A, a 42-year-old editor based in Bengaluru, had already been dealing with anxiety because of a toxic workplace when she was diagnosed with early signs of obsessive compulsive disorder (OCD) in March. The psychiatrist prescribed her a course of medicines, after which she was advised to meet a therapist.
But before she could book an appointment, the coronavirus pandemic hit India and the government announced a strict national lockdown. This meant that most private offices, including those of therapists, were shut down. As many therapists switched to online sessions, A decided against setting up the meeting for now.
“I don’t know the therapist, so I’m not sure online is the best medium to forge a new therapist-patient relationship,” she told HuffPost India.
23-year-old Manikuntala Das has similar doubts. She had a tough time last year after losing her job in Mumbai and dealing with delayed salaries. While she did find a job in her hometown Kolkata, the shift triggered her anxiety and depression.
“I could not adapt to this change easily, giving me sleepless nights, breathing troubles and a feeling of loneliness. So I decided to consult a therapist to help me cope with this,” she said.
However, she has decided to delay this now, as she feels uncomfortable talking into a screen.
While the shift to online therapy was essential, many Indians—both those seeking therapy as well as the therapists on the other side of the screen—are struggling to adjust to discussing their thoughts and fears without being in the same room. With mental health still not given the priority it deserves in the country, the sudden change has dealt a setback to those who were planning to seek help.
Those who have taken the step or are continuing their regular sessions report other challenges, like the lack of space and privacy in their homes, as well as feeling the need to save money out of fear of losing their jobs in the Covid-19-induced economic crisis.
“Mental health is not something that people are even focusing on… their focus is on food and other basic necessities which is much more important at the moment,” said Mumbai-based psychologist Tanya Vasunia.
About 50% of her clients, she said, had dropped out of therapy because of various constraints.
Unfortunately, the hesitation to try out online therapy is occurring as the prolonged lockdown and constant worry and consumption of bad news heightens anxieties, not just in India, but around the world.
““Even when the person walks in, my body language, the conversations that happen around the person coming in... You don’t get opportunities for that in the online format"”
Is it really difficult to connect?
Bengaluru-based S had taken just one online therapy session before the lockdown, because she wanted help with some issues she was facing with her parents. While the 20-year-old was able to speak about some problems during the session, she said she is not likely to continue them.
“I didn’t feel entirely safe, (I had a) constant fear that someone would barge in or overhear. I would’ve prefered face to face… The money I spend on it just doesn’t feel justified if I don’t do it face to face,” she said.
Many therapists are also negotiating the challenge of building a rapport with their clients online.
“Even when the person walks in, my body language, the conversations that happen around the person coming in, there are simple niceties like ‘let’s have some tea together’, some icebreakers. You don’t get opportunities for that in the online format because everything is timed,” said Delhi-based counselor and psychotherapist Vaishali Rathore.
Getting to know a client also can take longer for therapists during online sessions.
“The bonding takes a little longer and I’m very open with my clients about that. I find that online transactions are not as beneficial as they are in person and I’m very aware of it. So I tell them, ‘give me a little bit of time’. It also leads me to ask a lot of personal questions, which I would otherwise wait for them to to tell me,” Vasunia said.
The big privacy question
For many people in therapy, especially those at home with families that don’t understand, the lack of space and privacy at home can become a barrier. Many people who seek help do not tell their families or don’t want to be overheard.
“A lot of people had to drop out, not just because they were not comfortable, but also they don’t have privacy at home, because you need to be in a safe and secure environment,” said Asmita Sharma of Antaraal, a Delhi-based organisation that provides psychotherapy and counselling.
This is relevant not only for individuals but to people undergoing marriage counselling or family therapy.
“Finding space in the house where you would be all by yourself, not disturbed, no distractions and also the fear of being heard by the other person because you would want complete privacy. I think that has been my biggest challenge.” said T, a thirty-year-old journalist in Delhi, who has had several sessions of therapy and marriage counselling since December 2019.
Among distractions, she counts vehicles honking, dogs barking outside and even her own dog trying to barge into the room.
A small space of one’s own in a luxury in many Indian homes, even if all you need is a moment to yourself. Make it an hour to speak freely to your therapist, and many people may be looking at the impossible.
“Space and privacy are a luxury and it’s very hard to have that,” Vasunia said, describing how she even has a client who speaks to her from the bathroom, lest anyone hear them.
The loss of business and jobs because of the economic crisis has also brought financial concerns to the fore for many people. While this may put additional stress on those already struggling with their mental health, many have had to drop out in a bid to save money.
Sharma said that she is working with some patients pro bono or with low fees, but there are limitations.
“Some people are not comfortable with loaning money and prefer to pay the full fee and not some of it. In those cases I have to respect their wishes, that they do not want to feel that sense of indebtedness,” she said.
Paying online could also be a problem, especially for students and others dependent on someone else for money, Many students, especially, save up money without telling their parents to pay for sessions. Some of them don’t have bank accounts or have joint accounts with their parents. This means that they cannot pay right away.
While the experts who spoke to HuffPost India said that they were trying to find a workaround solution, there are many therapists who only work with advance payments, which is likely a constraint for many at the moment.
The right setting
Many therapists feel that nothing can replace the experience that you have when you meet your counsellor or therapist in person.
“There is value about someone actually making time and space within a particular setting. A lot of my clients talk about how when they come into the centre, when they come and see us in person, there is this space that they don’t associate with anything other than just being able to share their feelings. And that itself has a very positive association for people. If you’ve come to a place and you have found comfort you are likely to have a positive association with it,” Vasunia said.
Sometimes when one associates one’s home with bad memories or trauma, it is tough to find a sense of comfort and express honest feelings about it when you’re in that space.
Physical cues, such as body language and hand gestures, are crucial in human connection and communication. How the other person is reacting physically while speaking can communicate a lot about how they’re feeling and what they’re thinking. Like patients need the affirmation that their therapist has understood what they were trying to communicate, therapists also need to observe the physical reactions of patients.
“For example, sometimes a client may be smiling, but if their shoulders are tense, you know something has triggered something and when you mention it to them, it helps them kind of reflect on it. All those tiny bits of biofeedback make a significant difference in the therapeutic setting. Doing this online is quite difficult because you don’t get the input as quickly and you don’t get the feeling as easily. Because you only see a person from the neck up most of the time,” said Vasunia.
She said that a patient’s personal hygiene and appearance can also be an indicator of their mental health.
And for those who have psychotic disorders and need constant guidance, interacting online can be a challenge.
“A lot of the symptoms or warning signs we get are by seeing them physically. They find it much harder to interact with the screen. Often, they find it difficult to engage in person in general, so for them to engage over the screen is even harder. Also, you will be unable to tell their personal hygiene or whether they are actually focused on you,” Vasunia added.
When patients have low motivation, therapists work out ways to bring about change. That becomes difficult online.
“Definitely, meeting in person gives you more opportunities to understand everything and gives the therapist also more influence and more power to influence change in the person’s thought process and belief systems,” said Rathore.
“There are often glitches in connectivity, or of sounds and we’re at a crucial juncture and we might be dealing with something particularly intense and we lose each other, it disrupts the pace of the work.”
A bad internet connection or technical glitches can mean a world of difference not just in crucial work meetings, but also your therapy sessions.
“Most people are working online now, there are often glitches in connectivity, or of sounds and we’re at a crucial juncture and we might be dealing with something particularly intense and we lose each other, it disrupts the pace of the work. That can be challenging, at times, both for me and the patient,” Sharma said.
While it may seem easy to go back to asking the same questions, experts say that it’s not the same. In a therapeutic setting, losing out on the cathartic moments can take you several steps backward.
Vasunia described what losing out on such a crucial moment during therapy looks like.
“I remember a client, who was unfortunately having a really tough time, and they broke down. They were saying something very important which was very key for me to hear, but then, all of a sudden the sound went off for a few seconds. I lost that bit of information. Now, I can ask them to repeat it but I will never know if it is exactly what they had said within the heat of the moment or whether this is their edited version of what they had said.”
Given the constraints that their patients are under at home, therapists and counsellors have had to bring about a huge change in their work schedules to accommodate their patients.
Sharma usually likes to have her patients take appointments a few days in advance. But given the situation, she is working around it now.
“Some of my clients can get a private space for a short while, and they inform me a day in advance or a few hours in advance and if I have time, I will offer it to them. Or they can write to me and I can message,” she said.
This has led to an increase in work hours and subsequently, exhaustion.
“We are one of the few professions who have been working continuously throughout the lockdown. And the work is difficult. So one of the by-products of working online is, a lot of us are saying it’s way more draining to do sessions online than it is in person. Because you’re working 10 times harder to focus, you’re trying to read any sort of small signals you can, it’s a lot,” Vasunia said.
They’ve also been dealing with their own personal worries and economic anxieties and trying to plan for the future.
Is it all doom and gloom then?
Not at all. While there are difficulties in adjusting to a new normal, mental health is a priority. If you can afford to, it’s worth sticking to the online sessions and focusing on the silver linings. HuffPost’s Lindsay Holmes has some suggestions here on how to make the most out of online therapy sessions—some of it may not be applicable to an Indian context, but it could be a start.
There are other moments of joy as well.
Journalist T, who lives an hour away from her therapist’s office, says she is able to concentrate more on her thoughts because she doesn’t have the hassle of travel.
“I’m more focused on what I want to say and more in anticipation of the therapy instead of being tired after travelling for an hour and then spending the next five minutes trying to gather my thoughts,” she said.
Sharma has noticed that some of her clients are actually able to express themselves better because they’re not conscious of someone observing every gesture and word.
“With some (clients) things have improved because they are less aware of my presence and can better express themselves on what they are going through because they are in their own familiar spaces,” she said.
Many people who have been in therapy for a long time and know their therapists well have also settled into the rhythm.
Vasunia also experienced something unexpectedly positive during a session.
“I had a client a few weeks ago who was sitting in his bedroom and he was like ‘this is where I spend most of the time. When I was telling you I had a panic attack, I was sitting on the floor’. So he actually turned the camera to show me where he was. So they use this as an opportunity to to really let me see their world, and I really appreciate and respect that because it helps me understand and visualise when they are talking about it,” she said.