World mental health day: Address broken family and social systems, not the individual

On the day of Diwali, the doors of Aanchal Narang’s Another Light Counselling are open all day. Anybody can drop in for free half-hour therapy sessions. Their team of seven therapists and herself have been doing this for the past three years since Narang started the Mumbai clinic. Narang believes the festival months can be paralysing even for people who may not have clinically diagnosed mental illness, but struggle with loneliness, anxiety because of social and financial pressures, and have to tackle feelings of un-belonging, chronic or circumstantial, in any social structure. The maverick or the outlier is often the one who needs an empathetic ear and an open heart. That is an ubiquitous population anywhere in the world, and largely a silent majority in India, which suffers in the crevices of our broken familial and social systems. In India, for an overwhelming majority, mental health is stigma, something to be feared or shunned or be hush-hush about — certainly not something to articulate or address.

So, when Shyam Bishen, head of health and healthcare at the World Economic Forum, urged stakeholders from the public and private sectors to come together and realise the vision of this year's World Mental Health Day, observed on October 10 — to “make mental health and well-being for all a global priority” — he probably didn’t just mean the effort should be to normalise and treat bipolar disorder or depression or schizophrenia, which are anyway illnesses that have the backing of big pharma, but to also prioritise seeing and acting upon the pervasive and equally damaging borderlines.

Narang, 28, has a multidisciplinary approach to therapy. After a psychology master's degree at Mumbai’s Tata Institute of Social Sciences (TISS), the queer-affirmative therapist studied eye movement desensitisation and reprocessing (EMDR), internal family systems (IFS) and compassionate inquiry (CI) — therapy systems that aren’t yet as commonly available in our country as it is in the West, but which are highly effective tools in healing trauma-induced conditions of mental disability. Narang’s work is largely confined to traumas that arise out of addictions and abuse in people who fall in the unconventional gender-sexuality spectra of society. Their practice is holistic and more culture-specific than a majority of Indian therapists because it takes into account the social and cultural pressures of caste, gender and social classes unique to India. It is queer-affirmative and feminist.

Similar to their approach are two caste-aware and caste-affirmative organisations in Mumbai, The Blue Dawn, a community support group facilitating accessible mental healthcare services to Bahujan individuals, and Guftagu Therapy, which seeks to heal individuals as part of communities. There is a misconception around how we see mental health as only from a lens of disorder. This makes it harder to work on concerns which have to do with improving life quality and effective coping strategies.

Going to therapy, and spending a lot of money to be at the shrink’s couch, has been gaining currency in Indian cities over the past decade. Bollywood star and millennial icon Deepika Padukone did a great job talking about her experiences with depression. When Sushant Singh Rajput committed suicide, the media picked up on the conversation around the state of his mental health — and in turn, the mental-health concerns that can emerge from risky, capricious trajectories of artistic professions where nepotistic discrimination, back-slinging and cut-throat competition can swell a person’s inherent insecurities. Padukone’s therapist, Bengaluru-based Shyam Bhat, and Singh’s therapist, Mumbai-based Susan Walker, became the kind of shrinks a section of urban Indians saw as menders of the rich on the fritz. In reality, they aren’t miracle workers. The balm to our growing mental-health crisis — which the two years of the pandemic very logically compounded — is a shift in thinking. It is to make mental-health solutions or treatment the opposite of luxury. A majority of Indian psychologists are trained in the Western concept of mental health, which makes them empathetic and non-judgemental. There is often a blindness or unwillingness to engage with social realities.

Unhealed familial patterns are often fuel and nurture long-lasting and intergenerational traumas, but equally responsible are histories of discrimination and violence that a person belonging to a particular backward community or caste or marginalised sexuality carry forward in their consciousness.

I met Narang on a Sunday, in between sessions. Besides working pro bono with NGOs such as Oorja and others, they run a for-profit practice, with Rs 2,000 fee for those who can afford. “I am not rigid about fees. Sometimes, I work pro bono with individuals who I know can’t afford a fee but I know their life can change with therapy. Narang has a deeply understanding gaze, and she speaks in measured words — they are a wounded healer. At 12, Narang developed suicidal thoughts, a result of a broken family with alcoholic parents. Narang has been in therapy for several years; they have been diagnosed with borderline personality disorder; their academics, relationships and overall wellness have suffered acutely because of the traumas they experienced growing up. Narang’s own healing and her expert efforts to understand others like her or those worse off than her to heal them run parallelly.

More practices like Narang’s, and of others like them, are crucial to arrest the mental-health crisis that grows year by year. A 2022 World Health Organization (WHO) report mentioned that there was a 25 per cent increase in anxiety and depression among people worldwide. In 2017, the WHO reported that there were about 9,000 psychiatrists practising in India, which equates to 0.75 per cent for every lakh of people.

WHO estimates that the ideal ratio is three psychiatrists for every lakh of people. Similarly, India has 1.93 mental-healthcare professionals per 10,000 residents, compared to the global average of 6.6. The alarming rise in suicides are a fallout of this crisis. About 164,033 Indians died by suicide in 2021. Since 2010, India has lost over 1.6 million people to suicide, with numbers rising 7.1 per cent in 2021. For the first time, India’s daily wage earners comprised over 25 per cent of the country’s deaths by suicide in 2021. This is a staggering 113 per cent rise from 2014.

The National Mental Health Survey of India 2015-16 found that 150 million Indians needed mental healthcare intervention, of which only 30 million were seeking it. The survey added that a staggering 80 per cent of people suffering from mental disorders didn’t receive any treatment despite over 12 months of persisting illness.

Several societies and cultures in our country still perceive supernatural or parapsychological forces as causes of mental health issues and consider them the result of wrath or denial of spirit or deities. Narang told me there are people even in pockets of urban India who perceive mental illness as suffering that is predestined for them, which keeps actual causes — genetic baggage and trauma-inducing behaviour of parents, family members and the immediate social structure around individuals — hidden and unacknowledged.

Narang told me about a 35-year-old woman living in a Mumbai chawl, who had suicidal thoughts, hallucinations, anger outbursts, flashbacks of sexual abuse from her stepfather because of which she has suffered years of insomnia and sleep paralysis. She would cut herself as a coping mechanism. She developed difficult relationships with food and her body early on. Narang used EMDR to process her experience with sexual abuse. They used grounding exercises like ball catching for an extended period of time to bring her focus to her body — she had dissociating from it long ago. After years of therapy, she has also overcome her severe hookah addiction. She sleeps now, and she is able to relate to and engage with people around her. She has a semblance of normalcy.

Narang also told me about many queer and trans people who come to her for extensive therapy. Narang’s own queer identity is an advantage. They counselled and transformed a 24-year-old trans man with depression and self-harm tendencies. “They have to believe that they are not along, and that there is a large community of people who he can feel he belongs. So usually I would send queer or trans clients to places and parties meant for people with their sexual orientation.” And then move on to the multidisciplinary therapies. Now he is employed and functional with people around him. While being on therapy with Narang, he also transitioned with hormone replacement therapy and sex-affirmative surgeries to realise the ideal self he wants to be.

Narang’s stories and experiences as a therapist and as a trauma-induced, maladjusted person point searingly to the dissonance between who people are and who society expects them to be — and how this dissonance is at the root of mental-health concerns. for many. Most therapy practices try to find out what is wrong with the individual instead of acknowledging that the world they inhabit is irreparably broken, too. They base their understanding and treatment/management of mental illness on the belief that biological influences precede cultural influences and set predetermined limits to the effects of culture — risk factors that trigger genetic mutations. The medical model, necessary and vital, pathologises them.

Sigmund Freud, who is considered elitist and his psychoanalytic practice geared only towards the intellectually and financially endowed, started free outpatient clinics as early as 1920, up until the late 1930s. In her book Freud’s Free Clinics, psychologist Elizabeth Ann Danto writes how, between 1920 and 1938 and in 10 different cities, Freud and his contemporaries such as Wilhelm Reich, Erik Erikson, Karen Horney, Erich Fromm, and Helene Deutsch envisioned a new role for psychoanalysis. They created outpatient centres that provided free mental healthcare. Danto's narrative begins in the years following the end of World War I and the fall of the Habsburg Empire. Joining with the social democratic and artistic movements that were sweeping across Central and Western Europe, these analysts, led by Freud, saw themselves as brokers of social change and viewed psychoanalysis as a challenge to conventional political and social traditions. They believed that psychoanalysis would share in the transformation of civil society and that these new outpatient centres would help restore people to their inherently good and productive selves.

There is compelling agency and promise in this idea of free clinics in the post-pandemic, post-truth, socially isolated, device-dependent era of us humans today. Dropping in to articulate why we feel un-belonged and what that makes us do or want to do to ourselves and others, is the most radically affirmative solution to mental-health imbalances in us and in our societies and communities as a whole.