As mental healthcare remains inaccessible to most, narrative therapy provides an inclusive approach

“Mental illness is often a ‘buy-one-get-four-free’ deal where you’re likely to suffer from symptoms of multiple mental health issues when diagnosed with one,” says Maria, a Mumbai-based artist who was diagnosed with multiple mental health issues when she was in her preteens. “Recognition led me to understand and cope with what I now know to be bipolar disorder along with anxiety attacks and hallucinations,” she says.

Maria went through a series of terrible experiences with mental health professionals before she found Jehanzeb Baldiwala, who uses the narrative approach to therapy as a prime mode of support.

Jehanzeb works at Ummeed, an organisation in Mumbai which attends to the mental health and developmental needs of children and adults. Ummeed exclusively employs narrative therapy as a part of their clinical services and has used it against a range of issues such as anxiety, depression, trauma, abuse, and psychosis, among others.

Categorised under the ‘postmodern’ approaches in psychological treatments, narrative therapy is a non-pathologising therapeutic intervention that views people and their issues from the social lens and relies on the way people tell their stories and seek ways to recover.

It was developed by Michael White (Australia) and David Epston (New Zealand), who drew from their work in mental health from developmental, social and anthropological thinkers, and developed a model that was more respecting of people’s agencies and their social contexts.

Explaining the essence of it, Jehanzeb says, “Narrative therapy works on the belief that people are experts in their own lives and make meaning of distressing situations based on their own past, culture, history and social identities. Often this is not visible because their problems have taken up so much space. But when we use the medium of narratives and stories as a metaphor, the problems and their influence start to unveil to the person.”

Though it seems to be a fairly new treatment mode, narrative therapy has recently emerged as one of the non-directive approaches being practiced by many emerging mental health professionals in India.

Image courtesy of Ummeed

Doing away with the ‘doctor-patient’ dynamic

Many mental health treatments involve establishing a relationship between the professional and the client, where the therapist leads the process, often becoming the person who is ‘in charge’. Instructions are laid out by the therapist, and the client follows them in the journey. Depending upon their issues, this method works for some people. But in disagreement with this Freudian setup, psychologist Carl Rogers introduced client-centered therapy, which believed that people a better ability to understand themselves and hold the potential to emerge out of their issues.

The therapist does not directly participate in the process but rather lets the client take their course. This helps the client to realise that their rights, choices and decisions are respected and that they now have a safe space to talk about their issues.

Over the course of working with Jehanzeb for more than five years, Maria recognised the importance of changing this power dynamic. “I learnt that it is more about asking the right questions rather than providing the right answers. This creates a safe space to talk about issues without judgement, adverse reactions, pity and fear. We can constantly discover new tools to use for the next time the same situation arises. It is a journey of exploring what works for you and how best you can cope with the additional difficulties.”

The 'right questions' that Maria refers to come from an attempt to know the unknown. “Take the example of an abusive relationship,” says Sadaf Vidha, a counselling psychologist working in Mumbai. “There is no way I can directly ask the person to leave or sort it out quickly, but the questions I ask can make them negotiate their safe space in the relationship and their capability to deal with it, and eventually, they will make the right decisions themselves. This is the environment narrative therapy provides.”

References from several papers suggest that this elimination of authority is helpful for therapists to see the issues from their clients’ point of view, or as Irvin Yalom puts it in his book Gift of Therapy, “Looking out the client’s window.”

A non-accusatory, inclusive approach to mental healthcare

The development of narrative therapy gained speed during the time when the feminist movement was influencing ideas of mental healthcare. Consequently, a lot of self-identifying feminist professionals use narrative approaches in their treatments.

“Narrative therapy resonates with feminist principles when working with people who have experienced abuse,” says Radhika Sharma, a psychiatric social worker based in Mumbai who works with women who have experienced gender-based violence. “The notion that people are always responding to circumstances opens up possibilities for their skills to emerge, which would otherwise remain invisible to them. The key intention then is to make these personal responses visible, help the person realise where it is coming from (for example, responding to patriarchy) and then identify possible future steps the person wants to take that fit in with their hopes and dreams.”

For India, this could be a step forward in promoting the kind of mental healthcare that is sensitive to gender, caste, sexuality and other systems in the hierarchy of social oppression. This is at a time when the unethical nature of mental health practices prevalent in the country are affecting a major portion of clientele that belongs to minorities.

Also read on Firstpost - Mental healthcare in India: Accessibility still a challenge, as minority issues remain unaccounted for

“If the person remains unaware of inequalities and oppression, it becomes hard for them to understand why they have been feeling the distress in the first place. Take the example of a woman stressed about losing weight while wanting to get married. Now, if we don't explore the underpinning issues of body image and gender role expectations, things will not progress,” Jehanzeb added.

Separating the person from the ‘problem’

Another key element of narrative therapy is ‘externalisation’. Unlike traditional approaches where the person is destined to carry the burden of their illness with themselves, narrative therapy separates the person from that problem. Speaking about externalisation, Jehanzeb says, “The idea that the person is not the problem (but the problem is the problem) makes people recognise their skills, knowledge, values and agency, which were earlier concealed by that burden. We as professionals are interested in those stories and their interpretation, which inform people about who they are."

By stories, Jehanzeb means a universal way of stitching together the events and thoughts that become meaningful to the person irrespective of language or culture, using the medium of talking.

Also read on Firstpost: Atasi, a documentary about mental health, shows the focus should be on the person, not the 'problem'

Maria had soon begun to comprehend the benefits of externalisation. “I never felt like my voice and thoughts were being disregarded. Very often, people with mental illnesses are mistreated because anything we say is perceived with that insane 'label' and hence, not taken into account. Our agency and power need to be seen as human; we are more than our disorders.”

Ipsa James, a psychologist based in Delhi, works with the LGBTQ community and weighs in on the benefits of externalisation offered by narrative approaches. “It is very common for people from the community to engage in self-blame for their deteriorating mental health, due to the stigma. Building the separation between them and the issue helps them get a better picture and prevents them from blaming themselves for their sexuality and the gender they identify with.”

Whatever floats your boat

“Coping mechanisms are often deemed as negative, when in fact everything is a coping mechanism of sorts. We just have to find the least harmful ones and preferably those that might even do us some additional good,” says Maria, as we moved on to the ‘solution’ aspect of narrative approaches.

One of the most remarkable works featuring the use of narrative approaches was with the aboriginal communities in Australia, who have endured centuries of abuse, violence and suicide. A prolonged series of studies established that in the most horrific of situations, people still possess the resilience to survive and can be helped if their ability to deal with the pain is identified. But where does one look for this?

Radhika says it comes from how we respond to a particular situation. “Every response and measure people attempt in their battle, however small it may seem, should be seen as an ability. This is what sets the way forward. In the case of gender-based violence, society even stigmatises the victims’ responses to the violence, when what they actually reveal are victims’ ability to cope with the distress.”

Research on the uses of narrative therapy with marginalised sections have supported its propensity to become a mental health tool that is intersectional, thus aiding a very large population of people in India who do not have access to mental healthcare in the first place.