This article is part of a series that will explore how marginalisation and oppression can affect an individual’s mental health.
Apprehensions before starting therapy are not uncommon. Unlike a medical exam with a doctor that ends in 15 minutes, therapy is an intimate deep-dive into an individual’s life. A quote about how it’s about the journey may romanticise a scientific practice, but the reality is that the exploration that occurs during the process is as good as a journey because the individual is unlearning, relearning, evaluating and transforming narratives of their lives. Additionally, when a patient finds a right fit for their symptoms and stressors, the process becomes seamless and there is less room for exploitation.
The emphasis on therapeutic alliance is a part of the therapist’s training and is necessary for therapy to work. It’s about recognising patterns, understanding the impact of traumatic experiences, becoming acquainted with words like ‘gaslighting’, ‘depression’, etc., gaining agency through psychoeducation and jointly developing a treatment plan. Not everyone seeking and providing therapy is fixated on a diagnosis, but a focus on treating stressors is always crucial. We discuss how anxiety is a natural response when the body is attempting to protect itself. It is obvious that anxiety and suspicion are congruent with the mental state of someone seeking help for issues that are largely stigmatised and unrecognised in our communities.
Dismissing confidentiality
The discussion that follows is based on research founded on testimonies. The prompts include direct messages received on Twitter.
Confidentiality is a pillar of psychotherapy. Informed consent involves an exchange of information where the clinician should explain the contexts in which confidentiality does and does not apply. For example, if there is reason to believe an individual’s life is threatened by suicide or homicide, the clinician should clarify that they are required to report this information to the concerned authorities to protect the individual.
Such a conversation must happen at the beginning of the therapeutic relationship so that the individual is not taken by surprise or feel betrayed if information is disclosed. The dismissal of confidentiality leads to a rupture in the therapeutic alliance, and will likely deter the individual from seeking help with mental health issues again.
Quality mental-health care is composed of active listening, emotional processing and validation. In this framework, and in my experience, individuals frequently bring up gaslighting as an issue. Gaslighting includes individuals being told by their therapists that they’re being dramatic, asking them to “get over it”, blaming them for their struggles and creating an environment of shame and even withholding information.
Also read: Sexual Violence Trauma Is Complex Because It Impinges on Multiple Identities
In one of my interactions, one person revealed that he was blamed for being depressed because he identified as a member of the LGBTQIA+ community and told that he should make better choices. This particular community is very marginalised in India, which could be one of the leading causes of depression in itself.
When a source of support and help aids a cycle of oppression through ignorance, stigmatisation and invalidation, depression will continue to worsen, with additional feelings of hopelessness and internalised shame. In another instance, I was informed that a person wasn’t informed about a change in her medication and that it was incongruent with the diagnosis provided. This is clearly deception and can lead to severely internalised anxiety and a fear of being lied to. It could even result in some people refusing medication.
Over- and under-diagnosis
Therapy and psychiatric care are integrative but they also tend to overlap in India. Due to a shortage of psychotherapists and a heightened faith in medical professionals, individuals tend to seek therapy from their psychiatrists. Over-diagnosis can lead to overmedication, and also to additional stigma attached to specific diagnoses. As clinicians we are responsible for how we collect clinical data, monitor and educate the individual, and ensuring the treatment plan is adaptable. If we fail at keeping ourselves in check, we’re also endangering the people we are responsible for.
For example, one study, published in September 2017, found that doctors may have been over-diagnosing bipolar disorder in India. It concluded that self-reporting and the Diagnostic and Statistical Manual of Mental Disorders may not be the most reliable guides when collecting clinical data, and that patients have to be compulsorily monitored. In other words, doctors have to commit one hour every week to assess their wards. Under-diagnosis, on the other hand, can lead to poor management of the illness and poor access to resources, again endangering the individual’s health.
The larger and more diverse a population is, the more variegated the mental health issues as well as their stressors are. Marginalised groups are often taught to treat healthcare as a privilege, not as a right. However, good-quality healthcare is indeed a right.
Also read: Why We Need to Pay More Attention to Mental Health at the Workplace
At the same time, mental healthcare isn’t easily accessible in India, so if you’re reading this and feel averse to seeking help, remember that there are mental health resources that are reaffirming, supportive and dedicated to collaborative treatment approaches.
If you’re feeling uncomfortable with your current therapist, consider seeking a different one simply because you deserve better. There are plenty of clinicians who provide more efficient services.
It’s okay to take a step back after a bad experience with a mental health professional and normal to feel invalidated and failed by the system. Questioning one’s self-worth is at the core of numerous mental health stressors, and accepting poor services can tie into it. Help is often defined on the back of a Westernised model – with a power dynamic between a clinician and a patient – whereas there are other options for patients to develop treatment plans with. However, if a therapist/psychiatrist-patient modality seems worth a shot, try to utilise the anxiety and skepticism experienced at the beginning to your benefit.
For example, use the first few appointments to assess level of comfort, ask questions, clarify doubts and debate the approach the therapist plans to take. If a patient visits a doctor for an injured back and the doctor treats them for a sprained ankle, the mismatch is not going to yield the right treatment. Every clinician has their approach and finding the right fit is a process. Help needs to be interpreted and addressed in a language that the patient can understand and benefit from. It’s not an inconvenient method of practice. It’s the correct one.
Ruchita Chandrashekar is a licensed clinician in Chicago where she works with participants of a federally funded programme. Her expertise lies in LGBTQ+ mental health, sexual trauma and complex trauma recovery, mood disorders and personality disorders.