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The space between psychotherapy, mental health and social development: challenges, implications, questions and reflections

Interview with Ganga Nair by Hala Abu-Maizer



Ganga is a counselling psychologist practicing in India for the last decade. She has an undergraduate and postgraduate degree in counselling psychology. Her interest in social development started in her late teens when she found herself supporting children with behaviour and learning special needs. She is the founder of The Listeners Collective, a mental health support organisation helping local communities and individuals through psycho-social interventions in Bangalore, India. I sat down with Ganga and she shared with me her valuable insight and  perspective on social development, development practitioners, mental health, and the steep learning curve one goes through when undertaking this work. She also shared the raw rite of passage every development worker goes through in their evolution and relationship to their work.


Thank you for taking the time to talk to us. I am always curious to know how one ends up practicing their craft. Can you tell us your story and how you embarked on this journey operating in the space of mental health and social development?


I started working in this field professionally after my degree in counselling psychology. My first experience was working on rescuing, rehabilitating, and repatriating survivors of human trafficking, bonded labour, slavery and child labour in India. As a fresher, I was quite thrown into the deep end with very little exposure or access to studies, manuals or even an introduction to how social systems impact someone's emotional wellbeing within this intersection. I found myself having to lay out processes intuitively and independently, for example like crisis intervention models. I was able to find resources online most of the time, but they were mostly built around Western contexts. Therefore, I had to draw heavily from those to build a system that could be adapted to offering psychosocial support to my local context. Like trying to find answers to process surrounding the local judicial system in India that has an impact on the mental health of victims, or find protocols that can cater to the emotional wellbeing of beneficiaries after repatriation. You tend to play multiple roles in this setting. As a psychologist, you accompany a survivor to court hearings and visit them along with other after care workers within the shelter home. There are certain boundaries that you have to maintain, but at the same time, there lies a huge overlap of work that happens within these spaces. I found myself having to find my own way because I had no access to a paved road. Within my education, I was taught that therapy often happens within a private space where a person seeking therapy is most often seeking it voluntarily. This was not necessarily the case in practice. My very first experience working with a survivor one to one was after university, and it took place in the courtyard of a shelter home. I remember asking her “do you want to talk about how you're feeling?”, and at that instance she abruptly got up and sternly said “I’m not interested in talking about how I’m feeling. Do you have any information about what's happening in court?”. Her response felt like a slap in the face to me. I had no information about what was happening in court, and I didn’t think it was my responsibility to know. I eventually figured that this was an important piece of information along with so much more that was not visible to me at the time.


“I had to draw heavily from those to build a system that could be adapted to offering psychosocial support to my local context”

 

There are many different identities a survivor comes into a space with, and different experiences that are interacting at that point in time of which I had no real clarity or perspective on. There were cultural issues and other nuances to their experience that collide and come together in that space. For instance, not being able to adapt to the food, living habits, the language that’s being spoken, that were not considered very important by the shelter home staff or other organisational systems that were in place. This is not because people did not care, but because they are things that can be easily missed and may not be considered circumstances. These considerations make a world of a difference for someone who holds a different nationality and associates a sense of home and belonging to a certain culture, in a multi-cultural society. I now have the language to be able to interpret what those experiences were and how people might have been feeling at that point in time. Back then I had to rely very heavily on my intuition to guide me along this path on working in this novel context of merging psychology and social impact, which was almost unheard of in India. I realised that within the space of social impact, you’re always going to be a psychosocial counsellor, not just a social worker or just a counsellor. You’re not purely or fully only going to be a mental health practitioner. You’re going to need perspective and a deeper understanding of social systems and structures other than just psychology and human behaviour. For example, I had to familiarise myself with the Juvenile Justice Act, the primary legal framework pertaining to juvenile justice in India and not just what to do when parameters of confidentiality are broken. It is imperative to know things outside your traditional training as a counsellor and it’s very disappointing and disheartening as a fresher being faced with this reality. The Listeners Collective was born from my journey as a mental health and social impact professional and the aspects that were particularly challenging to me on this journey; due to the scarcity of templates and scripts on how psychology can merge and integrate with social development.


“Back then I had to rely very heavily on my intuition to guide me along this path on working in this novel context of merging psychology and social impact, which was almost unheard of in India”

  

Psychology is one discipline that is strongly cross cutting in nature and has an obvious role to play in the social development discipline. Can you tell us more about that intersection and what that relationship is like?


There are very few fields of application for psychology that we recognise beyond the usual clinical, hospital, educational, or the organisational setting. Most other areas remain quite ambiguous as to how psychology plays a role and how we leverage understanding of human behaviour within these spaces. Although the discipline of psychology recognises that mental health is a construct determined by the reality and complex interplay of the individual along with their social and structural vulnerabilities; there is a need for road maps that talks about how we can address the impact of social factors on someone’s emotional well-being. Within the purview of individual therapy, mental health practitioners often feel helpless and resign to the knowledge that this is beyond their control to respond to. The most someone can work with is the individual sitting in front of them. However, this is in many ways teaching the individual to cope with injustices that shouldn’t exist in the first place. So, the question then becomes how do we interact with these vulnerabilities or the existing unjust systems or structures? We cannot look at psychologists as only sitting in offices where people go to have available one on one therapy. The intersection exists, and we need to recognise it and lean into it. Although mental health is a part of the third Sustainable Development Goals (SDGs) of Good Health & Wellbeing, I believe, it is a cross cutting component to all other SDGs; one that will enable us to successfully realise them. This is not reflected in reality as it stands which means that it will becomes more challenging for a social development worker to sustain themselves in a field where they are making it up as they go on their own, due to a lack in trajectories, terminologies, and people working in silos in a fragmented space. The more I worked in this space, the more responsible I felt towards my clients, and the more I realised how badly social development work needs a mental health lens. Hence, through our work at The Listeners Collective, we have attempted to create access pathways via a few permutations and combinations of the two disciplines, ultimately towards incorporating mental health support components in social impact programs. For instance, in a program addressing say, gender-based violence, we incorporate the provision of primary level trauma and mental health support through community gatekeepers. So when aiming for social change with the experiences of gender-based violence, we also need to consider the mental health impact it has on individuals experiencing it. In a program where we attempted to do this, there was a larger uptake of the survivor-centric lens among members of the Internal Complaints Committee (The ICC is responsible for responding to instances of workplace harassment). Ultimately, we need to operationalise what it means to consider the whole of an individual when we talk about their mental health and well-being, as opposed to just what they're experiencing individually. For instance, in a program addressing say, gender-based violence, we incorporate the provision of primary level trauma and mental health support through community gatekeepers.

 

“Within the purview of individual therapy, mental health practitioners often feel helpless and resign to the knowledge that this is beyond their control to respond to”

 

I was lucky to have started my career within a foundational programme that aimed at building the right structure for people that are looking to enter the sector, but I haven’t come across anything like this for people changing careers. There is so much work and skill that goes into the work, like developing the way you speak to the affected population, in the way you manage their expectations, to the way you interview people etc. One can easily do more harm than good and end up re-traumatising those they interact with as you previously mentioned. A lot of people don’t know about many standard operating procedures that happen to fall into this work, perhaps for personal reasons like redeeming personal narratives. This is not to say that they’re less intelligent or that they are unqualified to do certain work, but it is to say that there is a lack of serious awareness and serious foundational training for those that do not have exposure to development studies, and even then, theory does not prepare you on how to deal with the shock associated with front line field work that is so often hyper-romanticised. Consequently, despite not being as involved in the space as I used to be, I continue to see development professionals in need for mental health support, especially in less developed countries. Even though organisations recognising they have a duty of care; some may offer to pay for the first 5 or 6 sessions of counselling and then stop. And even this is not standard industry practice, which often depends on the size and wealth of an operation. For someone that may need long term support, the risk of inconsistency is great. This leads me to a curiosity on why you think things needs to change in this space?


There is an impact on both the professionals and their clients or affected population, and I do see a dire need for mental health support for the development professionals themselves. We recently ran a programme catering to the emotional needs of managers in a social development organisation, and while talking to one of the participants and hearing their feedback, I realised how topics like compassion fatigue, saviour complex, and other fundamental mental health and behavioural concepts were virtually unheard of. In the conversation, it was pointed out to me how this sector will always be populated by diversely qualified professionals who are coming together in multidisciplinary teams to tackle issues like hunger, poverty, climate change, housing and so on, and these individuals may not necessarily have a background in the social sciences or social development. This challenge becomes compounded with the incorrect and often harmful messaging one gets bombarded with when working in this space, where development workers are often put on a pedestal and receive so much adulation for the work they are doing. Social workers hear things like they are saving the world, and this message then becomes internalised for many as they begin to build expectations around say, receiving as much love as they are giving out. There’s nothing wrong with seeing the work as noble and heroic, except that it tends to then build a sense of guilt for the individual for not having the right and necessary boundaries in place. Unfortunately, training in social sciences and development does not prepare people to navigate this minefield. It also does not teach them how to keep themselves in check through engaging in self-inquiry practices and knowing whether they are internalising these messages and its implications. Reflection is important and people need to ask themselves how do those messages interact with my work? What’s the relationship that gets built with communities on the ground with that kind of messaging? How do I keep myself in check about the biases I may hold? What are my belief systems? and how do they interact with the work? How do I take care of myself and not burn out?




“Unfortunately, training in social sciences and development does not prepare people to navigate this minefield. It also does not teach them how to keep themselves in check through engaging in self-inquiry practices and knowing whether they are internalising these messages and its implications”

 

Another phenomenon that I have seen cut across the sector locally and globally presenting through the “cynical vs jaded” dichotomy. What is meant by that is due to the lack of preparedness and skill in emotionally responding to arising issues within the work, many more senior and veteran development professionals have normalised and learnt to just live with moral conflicts. The dichotomy then becomes represented through starting to get the impression for young professional that unless they become cynical then they cannot fit into this work, and therefore if they don’t, then they must exit the sector. I personally made the choice to continue my work in the sector because while it’s understandable for someone to become jaded, cynicism stands in the way of providing informed care, and that will inadvertently re-traumatise communities that have already undergone years of oppression. This work needs to be seen as professional work that requires high levels of skills from professionals. It is not enough to just want to do it out of the goodness of your heart, as it’s the kind of work that risks so much harm to the person practicing it. So much of one’s personal self interacts with the profession and the work, unlike other sectors and professions like say being a software engineer as opposed to a teacher or a psychologist or even a social worker. There’s so much more of that interaction and overlap between the personal and professional, and it becomes difficult to tease the two apart.


What do you think are the challenges in integrating and merging mental health with social impact work?


The fact of the matter is that the social development sector is an extremely morally challenging place to be in. For one, it is far from a perfectly sanitised space, and I find it to be particularly morally challenging one to exist and operate in. Many of us have heard stories from different countries and contexts on the mismanagement and misplacement of funds and the interference of personal and political agendas and so on. It becomes especially challenging to occupy for young mental health practitioners and small organisations as it gives rise to several conflicts. One of them being the feeling of wanting to do more versus the reality that sometimes there really isn’t more that can be done. I feel like at any given point in time there’s only so much that an individual, or even research for that matter can do. Even the Hippocratic oath of Do No Harm that development professionals abide by, are talking about perceivable harm, right? If there’s one ideology that I know we hold as an organisation, and I reinforce consistently, is that I don’t think that we know everything. There’s only so much that academic research can answer, even at this given point in time the whole space is so dynamic because we’re learning so much on a day-to-day basis in practice about the people we work with and the communities we interact with. So even when we say “do no harm”, it’s harm that’s perceivable, that you recognise, that you can prevent yourself from doing. When you do not know everything, then there’s also the possibility of affecting them unintentionally. In the words of Maya Angelo, “do the best you can until you know better”, is an ideology I live by.


“This work needs to be seen as professional work that requires high levels of skills from professionals. It is not enough to just want to do it out of the goodness of your heart, as it’s the kind of work that risks so much harm to the person practicing it”

 

There are two schools of thought that I am able to identify here pertaining to working in social development. The first is “doing something is better than nothing”, and the second is “if you can’t do something fully well, you don’t do it at all”. I don’t know which of these is perfect or the one to go with as an ideology and as a perspective. I also don’t know if there’s one that’s universally known to be a good one to follow as well. To answer your question, in short, the way we engage and show up in the space needs addressing. The fact of the matter is that the circumstances that we’re working with are supremely blemished, and everyone you work with is going to also come with their own set of limitations. With that in mind, I think it needs to be understood that you’re not going to be able to do a perfect job since this is not a clinical environment where you get tocontrol all variables and have the systems in place to abide by. I often see many opinions online when the imperfect reality of the work is being presented and talked about. People find it easy to ask “what about X? Are you considering Y? Are you aware that you can do Z?”. These questions sometimes carry a tone of point, blame and shame instead of allowing grace and space for nuance, dichotomy and variables, and suggesting other ways of looking at challenges that may arise in a not so perfect environment. Learning cannot happen in a climate of shame where the person is scared to ask out of fear of being labelled as someone who is insensitive or someone who doesn't have the best interest at heart. This goes for internal work within a team as well as for collaborators. If an organisation is doing only a set amount of mental health support sessions, I would be all for it. As I much rather develop a long term working relationship with them/the organisation and get something in there, instead  of antagonising the employer/organisation with “but you do not understand X”. I once read a quote that really stuck with me that says “be hard on the problem and soft on the person”, and it has been a good reminder for me when feeling the tension like we are abandoning our own ideologies when we try to meet someone halfway. Additionally, mental health professionals often struggle with feeling of not doing enough, especially when there is  always more work to be done in this sector. On one hand, the field of psychology and mental health as a discipline has advanced dramatically in the past two decades, especially in India where psychologists have highly sophisticated training that are practising with a population that’s more attuned and receptive to mental health support. On the other hand, we are deconstructing really complex psychological theories and bringing it down to something that's foundational and accessible for a population that is only now starting to interact and believe that mental health as a construct exists and is important.


“It becomes especially challenging to occupy for young mental health practitioners and small organisations as it gives rise to several conflicts. One of them being the feeling of wanting to do more versus the reality that sometimes there really isn't more that can be done”

 

Can you tell us more on what the impact of working within the intersection of mental health and social development look like for mental health professionals?


It becomes very interesting when you operate in a space where you don’t know what a successful outcome may look, you don’t know for sure what a good job done looks like because it’s not as straight forward. It’s merging the best and the worst of those two disciplines and fields together. Aside from working with collaborators in the space that may have misaligned values or belief system, the field of psychology in itself is under resourced when it comes to how you navigate the application of psychology in the social impact world. The way you think about executing a model of therapy in any given environment needs to be revised and revisited and re-adapted all the time, especially in group settings. That in and of itself is a challenge, choosing to go with either preventative care, rehabilitative care, Cognitive Behaviour Therapy (CBT) and so on. Something like CBT has been found to have a high success rate due to its formulaic nature and ease of implementation, however that isn’t to say that everyone will benefit equally from it in an intervention. If for instance we see someone who can benefit from an alternative model of therapy or school of thought, the challenge becomes how can we layer this within a group setting? Can we look at individual models of therapy to be able to build that into basic modules of mental health literacy?


Things are much easier applied in one-to-one work where you can be more adaptable and flexible in customising your approach as you go. We often use techniques that we feel might be most helpful for a certain topic that may aid reflection, with an emphasis on building in controls in order to be able to contain anything that we feel might emerge or surface. During programme implementation we also try to encourage the organisations or collaborators to allow for us to have systems outside of sessions that individuals can access. This is often unmet as organisation do not have the funding capacity to provide that, so we attempt to bridge this by supplementing the sessions with information on emergency helplines. This again goes back to the dichotomy of do you not do anything at all in those scenarios? Or do you enter a community, and provide at least preliminary mental health support?

One caveat with building foundational mental health literacy is that there’s hope for the conversation going any which way. Once an individual has started introspecting, they will introspect on their own accord, and we may not always be able to provide a supportive ecosystem to respond to that. This highlights the complexity compounded with the huge treatment gap we have in India.

 



“Once an individual has started introspecting, they will introspect on their own accord, and we may not always be able to provide a supportive ecosystem to respond to that”

 

It’s an interesting point you raise there that emphasises the risks the work carries for people that are going through crises. Many people do not have the luxury of time for reflection, introspection, and conscious behaviour change. I also assume one risk you run in engaging the population in such discussions is the inability to go back to the starting point. Once we start confronting patterns and beliefs and then embark on the journey of challenging and deconstructing them, we must be prepared for what is to come in the process of reconstruction and reframing. Once we know we cannot unknow, and it becomes increasingly difficult to put the lid back on and continue to supress and ignore, especially for people that are constantly living on the edge. This will require long term support and time in some cases, where people may not have the luxury of indulging in and accessing beyond a said intervention.


You see most of the women I worked with in the shelter homes that were “rescued” from human trafficking made it very clear that they wanted to go back. This is because they felt that they experience more dignity there than in a shelter or back home or their own community. In their perspective, going back home meant that they would have to live in poverty and uncertainty of where their next meal is going to come from, not have freedom of movement, and most importantly they are not earning. They also see that if they are to be sent back home, they will be going back to the terrible conditions that drove them out, and therefore be unemployed in a community that doesn’t know what to do with them, and that will probably end up harming them. These women do not feel rescued and the joy of being in such a position. Rather they feel stripped of their agency, power, and freedom while being held in a restricted prison like environment in a country where it’s legal for an adult woman to engage in sex work. These are uncomfortable and unsettling truths. What’s more heart breaking is that the social change necessary to eradicate trafficking is still going to take years to resolve. And in this realisation is when you feel the urgency for social change. You are working with an individual against the backdrop of a society that isn’t conducive for them to live a dignified life. So, do you stop the work till the social change has happened knowing that you are opening a can of worms otherwise?

 

“Most of the women I worked with in the shelter homes that were “rescued” from human trafficking made it very clear that they wanted to go back. This is because they felt that they experience much more dignity there than in a shelter or back home or their own community”

 

I am hearing you touch on an important point around power, and the perception of power one might have in taking up the role of the “rescuer”, and the “rescued” and perhaps even the “prisoner”. I am also hearing the importance of meeting people where they are rather than where we would like them to be in the context of social development, especially when they vocalise their needs and preferences despite not being aligned with what a practitioner may have in mind. There is something quite arrogant, paternalistic and top down in the way we address the “other’s” needs in working under the assumption that we may have something they inherently lack and therefore must bestow onto them, be it “empowerment”, “freedom”, and access in the form of “saving” and “rescuing”. It is a strong human trait to want to help those perceived to be less fortunate, however this carries power that we may not be aware of. There’s a marked difference in helping someone because we think they need our help, versus engaging to work with someone to help in a mutual exchange.


Yes, we can build X number of hospitals, or increase haemoglobin levels for anaemic patients to the required range, and the delivery on those targets are straight forward, but addressing psychological needs in an ecosystem that works mostly in tangible and physical outcomes tends to translates very differently. And this also begs the question, how do we ensure that a community feels safe enough to identify and voice their needs, for us to truly be community-led in mental health interventions?

  

 

 

To find out more about The Listeners Collective, visit their website at www.thelistenerscollective.org


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