Mental health intervention in the new normal

mental health intervention, put quite simply, comprises the variety of techniques used by psychologists to treat individuals with issues pertaining to mental health and wellbeing. A common misconception is that mental health intervention is simply counselling, but this is not so. There are diverse techniques with various levels of physical and emotional interaction. These techniques include counselling, psychotherapy, vocational therapy, and even medication.

Mental health as a topic in Sri Lankan society is one that tends to get swept under the rug. No one ever wants to admit that they need mental health support or treatment because of the stigma attached to it and the chance that people will treat them differently.

However, in recent years, with the whole world beginning to prioritise mental health, and organisations in Sri Lanka working to build awareness while breaking the stigma, more people are talking about and seeking support about their mental health than ever before.

Like almost every other industry, the field of psychology and mental health intervention services too has been affected by Covid-19. Lockdowns and curfews have made it so that professionals and patients in this field of healthcare have had to adapt to meet new challenges.

Sri Lanka’s nine-week lockdown meant that patients who depended on seeing their therapists regularly were suddenly unable to get help at the level they needed. The aura of doom and gloom that came with the first few weeks of Covid-19 and lockdown did little to help those who were already anxious, stressed, and depressed.

In light of this, The Sunday Morning Brunch reached out to psychologists and therapists to learn more about mental health intervention and how Covid-19 has affected the field and those in it, be it on a professional level or personal level.

Adapting to the lockdown

Clinical Psychologist Dr. Suhaila Shafeek Irshard

Speaking to clinical psychologist Dr. Suhaila Shafeek Irshard who serves as the Director of Child Adolescent and Family Services (CAFS), an independent not-for-profit organisation headed by a group of psychologists that provides multidisciplinary mental health services, we learnt that virtual mental health intervention, particularly virtual counselling, was not unheard of. It has been used extensively abroad to varying, situation-specific levels of effectiveness.

Locally, virtual intervention has been limited mostly to over-the-phone counselling through organisations like Sri Lanka Sumithrayo which provides free virtual counselling and mental health support to those who come forward, working with them via the phone as well as in person depending on the situation.

Clinical psychologist Roshan Dhammapala, who has worked as a counsellor on the recent helpline set up by the Government during the pandemic, explained that people from very diverse backgrounds and settings reached out for support on the helpline, adding that despite these differences in demography, people still managed to make successful connections and speak about their issues and seek support/advice.

In her own practice, Dhammapala made the switch to consulting with her clients remotely and not just with her existing clients, but also with lots of new ones who reached out for support and treatment during the lockdown. Dhammapala made an effort to be flexible in how she consulted, whether it was over the phone or through video conferencing, accommodating clients’ need for privacy as the situation demanded.

In terms of anxiety, Dr. Irshard shared that there were three “peaks of anxiety” that she had observed when dealing with her clients. “There has been a rise in reports of anxiety over the last few months, with roughly three ‘peaks’. The first was at the start of the lockdown amidst all the uncertainty at that time. The second was at the one month mark of the curfew, with people very worried, and the last one, which is more recent, took place once restrictions relaxed and people started to go back to their daily lives,” Dr. Irshard said.

With face-to-face counselling and intervention no longer an option, many psychologists, Dr. Irshard included, needed to make the shift to virtual intervention, moving to interact with patients and clients via video conferencing platforms, the phone, and text.

Pros and cons of virtual intervention

Virtual intervention carries with it a lot of benefits, particularly in times like these when public health is a major concern. It provides a safe way for psychologists to consult with clients, touch base, and help work through issues without needing to interact physically.

Clinical Psychologist Lakmal Ponnamperuma

Speaking to clinical psychologist Lakmal Ponnamperuma, we learnt that another benefit of virtual mental health intervention techniques was that of time and cost savings. With traditional physical intervention and counselling, there is an amount of time that is lost, particularly on the client’s side. They have to take time out of work or away from their families, travel to meet their therapist, spend time in waiting rooms, spend an hour or so with their therapist, and then travel back. Virtual intervention saves on this aspect of time, with clients given the ability to engage with their therapists in a familiar setting while saving time that can be used in other ways. It also stops clients from running into people they know due to privacy reasons.

Privacy is also a benefit that clients can expect from virtual intervention. The aspect of being uncomfortable while in a hospital waiting room and potentially worrying about stigma is also cut out with the clients being able to consult remotely. The stigma surrounding mental health in general makes many clients reluctant to admit that they are seeking mental health support and intervention.

Dr. Irshard also shared that with the pandemic serving as a catalyst to normalise virtual interaction, on the whole, services like personality assessments and similar questionnaire-based assessments were made available in a virtual context, which has made assessing new clients possible and working out therapy techniques easier.

The drawbacks of virtual mental health intervention mainly stem from lack of physical interaction. Dr. Irshard explained that particularly when dealing with new clients and those with specific difficulties like extreme grief, for example, there is an element of agency lost on behalf of the therapist because of the lack of physical connection. In moments of distress, it is very easy for clients to disconnect or cut the session short, whereas with physical intervention, being in the room with someone makes it easier to power through unpleasant or uncomfortable moments in the process and work through issues.

Ponnamperuma also commented that there are types of clients who are less suited to virtual intervention because of their specific needs; some need more physical interaction than others. Dr. Irshard also commented in a similar vein, explaining that this was particularly relevant in cases like younger children where building a rapport and holding attention is key. However, doing this effectively from behind a screen is not easy.

Privacy was also an issue raised by Dhammapala, Ponnamperuma, and Dr. Irshard, although in different respects. Ponnamperuma talked about the aspect of privacy in terms of platforms, explaining that he had dealt with clients who were reluctant to turn to video and phone conferencing as methods of consultation because of the chance the platforms or apps themselves may be insecure and subject to security breaches that could compromise their privacy.

Dr. Irshard said privacy became an issue with clients because of the change in surroundings. While clients are consulting from their own personal and familiar spaces, and this can be positive, there is also an inherent lack of privacy in these spaces for clients. Many people live with their families, which can make honest, open dialogue difficult. This is particularly true in the case of clients who have children and in the case of clients who live in abusive environments or are otherwise keeping their treatment private.

Clinical Psychologist Roshan Dhammpala

Another major drawback of virtual intervention is technology, with only some clients being technologically savvy to be able to benefit from virtual counselling effectively. Unease with technology will automatically impact the quality of the session because the client is distracted and uncomfortable. When compounded with issues like internet access and quality, this can become an obstacle.

Dhammapala also weighed in, explaining that sometimes the disadvantages of virtual intervention can also be advantages, particularly in cases where the client has to gauge the therapist based on one sense, like over the phone where it is entirely voice-driven. Sometimes this can help because it blocks out other data that may interfere, but it can also make things harder if the client and therapist are both people who also need to make a virtual connection. The inability to be able to respond to non-verbal cues like facial expressions or body language can also make intervention harder on both ends.

Treating clients with specific physical needs

Counselling as we know it is not the only form of mental health intervention; there are many techniques, with some being more interactive than others. One interactive form of intervention is drama therapy, a creative arts psychotherapy that uses the medium of drama to help clients process, building in elements and practices like storytelling, enactment, movement, and art to build awareness between the mind and body.

Dramatherapist Tehani Chitty

Forms of intervention like drama therapy require a strong physical presence within a space, which limits how therapists can adapt in a virtual environment. Dramatherapist Tehani Chitty explained that given the nature of dramatherapy, adapting to a virtual environment is quite challenging, adding that technological difficulties can also hamper the process further.

The biggest challenge to conducting intervention forms like dramatherapy virtually is that dramatherapy in particular is heavily client led, with therapists acting as facilitators. In an online environment, therapists need to be direct, which can hamper the process if not done carefully. Chitty did adapt to conducting therapy online during the pandemic but is now back on track, meeting clients in person for maximum effect.

Sharing her views on the short term, Chitty feels that there will be an increase in virtual intervention in the short term, but shared Dr. Irshard’s feelings on clients feeling safe in their own environments in situations where confidentiality is a priority. Sri Lankan culture is such that many people live with their parents or other family.

Chitty was of the view that the ideal form of mental health intervention is physical because the relationship between the client and therapist has always been an important part of the process of healing, and there are elements of this that are lost in a virtual environment.

The impact of mental health intervention in the long-term

In general, treating issues with mental health is something that is very hands-on, particularly given its sensitive nature. To truly measure the impacts of virtual intervention techniques versus physical health techniques is something that would require in-depth studies to be conducted.

Ponnamperuma explained that recent studies conducted abroad have indicated that for the most part, virtual intervention is as effective but quite subjective, which makes the weight of these studies potentially problematic. Locally, no such studies have yet been conducted, so gauging how this works in a Sri Lankan context is not yet possible.

The year 2020 and the global pandemic have served to normalise digital working methods across the board. Commenting on the long-term viability of physical intervention, Dr. Irshard commented that physical intervention will always be more effective because of the infinite possibilities of physical interaction. However, Covid-19 has shown that everyone needs to change and that anything is possible. It may not be a matter of online being better than physical or vice versa, but more about virtual intervention improving and growing as a standalone form of treatment for specific clients.