Illustration by Sonya Korshenboym
An edited version of this article written by Anugraha Raman (Associate, Belongg) appeared on IDR and Times of India.
“I am going to therapy and I do not want to teach him (therapist)”
– Ajay, a 28-year-old Dalit queer student.
Globally, mental health professionals are (very) slowly beginning to take note of the social world that has always surrounded the individual. Increasingly, politics, history and economics are being acknowledged in conversations about individual mental health. However, the multiple social determinants of individual mental health including discrimination, prejudice and bias, are acknowledged by a very small number of researchers and a smaller number of mental health practitioners. The result is a field that is largely non-inclusive both in its theories and practice.
There is large research evidence of the identity-related inequalities in mental health outcomes, the world over. Minorities and stigmatized groups are disproportionately affected by stressors and the prevalence rates of mental disorders like depression and anxiety are higher among them as compared to the general population. An individual’s social identities, like their gender, religion, caste, sexuality, etc operate simultaneously to either enhance or constrain their life experiences and they operate at multiple levels – individual, interpersonal and institutional. The individual and interpersonal levels are obvious campsites for a therapist to help mental healthcare seekers to reconcile with the structures that define their life, drawing boundaries on their power and freedoms and impinging on their mental health. In reality, this is a site that therapists very rarely spot, let alone camp in, in therapy.
Very few mental health professionals recognise the psychological relevance of taking an individual’s social identities into account while engaging with them in therapeutic spaces, designing interventions and conducting research, especially with minority participants and even fewer do so in their practice. Instead, mental health professionals often borrow self-satisfactory explanations to adopt one-size-fits-all practices, making little effort to consider the sociocultural relevance of their approaches and interventions vis-a-vis an individual’s identities.
For example, therapists often believe that a ‘person-centric’ approach, zoning in on the individual, even further than their individualistic theoretical orientations mandate, negates any need to address the social realities within which individuals seeking mental healthcare experience their lives. But doesn’t ‘center-ing’ the person include centering all the social conditions that shape their life experiences? After all, the personal is (deeply) political.
Dear therapists, your clients notice when you do not address the social issues related to their identities in therapy and feel that they are worse for it.
As a follow-up to a previous 2020 study, Belongg’s Anugraha Raman and Saransh Bisht, undertook a study at the beginning of 2022. They asked 111 individuals about their social identities, their experiences with identity-based discrimination and prejudice, their mental health and about their experiences with mental healthcare such as any therapeutic or psychiatric services they have sought in the past. More than half of the participants (59.46%) of this study reported having faced identity-based discrimination in their lives and a quarter of them faced such experiences every day. Only half of them were using mental healthcare services (therapy) and those who weren’t, cited affordability as the major barrier to them seeking mental healthcare.
When individuals who have experienced identity-based discrimination overcame financial barriers and mental health stigma and finally reached the steps of a mental health professional’s office, a whole slew of issues awaited them. They were confronted by unreadable therapists whose acceptance levels vis-a-vis different social groups were unclear, surfacing in insidious ways like a casteist comment that a respondent’s therapist passed one day that encouraged him to carefully conceal his Dalit identity in therapy.
Hence, by playing hide and seek with their social and political stances, mental health professionals made therapy a very laborious task for mental healthcare users who felt they were “testing the waters” as Ajay, a 28-year-old queer Dalit person and Ahana, a 20-year-old woman put it. Ajay reported bringing up certain topics carefully in therapy and filtering out their caste from therapy when the therapist’s reactions revealed caste blindness. Eventually, a hide-and-go-seek cycle unfolds with the professional and the individuals seeking care concealing parts of themselves in an attempt to refrain from offending or being offended by the other. ‘Queer-affirmative therapy’ often takes such ugly shapes, validating an individual’s sexuality while discrediting other, possibly more salient, parts of their identity. Caste-based discrimination has profound implications for a person’s mental health that are compounded when a lower-caste identity intersects with a minority sexual identity (Askari & Dolittle, 2022; Pal, 2020).
Therapists do not need a grand coming out as inclusive or anti-oppressive or rights-based. Madhu, a 28-year-old queer woman said, something as simple as a “ small rainbow flag in your room tells the person “Hey! I’m safe to talk to””. A study on client perceptions of therapist multicultural competence used different wall art and found that therapists with more multicultural art like a framed textile from a non-western country in their room were rated more positively by ethnic minority clients than therapists with western art (Devlin et al., 2013). Professionals can take such small steps – adding an item in their office room, a pin, a poster, or even a few words on their websites – to relieve those seeking their support of paramount stress.
Unsurprisingly, very few respondents reported discussing their identity-related experiences in therapy and those who didn’t, rate their service use experiences poorly as compared to those who had discussed their identity-related experiences like discrimination from family members, professors, peers, etc. with the mental health professional. Clearly, there is a need for mental health professionals to create a safe space for individuals to discuss their social identities. As Indian society becomes increasingly divisive, professionals must actively prioritize signalling social tolerance and acceptance and move away from the assumption that their professional title and the promise of ‘unconditional positive regard’ and ‘compassion’ makes individuals feel safe in their presence, especially because, at the outset, the client-therapist relationship is one of extreme power imbalance.
Mental health professionals who had been specifically trained to work with certain minority groups and those who had experience working with them were rated more positively than those who did not have such qualities. Participant’s asks from mental health professionals were shockingly simple. They wished that professionals would introduce themselves in greater detail so that care seekers did not expend energy and money trying to understand the professionals during the first few sessions, be more socially aware and update their knowledge and skills using workshops.
A very important finding from this study was that some of the participants who had faced discrimination felt that no amount of training, upskilling and reading can make up for the social differences between them and the mental health professional. Neha, a 25-year-old woman from northeast India who faced discrimination on account of her northeast identity frequently, especially during the pandemic said, “No matter how comfortable the therapist can make the room to be or the conversation to be, I don’t think they can help”. Echoing a similar sentiment, Madhu said, “I need a therapist from the (queer) community to feel at ease”.
For individuals, specifically, those from minority social groups to be matched to a professional from their community and maximize the benefits they gain from mental healthcare, system and institutional-level changes are necessary to make education more accessible to minority communities and to make psychology and mental health a more stable profession that is attractive to such community members who often require the promise of financial stability and social stability from their professions.
In conclusion, in addition to the wide mental health treatment gap, this study identified a pit in the mental healthcare landscape. This pit represents the limited psychological gains that those who possess stigmatized minority identities, who work as hard as the mental health professional when seeking care, experience, as compared to individuals from majority social groups. For the pit to be filled, a mix of simple changes that professionals can implement in their practice and big changes that require seismic shifts in the design of our education and healthcare systems are necessary. These changes, however demanding, are necessary as the payoff is the guarantee of improved quality of mental healthcare services made available to the marginalized.
Askari, A. S., & Doolittle, B. (2022). Affirming, intersectional spaces & positive religious coping: evidence-based strategies to improve the mental health of LGBTQ-identifying Muslims. Theology & Sexuality, 1-10.
Devlin, A. S., Borenstein, B., Finch, C., Hassan, M., Iannotti, E., & Koufopoulos, J. (2013). Multicultural art in the therapy office: Community and student perceptions of the therapist. Professional Psychology: Research and Practice, 44(3), 168–176.
Pal, G. C. (2020). Caste and Consequences: Looking through the Lens of Violence. CASTE: A Global Journal on Social Exclusion, 1, 95-110.