By- Prairna Kumar
“Water water everywhere, Not a drop to drink.”
Do you recall these lines from ‘The Rime of the Ancient Mariner’ by Samuel Taylor Coleridge? I remember I was a curious little teenager, wearing my hair in two plats, when I read this neverending poem in school. Of the million and eighty lines the poem had, these two have stuck with me the longest. I find myself quoting these in multiple scenarios, but in no other scenario have these been more relevant than in the context of getting access to mental health.
When we think ‘access’, we typically think ‘availability’. We talk about the supply gap issue in the sector – and rightly so – there just aren’t enough mental health professionals (MHPs) to cater to the population size, let alone catering to the remotely located population. And that isn’t just true for India, but all countries across the world, with the exceptions of a few like Argentina.
At most, we find some mental health organizations talk about discoverability-of-the-available professionals and getting connected with them remotely. All of that is great. And much needed. But I have a different question for us to explore today.
While we should solve for availability, discoverability, and remote
connectivity, is that enough to solve the world’s mental health crisis?
Much like the lines in the poem, does being in a boat surrounded by water solve the thirst of the mariner?
If Access = (Availability + Discoverability + Connectivity), is Access = Positive Outcome?
In my curious inquiry on this topic, I came across some facts that blew my mind:
– Of every 10 people who get help for their mental health,
- 5 do not think they are benefitting from it2
- 6 drop out prematurely3
- One gets worse4
- Those who benefit, typically do so with their 4th therapist5
What’s worse is that it takes an average American 11 years to seek help from the time that symptoms first develop.6 This gap is predicted to be longer for the average Indian.
Imagine the agony – after 11 years or more of suffering and denial and frustration of nothing else working out, a person gets past the social stigma and ‘availability’ hurdles, only to have a coin-toss chance at improving.
We don’t see that happening with any other healthcare profession. Then why are these stats so alarming in mental health?
A cautionary tale from experience
Personally, it took me 5 years to seek help. I am a domestic abuse survivor and even though my ex-husband was hurting me physically, emotionally, financially, and sexually, I protected him to no end and believed that I was in love with him. More accurately, I was trauma-bonded, as I now know. I thought he needed help. I thought I needed help. And no, availability, discoverability, or connectivity were not hurdles for either of us. Yet, it took us 5 years to finally get the help. Even then, my experience with my first MHP pushed me further down the rabbit hole of co-dependency and abuse enablement. Not because my MHP was not skilled or not good, but because we did not have a good working rhythm. I quit therapy and took a break from getting any help at all. But when I tried a second time with a different MHP, that experience was transformational. It helped me recognize abusive patterns, break the trauma bond, and learn to draw boundaries and build healthy coping mechanisms for my posttraumatic anxiety. But most of all, it helped me create such a life for myself that I do not need an escape from it anymore. Therapy moved me from crippling self-doubt and helplessness towards obtaining enough agency to begin a start-up and live a wholesome life today.
I say therapy, but I mean the way my second MHP and I worked together. Not therapy in and of itself.
Not just therapy. Therapy done right.
I have interviewed over 50 therapy goers in India, to date, and many of them share a similar experience to mine that not all therapy relationships are equal.
On the flip side, I have also interviewed over 35 mental health professionals and it is evident that they find it heartbreaking to see their clients quit prematurely, and worse, ghost – likely for no fault of theirs. Even with the best of intentions and training, sometimes, it just doesn’t seem to be working out.
So the more meaningful question that I grapple with now, when I think about access, is ‘How can we ensure that people don’t just seek help, but that when they do, they benefit from it?’
Mental health is different from the rest of healthcare in that this is the one form of care where the ‘alliance’ between the therapy seeker and the provider (the therapeutic alliance) is more important than the choice of treatment itself. While the therapeutic alliance is important in other forms of healthcare as well, it is paramount in mental health.
Several meta-analyses of studies examining the linkage between such alliance and outcomes in both adult and youth psychotherapy (Martin et al., 2000; Shirk and Karver, 2003; Karver et al., 2006) have indicated that the quality of the alliance was more predictive of positive outcome than the type of intervention.7
Quoting from one such study, “Some theorists have defined the quality of the alliance as the “quintessential integrative variable” of a therapy (Wolfe and Goldfried, 1988), and in the present state, it seems possible to affirm that the quality of the client-therapist alliance is a consistent predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures (Horvath and Bedi, 2002; Norcross, 2002).”7
Yet, when we talk of access to mental health treatments, we hardly ever talk of access to mental healthcare with a strong therapeutic alliance.
The World Mental Health Report 2020 by the World Health Organization states, “Nearly a billion people around the world live with a diagnosable mental disorder. Most people with mental health conditions do not have access to effective care.[…] For people with mental health conditions that are detected, the care and treatment they get is all too often inadequate or improper.”
It’s not enough to bring a person to a mental health professional, the intended therapeutic outcome needs to be achieved. Access is not enough. Meaningful access is key.
Not just access. Meaningful access.
Meaningful Access = (Availability + Discoverability + Connectivity) * Therapeutic Alliance
Access to meaningful mental healthcare, like other forms of healthcare, is a fundamental human right. And so, while we think of ways of creating access, we need more systemic ways to ensure that we get the therapeutic alliance right, every single time. The solutions that help create access to other healthcare, may not give the same results when applied to mental health. Mental healthcare needs unique solutions that promote alignment, collaboration, and trust between the MHP and their client.
Going back to the analogy in the lines from ‘The Rime of the Ancient Mariner’, surrounding oneself with water is not enough. The water needs to be potable, the water needs to be consumed, and the water needs to be absorbed in the body for the Mariner’s thirst to be quenched.
References:
1. Comprehensive Mental Health Action Plan 2013–2030, WHO
2. Eleanor Cummins, Why Therapy is Broken, the Wired, 2022
3. Bernard Schwartz, Three Main Reasons Clinicians Fail Their Clients, New Harbinger Publications, 2017
4. Miranda Wolpert, Failure is an option, 2016, The Lancet Psychiatry
5. Chris Melore, Survey by OnePoll in partnership with Mindstrong, 2022
6. Philip S Wang, Patricia A Berglund, Mark Olfson, and Ronald C Kessler, Delays in Initial Treatment Contact After First Onset of a Mental Disorder, 2004
7. Rita B. Ardito and Daniela Rabellino, Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research, National Library of Medicine, 2011