The covid-19 pandemic has pushed many of our physical life experiences into the virtual realm. Seeing a mental health professional is no exception. In the days of yore, a session with the therapist would involve commuting to their clinic, whiling away some time in the waiting room, then sitting in front of them for roughly an hour and speaking, before making the journey back home.
Cut to 2020 and it’s now possible to attend a session from the comfort of your own bedroom—if you are lucky—in your PJs, with a cup of steaming coffee at hand. “We have seen a 2x growth since the lockdown in the number of users seeking therapy,” says Divya Kannan, a clinical psychologist with mind.fit, an online platform that provides mental healthcare services.
Therapists of a certain provenance who believe in the primacy of physical proximity with their clients may be aghast at this shift to the virtual space but the move is far from an unmitigated disaster. “It’s true, there is nothing like a face-to-face session, but that’s no longer sacrosanct to the profession,” says Namrata Rynjah, a psychotherapist based in Guwahati. “On the contrary, a remote session can be immensely helpful for someone who may be feeling especially low or is unable to get out of bed.” There is the additional benefit, both for the therapist and the client, of scheduling sessions at mutually convenient hours.
Create your safe space
The practice of online therapy is not exactly new. Early adapters like Rachana Patni, a Goa-based leadership consultant who works psychotherapeutically, have used it to attend to clients from all over the globe. Although she works remotely, Patni likes to give her clients guidelines about how they should choose the space from where they speak to her and arrange it before every meeting. “They should ideally be in the same space during each session and clear it of any clutter,” she says. “It should be a spatially stable space and allow for their emergence in the process of the work.”
There are practical benefits to online sessions even when you are in the same city as your therapist. In cities like Bengaluru and Mumbai, where even a relatively short commute could involve wading through heavy traffic for an unseemly length of time, many people were happy to make such a switch before the novel coronavirus made it the new normal.
A media professional based in Bengaluru, who requested anonymity, spoke of her decision to opt for online therapy after tiring of the drive through dense traffic and bumpy roads to meet her counsellor. By the time she would reach her appointment, she would be drained. And then there was the tortuous drive back home. “I couldn’t quite process what happened in those sessions,” she says. “So I switched to Skype and got used to it quite easily.” These days she prepares herself in advance for a session by settling into a private space in her home, with a glass of water or notebook at hand. After the session, she takes out some quiet time to reflect on it before going back to her daily routine.
A large part of the transition to virtual therapy depends on the level of trust between therapist and client. The worst discomfort is usually tied to the fact of not being able to “see” one another in a real physical space. Therapists often worry about not being able to make sense of clients without seeing them, says Hena Faqurudheen, a Delhi-based psychotherapist. Body language, physical cues and the need for human connection can be potent factors in evaluating the state of a client’s mind. And yet, the advantages of taking the practice online are tangible too, especially when it comes to enhancing inclusivity for clients.
“Think of how many disabled persons cannot access therapy due to the unfriendly spaces they have to navigate to get to their therapist’s office,” Faqurudheen says. “So many people’s access to therapy has been hampered by ableism. And I am not necessarily referring to people in wheelchairs, but to those who may be agoraphobic or have social anxiety, for instance.”
Online therapy has brought the world closer in other ways too. In the early days of the pandemic, especially during the extended lockdown, Faqurudheen did pro bono work with students from small towns in Uttar Pradesh. Many of these young people, who were suffering from anxiety attacks, were unable to step out of their homes to seek help. Oddly, a public health disaster enabled them not only to “see” a therapist, but also one from the Capital, miles away from where they live.
With therapy moving online, a far wider cross-section of people can access the best professional services from wherever they are, without having to travel long distances. And most of all, the stigma attached to seeing a therapist, still quite pervasive in Indian society, is mitigated to a large extent if consultations happen virtually instead of in the real world, away from the public gaze. The shift to the virtual space also makes it easier for therapists to refer clients to colleagues who speak the language the clients are comfortable in.
In theory, the prospect of online therapy does sound like a boon, but the picture is not unqualifiedly rosy. According to a report from May, India had 227 million active internet users in rural areas as of November 2019, roughly 10% more than the 205 million users in urban centres. For a country with a population of 1.3 billion, these numbers are far from sizeable. Apart from the many lower-income people who do not have access to the internet, there are people who are unfamiliar, or simply uncomfortable, with using technology.
“I see a number of clients who belong to this subset,” says Himani Kashyap, associate professor of clinical psychology at the National Institute of Mental Health and Neurosciences (Nimhans), Bengaluru. Since the pandemic, Nimhans has launched dedicated landline numbers for clients to have sessions via phone calls. This is just as well because even in India’s metropolitan cities, the quality of internet connection can often be patchy, and frequently disrupted by outages.
“Poor connectivity can be particularly jarring during a session, especially when a client is speaking intensely about something important to them,” Rynjah says. “It’s also hard to explain any relaxation techniques, for instance, or help the clients implement them, if you have to keep asking, ‘Can you hear me? Can you see me?’” Such glitches can also lead to tonal mismatches. “A client may mistakenly imagine I am not interested in what they are saying, when that’s far from the truth,” adds Kashyap.
There is also the bigger problem of finding a suitable, safe environment at home for a session. For many clients, especially those who suffer from personality disorders or are dealing with domestic violence, finding a niche within their home that can enable an open conversation with a therapist might be a challenge. As the lockdown forced people into their homes, some of Rynjah’s clients, for instance, dropped out of therapy. “Clients from my home-town Shillong told me they could not speak either on video or phone as their parents were home,” she says. “Since their parents are reluctant to allow them to seek therapy, they were only comfortable with texting.”
The role of the “holding environment”, where clients can process and contain difficult emotions, cannot be underestimated, says Kashyap. From the therapist’s waiting room to their chamber, physical spaces can help a client contain and regulate emotions. “This is particularly important for those who need a mental representation of a safe space to be able to open up in therapy,” Kashyap adds. The presence of a trusted therapist in the room can also help the client manage anxiety signals in the body.
Yet, for all its limitations and drawbacks, online therapy’s advantages outweigh the cons in a country like India. According to an estimate by the World Health Organization, about 20% of India’s population is suffering from mental health illnesses, with less than 4,000 trained professionals to look after them. With a treatment gap of 85%—which means only 15% of the afflicted get the help they need—the system needs whatever help it can get. If psychotherapy can extend its reach to many more by going online, that can only augur well for the future of India’s mental health landscape.