Counselling for depression: A journey within

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Psychotherapy could not be more unlike the many psychometric tests that are administered to evaluate a person’s aptitudes and skills. The process pertains to the acquisition of  the competencies required for a realistic self-appraisal of one’s emotional state of being. It is intended to help a person take charge of himself  through enhanced self-awareness.

The judgement whether one needs greater self-awareness and the decision to actively seek specialised intervention is itself subjective. A person who feels he needs to stay connected to himself avails of the service of a psychotherapist. Somebody  who finds his daily life directionless, unsuccessful, unfulfilling and unworthy in other ways should consider consulting a counsellor because these mental states can be corrected permanently through developing the requisite emotional coping skills. Conversely, they could prove extremely counterproductive, even debilitating, if allowed to persist over a long period. After all, whether you recognise it or not, how you feel influences what you think and what you think determines what you do or do not do.

Many of us grow up believing that we did not cause the miseries we live through and therefore cannot alter them. Therapy offers an alternative route wherein you begin to differentiate between matters that are within your individual control and those that lie outside your purview of influence. You thus actively address the former and stop agonising over the latter.

A therapist is not somebody who pretends to propose solutions to your problems. Instead, he is one who helps you find your own solutions.Very early in my therapy sessions, the counsellor drew my attention to an important comparison concerning  contemporary life. We discuss current affairs, sport and entertainment with anybody and everybody, he noted. But when it comes to  matters of the mind, meaning our emotions, we treat them, he observed, as entirely and extremely private affairs and consequently give them far less attention and consideration than they merit. These latter are sought to be addressed in therapy.

A therapist is not somebody who pretends to propose solutions to your problems. Instead, he is one who helps you find your own solutions. He is a facilitator of this journey of self-discovery. Its effectiveness or otherwise is entirely contingent upon how you, as a client, approach your interactions with the therapist.

In a typical session, a frank, open and honest articulation of one’s troubles or anxieties often produces the most fruitful results. For one thing, such ventilation is an end in itself. That is to say, it instantly relieves a huge emotional baggage, which is invaluable in its own way. Once cleared of the toxic feelings, the mind automatically begins to focus attention on the problem in a dispassionate and clinical manner. Ventilation is, in that sense, also a means to an end.

It is relatively easy to express one’s anger, sorrow, a sense of betrayal and so on. Conversely, it is that much harder to face up to one’s own shortcomings, flaws, dishonesty, deceit and other aspects of one’s personality. But in the end, somebody who can be honest in relation to both the above aspects stands a better chance of getting a hold over his emotions.

The release of emotions in a therapy session is a structured process of acknowledgement or stock-taking of  what  has happened. A therapist actively listens to what is being expressed. The word active is important here. Unlike family and friends, he does not sit in judgement over what he hears. He is a disinterested party to the conversation. He does not react immediately with statements to the effect that this is right and that is wrong. By lending his ear, he facilitates clarity on the issues that confront a person. One day soon, you will make all those judgements independently, comfortably and confidently. That benefit is something to be felt and experienced first-hand; and over a duration of time.

The benefits spelt out in the above paragraphs, even when they become apparent, do not accrue to your account instantly. They rise to the surface and recede just as quickly as the waves on the oceans. You come out of a session feeling on top of the world. You go back into the next one again with the same seemingly intractable dilemmas. It is hence important to persist in the conversation, session after session, with a view to learn how to  accept the highs and the lows with equanimity.

A competent therapist never becomes involved in the life of a client; he merely engages with the issues that are presented before him. An ethically scrupulous professional is seldom seen chasing clients for the next appointment. That is usually the latter’s call.

The rewards from psychotherapy are both instantaneous and long-term. That is the secret of its efficacy and appeal to those who have the patience to persevere. More important, it is not driven by a time-bound or deadline-dictated programme that a client is expected to complete. It is rather an exercise the individual in question initiates and carries forward at his own pace. Happy therapy.

(The author wishes to remain anonymous)

Depression: The fault lies in classification

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The World Health Organization estimates that more than 300 million people across the world are living with depression. “But that does not mean that all the 300 million people would need medical intervention,” says Vikram Patel from Harvard Medical School and the Delhi-based Public Health Foundation of India. The reason: the current binary classification of depression that distinguishes people as either “well” or “sick” is fundamentally flawed. The binary model is “unsuitable” for depression as there is no clear line that differentiates the miseries of daily life from the disorder that can be treated through medical intervention.

Levels of depression

In the absence of a biomarker that neatly distinguishes healthy and depressed people, the binary model relies on symptoms of emotional well-being — feeling miserable, losing interest in things, unable to sleep, idea of self-harm and feeling profoundly fatigued — and assesses the duration and impact of these symptoms to arrive at a diagnosis.

“The binary model uses the answers to a list of questions and then applies a complicated set of rules to arrive at a diagnosis for depression,” says Prof. Patel. “It uses a set of symptoms without recognising that there might be stages through which the symptoms graduate to a full medical disorder.”

In an essay published in PLOS Medicine on April 4, Prof. Patel proposes a continuum of stages to define depression. At one end of the spectrum are people who are well and do not have any distressing emotional experiences. “But many people have depression-like symptoms in reaction to the trials of everyday life, for example when there is the death of a dear one,” he says. A significant proportion of people now diagnosed as suffering from depression have only mild to moderate symptoms and most often do not need clinical intervention. What such people need is advice on how to help themselves recover and support from friends, community-based workers or the Internet.

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The next stage is when the distressing experience lasts longer — at least two to four weeks — and severely impacts day-to-day social functioning. This condition needs medical intervention — antidepressants, brief psychological treatments or both, though most of this can be provided through primary care physicians and community health workers. At the extreme stage are the recurrent or refractory depressive episodes where patients do not respond to existing treatments or suffer from relapse. “This constitutes only a small fraction and they need to see a psychiatrist or clinical psychologist,” he says.

Since the model of various stages would dramatically reduce the number of people with depressive symptoms who need medical intervention, the focus of specialists can be to treat severe cases.

Staged model in India

There is a body of evidence to show that with appropriate training and supervision, front-line community health workers can effectively deliver psychological treatments for moderately severe to severe depression, such as the Healthy Activity Program, a six- to eight-session treatment; the results of the study were published in December 2016 in The Lancet.

In the VISHRAM (the Vidarbha Stress and Health ProgRAM) programme in 30 villages in the Amravati district in Vidarbha, central India, the staged model was implemented by providing care for mild stages by community agents, while more severe stages were treated by lay counsellors working in collaboration with primary care physicians and visiting psychiatrists. This led to a huge reduction in treatment gap for depression, according to a paper published in January this year in The Lancet Psychiatry.

Following the study, all the 30 villages have a community health worker “who is trained to detect depression, provide low-intensity psychosocial interventions, and refer the patient to the public health system for further management”.

Published in The Hindu on April 8, 2017

People seeking mental healthcare increased six-fold

DepressionThe proportion of people with depression who sought care increased six-fold from 4.3 to 27.2 per cent in 30 villages in the Amravati district of Vidarbha. The proportion of people who accessed mental healthcare was the same across sex (53 per cent males and 47 per cent females), education, income and religion. As a result, the prevalence of depression among nearly 1,900 participants dropped from 14·6 to 11·3 per cent during this period. The results were published on January 5 in the journal The Lancet Psychiatry.

The prevalence of suicidal thoughts reduced by about 50 per cent — from 5.2 to 2.5 per cent. The actual reduction in the prevalence of suicidal thoughts was only small and was not the primary objective of the intervention, says Prof. Vikram Patel from the Public Health Foundation of India (PHFI), Delhi and the senior author of the paper.

The Vidarbha region has witnessed a large number of suicides in recent years. While other benefits have been extended to people in the region, access to mental care has not been provided. The intervention was carried out by VISHRAM (the Vidarbha Stress and Health ProgRAM), a grass-root community mental health program that has been designed to address the mental health risk factors for suicide (depression and alcohol use disorders).

There were just eight counsellors providing advanced psychosocial care and 39 community workers who helped increase awareness about mental health in the 30 villages. A baseline survey was conducted on nearly 1,500 participants who were randomly selected and another survey was carried out on nearly 1,900 randomly chosen people at the end of 18 months.

“The pilot study has shown that the programme can be expanded to cover the entire State,” says Dr. Rahul Shidhaye rom PHFI and the first author of the paper. “A similar approach pilot tested in one district in Madhya Pradesh under PRIME (programme for improving mental health care) was scaled up last year to cover the entire State.”

In India, 2-3 per cent (13 million people) adults suffer from depression. Yet, only about 4.3 per cent access mental care and nearly 90 per cent do not.