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Webinar- Importance of Therapeutic Relationships and Emotional Awareness by Tatva Centre

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June 1, 2021

In our weekly webinars, we talk about various industry scenarios and challenges of rehabs across the country, along with the de-addiction and mental health challenges faced by the mental health community and people in general.

In the tenth webinar of the series, we invited Ms Kripi Malviya – A psychologist, experiential psychotherapist, and mental health advocate at Tatva Center. The webinar was hosted by Mr Vikram Kumar – Managing Director of RehabPath, India. In the webinar, Ms Kripi shared her views on the importance of therapeutic relationships and emotional awareness.

In this blog, you can read the summary of the webinar, or you can watch it online here.

https://www.facebook.com/DeAddictionCentres/videos/3356747151041683/?__so__=permalink&__rv__=related_videos

Vikram: Please tell us about you and Tatva Center.

Kripi: I am the co-founder of Tatva. We were based primarily in Goa, but now we work pan India and also internationally. There are many modes with which we cover mental health – from awareness to treatment with different modalities like online, residential, and home-based. It is a very intersectional and inclusive mental health practice that tries to work with people as people. Addiction management is a qualification and something that I care about and has been part of our education and journey.

Vikram: Can you help us understand what therapeutic relationships and emotional awareness are?

Kripi: Everybody has different ideologies for mental health, addiction treatment, and work. Combining these two basic tenets of a therapeutic relationship or being in a healing relationship is considered the most important aspect of working with people. Therapeutic relationships are prioritized because the mode of treatment or management is not as important to us as the bond between the therapist and the client. We spend a lot of time building trust and alliance in that relationship, which is done through longevity. 

For example, we primarily have long-term therapeutic relationships, meaning we don’t do short-term work. This is because it allows us to form a real bond and get an in-depth analysis of who we are as a person. This makes the relationship the core and foundation which can be used for change and growth in any area of your life. It is why therapeutic relationships are given such importance. Some people ask what we are going to do together, I spend much time explaining that we will first get you to the point of vulnerability, authenticity, and trust to dig deeper and understand why you are where you are. It is the only way where we can be co-travellers in this journey of healing. That’s what a therapeutic relationship is all about.

I think you and the people working in this field would agree that culturally we don’t spend much time understanding our feelings or expressing, naming, or knowing them. Being emotionally intelligent has not been our priority. As you would know and may agree, trauma is an inescapable aspect of addiction and most mental health issues. At one point or another, we go through adverse experiences that form us, and addiction is one way people manage such traumas. Knowing what you are experiencing and how to be expressive about your needs are the strongest tools for self-determination and healing. Only then are we able to grow and transcend as people to keep moving.

These are the two pillars of our therapeutic approach on which everything else is built. If we use arts, culture, nature, or collaborate with other people – these are the two foundations where everything sits. 

It is a philosophy for a modality that we practice. We are an experiential practice, meaning we are experience-driven. We believe that people have to experience things that they want to grow in, including ourselves.

We are a humanistic practice, which is also David’s (co-founder) background as a therapist, which is human psychology or psychotherapy model. I am an existential psychotherapist.

When you combine these three main ways of looking at the world, it makes it impossible not to focus on the relationship. We are not looking at technique as much as what exists between you and me. It becomes the foundation of what we are going to do. We choose to prioritize it.

Trauma and pain happen through the actions of other humans in our life. We need to prioritize the healing relationship, which has to reset from what we have learned and become the basis with which we can live differently.

Vikram: Not many people visit therapists in India, let alone people with addiction. There can be many reasons for it. Specifically talking about this population, understanding the importance of therapeutic relationships is far beyond. How do you handle such situations?

Kripi: The model is important. You got a problem, it’s a disease – let’s treat it, and it is only one approach. I come from an addiction management approach where I believe some people facing addiction problems need to undergo some intensive programs to manage or get over it. I also believe some people also need an approach where we need not tell them what to do. 

As professionals, I feel we need to meet people where they are and have an open mind to see them. What you are talking about, I think, is specifically right in the centre of using the substance, and they haven’t had enough time to be with themselves. So they can’t get through it. This is the pre-detox period where a person is actively using the substance.

At that time, you can’t even get through to the person. The only point is that many times when people work with us with whatever state they may be in – using or withdrawing – they have their days where they want to get out, and then the other day, they feel fine. We try to have courageous and honest conversations with them. There’s no right or wrong, and they don’t have anything to prove. I will try not to guilt them as it is a real problem we have within addiction circles where conversations go like – do you know what is happening to your child or similar. It drives the person further into the addiction as it makes them feel guilty, and they want to get rid of it. 

I want to appeal to you as a person for whom addiction is a part of life but not the entire identity. I can’t tell them what to do with their life, but I’m right here. The only way I can meet you as a person is if you have some time away from the substance or process addiction and give us a chance. 

You may disagree with everything or find it incredibly painful and difficult to do so. It is about taking that chance because everything else you have been doing, you already know.

It is like an experience whether you want to go for it or not. You can go back to your life anytime you think it’s forfeiting. I will always be waiting on the other side whenever you are ready.

The relationship in that sense has already begun. It is like building faith because people with addiction are already testing the world. I say that I will double question you and won’t take your foolishness but also let you know that you are a person worth loving in this world. I will help you through it.

Vikram: If you look at the entire treatment of somebody with addiction, where does the role of a good therapeutic relationship come? 

Kripi: There’s a difference between mental health professionals and addiction professionals who engage in a 12-step programme or similar. Here are some people who have theoretical understanding and clinical experience of the field, then psychiatrists who work in the field to a degree, and then lastly, you have people who have gone through it. So, the last kind of people have an experiential understanding of it, but they don’t have any training in the field per se. I saw a stark divide between these people.

In India, I have seen some horror stories of rehabs. So I want to have a crossover between people who have experienced it and those who have earned clinical experience. It is what I did when I became an international addiction counsellor and trainer. I trained alongside other mental health professionals. This crossover is essential. 

Just because someone knows about addiction or has experienced it in their life does not give them legal training, accountability, or the authority to help someone else.

This is not a profession that can be checked; there’s no qualification — people often just do what they feel right. I continue learning from people who have faced addiction. My work is incomplete without it. It’ll be egotistical to think just because I have legal training, I understand everything. Every rehab facility needs to understand this.

The other thing is clear: we have a long way to go for comprehensive addiction management and treatment in this country. Right now, we do not have that passover. We are not a primary addiction or rehab facility, rather secondary. We are like a halfway house where you already have detoxed for some time, and then you’ve visited us.

We also do not have space from where people transition out. We do not have a halfway home, tertiary family therapy, or post-residential work, which goes on until 9-12 months if done properly.

A person goes from full-time rehab to doing their sessions on the side while living their life. We need that transition. It is where therapeutic relationships are important. The professional bond between the person going through a life-changing experience and someone who is invested in your life has to live that long, where it’s not like you come and go. There needs to be a multi-pronged approach. 

Every place that works with addiction needs to have people who have faced addiction to help them understand, be their peers, make them not feel alone, and support them. Similarly, every treatment centre needs a clinician, someone who is focused on accountable professional healing and management, who will keep everything else in check. It’s an intersectional model.

Vikram: Comparing the US and Indian markets, therapists are like a star in the US as they help people get better and develop & think better mentally. In India, the number of therapists is increasing, but there aren’t enough people approaching them except the top ones who have established themselves. How do you look at such scenarios and make sure there is a connection between the person and the therapist? How do we learn from the Western market to do better?

Kripi: It is important to factor in that our culture is different from the west. We treat people who imposition authority as Gods. It is also why psychiatrists also primarily do therapy because they are doctors, and they are at the top of the food chain in terms of how we treat or think about them. We want them to fix us. I think a narrative shift is required. The point is not having someone or something to fix you but to work with you, and it is not a passive process. We still have that “better give me a pill to make me better or send me away to cure.”

Especially around addiction, the language of cure is dangerous because dealing with this is a socio-political-economic issue. When we make it only about the person or their disease, we take away all the reasons why addiction exists in the first place in society.

First of all, it is not the client’s or the person’s duty who is seeking support to do this work. As mental health professionals who work with people, we have a duty to continue learning and work together.

We have a big gap in such partnerships in this country. Rehab is also a business.

The moment it becomes a business, it becomes about making a profit or being the most famous or successful. We lose the essence of having a multi-dimensional approach.

I have never worked with any person in addiction or mental health who doesn’t have at least these four or five main elements of support – a professional therapist, a community or peer group, a healthy personal relationship, something they are doing that they believe in with meaningful engagement, and a sense of wanting to help other people and grow.

I have learned that we need all of these to move ahead. We need a proper psycho, social, spiritual, and personal model to help one person because everything in their life was affected by one of these when they started to struggle.

They had a difficult social situation, a family or personal relationship situation, past trauma, or pre-existing medical condition. It all gets a person to the point of addiction, not just substances but it can be all process addictions, which are not even treated, like an obsession to fitness or partner or relationship or looks or social image.

We allow these addictions because they are not ‘substance’ related. The US has a long way to learn too.

We have better models in the world like Portugal, Scandinavia, and New Zealand models, where it is treated as a societal thing and not as a moral flaw, and legality is removed from this idea.

Without these elements, you see the coverage that is happening right now. It tells us everything we need to know about the psyche of a nation.

It is terrible like patriarchy because it is an attack on a woman. Let us make no mistake about it, and her morality mixed up with deep-rooted ignorance.

No matter how good the doctor is, what hopes you have of having a good life or well-lived life as a person who doesn’t want to be independent anymore when you are in a culture that constantly makes you feel something is wrong with you.

Somewhere, it’s all of our duties, where parents need to have this conversation with their children and vice-versa at home. People need to understand science and the real psycho-social reasons for why people use the substance. It collectively builds up the possibility of a person doing well.

When you talk about the west, it is an acceptance around therapy. This is because the first thought isn’t ‘something is wrong with you, it is ‘you need help.’

We need to change the narrative from deep inside us. We have the highest depression rate in the world, and it is because we pretend that we don’t have any problems. We act like we can do everything on our own. Instead of accepting, we try to hide and perform.

We teach our boys not to cry. We teach our girls that they are too emotional.

We want an approach where the world works with addiction or every other mental health distress that is truly good for them and us because it can be anyone, even our family, who can experience this.

Vikram: When we talk about 130 crore+ Indians having access to cell phones or Twitter and other social media platforms, you cannot just stop them from saying something. Whatever they will talk about or say will be based on their understanding or belief mixed with an agenda or philosophy or concepts like patriarchy. It is all a complex structure. How do we fix this problem in India? Are we going to take another 500 years to be socially responsible towards addicts? Do you think the government will step in? 

Kripi: We all like to think that we are a collective culture, but we are very ‘us vs. them’ in our hearts. When we feel different from the west because we look out for each other, but the moment something questions our already held beliefs, we behave like cornered animals — ‘how dare you to say this or question me’ or ‘who are you, I’m better than you.’

If 500 years are just allowed to go on like this, maybe yes. We can do this rapidly if we take steps aggressively. This is why the change needs to happen on a systemic level. For example, LGBTQI+ rights — the country may have a long way to go in acceptance but changing the law helps.

We need to have something happening on our structural level, and people will arrive at it. All the rights groups or the information disseminating from awareness campaigns and funding that area keeps people moving.

I think we are somewhere in the 1950s west where the war on drugs was started, and there was only one agenda: how bad it is or don’t consume it. We are still in that regressive stage. 

The only thing that’s changed is the people I know who care or have gone through these experiences to be courageous and loud. They voice what they believe in and create as much they can, and get it into as many places as possible.

The only thing to count on is to have your own. Create enough equitable noise, and it will help.

People should know some other way of engaging with us, which is why I’m against involuntary admissions.

Sometimes, people with addiction need to be taken away because they are a danger to themselves, and I understand that. But we are already a society that doesn’t give much importance to the autonomy of a person.

Whenever a family comes and says, “it’s his/her problem, please keep him/her,” I always tell the family that the person wasn’t born in a vacuum – you are a part of this. The attitude ‘something is wrong with you, but I’m okay or ‘you are the problem’ needs to be changed.

We NOT work with the family. We include them not to explain ‘look at your broken person,’ rather get them into the therapy process ‘you are part of the problem.’

You need healing, but you also need to know your role in the person’s addiction. It is like holding everyone responsible equally, which really helps.

Addiction and mental health problems are in our homes, and we need to accept that for personalising.  

Vikram: Can you help us understand the models Tatva has, especially the EDAS model?  

Kripi: It is called direct or home-based treatment. This model is probably followed by one or two organisations in the world where they say that we will come to you if you have a problem. Most of the time, the person is removed from the place they are in for some time. It works for some time but is rarely a long-term solution.

Until and unless the person’s home, where they’ll be going back, has shifted along with their shift, the relapse is high.

We don’t make it about where the person’s life is and only focus on where we are. The point is a team of two to three international experts will visit the person’s area and be available to them 24*7.

We do regressive therapy sessions, get to know you in your environment, and point out exactly what is happening to you that we can see.

This persists for the first few days when you have cravings or want to go out to do something that is going to self-sabotage you. It helps as we are able to see family dynamics in place.

We are able to see who is triggering which aspect of the disease or problem. What kind of trauma or conflict exists in the family? What kind of work-life does the person have?

It has helped people who involved us on a very deep level. There are huge contracts that are drawn around boundaries and on professionalism.

It is like having a personal therapist or your life coach or the person to a large degree who helps you rebuild a life in your environment.

It takes a long time for a person with an addiction problem to get truly honest about life with anyone. It takes time to build trust.

When you are getting them to your environment, there is no time for all that. You get straight to the point as to what their life looks like.

For people with disabilities or people who don’t want to be seen in public rehabs for whatever reasons, home-based programmes work well.

Even gender constraints for many women in different countries where they can’t go out, it is visible to the whole community of the entity itself in this model.

We don’t live in their homes; we live nearby where we are reachable or accessible by the person. We are family therapists too, so we have to practice incredible boundaries. 

We try that our presence can bring some truce to this and encourage them to engage with us.

We can intervene in the time of craving, in real-time. We can go through the process of what went down before and during it all happened. You have someone with you in your atmosphere.

Vikram: Can you explain for how long do these programmes go? 

Kripi: We never go at a quick pace. Addiction is complex. It sometimes takes a lifetime to get to the point from where they have come. When people believe that they can get in a short period, it doesn’t usually work.

We are usually up-front that if you have invested so much time in your addiction, at least invest a quarter of it in your recovery work as this is not a shortcut. 2 weeks are required to see what is happening, and four weeks is the minimum required. Combining the aftercare and different levels of approach for reducing the engagement slowly, the ideal time is always 90-days.

Vikram: It sounds like you are relocating an entire team to a location for treatment. Is it affordable for the middle class, or is it for someone who has a higher budget relative to India’s mid-range rehab centres?

Kripi: We have a sliding scale. We do a good analysis of the person’s economic condition and whether we can do this with them.

I would like to mention here if you’ve got money for your son’s or daughter’s weddings, you’ve got money for mental health. It is about what you want to spend it on.

We are able to take these things that we think are important for culture or society, but we hiccup and think these things shouldn’t cost us money. Of course, if you don’t have the means, you don’t. But when you do, it is visible that you live your life.

It is about whether you are going to invest here or not. How important is mental health in your life? We collaborate with primary rehabs around the world if a person requires such treatment. You can come to us if you have already been in detox for a month. We tell the person clearly which intervention is required at what time.

Vikram: If somebody needs help right now and likes the Tatva centre’s idea, how do they approach you?

Kripi: They can write to us through our website or various social media platforms. We get on a series of calls with them to understand the problem and plan things out for the next few months. We make them aware of their rights and the boundaries in place and everything else in place about it with signing contracts.

These days, everything is happening online due to the COVID situation. In a way, we have always been doing online work since we have clients from different parts of the world. Specifically, these days, whether the training, workshop or treatment, it’s all online.

Vikram (Question from participant): What are the key elements of a therapeutic relationship?

Kripi: Basic thing for the therapist and the person we are working with is that we don’t work by different rules. If I’m asking for an emotional engagement from your end, I’m engaging myself emotionally. It is a mutual dedication to self-exploration and looking into yourself and wanting to understand who you are, a curiosity about your life and where you come from. You are often investing in yourself for the first time as your project – as you write about yourself or your life story. The therapy relationship is based on this foundation that we are going to delve deep into, and we need to do this together. It is one of the main things.

I’m not looking at an issue and isolating it because you are flesh, soul, and heart, all in one person. So, we can’t treat you like parts. If someone says they have anxiety, we work with it in its entirety. 

We change the dynamic from ‘I know better’ or ‘I will tell you what to do with your life to ‘we both are in this together.’ It is similar to a relationship but with therapeutic boundaries.

You have a friendship or a relationship, and you know what its tenets are; similarly, in a therapeutic relationship, we co-agree on things or details or our relationship. We treat it like an alliance between two people.

The best part is that you get to see and be with a part or return in a part where they can be your mirror to everything. You don’t have to explain everything to someone who doesn’t have any agenda or feeling other than professionally being with you.

It helps people transcend these ideas that they can only go to their families or friends and understand that we can go to this person who we don’t have to worry about.

We think about what they’ll think, how they’ll feel and we stop being honest. Here, you can say whatever you want, and my job is to be there for you. It helps.

Vikram (Question from participant): How does one help someone gain self-confidence or help someone achieve ambition who doubts themselves?

Kripi: As a therapist, the main thing to look at would be how we learn from somewhere that we shouldn’t believe in ourselves and that we are not born with it. We learn along the way. Somebody questions us too much, others critique us too much, or we have been shut down by the world too much. We are made to feel bad about ourselves.

It is where a lack of self-confidence comes from. The main thing is to look at the source where it came from and challenge it.

Try to set the entire new alliance in motion like – I need to have someone in my life, or I need to look into my relationship with my parents or talk about how it’s not helpful for me to be critiqued all the time.

I need someone in my life that believes in me.

It is the only antidote and not demeaning yourself, having an ally works in such situations.

Vikram (Question from participant): Do LGBTQ+ people face mental health challenges more than straight people? If yes, how do we address them?

Kripi: Yes, they face more challenges. The world is not designed to accommodate or normalise the people who are not under ‘normal’ gender or sexualities yet. It is a world that treats straight people as normal, and therefore, anybody who is not considered under the norm faces more challenges on every level they encounter – whether they are watching a movie or trying to get a job.

On every level, they face more resistance, doubt, loneliness, and other challenges. They face it not because something is wrong with them but because we are treating them that way.

Vikram (Question from participant): Do therapeutic relationships always have to be healthy? What if it’s not?

Kripi: Many people are in an unhealthy therapeutic relationship with their psychiatrists or therapists. This responsibility always lies in the hands of the professional. You are the person who is making this space inviting and working with someone who has trusted you.

Therefore, an unhealthy relationship can be seen in two or three ways – one: is the person maintaining the relationship with you even though you feel something is wrong only because they are getting paychecks or are they there with you?

Second: are they able to address your issues in the session even if they are against the therapist, or are they open to be challenged?

Yes, it has to be healthy because it is my duty to say “I don’t think this is working out or don’t feel it is a good fit, or something else can help you better”.

As a therapist, you have to be humble enough and have to face that I’m not God and won’t be able to help everyone.

Everyone has different needs. It is my job to keep it healthy.

It does not mean that there is no conflict. You may disagree or not like them sometimes, but the point is to grow from it and see that it moves forward.

After many relationships that somebody has gone through, this has to be the healthy one.

You shouldn’t stay in an unhealthy therapeutic relationship even if you trust them. 

Vikram (Question from participant): How to help one control anger who is 30 years old female intelligent in every manner but cannot control her anger and is being disturbed fast enough in negative situations? 

Kripi: Maybe she’s angry because she’s being controlled. Women are usually not allowed to express anger in our culture, so it usually comes out in all directions.

Either they pretend not to be angry and burst out at some point or become passive-aggressive self-harming. The way to address this is to understand where this anger is coming from and help them understand how they feel, whether they feel stuck, controlled, free, or treated well.

If you can get to the heart of it, that person will not be able to feel the need to be in a rage all the time. Because we live in an unequal world, and if a woman faces this due to cultural issues, we need to come together and figure out what we can do to help her express herself better.

Vikram (Question from participant): Is Tatva pan India?

Kripi: Yes. We do workshops and training in different cities all the time. We are taking online sessions these days. Goa is only the residential model, and everything else is pan India.

Vikram (Question from participant): How do you deal with known denial? Therapy can never be enforced, right?

Kripi: I’m yet to come across someone who has had a good recovery and was forced into long-term treatment. From recovery, I don’t mean just clean, I mean having a good life. The trauma of forcing someone into treatment is something that they might get off for whatever reasons they have gone into it, but they may develop other things because of that breach of trust due to the forceful way with which they have been treated.

No one can make anyone good with it. Therapy is not necessarily a medical intervention, meaning without your engagement, it is nothing.

It can sometimes seem like nothing is moving for a long time in therapy; it is because everybody has their own pace, which can range from weeks to years. We shouldn’t give up on people; meanwhile, we can’t force them to do things.

Denial only makes things challenging, even more than any other mental health struggle. Denial is tricky, where you have to watch the other person harm themselves.

It may be used a lot in addition, but it is generally a defence mechanism. It is your brain’s response to not deal with the painful reality.

Safety is something that unwraps denial. If people start feeling safe, they come out of denial.

Vikram (Question from participant): What are the components of emotional awareness? What are the emotional triggers?

Kripi: Cultivating a sense of stillness in yourself which is having the ability to be with yourself without distraction from thoughts, phone, music, sound, or anything. It is when you know you have the ability to be emotionally aware.

If you don’t slow down, you will not catch your feeling or know what they are.

Sit with yourself every day for 20-30 minutes, ask what is going on, and then develop certain other components like having a language. 

Our country has no limits in terms of IQ. But the same person who can write a thesis on molecular biology may not be able to say more than five words to describe how they are feeling, which needs to change. 

Knowing how to label feelings or what to call them.

Vikram: If somebody wants to reach out to you, how do they do it?

Kripi: Best place to reach out to me is through the Tatva Facebook page as I’m active on it. Whenever you drop in a message, I immediately get a notification through which I can address it right away. You can reach out to me through Instagram as well. It is also advisable to send me an email explaining your situation a little.

Vikram: Please share your message with all of us.

Kripi: I have been saddened and scared for all the people who have an addiction or use a substance, especially during this time. I’m worried about their detox process and managing themselves and their substance use.

So, I urge everyone to be gentle and kind to allow people to come to you about whatever they are experiencing. Instead of shaming them about it, understand that using a substance is a spectrum, and people are at different stages, and it is not a moral issue.

We need to try to help people the best way we can in this situation. Be sensitive to people who have addiction problems. 

If you have any other substance abuse problem, get help as fast as you can. Go to your nearest psychiatrist or a rehab centre and get the help you need. All the rehabilitation centres are open.

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