by Ujjwala Singh and Dr. Shalini Masih
“I woke up, startled, by the sound of my phone ringing. Before I even answered the call, I switched on a light and checked the time. It was 2:50 AM. I knew it was a distress call from a student. I answered the call and heard an anxious voice on the other end. A student reported that they were having a panic attack following a fight with a friend. I got ready and walked towards the clinic to help that student.”
This is a common experience of a Psychotherapist working and residing in a residential campus of grand educational institutions. We spoke to one such colleague.
“Q. What has been your experience of working in university clinics of the kind you worked in?
A. It has been a mixed experience. The part of working with the students in sessions has been meaningful. However, the aspect of the institutional framework and how they saw mental health intervention was very difficult to work around.
Q. Could you tell me how the working of counselling spaces are designed in these universities?
A. The counselling units are run like a standalone centre, which comes under an administrative role for the university and not an academic one. That deeply impacts our working because like an admin department, we are expected to work beyond the working hours of the campus and it also impacts the leaves we get as we are expected to work even during the holidays. In fact, what sets it apart from even the general administrative role is that there is no concept of a working hour or shift in practice.
Q. What does that mean exactly? How many counsellors are there in such universities and how is the working hour decided?
A. See, I cannot speak for all the universities but in the ones that I have worked in, the counselling center is open to all students, staff, faculty as well as the family of staff and faculty. So, the ratio would be estimated like 1:1500-2000. In terms of working hours, our work day officially involved an 8.5- hour shift. However, an important caveat to this was that in addition to the usual working hours wherein we carried out our one-on-one sessions, we were also responsible for handling emergency situations, which meant we could be called upon at any hour of the day or night whenever an emergency arose. Further our official work days were from Monday to Friday, however due to the nature of emergency intervention work, in practice we were expected to be in/ around the campus for seven days a week.
Q. I am trying to understand this in more depth. As part of our work as therapists, when working within the field of mental health, emergency sessions/crisis calls/ helplines are a known occurrence. How does this work in such university set-ups and is there a difference you have felt in its nature? Also, if possible, could you help me by telling me some moments or examples of these?
A. Right! Well in the mental health field, we are trained thoroughly to understand the importance of crisis calls and emergency situations. In private practice, we try to coordinate a more collaborative system to work around these situations. You know, taking emergency contacts of the client, also making use of helplines etc. is part of the larger network of mental health and helps us mitigate any situations of self-harm etc. These resources are very helpful when the therapist is not present for example and what I have noticed is that these emergency calls and sessions are more of an exception to the general rule of a boundary that the therapeutic frame requires for us to set. Thus, in situations of everyday distress, the idea is to communicate and talk about these pressing concerns that might be causing distress in the following session as and when scheduled.
However, in these institutions, especially in residential campuses primarily, unlike dedicated crisis helplines and other such intervention models, the emergency service is very different. When the university makes available a 24/7 emergency service over and above the usual working hours of the counselling services / clinic, contacting the counsellors is an everyday norm rather than to be used as an exceptional circumstance for very dire or absolutely unmanageable circumstances.
On the one hand, yes, it is important that there is de-stigmatization of mental health needs and services. But the ways in which it is made available is what creates more of a problem if you think of psychic work. It frames these mental health services in the mind of the students as a right to be exercised as and when one needs and that too immediately. This can be deeply hampering in some ways. There is a need to immediately remove any feeling of distress, discomfort and we counsellors would get a call to help or manage these situations. We would receive distress calls during exams, assessment submissions which were in fact very common. Panic attacks and anxiety attacks were most common in residential universities for which we were contacted at all odd hours of the day and night. Very often, when students are out socialising and partying, those were difficult days for us as counsellors as we knew we would be called upon by the administration to handle fights, incidents that occurred in these settings and so on. Relationship fights or breakups etc. were also very common reasons to contact us at odd hours.
I remember one time I received a call and it did not feel like there was an immediate need to be physically present and was trying to intervene through the call itself. But the person responded by saying that the other counsellor came last time -so why can’t you come?”
Most of these institutions take pride in top-quality education facilitated by faculties from all over the globe and state-of-the-art amenities that are offered to the students. A mental health facility is one such amenity that is put in place to present the institution as carrying the mental health of its students as a palpably alive concern.
However, in this article, we will be zooming in on the structure of these mental health facilities to highlight some ways in which these structures may be unhelpful. At the start, we would like to acknowledge that we are not saying that a mental health facility in an educational institution is not helpful at all. We are not examining the good intentions with which these structures are set up, with which the counsellors work with the students or the intentions of being cured that students bring to their counsellors. We are only going to be looking at one strand of the frame of such a setting and how a certain quality of this frame may prove more detrimental than beneficial to the mental health of those who avail these services. In other words, we are reflecting on the frame and its implications for lasting psychological change.
This is a reflection on frame or structure and not a plea for respect for the counsellor’s boundaries. We believe respect for the other person should be a norm and not something received through supplication.
So, the question we are reflecting on is – What could be the implications of having an easily accessible counsellor?
As a country, it’s taken us some time to reach a point where mental health is being taken seriously and efforts are made to make mental health services accessible to many. While such attempts have served to diffuse the stigma around mental illness, nonetheless there is a need to tread mindfully.
A frame that presents the counsellors as easily accessible does not prove helpful in evolving long-lasting psychological changes. No matter how noble the intention may seem, to have an all-the-time-available counsellor may become a reason why someone may never feel the need to cultivate in themselves the psychic capacities to contain their own distress. Such a frame establishes the counsellor as an object that can be used relentlessly without ever becoming a counsellor who can be internalised-as-a-function in the internal world.
Additionally, the implications of such a frame can limit and incarcerate the therapeutic role solely within a management role (management of the symptom rather than working through it).
A crucial part of psychotherapeutic work, especially in the psychoanalytic tradition, involves the therapist enabling the evolution of a mind that can reflect on emotional experience. A capacity to reflect on one’s own emotions also eventually establishes the capacity to learn from experience. It cannot be stressed enough that such a capacity can be especially beneficial for a student who has the task of using their academic resources well and excel. Drawing from the psychoanalytic theory of mind and its validation found in clinical experience, we believe that a capacity to tolerate frustration is the antidote for the human need for immediate gratification. This does not only apply to impulse control but is also very relevant in building a capacity to think. When a therapist is treated as an ‘always-available container’ of emotional distress and an encyclopaedia for the meaning of that distress, the client can bypass the delay inherent in psychic work that goes into cultivating in oneself an internal container of emotions and a capacity to reflect on them. When institutions take pride in making mental health services easily accessible, they perhaps have overlooked the importance of a frame where some delays and frustrations are necessary in order to create opportunities for building tolerance for these frustrations. In such a setup then, everything becomes a crisis. In other words, there is no room for imagination of the ‘ordinary’ suffering of life when everything that happens to a person is experienced as an emergency which a therapist (as a miracle worker) will deliver one from. We have realised that gaps between therapy sessions are as important for clinical work as the work that transpires in those sessions. In the absence of the therapist between sessions and the awareness of a rhythm of therapy, the client’s mind moves to do the psychic work of using the memory of the therapy. In other words, reliance on the memory of help received from the therapist replaces falling back on the therapist. A reliance on cultivating something abstract in the mind replaces a reliance on the tangible existence of the therapist.
If anything, these experiences of moments of felt crisis are very critical for psychological growth wherein psychoanalytic theory has foregrounded for us how with a favourable balance of factors in place, certain experiences with difficult emotions like anxiety are essential in the development of one’s personality and are different from the kind of boundless anxieties that can lead to severe psychopathologies. In times of distress, there can often be an inclination to immediately rid oneself of difficult feelings in self-destructive and moreover ‘self-depleting’ ways. There is a need to evacuate these overwhelming feelings to regain a sense of composure and relief, which although momentarily seems satisfactory, can overtime inhibit the development of one’s self. Thus, one of the most integral functions of psychotherapy is to allow for a therapeutic climate that fosters the ability to translate what was formerly chaotic, unthinkable and unbearable into more thinkable thoughts, hence engendering a capacity to endure these difficult states. This leads to transformation in one’s capacity to think as well as function more creatively and symbolically. In other words, instead of expelling the feeling one stays with it, deliberates on it, learns from it and works towards a symbolic expression of ‘reflective’ nature rather than an expulsive nature.
However, for such work in psychotherapy to happen, it is important that it is present in a manner that renders and provides an alternative to acting out of such anxieties. The propensity to act out in ways that can be further damaging can only be transformed into a more fertile capacity for working through such feelings when the therapeutic frame is not offered as an agent of the very acting out. It is here then where we mark a distinction between merely making therapy available v/s inaugurating a therapeutic climate. Psychotherapy can work towards developing such a climate only when it is aided by our larger organisations in its workings.
How does one then institute a more creative use of mental health facilities in these universities? Is there a way to imagine using these spaces in a more dynamic way? Our mental health units, as envoys of psychological support should be prospected to continually facilitate and nurture psychic and social processes and not get translated into a unit that replaces these psychic and social processes.
The idea is to locate and utilise these resources (our counsellors) in a more facilitative way, thus keeping it from becoming an all-time available, mutually exclusive, designated space to talk about complex affects and moments. Instead, a more visionary use of mental health spaces is to cultivate a capacity for these feelings to find multiple avenues of comfort along with but not restricted to the counsellor and that necessitates a change in the frame and its boundaries at the foremost.
There is no doubt about the fact now that colleges and university campuses in India and all across the globe are rife with one or the other form of psychological distress, which unquestionably calls for accessible spaces to be put in place. Thus, it is not the accessibility that is in question. It is how these spaces are being employed in the institutional edifice that is more of our concern here. “A student/teacher/staff etc. is in distress- here! we have a 24/7 counselling service available”- this cannot be the answer. We need to ask ourselves why so many people are suffering. The outsourcing of this function to our counsellors is what is perhaps curbing our capacities for long-lasting change (both psychological and systemic). Phenomenologically, one is not unaware of how pedagogies operating in very rampant and ruthless cultures of managerialism have impacted the mental health world and as Churcher (2015) has argued, “a perverse overvaluation of targets, indices, audits, etc have displaced trust and intrinsic motivation, and by a general political and institutional pessimism, and loss of morale.” Thus, we need to pose a larger question here as to what are the internal resources that are imperative for carrying out the work that we all do as therapists and more importantly ask what provisions need to be accommodated in the structure of these universities to nurture and maintain those internal conditions.
We believe that working with mental health facilities as a resource, not as an outsource, will inevitably bring us closer to the imaginations around change and transformation. A simple shift in our (re)framing of what is the primary task of an organisation as Churcher (2015) says, from “What is the task?” to “What should the task be?” will engender a more lively spirit to the field of mental health. On one hand, we are trying to understand what are the implications of having an easily accessible counsellor in fostering psychic capacities in individuals who seek these services. Analogous to this, it is important to acknowledge the implications of such a frame in terms of the psychic cultures of the university as well.
With the pervasiveness of rising adversities and vicissitudes of suffering in people who come to our clinics, it may be helpful to acknowledge that the process of containment that is important for the working through and improvement of such intense feelings and anxieties has to be brought about and facilitated more collectively- by one’s families, schools, universities, workspaces and the society at large.
As long as universities continue to (mis)use their psychotherapists as a containing function only to perpetuate the values of a world that serves to escalate such distress through its evacuation, we are heading for an impasse.
Shades of Becoming 