Shweta* had been consulting a psychiatrist for about a year for a mood disorder. At one point, she discussed some issues she was having with her partner with the psychiatrist, who then took her partner’s number and asked Shweta to wait outside. When she was called back inside, the psychiatrist, after speaking to her partner, told Shweta to simply do what her partner told her and not argue.
“Shweta’s version was completely discounted. The psychiatrist exercised the same stigma that disbelieves people with mental health issues as if they cannot speak the truth. It wasn’t just the dismissal, but also the way it was done – speaking to the partner in the absence of the client, and then simply saying don’t talk about other things, listen to them and take the medication,” says Saravana Raja, the founder of Mind Matters Circle, a peer support group for people with psycho-social vulnerabilities and disabilities, as well as caregivers.
What happened with Shweta was in violation of her rights as a person seeking mental healthcare. However, it is not an isolated experience. From what is therapy and counseling, to the importance of confidentiality and when it can be breached (if at all), here is a primer.
While counseling and psychotherapy may involve talking and sharing feelings, it should not involve the professional giving you advice.
Shanmathi, senior crisis counselor at Chennai-based PCVC, says that the first thing to ensure is that they provide a safe space for people to get unconditional support. “We get many domestic violence survivors who have faced a lot of trauma. It is not easy for them to reach out because of the judgment and stigma they have already faced in the society and families. So, our approach is that the client knows best,” she tells TNM.
It is also important to understand that therapy and counseling do not entail the mental health practitioner giving advice. Sivakami, a psychotherapist, points out that effective counseling processes would engage the client as the person who is an expert on their life. “It’s about facilitating and providing perspective to enable someone seeking a change in their life to approach things and problems in different ways. As you keep engaging, you can develop certain pathways that help in that change.”
Saravana Raja says that a good mental health practitioner will not give you dos and don'ts, but would rather help you travel and navigate what you are going through and let you come up with them, if at all, yourself. At no point can a mental health practitioner make decisions for you, or threaten to take action for you, even using that you have told them.
While counseling and therapy are used interchangeably in common parlance, there is slight differentiation between the two, apart from the qualifications of the service providers. While counseling could be more short term and involve talk therapy, psychotherapy is more long term, and could involve various different methodologies and exercises apart from talking.
A few months ago, as the case around actor Sushant Singh Rajput’s death unfolded, it put the spotlight on mental health and confidentiality between a client and a mental health practitioner when details about his psychiatrist’s statement were released in the media.
The mental health practitioners that TNM spoke to said that confidentiality is sacrosanct, and the client has a right to know about the situations where it might be breached.
“Informed consent becomes very important here,” says Sivakami. “A client must know when his/her confidentiality may be breached – which is if they are a minor unable to give consent and/or at risk of harm to self or to others. But beyond that, even if a loved one or family calls and asks a professional if the client is doing well, the practitioner should ideally not even confirm if they are providing the service to the client.”
Shanmathi says that before any counseling process, they educate the client about confidentiality, which will not be breached unless they are at risk of harm. “Even in the situation there is a breach, we tell them that it is not their whole history that will be disclosed, but only the relevant details or incidents. A counselor need not speak for the client.” At no point though, can a mental health practitioner use any of these reasons to blackmail or threaten a client with disclosing their information.
Section 23 of the Mental Healthcare Act 2017 also says that a person with mental illness has the right to confidentiality, which should not be breached unless under certain specific circumstances. These include – apart from threat to life – releasing information to a nominated representative of the client to fulfill their duties, to another mental health professional to enable them to provide care and treatment; when this information is required by a court, or for public safety and security; among other things.
If a person feels that their confidentiality is breached without consent, he/she can file a complaint with the Mental Health Review Board, mandated to be instituted by the state governments under chapter 9 of the Act. Section 77 of the Act says that any person or their representative, if aggrieved by the decision of the mental health establishment, can make an application to the Board seeking redressal, without being charged a fee.
“A person can also file an appeal with the High Court if their confidentiality has been breached,” Shanmathi adds.
It is important to remember as a person seeking mental healthcare that the relationship between you and service provider is an equal one. This does not always happen though, says Saravana Raja, “because in India, the word of a doctor becomes akin to the word of god.”
“When people view doctors as authority figures, they may not even understand that there has been a violation of their rights. This has to change,” he adds.
This also means that a mental health practitioner is not entitled to judging your life choices and events. However, this is not always the reality, says Saravana Raja, recounting how many people have faced judgment especially because of their gender, sexuality, religious identity and so on. “One should be aware of this judgment, and if they are aware, they are in a better place to stand up to it,” he says.
Shanmathi adds, “A mental health practitioner does not have an upper hand in this relationship. The client has the right to speak up when they are uncomfortable, or they feel that the focus of the therapy or counseling is going in an unfavourable direction. They have the right to stop and discuss redirection.”
So, for instance, if you are a violence survivor in therapy and are considering approaching the police, a mental health practitioner is not within authority to discourage you, or on the contrary, encourage you.
Sivakami points out that as of now, India does not have a uniform licensing body to certify mental health professionals, which often puts the onus to uphold a client’s rights on practitioners, organisations and their own moral compasses. The Rehabilitation Council of India, a statutory body, only recognises clinical psychologists and rehabilitation psychologists.
Further, due to the stigma associated with mental health, people often get wary of any written or signed document – even if it is a consent form at the beginning of the service – while seeking therapy. “So then, even something like getting informed consent and educating the patient of confidentiality becomes a prerogative of the practitioner, because a written document is not always required and may even drive the patient away out of fear and stigma,” Sivakami adds.
There is a code of ethics for psychiatrists, which is approved by the Indian Psychiatric Society. However, this too is not enforceable.
Experts TNM spoke to said that there are a few things one can do to check the authenticity of persons and/or organisations claiming to provide mental healthcare. These include checking for online reviews and credentials, cross-checking references, and going by word of mouth.
Manoj, the CEO of White Swan Foundation, an organisation that does mental health awareness and advocacy, stresses that one can always ask a mental health professional about their qualifications directly. “The focus on mental health is relatively recent compared to other disciplines. But as people start becoming more aware and demanding answers, service providers will also feel the need to be more transparent about accreditation,” he says.
If you want to know more about a non-governmental organisation that is offering mental healthcare, you can follow some of the steps here to check authenticity.
*Name and some details change to protect identity