Mental health therapy in India exists in a highly stigmatized space; telling a loved one you need therapy often prompts them to ask if you’re crazy or to suggest alternative solutions, such as eating healthy or doing yoga and exercise. In such environments, accessing therapy becomes difficult. Stack on top of that the cost of therapy and the commitment it takes to see gradual results — which makes seeking help for mental health issues seems like an insurmountable feat.
It’s important to understand that mental health therapy is a process, and any process takes time, according to Dr. Anjendra R. Targe, a Pune-based psychiatrist. “It’s a process of exploring and understanding one’s own self; it’s a process of change and growth,” he said. “The revelations brought about in the process of therapy are life-changing, and are generally that which helps in finding people a ‘cure’ to their problems.”
This process, however, or rather the prolonged cost and effort to engage in it, combined with the difficulty of finding the right therapist (which can often be a trial-and-error ordeal), can be a deterrent for some — especially young people starting out in their careers who can’t dedicate a set amount of money per month to deal with any and all stresses.
“The session costs are pretty steep and one session is never enough. To go for prolonged sessions means dedicating both time and money. A good therapist charges an easy [Rs.] 1,500 to 2,000 a session,” said R.M., 25, who feels a need to go to therapy but thinks she can’t afford it. “Once, twice, it’s okay. After a point, it pinches your pocket and only results in more stress. And since it’s still a taboo in the society, I mean mental health, it’s not really easy to come out to your parents and ask for help.” Currently, R.M. uses journaling and searching for alternative coping mechanisms on YouTube and Google to deal with “anxiety, fear, future, a general mix of adulting things,” she said.
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What to Expect From Therapy, and What Not to Expect
A.G., 21, is an intern, and can barely cover the cost of commuting and basic expenses with the salary she earns. Having gone to therapy before, she understands its benefits but doesn’t feel like she can rely on her family to pay for therapy. “No one ever explicitly said they don’t want to pay for my therapy, but I know the circumstances my family is living in and the last thing I wanted was to become a burden,” A.G., said. “Avoiding therapy is adding to my difficulty in focusing; I get angry in a significantly shorter amount of time than I used to, and sometimes on useless issues. I’m following the same patterns [from before therapy?]: no relationship, constantly pushing everyone away, drowning myself in work.” For A.G., therapy is the “perfect solution,” but the barriers seem insurmountable. “Convincing people around you and you accepting that you need therapy along with understanding that it’ll be a long process and having the patience and commitment to regularly go to therapy are issues enough. And once you somehow tackle them, the cost adds to the issues further,” she said.
We need to create more awareness about the need for therapy in an individual’s life, not only among those who need it, but also among “parents/schools/companies/other institutes [that]fund people who aren’t able to pay themselves,” Dr. Targe said. The stigma surrounding therapy, and a dire lack of awareness about the process leads people to chalk it off as an added, perhaps optional, expense, according to Dr. Targe. He says there are several misconceptions about therapy that people have: “how can just talking help?” “I can do the same with my friends/family, too;” “it’s a waste of money;” “it’s a long process, and I don’t know if it’s worth it.” These notions make the cost of therapy seem even steeper, according to Dr. Targe, whose fees range from Rs. 1,000 to Rs. 2,000 per session.
The cost is a deterrent because there is a “general lack of self-awareness regarding the process of recovery from mental illness; stigma and misconceptions associated with treatment; a general lack of patience from the patients’ side and the desire for quick results; which is especially true in the Indian setup; lack of knowledge of what ‘therapy’ or ‘counseling’ entails,” Dr. Targe said. “Mental health is not prioritized, like other ‘physical’ chronic and debilitating illness for which patients are willing to shell out whatever is asked of them.” Many hold a general mistrust of sharing their problems with strangers, which further makes people believe the cost isn’t worth it, Dr. Targe said.
“Considering what the average young person — even if they aren’t financially independent — spends on leisure and other activities,” therapy isn’t that expensive, Dr. Targe contends.
The cost of therapy can also be adjusted depending on the frequency of sessions, which in turn can be increased or reduced depending on if the patient is experiencing immediate crises, Dr. Targe said. And the cost is set according to the amount of work both parties need to do in order to progress — “Therapy is constant work from both ends — the patient’s, and the therapist’s. The therapist can’t just see the patient from appointment to appointment without working on the individual patient notes and doing his/her research on it,” Dr. Targe said.
Related on The Swaddle:
All the Arguments You Need: to Convince People Therapy is Not a Scam
From initially free counseling sessions, to discounts, to installment plans, therapy clinics across India offer different payment models to patients, depending on their needs and the doctors’ availability.
Initially, Rahul Gohrani, 28, thought therapy was a stupid idea and that it was not for him; then, he thought he didn’t have the guts to speak about his issues to a stranger. When he got around these notions, the financial cost of therapy proved to be the final deterrent. Eventually, he found a clinic that offered a free session for first-timers. “I loved it, and realized it could help me in some ways,” he said. He paid Rs. 1,250 for the first two, and then asked for discounted rates, and has been attending therapy for Rs. 850 since. To his mother, however, Gohrani initially lied and said he was paying Rs. 500; otherwise, in his words, “she would have flipped.”
“First time, I was actually traveling, commuting to the therapist. I could only think about what therapy has been in the books and movies — Karthik Calling Karthik, Tuesdays with Morrie. It’s not like that — they don’t give you gyaan. They just make you talk,” Gohrani said, adding that all of his reservations around therapy, the mental block he had before, disappeared after the first session.
“When you fall sick, you have two options. Try a home remedy, take a steam, drink kadha. When it doesn’t work, you seek professional help,” Gohrani said. “When there’s something troubling you so much, but you’re scared, and if you speak up people will judge you. We always try to solve everything all by ourselves — [watch] YouTube videos, read on Medium, Google stuff, [keep] gratitude diaries, start by yoga. These are all secondary things. The first thing is that you have to have a concrete, reliable system of seeking help — and that’s a therapist.”
Bangalore’s NIMHANS (National Institute of Mental Health and Neuro Sciences) estimates that seven crore Indians suffer from mild to severe mental illnesses (not counting age-related conditions like Alzheimer’s and Parkinson’s). This works out to roughly one in 20 Indians.
Compound these figures with the burden of living in a stoic society mired by superstition and stigma that surrounds psychiatry, and you have a country on the brink of a mental health catastrophe. Never has it been more necessary or challenging to find a qualified mental health expert.
But, in order to find help, you must first overcome the reluctance to look for it.
“These are all American ideas,” the man says curtly. He’s been sitting silently so far, flipping channels on TV, while his wife tells us about their 19-year-old who was recently diagnosed with Manic Depressive Disorder after she swallowed disinfectant. She breaks down, saying her daughter had admitted that this wasn’t her first attempt. “There’s nothing wrong with her…ours is a good, religious, simple family. See our older daughter. She is perfectly fine,” he says before putting the remote down and leaving the drawing room of his Prabhadevi apartment.
Before the near-fatal incident, their daughter’s temper tantrums were put down to PMS and a particularly bad episode was treated with a consecrated thread and ring prescribed by the family guru. “Everyone has good and bad days. You don’t automatically assume it’s depression and drag your child to a psychiatrist,” says her mother.
A visit to the psychiatrist is largely perceived as an extreme measure.
Dr Yusuf Matcheswalla, who is affiliated with top city hospitals including JJ and Saifee, says awareness is growing. “Religious guides hold sway over Indian families dealing with any problem; more so when it’s a psychiatric one,” he says, adding, “But the scenario is changing rapidly. It’s not unusual now even for spiritual gurus to recommend complimenting their services with those of a professional counsellor.”
It has its advantages. It’s critical, after all, that the patient is comfortable around the psychiatrist.
When recommendations from religious guides carry so much weight, however, the proliferation of incompetent self-certified counsellors is hardly surprising. One life-coach this writer encountered online while researching this story offers his services via Skype or private chatroom sessions at Rs 2,000 per halfhour. He dangerously promises to “cure self-destructive tendencies and extreme mood swings” on the strength of little more than a sales background and a money-back promise. Other online counsellors promise “complete cure,” and “cure within minutes”.
The fee, we discovered, cannot be used as an indicator of qualifications because on average, professional therapists charge anywhere between Rs 500 to Rs 5,000 per 45-minute session. Fees at charitable centres trickle down to a mere Rs 5 per session. And the number of sessions varies too. “In the old days, psychoanalysis meant five days a week of 45-minute to one-hour sessions. And this would go on for years,” says Matcheswalla, “Now, it’s usually between five to 25 sessions, twice a week. The therapy may be tapered depending on the patient’s response.” Although session duration varies from case to case, most experts agree that anything under 45 minutes may be too little.
Online therapy may sound suspicious but Skype has become a valid tool for most psychiatrists today, especially since patients prefer to continue their therapy with the same doctor even when they relocate or are travelling. Consulting psychiatrist Dr Kersi Chavda, however cautions against prolonged chat-room therapy, “because there are so many facial cues that the doctor tends to miss online.” He doesn’t discount it completely though, saying such counselling can be life-saving when a patient is on the verge of suicide. “When in doubt, it may be wisest to stick to a psychiatrist affiliated to a hospital,” Matcheswalla prescribes, recommending that you check the expert’s credentials on a visiting card or letter head and cross-check these with regulatory authorities if need be.
Who’s your man?
But which expert must you turn to – counsellor, life-coach, psychologist, psychotherapist or psychiatrist – and for what problem?
Chavda explains, “Psychiatrists are physicians, authorised to prescribe medication. They study medicine and thereafter, specialise in psychiatry during their postgraduate years. A psychologist, on the other hand, is simply anyone with an MA in psychology; no medical training is needed. Both, psychiatrists and psychologists may practice psychotherapy after receiving further training in the area.”
Breaking it down further, behavioural and psychological therapist, Dr Nivedita Rawal says, “A counsellor is someone who offers brief therapy lasting six to eight sessions. This could be supportive therapy like in the case of helping a client improve relationships at work and resolve conflict at home.” A psychotherapist, she says, is qualified and trained in more intensive intervention. So, for cases of sexual abuse, Obsessive Compulsive Disorder (OCD), depression, Selective Mutism, addictions, suicidal ideation and couples therapy, you need to look for a psychotherapist.
“A psychologist should be approached for cases concerning dyslexia, dysgraphia, dyscalculia, ADHD, dyspraxia, since they are qualified to evaluate learning disabilities,” Rawal adds. A visit to a psychiatrist is warranted if medication is imperative as an adjunct to psychotherapy because medication alone can’t make a phobia, human conflict or loss go away. In cases such as schizophrenia, certain types of OCDs, psychosis and clinical depression, medication is needed to address the chemical imbalance that has occurred in the brain. “Post this, psychotherapy helps deal with real-life issues s/he may be facing,” she clarifies.
Affiliations and credibility
Although practicing therapists (that’s any of the above) need to be registered with the Rehabilitation Council of India, Matcheswalla says it’s not regularised yet. “It’s not uncommon for people to launch a counselling practice after completing a two-week course at a small institute,” he says. Rawal says a degree in psychology is not the same as one in professional counselling psychology. “The two are very different,” says Rawal, who’s in the midst of launching the Association of Psychologists and Counsellors (APAC), India, in affiliation with APAC Singapore, Hong Kong and Australia. “As a rule, a psychologist cannot treat a patient unless they have licensure to practice from a regulatory body because securing this requires a minimum of 1,000 hours of practicum training under logged supervision by a supervisor accredited by a licensing body. For every 60 hours of counselling work the psychologist engages in with clients, s/he is required to undergo 10 hours of clinical supervision. This is to ensure the highest standards of ethical and professional delivery. We deal with clients who are suicidal, going through a divorce or addiction. It’s not a job to be taken lightly.”
It was while interviewing candidates for her own practice that she realised the extent of the problem. “When I presented candidates with cases of OCD and anxiety disorders, beyond telling me about general psychometric tests, they could not give me a case formulation as to how they would treat the case,” the doctor shares.
Meanwhile, a helpline operated by the Tata Institute of Social Sciences received three times as many calls this year as it did last year, and the BMC’s mental health helpline continues to receive over 100 calls every day. A report in the June 2011 issue of weekly peerreviewed medical journal, The Lancet states that one in two adolescents globally suffers from neuropsychiatric disorders, that one in five has an emotional, learning or development disorder and one in eight has a serious mental disorder. Depression, bipolar disorder, alcohol abuse and schizophrenia, the report states, comprise, more than 45 per cent of the mental health problems faced by young people (aged 10-25). The mental health bomb is ticking. Time to snip the crossed wires of misconception?
THE QUICK SELECTION GUIDE
Questions you should be asking yourself before you decide if a mental health expert is right for you:
» What’s his/her training?
» What’s his/her speciality? Has s/he worked with people who have the same issues as you?
» Do you want to consider gender? Will you be more comfortable with a specialist of your gender?
» When you meet them, judge if you sense distraction (takes phone calls mid-session), a lack of connection (won’t make eye contact), judgment or criticism (seems surprised by what you say), a lack of patience. Evaluate his/her communication skills. If you sense tension in the first meeting, it’s not a good sign. If you leave more upset than when you came in, don’t go back. After all, their job is about passing on hope without making sweeping promises.
» Is s/he addressing accompanying conditions? Do you suffer from hypothyroidism or vitamin D deficiency which may be playing a part in depression? “What else could be causing this?” is the question a good psychiatrist asks.
» Is s/he keeping records? Is s/he accessible when you need him/her?
» What approach is s/he using? Is it 360 degree? Is s/he evaluating your diet, sleep patterns, stress triggers? Is s/he asking about relationships that are important to you?
THE NUMBERS
NIH (USA’s National Institute of Health) estimates that between 43 and 87 lakh Indians are schizophrenic. Between 1.2 to 1.5 crore Indians suffer from unipolar or bipolar disorder and The Lancet reports that as many as 1.4 crore Indians could be described as “dependent on alcohol and in need of help”.
One Indian out of 20 needs psychiatric help; 1 out of 3,00,000 is likely to find it. Here’s a guide to help you bag the right shrink.Bangalore’s NIMHANS (National Institute of Mental Health and Neuro Sciences) estimates that seven crore Indians suffer from mild to severe mental illnesses (not counting age-related conditions like Alzheimer’s and Parkinson’s). This works out to roughly one in 20 Indians.Meanwhile, the World Health Organisation says we have 0.301 psychiatrists for every 1,00,000 people. That’s one trained mental health specialist for 3,00,000 Indians.Compound these figures with the burden of living in a stoic society mired by superstition and stigma that surrounds psychiatry, and you have a country on the brink of a mental health catastrophe. Never has it been more necessary or challenging to find a qualified mental health expert.But, in order to find help, you must first overcome the reluctance to look for it.”These are all American ideas,” the man says curtly. He’s been sitting silently so far, flipping channels on TV, while his wife tells us about their 19-year-old who was recently diagnosed with Manic Depressive Disorder after she swallowed disinfectant. She breaks down, saying her daughter had admitted that this wasn’t her first attempt. “There’s nothing wrong with her…ours is a good, religious, simple family. See our older daughter. She is perfectly fine,” he says before putting the remote down and leaving the drawing room of his Prabhadevi apartment.Before the near-fatal incident, their daughter’s temper tantrums were put down to PMS and a particularly bad episode was treated with a consecrated thread and ring prescribed by the family guru. “Everyone has good and bad days. You don’t automatically assume it’s depression and drag your child to a psychiatrist,” says her mother.A visit to the psychiatrist is largely perceived as an extreme measure.Dr Yusuf Matcheswalla, who is affiliated with top city hospitals including JJ and Saifee, says awareness is growing. “Religious guides hold sway over Indian families dealing with any problem; more so when it’s a psychiatric one,” he says, adding, “But the scenario is changing rapidly. It’s not unusual now even for spiritual gurus to recommend complimenting their services with those of a professional counsellor.”It has its advantages. It’s critical, after all, that the patient is comfortable around the psychiatrist.When recommendations from religious guides carry so much weight, however, the proliferation of incompetent self-certified counsellors is hardly surprising. One life-coach this writer encountered online while researching this story offers his services via Skype or private chatroom sessions at Rs 2,000 per halfhour. He dangerously promises to “cure self-destructive tendencies and extreme mood swings” on the strength of little more than a sales background and a money-back promise. Other online counsellors promise “complete cure,” and “cure within minutes”.The fee, we discovered, cannot be used as an indicator of qualifications because on average, professional therapists charge anywhere between Rs 500 to Rs 5,000 per 45-minute session. Fees at charitable centres trickle down to a mere Rs 5 per session. And the number of sessions varies too. “In the old days, psychoanalysis meant five days a week of 45-minute to one-hour sessions. And this would go on for years,” says Matcheswalla, “Now, it’s usually between five to 25 sessions, twice a week. The therapy may be tapered depending on the patient’s response.” Although session duration varies from case to case, most experts agree that anything under 45 minutes may be too little.Online therapy may sound suspicious but Skype has become a valid tool for most psychiatrists today, especially since patients prefer to continue their therapy with the same doctor even when they relocate or are travelling. Consulting psychiatrist Dr Kersi Chavda, however cautions against prolonged chat-room therapy, “because there are so many facial cues that the doctor tends to miss online.” He doesn’t discount it completely though, saying such counselling can be life-saving when a patient is on the verge of suicide. “When in doubt, it may be wisest to stick to a psychiatrist affiliated to a hospital,” Matcheswalla prescribes, recommending that you check the expert’s credentials on a visiting card or letter head and cross-check these with regulatory authorities if need be.But which expert must you turn to – counsellor, life-coach, psychologist, psychotherapist or psychiatrist – and for what problem?Chavda explains, “Psychiatrists are physicians, authorised to prescribe medication. They study medicine and thereafter, specialise in psychiatry during their postgraduate years. A psychologist, on the other hand, is simply anyone with an MA in psychology; no medical training is needed. Both, psychiatrists and psychologists may practice psychotherapy after receiving further training in the area.”Breaking it down further, behavioural and psychological therapist, Dr Nivedita Rawal says, “A counsellor is someone who offers brief therapy lasting six to eight sessions. This could be supportive therapy like in the case of helping a client improve relationships at work and resolve conflict at home.” A psychotherapist, she says, is qualified and trained in more intensive intervention. So, for cases of sexual abuse, Obsessive Compulsive Disorder (OCD), depression, Selective Mutism, addictions, suicidal ideation and couples therapy, you need to look for a psychotherapist.”A psychologist should be approached for cases concerning dyslexia, dysgraphia, dyscalculia, ADHD, dyspraxia, since they are qualified to evaluate learning disabilities,” Rawal adds. A visit to a psychiatrist is warranted if medication is imperative as an adjunct to psychotherapy because medication alone can’t make a phobia, human conflict or loss go away. In cases such as schizophrenia, certain types of OCDs, psychosis and clinical depression, medication is needed to address the chemical imbalance that has occurred in the brain. “Post this, psychotherapy helps deal with real-life issues s/he may be facing,” she clarifies.Although practicing therapists (that’s any of the above) need to be registered with the Rehabilitation Council of India, Matcheswalla says it’s not regularised yet. “It’s not uncommon for people to launch a counselling practice after completing a two-week course at a small institute,” he says. Rawal says a degree in psychology is not the same as one in professional counselling psychology. “The two are very different,” says Rawal, who’s in the midst of launching the Association of Psychologists and Counsellors (APAC), India, in affiliation with APAC Singapore, Hong Kong and Australia. “As a rule, a psychologist cannot treat a patient unless they have licensure to practice from a regulatory body because securing this requires a minimum of 1,000 hours of practicum training under logged supervision by a supervisor accredited by a licensing body. For every 60 hours of counselling work the psychologist engages in with clients, s/he is required to undergo 10 hours of clinical supervision. This is to ensure the highest standards of ethical and professional delivery. We deal with clients who are suicidal, going through a divorce or addiction. It’s not a job to be taken lightly.”It was while interviewing candidates for her own practice that she realised the extent of the problem. “When I presented candidates with cases of OCD and anxiety disorders, beyond telling me about general psychometric tests, they could not give me a case formulation as to how they would treat the case,” the doctor shares.Meanwhile, a helpline operated by the Tata Institute of Social Sciences received three times as many calls this year as it did last year, and the BMC’s mental health helpline continues to receive over 100 calls every day. A report in the June 2011 issue of weekly peerreviewed medical journal, The Lancet states that one in two adolescents globally suffers from neuropsychiatric disorders, that one in five has an emotional, learning or development disorder and one in eight has a serious mental disorder. Depression, bipolar disorder, alcohol abuse and schizophrenia, the report states, comprise, more than 45 per cent of the mental health problems faced by young people (aged 10-25). The mental health bomb is ticking. Time to snip the crossed wires of misconception?Questions you should be asking yourself before you decide if a mental health expert is right for you:» What’s his/her training?» What’s his/her speciality? Has s/he worked with people who have the same issues as you?» Do you want to consider gender? Will you be more comfortable with a specialist of your gender?» When you meet them, judge if you sense distraction (takes phone calls mid-session), a lack of connection (won’t make eye contact), judgment or criticism (seems surprised by what you say), a lack of patience. Evaluate his/her communication skills. If you sense tension in the first meeting, it’s not a good sign. If you leave more upset than when you came in, don’t go back. After all, their job is about passing on hope without making sweeping promises.» Is s/he addressing accompanying conditions? Do you suffer from hypothyroidism or vitamin D deficiency which may be playing a part in depression? “What else could be causing this?” is the question a good psychiatrist asks.» Is s/he keeping records? Is s/he accessible when you need him/her?» What approach is s/he using? Is it 360 degree? Is s/he evaluating your diet, sleep patterns, stress triggers? Is s/he asking about relationships that are important to you?NIH (USA’s National Institute of Health) estimates that between 43 and 87 lakh Indians are schizophrenic. Between 1.2 to 1.5 crore Indians suffer from unipolar or bipolar disorder and The Lancet reports that as many as 1.4 crore Indians could be described as “dependent on alcohol and in need of help”.
