom needs. However, efforts to achieve future goals, efforts to have a profession, goal-oriented behavior, and tendencies toward perfectionism are indicative of adolescents feeling in control. Additionally, some adolescents lack awareness of their future, have negative perceptions based on loneliness and hopelessness, and, in this regard, feel a lack of control. According to reality therapy, it is crucial for adolescents to gain internal control. These findings suggest a need to focus on adolescents’ negative perceptions of control and situations where they do not feel in control. Moreover, considering that motivation increases when psychological needs are met (Maralani et al., 2016 ), adolescents may increase the likelihood of creating a positive perception of the future by feeling in control. In short, in the process of planning future expectations, it becomes crucial for adolescents to have positive orientations toward the future, be aware of their values, and internal motivational sources. This is because when adolescents have high internal motivation, they can make their own decisions, cope with the negative effects of stress, and establish healthier relationships with their environment. In other words, they can feel in control. Planning various studies to help adolescents gain control over their future perceptions, develop their quality worlds, and acquire responsibility could be beneficial. Additionally, interventions focused on reality therapy have been shown to be effective for adolescents in terms of internal control and academic motivation (Kim & Hwang, 2001 ).

In the study, adolescents discussed concepts such as the desire for control, gaining autonomy, and the desire for social order, effectively indicating successful identity patterns. They also emphasized unsuccessful identity patterns by including expressions related to creating unrealistic expectations and avoiding responsibility. Adolescents with positive attitudes towards the future are thought to be able to develop a healthy identity. Therefore, during adolescence, Seginer ( 2003 ) considers the orientation towards the future or individuals’ images of the future as an important developmental task since it lays the groundwork for planning goals. When adolescents explore opportunities for the future, they discover new things and support the formation of their own identities. In parallel, attention is drawn to vocational tendencies regarding identity acquisition and development. Becoming a professional and receiving education for it, and thus preparing for life, is important for identity acquisition during adolescence. These studies highlight future expectations such as professional success, economic gain, and a happy marriage (Yavuzer et al., 2005 ; Öztürk & Uluşahin, 2011 ; Konate & Ergin, 2018 ; Avar, 2019 ). The research findings also indicate that adolescents have similar perceptions of the future. Within the focus of reality therapy, the successful development of adolescent identities, the formation of a positive self-perception, making healthy choices, taking responsibility, and meeting basic psychological needs are effective in shaping adolescents’ future perceptions and assisting them in becoming healthy adults (Zeira & Dekel, 2005 ; Yalçın, 2007 ). Furthermore, in the research, adolescents also mentioned unsuccessful identity patterns. Similarly, in a study, adolescents who perceived themselves as unable to use personality resources efficiently and questioned identity acquisition during this period were found to have anger and inadequacy perceptions towards themselves and the environment (Gümüşel, 2017 ). This could lead to unrealistic expectations and behavioral tendencies to avoid responsibility.

One of the important findings in the research is the feelings that adolescents express regarding the future. It can be said that adolescents’ positive feelings towards the future are parallel to findings in other studies. It can be stated that adolescents experiencing positive feelings towards the future have an increased subjective well-being, and the likelihood of experiencing depression and anxiety feelings decreases (Young et al., 2019 ). In another study, it is indicated that individuals who exhibit positive feelings towards the future and approach it with an optimistic, hopeful perspective will be determined to achieve their goals, make efforts, and demonstrate a positive attitude (İmamoğlu & Güler-Edwards, 2007 ). Similarly, it has been revealed in a parallel study that as adolescents’ hopes increase, their levels of psychological well-being also increase. The source of negative feelings can stem from unmet psychological needs according to reality therapy. These felt emotions challenge the adolescent because adolescence is a period of emotional difficulty and also carries the risk of new onset of anxiety and depressive disorders (Young et al., 2019 ). Therefore, working on emotion regulation skills during this period will contribute to the adolescent’s development of a positive perception towards the future and psychological well-being. Additionally, due to the uncertainties of the future, it can lead to negative feelings in adolescents. For these reasons, adolescents may need motivation, planning, and evaluation for a positive perception of the future (Şimşek, 2011 ).

The second theme obtained from the research findings is the WDEP system for the future. Under this theme, four categories were identified: wants, doing, evaluations, and planning. In the wants category, there was an emphasis on the expectation of economic well-being and physical health in the future as part of meeting physical needs. Additionally, adolescents expressed wants related to meeting the future needs for entertainment, power, and freedom, as well as aspirations for family formation and socialization. It is observed that social support is an important factor in shaping adolescents’ expectations for the future (Sulimani-Aidan & Benbenishty, 2011 ). Wants are an important stage in understanding the needs that drive behavior in reality therapy. In a study, it was found that adolescents want a satisfying job, family, and economic power, and they aspire to have job security, similar to the research results (Briones et al., 2011 ).

The WDEP system in reality therapy aligns closely with three fundamental processes present in the perception of the future. These three fundamental processes are motivation, planning, and evaluation. In a study on how adolescents perceive the future, it is shown that the goals and interests of adolescents relate to the core developmental tasks of late adolescence and early adulthood, reflecting expected lifelong development. The family context has also been found to influence adolescents’ interests, plans, causal attributions, and emotional responses regarding the future (Nurmi, 2004 ). Adolescents’ evaluations of the future are categorized under three headings: avoidance of responsibility, striving for goals, and confronting reality. In their expressions, adolescents included concepts representing avoidance behavior, such as procrastination, insufficient effort, external locus of control, perception of obstacles, negative self-efficacy beliefs, negative emotions, and neutrality. The overall structure of avoidance of responsibility may involve behaviors that prevent individuals from accepting their own wrongdoings through faulty attributions, cognitive biases, and distortions. Similarly, in a study where adolescents indicated obstacles to achieving their future expectations, they believed that obstacles stemmed from negative environmental conditions and themselves. Factors such as not working hard enough, fear of failure, exam stress, lack of self-confidence, and laziness are considered obstacles originating from themselves (Ege, 2018 ). In contrast to these findings, it is also observed that some adolescents are optimistic about their future. It is thought that increasing optimism or reducing pessimism about the future could contribute to a healthy perception of the future.

Adolescents have mentioned action-oriented and emotion-oriented thoughts about the future. In their future plans, they have talked about goal-oriented, family formation, migration, development, economic, and responsibility-oriented behaviors. Expectations, goal setting, planning, and decision-making about the future are important in adolescence, making adolescents’ choices critical. Adolescents have thoughts about the future, such as completing school, building a career, starting a family, having children, experiencing a romantic relationship, having a profession, leading a happy life, achieving economic well-being, taking social responsibility, and maintaining health (Ege & Erbay, 2022 ). Additionally, it is stated that adolescents’ future goals have a multidimensional structure (Giota, 2010 ). The results of this study also indicate that adolescents are similarly goal-oriented. The multidimensional nature of adolescents’ plans for the future is a crucial factor to be considered in future studies. In the current behaviors of adolescents, there is observed procrastination, inaction, and a perception of inadequacy. This is a factor that needs attention. Adolescents who do not take responsibility due to procrastination, inaction, and a perception of inadequacy may develop a negative perception of the future. Similarly, adolescents have expressed negative statements such as economic anxiety, future anxiety, negative perception of social order, and thoughts of uncertainty. While waiting for the future, adolescents plan activities to achieve their goals and evaluate the likelihood of achieving them. Emotional components, whether positive or negative, can motivate life planning, decision-making processes, and behaviors by reflecting how much they believe they can influence their future. Having a positive or optimistic orientation toward the future can help adolescents make decisions while preparing for adulthood. An adolescent with a positive future orientation is more willing to set goals, make plans, and be successful in problem-solving, tolerating disappointment, or maintaining flexibility (Neblett & Cortina, 2006 ). Therefore, studies focusing on encouraging adolescents to make optimistic evaluations and plan for the future become crucial. When the statements of the participants are evaluated in the context of the stages of the WDEP system, it is seen that the psychological and physical needs of adolescents mostly create their wishes. Again, avoiding responsibility is a risk factor for adolescents who think they need to strive for their goals and be action-oriented. however, adolescents prefer their plans to be action-oriented rather than emotion-oriented. In this respect, it can be emphasized that when working with adolescents, the WDEP system will contribute to their awareness, that responsibility should be taken into consideration and that it is important to be action-oriented with plans.

Lastly, adolescents have emphasized the fundamental nature and necessity of all psychological needs and used metaphors to convey this. Adolescents who do not have their psychological needs met are reported to experience emotional and behavioral problems, struggling to establish and manage relationships (Glasser, 2014 ). In a study, adolescents expressed a greater need for freedom and a lower need for power and control as fundamental needs. It was found that girls expressed a greater need for love and belonging and a lower need for entertainment compared to boys (Harvey & Retter, 2002 ). Another study found a positive relationship between adolescents’ psychological well-being, psychological needs, and positive outcomes (Hamurcu & Sargın, 2011 ). Research supports that as psychological needs are met, subjective well-being, motivation, life satisfaction, and the desire for learning increase, leading to more successful initiation and maintenance of relationships (Demirbaş-Çelik, 2018 ; Guo, 2018 ). Therefore, the opinions of adolescents regarding the satisfaction of their psychological needs in the future are highly important. In studies examining the level and satisfaction of psychological needs, it has been found that as psychological needs are met, aggression, submissive behavior, and exam anxiety decrease, while motivation, life satisfaction, the desire for learning, and competence increase (Hamurcu & Sargın, 2011 ; Maralani et al., 2016 ; Guo, 2018 ). One of the strengths of this research is the use of metaphors to express psychological needs. Metaphors created separately for each need have specific meanings and qualities. Metaphors are powerful mental maps that can be learned, helping individuals make sense of their lives. No studies have been found in which adolescents’ psychological needs are expressed through metaphors in the literature.

Implications for theory, research and practice

This study provides some important suggestions for new research. Within the scope of this research, suggestions for both research and practice are included. Adolescents’ awareness and healthy fulfillment of their psychological needs are seen as factors that can contribute to the development of a positive future outlook. Therefore, when working with adolescents, interventions focused on understanding and satisfying their psychological needs can be designed. Elements within the quality worlds of adolescents and the total behavior that forms their emotions, thoughts, and actions are seen as influential factors in shaping their perceptions of the future. Consequently, professionals working with adolescents may consider focusing on their cognitive and emotional states, working with distorted cognitions, and supporting adolescents in emotion regulation. In interventions aimed at planning the future with adolescents, the Reality Therapy WDEP system can be employed, especially to understand the status of their desires and aspirations. Metaphors can be utilized to explore the meanings adolescents attach to their psychological needs. Furthermore, based on the guidance of research results, intervention programs can be developed to assist adolescents in forming a positive future outlook and addressing their psychological needs in a healthy manner. Finally, it’s worth noting that this research was conducted in a qualitative design. Future studies could be planned using a mixed-methods approach, incorporating quantitative or experimental designs into the process.

Methodological limitations

The research findings and recommendations come with certain limitations that should be considered. Firstly, the study is exclusively designed in a qualitative manner. Given the qualitative nature of the research and the sample size, different designs may be needed to explain individual variations in experiences related to factors such as age, gender, and birth order. Additionally, the sample is limited to Turkish adolescents. Including different cultures and developmental stages in the research could provide a broader perspective. Lastly, the future outlook and psychological needs are presented from the perspective of reality therapy. Evaluating cases in different theoretical contexts could contribute to the development of a more comprehensive knowledge base for professionals.

This study has evaluated adolescents’ perceptions of the future and psychological needs in the perspective of reality therapy. The adolescents who participated in the research exhibit both positive and negative expressions that can be assessed concerning their perceptions of the future. Moreover, adolescents place importance on needs such as love and belonging, power, freedom, and entertainment, attempting to fulfill them through various means. The study contributes to the literature by examining adolescents’ experiences in the context of the four psychological needs of reality therapy. Additionally, it is observed that adolescents feeling internal control, and having positive emotions and thoughts that constitute their quality worlds and total behaviors are crucial. Finally, it can be stated that the WDEP system is functional in understanding adolescents’ perceptions of the future.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on request.

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Dursun, A., Canbulat, N. Examining the experiences related to the psychological needs and future perceptions of Turkish adolescents on the basis of reality therapy: a qualitative study. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06288-8

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