The socio-political turbulence in combination with the Covid-19 pandemic has unveiled a plethora of issues in India. Loss of homes, livelihoods, and loved ones; the uncertainty of life and death; physical isolation; inaccessible health services; forced cohabitation, and surfacing of past trauma has escalated our otherwise slow drift towards a mental health crisis. While these may appear to be problems of individuals, they are all outcomes of conflicts and differences within and between social groups. Despite all the inequalities, mental health difficulties have affected individuals and communities across the caste-class-gender spectrum for decades, but remained invisible until recently. The mental health system in India, however, is not fully equipped to meet a mental health challenge of this magnitude. The need and demand for mental health services stand at a huge gap from its availability, accessibility, and affordability.
Group Analytic Psychotherapy is uniquely positioned to bridge this gap in several ways. It helps recreate an individual’s experience of a group or a community within the therapy group. This simulation of a community offers a safe space for many people to come together and collectively make sense of their inherited narratives, explore intolerances, question, compare and challenge social norms, resolve conflicts, form attachments, cope with losses, experience safety and belongingness, and integrate into the community. The group analytic approach is economic, faster, diverse in its application, and addresses the problems right where they emerge from – in a group.
Fateema’s therapy is being terminated. The charity she seeks therapy at has no funds to support their overworked staff team and is being shut down. In addition to bearing the loss of the relationships she developed with her therapist, Fateema worries that she will not be able to find a therapist who will accept her for who she is. Fateema , 27, is the bread-winner of a lower middle-class family who identifies as a lesbian.
Rahul is a young man brought up in an upper class, upper caste Hindu family. He recently ended a relationship that was violent and abusive. However, he finds that most people in his immediate social circle, and his family are dismissive of his experiences and is told to “man up”. Rahul seeks therapy, but is soon discouraged when his therapist is also dismissive of his experience.
Both stories are a testimony to the fact that mental health difficulties do not discriminate against, or favour any socio-economic group. When individuals like Fateema and Rahul break out of the dense cloud of stigma against mental health and reach out to seek help, they are faced by a system that is inept in meeting their needs. Who will bridge the gap between Meena and a responsive mental health system that understands and caters to her needs in the society? Before we even delve into the ‘how’ of it, let us examine this gap closely. We sat and thought a lot about the mental health gap. Our close analysis zeroed in on 5 major areas where the gap needs bridging. Group analytic psychotherapy has a high potential of bridging all of these gaps. Let’s see how.
All of us may need a mental health practitioner’s help at some point. Even if we break out of the stigma of reaching out, are there enough practitioners to cater to us? According to a report by the Ministry of Health and Family Welfare, India is looking at a treatment gap of 50% to 70% in mental health care. What does this mean? It means that there are about 3 psychiatrists per million people in India – most of them located in urban areas. The acceptance of a biomedical model of treatment restricts the conversation to psychiatric care and diagnoses. While specialised and varied modes of therapy slowly gain traction in the country, these services often fall outside the ambit of what is accepted as mental health care, often restricting their reach to a limited and rather homogenous population. The silver lining is that these numbers change drastically when therapists practice psychotherapy in groups. Why should we go to groups, you ask?
The Mental Health Act (2017) defines the right to access mental health care and treatment as the availability of affordable and good quality treatment that is available in sufficient quantity and is accessible geographically. It is also mandated that every insurer make available medical insurance for the treatment of mental illnesses as they do for physical illnesses. Despite this mandate, the budget allocated for mental health care in the country makes for about 0.04% of the total budget for health care in the country, out of which an even smaller portion is utilised for implementation. With the lack of government spending in the field, funding for mental health care falls into the hands of private practitioners and philanthropists. With a single session of therapy priced anywhere between ₹1500 and ₹4000, about 80% of those with mental health difficulties find themselves unable to access the required support. Moreover, this provision for insurance was written with the biomedical model in mind. It neither takes into account the links between mental health, discirmination and poverty nor does it provide for various modalities of mental health care; leaving insurance providers to adopt the same mindset. So, until we get policy makers to diversify their approach, group psychotherapy might provide temporary respite. With the potential of the same physical space and practitioner being tapped into the same time to cater to multiple people, the cost of availing psychotherapy is cut into half.
A quick research into the state of mental health care in India and you will most likely find articles and journals on the state of psychiatric care in the country. The scope of mental health care has expanded to include counselling psychologists and maybe psychiatric social workers. However, existing data and research still tends to focus on psychiatrists in the country and how psychiatric training may be improved to eliminate the stigma on mental illnesses. Training for mental health practitioners in India is still geared towards an effective identification of symptoms and behaviors of the “mentally ill”. Most mental health practitioners in India (excluding psychiatrists and clinical psychologists) continue to work without a formal license. The training for these practitioners (counselors, psychotherapists, social workers etc.) often ends with a masters degree (unless one decides to pursue further training on their time and dime) – making access to inclusive and socially conscious therapy a luxury. Training in psychotherapy helps bridge this training gap and enables mental health practitioners to think outside the box that their dated education had put them in. It helps look at the socio-cultural and economic context of individuals as key in their stories. It helps appreciate people as people, and not merely as a set of symptoms or labels.
Mental health care as it exists now views the narratives of its seekers in a linear framework. This framework often looks at “care” as an expert lead intervention where the desired goal is to function as a neurotypical person. Such a narrative renders those who seek therapy vulnerable and subject to a power hierarchy within a therapeutic relationship. It also tends to overlook the large socio-cultural and political contexts in which all of us (therapist included) function. In a group analytic setting, along with the guidance of the therapist, one would be able to draw from and contribute to experiences and feedback of fellow group members. This would ultimately allow for the expression of diverse perspectives within the therapeutic relationship. Like a microcosm of a society, our behavioural and relational patterns play out in the safety of the group.The group helps to discuss, appreciate, and tolerate the disparities and differences between us, encourages us to challenge stereotypes and social norms, and offers an experience of belongingness. This would help bridge the gap between the patient and the “expert” and offer a grounding experience that benefits both.
Our experiences and the emotions they incite, the patterns we develop, the coping mechanisms we fall back on are often located within us and our immediate relationships with others. However, we are also impacted by the larger social/public occurrences that we have no control over. The pandemic serves as a brilliant and obvious example here. But, not all sources of distress are obvious – eg: microaggressions towards those of a particular caste, class, gender and sexuality. Viewed in isolation, we end up underestimating our distress in such situations and often use it as a justification for not reaching out for support. We may also think that we are alone in dealing with our problems, and that no one else goes through such difficulties. Everyone has a story, everyone’s distress matters. On acknowledging that social context influences our emotions, thoughts, feelings and interactions, we must also acknowledge the need for interventions that focus on providing social support to those in distress. Groups address this need and lays the foundation for forming collectives that make the acknowledgment of mental health as a continuum possible.