Last month, following Sushant Singh Rajput’s death, I wrote on mental health on several different platforms including YKA. As a sufferer and supporter, I felt the need to, because the vacuum around mental health awareness is deep, despite all the dialogue. I received quite a few emails asking for a follow-up post (I had promised one in the original article), elaborating on the aspect of counseling/therapy (note: there is some distinction that is made between the two and I will come to that).
I have close experience with both; I’ve gone through counseling/therapy in two different nations, India and the US, and my experience with it spans two decades (meaning, I have seen therapy and outlook towards therapy evolve, especially in India). So, having established that, below are a few points I would like to note.
1. Life coaching, motivation, prayers together, meditation groups, etc. — Helpful but not, in most cases, equivalent to psychotherapy or psychological counseling
2. Finding the right fit is key but hard
3. There exists a whole spectrum amongst the practitioners: the good, the very good, and the worse than bad, aka the ineffective
4. Availability, accessibility and affordability of therapy till date, aren’t ideal
The key distinction between therapy (psychotherapy) and counseling (psychological counselling) is that the former is long-term and targets a broader range of issues. The biggest problem, particularly for therapy, which is what a clinical sufferer (vs a situational worsening of mental health) will most possibly benefit more from, is that there exist many different kinds and techniques of practice. As per reports for India, highly-specialised courses, for even psychiatry, are limited (to two in most cases: Geriatric, and Child and Adolescent). So, it’s no surprise that mental health professions further lag in specialisation and the know-how of therapy.
As WebMD notes, finding the right therapy technique is as important as finding the right fit (therapist). And I don’t believe that this is an definitive science, at least not yet. To complicate matters further, not every therapist specialises in each of the techniques. It is difficult to find practitioners of some techniques, especially in India.
For example, someone who practises cognitive behavioral therapy (or techniques of the same) can be found relatively easily (a lot exists on this on websites and mobile apps as well). But for something like EMDR (Eye Movement Desensitisation and Reprocessing) — a highly effective technique for trauma and trauma-related anxiety — finding therapists who offer this as treatment is hard, although professional organisations of the same exist in India.
So, even when a recipient is able to come up with a suggestion (now, this requires quite some awareness and resourceful reading off-course), if the therapist doesn’t specialise in it, there is no way to try it out without changing services. Which means, going on a hunt again.
Why is this an important consideration — most fundamentally, because therapy (and even counselling) takes time, and it takes trial and error, especially in complex or prolonged clinical cases, to find a method that works. It takes quite a few appointments for people to even get comfortable, let alone gauge the effectiveness of it all.
Combining this with the mental barrier that many continue to have (asking for mental health help is a sign of weakness) and ignorance-driven mental health, this means many will quit before results of therapy can be achieved. I have heard the following repeatedly, and I am sure many of us have: what can a therapist tell me that I don’t already know? Or I just go sit and talk — this is all nonsense. True, several methods such as Rapid Transformational Therapy are emerging, which might show quicker benefits. But again, there’s still time for such offerings to become widespread and effective for all.
Now, let me come to point 1. Talking helps, as do techniques such as meditation, group discussions, being a member of a group where you can share. But a lot of what is out there today — flashing up constantly as Facebook ads – is not medical treatment. In the US, this becomes a bit easy to demarcate as, in most cases, life coaching and other such services are not covered by insurance (and therefore, almost impossible to afford as a recurring treatment by many). But in India, this is a space that needs to be watched very carefully.
Again, I am not at all saying that such practices are bogus. But that there is a propensity (because of the spectrum that exists in mental health and the confusion between situational and clinical mental conditions) to think that everyone will feel better through yoga workshops or by talking to someone who can motivate them following a self-developed (albeit potentially well-researched and tried) system. Especially when the stigma is high and so much is unknown, a clinical sufferer might face extremely discouraging and detrimental consequences if they and their family members are made to have incorrect and unrealistic expectations.
Therapy involves specific techniques and has a course (like medication), and should be done by professionals specifically trained and licensed for the same. They will know when to call for intervention (medication or other), which, in most cases, non-professional support groups, confidantes and coaches won’t be able to, even with the best intentions.
I already mentioned fit, but let me share a couple of real-life scenarios to elaborate further. I will also make the third point while doing so. I saw a licensed counsellor for three years who had the best of intentions, but not the right skills needed for my then worsening clinical condition. And I didn’t have the expertise to understand that a psychotherapist specialising in a certain kind of therapy, and not a counsellor for trauma and family counselling, is what would work for me. I didn’t even know enough to think of doing a web search.
Result? I spent hours over a span of years with my counsellor talking, which was akin to venting (it did help a bit, and that’s the danger because that keeps us misguided and bound to something ineffective). I did not get the treatment I needed. I realised this only after I was forced to find a new therapist (because this practitioner’s office shifted), and found a new technique that worked.
I have several close contacts who have had a similar experience. One saw seven therapists in five years, and all of them admitted that they don’t have the skills to address his diagnosed condition best. This is a better outcome. In most cases, people will not tell you this. So patience, determination and faith in the process are needed.
Now, availability, accessibility and affordability. In the US, there isn’t a shortage of therapists per se. But still, there aren’t enough. The average waiting time I know of for an intake (first-time appointment) can range from weeks to months — unless you use EAP (Employee Assistance Program)/workplace provided assistance, which most people are reluctant to avail. Also, as mentioned, therapy has to be paid for by insurance, and therefore, you are further limited as not all therapists take all insurances.
In the Indian context, the challenge is quite different as of now, which is of having enough number of highly-skilled and trained mental health professionals who can meet the demand. As per a 2018 report in Times of India, the entire mental health workforce stands at 7,000 against a requirement of 55,000.
In March-April 2020, as the COVID-19 lockdown caused a mental health havoc, friends of mine were able to find only one or two therapists who had appointments available. Last year, a close contact was able to find only one service after months of search that she could feasibly drive to in a city such as Bangalore. Most of the access and availability is through social justice organisations, corporate workplaces and non-profits.
So what is an alternative when someone is going through a tremendous struggle and needs urgent help? I have explained in the previous article on why most will not be able to open up to friends or family, especially in case of serious clinical manifestations of conditions such as depression and suicidal ideation.
Well, the problem is, there is no perfect one yet.
One option is indeed finding immediate relief through government and non-profit helplines. Yes, many a times, the phone line will go unanswered (I have tried quite some to test), but they get answered too, and help is made available. Yes, the question of fit for longer term continuity and effectiveness will remain, but something is better than nothing.
Second (and there is no alternative to this) is to be self-aware. There are a lot of forums available on the internet, which, if veritable, provide excellent guidance, articles and peer-to-peer support (e.g. myptdsd.com). Often, folks on these forums have a much higher level of experience with clinical conditions, and therefore, have the understanding that some situations will need medical intervention. This is because many are diagnosed sufferers themselves. Even lurking and reading through these can help, because the sufferer or supporter will start realising that their condition can indeed be a medical one.
Now, finding a veritable forum and doing a lot of background research online is critical. Many feel that reading up on symptoms makes it seem like you could possibly have all sorts of disorders. It is important to understand that the goal is not to self-diagnose, but to become aware of what lies out there and when to seek help (for example, the distinction of being fully functional vs non-functional or seriously limited; situational vs clinical).
Disclaimer: I am not offering medical advice here and am not advocating not seeing a medical professional. The later is what I am absolutely suggesting. This is just a method to supplement (or find interim respite while waiting for) an effective therapist.
With the lockdown, most counsellors and therapists in the US as well as many Indian metros are now available online. For availing therapy online in India, privacy and access to technology (high-speed internet, device etc.) obviously are a concern for a lot of folks. There was a recent Huffington Post India article that goes into depth of the same. However, it is also true that mental barrier to availing counselling and being comfortable is seeking professional help is still the biggest challenge to overcome, not logistics.
App therapy services are also becoming quite a thing (e.g. Betterhelp, Talkspace, Seven Cups and such). Although availability in India and expense might be a short-term issue, given the huge demand vs supply gap, they are bound to be targeted soon in the Indian market. Combined with online, they can do a lot to address the shortage, specialisation and fit challenges when it comes to choosing practitioners.
Yes, some shortcomings (e.g. the comfort factor of in-person can’t be denied) will exist, but there can be benefits too. For example, concerns of stigma and commute (travelling to and walking into) a practice repeatedly, facing glances while waiting on a bench (I have faced this first-hand, so I know) can be averted. Also, working online, an understanding of what works and what doesn’t, and identification of a path forward, switching, or dropping can be easier.
All said and done, the only way is a constant increase in societal awareness (which off course also promotes the aforementioned self-awareness in a sufferer or a supporter). We need to become conscious of physiological and clinical manifestations that are behavioral and mental and seek professional help. We need to be aware that help exists but will require patience. As this happens, the barriers around psychotherapy will start dissolving.