S01E02: Distress In Cities

Interview with Aparna Joshi & Tanuja Babre, iCALL

Aparna Joshi is currently working as an Assistant Professor and a Centre Chairperson at the School of Human Ecology, Tata Institute of social sciences (TISS). She has been involved in designing and teaching courses for post graduate students of Applied psychology (clinical and counselling specialisation) at the School of Human Ecology since 2010.

Tanuja Babre is the Programme Coordinator at iCALL. Tanuja has a Master’s degree in counselling psychology from Tata Institute of Social Sciences and has worked in the area of mental health and psychosocial well-being for over 6 years.

Transcript

Deepika: So we began this podcast with the issue of loneliness in the city and you know while we were prepping for the episode, came across this concept in relation to loneliness called the snowball effect. And basically what it says is that the more lonely you become, the more hypervigilant, suspicious and afraid of strangers you become. So its a vicious cycle of rejecting the very thing you need the most which is human connection.

Arpita: Right, and i think ive come across this again and again, not only in my own life but in the people i know, the communities i’ve worked with.

Deepika: Yeah its a super common experience. And sometimes you are even aware of doing that but the isolation is so high, or you just don’t have enough social capital that you are just stuck in that cycle then. And it made me wonder what do you do? Who do you reach out to in situations like that?

Arpita: Well i think today’s conversation should throw some light on one such option. And I think through the conversation we’ll also begin to understand the complex landscape of mental health support systems that are required to address loneliness, which we spoke of in the previous episode, and other such mental distress situations within cities. Cause really one solution won’t do – it’s not only that the scale is so large in Indian cities, it’s also the sheer complexity of the issue. So, Initiating Concern for All or iCALL is a telephone and email based counselling service which run by the School of Human Ecology housed in Tata Institute of Social Sciences – TISS in Mumbai – also by the way my old alma mater so very excited to be talking about this project! 

Our colleague Srinidhi chatted with Aparna Joshi, Assistant Professor at the School of Human Ecology at TISS, Mumbai and her colleague and co-ordinator of iCALL – Tanuja Babre. She met them on a rainy Mumbai evening in the green campus of TISS and they began the conversation with Tanuja explaining the iCALL project.

Tanuja: So iCALL was started in September 2012 and it was started with the idea and vision that good quality, affordable, ethical, mental health services should not be limited to geographical locations, language, cost, class and all of these issues. So anybody, across the country who is going through any sort of distress, be it psycho-social distress, be it just distress emanating out of illness or practical problems or structural violence – should have access to good quality resources and mental health services within those resources.

iCALL began as a helpline with a vision to offer free-of-cost, affordable services to people across the country. A service which focuses on quality which will be intersectional, diversity friendly and which will offer counselling and not just emotional first aid. A lot of the other helpline models you will see across the country, are emotional first aid models but psychotherapy services are either in metropolitan cities or have different barriers to access which might be related to language, caste, class, travel, distance or all those things.

Deepika: That’s very interesting! Did she also say what prompted them to undertake this project? 

Arpita: Yeah, Aparna went on to explain why an intervention like iCALL is required in the present day. 

Aparna: If you look at the entire country itself, we are talking about 150 million people who are in need of mental health services and these are people who have reached a distress level of a diagnosis. So you can imagine for these 150 million there are many others who are in need of some other kind of a service. And given the availability of mental health professionals, it is impossible to fill in this kind of gap. 

I think iCALL plays a very important role over there. On the one hand, we are saying cities are experiencing a great amount of distress, and on the other hand we are saying that support structures are getting diminished or are not accessible to people. So iCALL I think fits very neatly into that space whereby it provides a safe, non judgmental space for people to talk about their stories of distress and most importantly to take charge of their own lives also. 

But I think iCALL, we don’t want to pitch iCALL as something you can come to once you experience distress but anybody who gets those warning signals and I feel that it is contributing largely to the city’s mental health also. We call mental health as the ‘cinderella of health sciences’ you know, very cliche but still. So i feel that anyway mental health is a topic nobody is talking about, mental illness is what we talk about mental health. We wait till we reach that point. We are saying mental health is as much a priority as finding a house, finding a good relationship. I think we are trying to give that message and i think iCALL can be that space where you can visit to take care of your own mental health.  

Arpita: So here Aparna is quoting the 2016 National Mental Health Survey, this was conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore. They assessed that while 150 million Indians are in dire need of mental health intervention, only 30 million actually have access to appropriate care.

Deepika: Wow, so that’s one of the gaps where people who have a diagnosis but don’t have access to medical help.

Arpita: Exactly, and as Aparna explains here, they see iCALL responding to the people also outside the arena of diagnosed mental health conditions. So her point being that the structural response to improve mental health needs to also address those who might not yet be in the ambit of illness but are under duress or distress. Simply because distress left unaddressed could potentially open them up for illness in the future.

Deepika: Be preventive and help people cope before situations like you said that situation becomes an emergency state right? And I think WHO also has this definition for health you know where they say that ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. So really looking at how well-being has to be a part of that larger strategy rather than just a emergency response to illness. 

Arpita: And how iCALL responds more holistically also has to do with their approach – the psycho social approach that we’ve spoken a bit about in the previous episode.

Aparna: I think we have been trying to unpack this word called psycho social for a very long time. Because people either talk psycho or people talk social and we are trying to combine both. What do we mean by that? What we are trying to say is that people’s internal realities which are comprised of their own private thoughts, emotions, or their bodies, their own experiences are not so isolated from the larger social context in which they are living. Their social contexts are very much a part of their narrative. They are either determining the distress, they are contributing to the distress that people are facing. 

For example to take a simple example of a city like Mumbai. Simply the fast pace of life, or the competitiveness or the everyday struggles of survival, earning money, the pressures to perform, provide. Even for men. A lot of us have been talking about women’s distress but I think even men are facing a crisis of masculinity in this city. And unfortunately there are no spaces where people can talk about this combination of private experience which is connected to the larger social context. 

And obviously there are contexts which are mundane like I said everyday city life, pace, travelling, isolation but there are more serious aspects of it like marginalisation, violations on the basis of different social locations. Many people call us in iCALL who are struggling with the dominant gender scripts or sexuality scripts and do not know how to negotiate with those and feel extremely isolated and lonely in those struggles. 

Poverty and unemployment are huge contexts particularly in the city. So even struggles to find home and some safe spaces to talk, love, live i think are missing. So we are trying to say that those larger social contexts are contributing to your personal narratives and personal distress. While providing this service we are mindful of both and definitely the conversations therefore iCALL holds are not only addressing the personal distress but are also trying to make people mindful of the larger social contexts and in our very modest way, we are trying to figure out how can people can be made more resourceful so that they can negotiate better with these larger social structures also.

Deepika: Right, so that’s what we were talking about in the last episode how to people are situated within their larger contexts of a community and an ecosystems and therefore you have to understand their loneliness or distress holistically. 

And you know that word distress, we are using it multiple times: I think the way i understand it is sort of that dictionary definition of – a feeling of extreme worry, sadness, or pain, anxiety – is that what we are talking about here? 

Arpita: Well you’re in the right space but there’s a bit more to it. Aparna explained this with examples. 

Aparna: One of the top concerns is emotional distress. And this distress could manifest through depression, anxiety, a lot of anger, lot of violence, resentment. The story is of this kind of emotional distress where people don’t have space to talk about. The distress itself is generated by various other themes that we are receiving calls for. So relationship concerns are a major theme that people are definitely, you know, these are stories particularly of romantic relationships or married relationships where people are not able to communicate or where there is violence. These are also stories of peer relationships and the larger story of family is such an important institution for us. Stories of parent child relationships. Unfortunately there is a breakdown of communication or there is very aggressive communication or disrespectful communication. 

Apart from that there are also themes of mental illness also that people are calling us with. Then there are general concerns of how to perform in academics, how to perform in careers. The work-life balance, particularly in the metro cities, people are coming to these cities to perform, earn and once they get into the entire rat race it is very difficult to connect back to the personal life. I think work life balance is becoming a huge concern for people. And violence and abuse is a major concern for people. 

Deepika: That really covers quite a number of issues

Arpita: Yeah and of course these are just the major themes they are highlighting there. Tanuja was saying how a counsellors job is always fresh in the way that you can never predict what the next client is going to bring in! 

Tanuja: When people are reaching out to us the journey is different for everybody. And for each person the meaning that they attach to seeking help or to resolution or to feel connected is really different and through our work we try and identify what is that meaning for this person? And how can we bring them closer to to their more authentic self or to whatever the objective of their journey might be. 

Arpita: But Aparna did point out two things that they often note in their clients.

Aparna: People who call iCALL have lot many times tried things at their level. So these could be individual solutions that they have tried or they have tried sharing their distress with somebody else who is in their close circles.. lot of times they have felt that it is not fully understood by the other person. They haven’t felt held together. They haven’t felt contained. They haven’t felt that there has been a nurturing accepting space also for them and therefore they come to iCALL. 

The existing spaces sometimes are nurturing but they are extremely judgmental. Sometimes they are not only judgmental but they instead of listening offer solutions. Sometimes, we are also realizing in a city and particularly observing this that, there are many more talkers than listeners. So when you start talking about your story, it becomes competition as to whose story is privileged also and therefore they want a dedicated space in the form of iCALL which is their space, which is under their control and they can claim it as their own, that is one pattern. So they have tried a lot many things. It’s not easy for anybody in today’s world to access any kind of an informal or formal support system. That is one. 

The second pattern we also see is that people are simultaneously accessing multiple support structures, they are talking to their friends, family. They’re also talking to a psychiatrist. They are talking to a doctor. They are talking to some other formal structure and they are simultaneously accessing iCALL. So I think for us the more the better as long as the person knows what is the synergy in these spaces. So those are the two patterns that come to my mind. 

Deepika: That makes intuitive sense, I know that when I’m in a situation of distress, I also react similarly. Try to figure things on your own for a bit and then look for multiple ways to resolve my crisis. 

Arpita: Absolutely and you know like they kept saying again and again – Inherently people are resourceful and I think we try our best to resolve our problems in our own ways but of course  all of us have faced those situations where we might need external support or help.

Deepika: Its so easy to slip into that place  of feeling overwhelmed and being buried by the crisis, then you don’t always know when to reach out for help. And the thing is then how are you to know that you might actually be in a situation of distress and have reached a tipping point might be in that situation of distress where it might be a good idea to step out and ask for help?

Arpita: Aparna explained what the possible indications could be that might help us understand that we might have exhausted our resources and its time to reach out for help. 

Aparna: First of all, I think the functionality is affected be it your everyday functioning be it your work, be it your relationships causing a lot of distress conflicts of pain or abandonment. I think so functionality.

Second thing, When you start some kind of experiencing self alienation also, you don’t feel good about yourself also. Distress not only affects relationships functionality, but it also affects your relationship with yourself. You don’t feel comfortable with yourself. So I think that’s also a good time to know that you know, I’m feeling either so alienated or I am constantly self-critical or i am too other critical also and that itself is causing distress. 

The third is that I’m engaging in some form of a self harm strategy.. I am not working towards my growth, im not taking care of myself and on the contrary I am working in a self-destructive pattern – and I feel body is also very good barometer to use when you don’t feel okay with your body because we believe that your thought, your emotions, your body and your behavior all are connected. 

That’s why in any of those areas if I engage in destructive behaviors, if your body is not feeling well, if you are not feeling emotionally well, or you’re so critical towards yourself or others. I think these are good indicators to use.

Arpita: Tanuja and Aparna also suggested basic coping mechanisms that one could consider as a regime of self-care that might help anticipate and dissipate these situations of distress.

Aparna: Some things could be done with your emotions. Some things could be done with the way you think some things could be done with the way you feel and behave and some could be with your body also. 

So anything that helps you ground yourself and bring that arousal down. These could be the self-care tools or boxes or grounding techniques. And those are very widely available on the internet. If you just type grounding techniques, they are simple counting techniques or they are re-orienting yourself into this moment, which helps you bring your arousal down. It could be simple meditation mindfulness apps. We prescribe  all of these things to bring the emotional arousal down and also some bits of daily self-care with routines that you will engage in which is a much more proactive strategy. 

The second one is to change your self talk, which is highly critical blaming or putting other people down or putting oneself. Through iCALL we are also trying to help people accept themselves as fallible human beings but many people in our culture particularly are disturbed by the idea of self acceptance because we feel self-acceptance will lead to complacency which means I cannot change.

So we tell people that accepting yourself doesn’t mean that you will be complacent so differentiate between things that you can control and things you cannot control and just be graceful about it. So helping people change self self talk is very important. 

Third is behavior. How can you develop more constructive behaviors what you said taking a nap but not sleeping so much that you are not working…everybody has that balance within themselves, but simple small self-care behaviors or routine behaviors that they can engage in and I can’t tell you what wonder it does to people. Sometimes you wonder why do you have to be a therapist for people to be told that you eat on time, sleep on time. But sometimes perhaps you require that external nurturing parent to tell you that it’s also a gesture of care. So engage in some simple healthy behavior routine, whatever it is, whatever is your definition or co-constructed notion of healthy behaviour.

And the fourth aspect is body because lot of psychotherapy focus on talk, but misses a very important component of body because you are an embodied presence. So listen to your body.. some breathing simple exercises. We particularly at iCALL are also in strengths-based, so we are not just helping people find out what’s wrong with them. 

We believe that while people bring a lot of problems. We have a lot of abilities, competencies but because of the despair and distress they are not able to connect with those able competent parts of their own selves. So one of our search through their narratives is also finding those exceptions those abilities and connecting people with their own scripts, so that it creates hope because if there is no hope people will not come back to you and people will not feel good about themselves. 

Deepika: Okay, so thats a bunch of things. Figuring out grounding techniques to paying attention to the self-talk that goes on and learning to be more accepting of self to having a self-care routines and all of those are really important and as I’ve learnt the hard way too, just listening to the body and what its telling you.

Arpita: Yes that’s a good summary! And Tanuja added in two more important points.

Tanuja: One is that you know the idea of engaging self-care not only when you are in distress but engaging in self-care just as it is, to make it a part of your schedule. Just knowing for yourself what is it that you do to take care of yourself is an exercise that all of us should do and mindfully doing those things. Not just because right now I am at a space where i might lose it but schedule it like any other doctors appointment for a regular health checkup or something. 

And second is, lot of times when we talk to people about engaging in self-care or engaging in self compassion being more compassionate with yourself, being more kind to yourself theres a lot of guilt that people experience that you know, it this okay for me to spend so much time, money, resources on myself to just make myself feel good. And you know engaging in self care is not a crime. It’s not something that you’re not supposed to be doing.  You do that for a loved one, you know in a moment. So the idea is also sort of again, you know resist and try and do that for yourself for a change. That is also something we should reflect on and talk about it. 

Deepika: You know as I was listening to Tanuja I was reminded of this poem by William Henry Davies, its a really famous couple of lines where he says – ‘What is this life if, full of care, We have no time to stand and stare.’ I thought of it because life that you are in and suddenly you realise you’ve stopped doing those things that make life meaningful and beautiful. Those little moments of wonder, calm, quiet, reflection. Those can vanish so easily if we are not paying attention. 

Arpita: Absolutely, and I think I’ve done this myself so many times where … I mean distressing situations in particular make it such that we can lose track of what is supportive and are healing elements of our daily routine. 

Yet as we’ve also been saying there is the constant tension between the individual and their contexts – so in terms of support and care – even as you address your own coping, there is need sometimes to also address elements in your environment for a possibly long-term resolution of distress.

Aparna: iCALL is for the psychosocial services so while we are talking about self self is not an isolated unbounded experience very very connected to the structures of the society and where we started this conversation that the structures of many – caste, class, the city, geography – all of them are also importantly contributing to the person’s distress and many of the people who are calling us are not calling us because their self is alienated but because they feel alienated or dominated or distressed by these very structures in the dominant discourses. 

Lot of girls call us saying that I don’t want to get married but my parents are forcing me. They’re not allowing me to educate myself or there is violence which is one of the very important themes why people call us and there are scripts of internalized patriarchy or privileges that people are unaware of or there are experiences of marginalisation.

So through iCALL and our conversations we are also helping people de-construct these dominant scripts which are being filed and understood as truths by many of us. So we are trying to see that these are constructed realities and we are helping people find out what are their preferred realities. Of course, we are sure that those preferred realities cannot impinge upon other people’s, you know rights but we are helping, you know, people create that script and one of the most important thing we are doing is lot of powerlessness that people feel in their lives is not necessarily to do with their psychological realities, but also to do with their structural reality. So we connect people to external resources, be it, supports the structures or support groups or government schemes or women’s organizations or legal support vocational support because we don’t want to call this service which indulges only as I said isolated self. The self is a part of the largest structure. So connecting people to helpful structures is also extremely important and that is what also one of the strategies that iCALL uses towards distress alleviation.

Deepika: You know when Aparna talks about caste, class and the geography of the city affecting distress, I remembered a study that i had read a couple of years ago by PUKAR which is a research collective based in Mumbai. 

The study has basically been done on “non-notified” slums – which is slums that are not officially recognized by the government. Among other things, the paper looks at the impact of the slum environment on mental health. And what they found was that being in a slum that’s not recognised officially plays a huge role to play in creating psychological distress.

And the reason for that is living with the high uncertainty of whether you don’t know if you’ll have a roof over your head or not the next day, you’re always at the risk of being razed, theres a lack of access to the very basics like water and electricity and having to fight for that – day on day and that just increases that sense of deprivation. So you’re living with a source of stress and living in a way that is antagonistic to the government and to the rest of the city because you most basic needs have been criminalised. So automatically, your community identity is built on a feeling  excluded from the rest of the city and the people in it.

Arpita: Well now to layer this with the imagination of taking a person who is extremely anxious person or depressed in these spaces and giving them access to medication and therapy even as they continue to live in that constant state of uncertainty and terror of having their homes and livelihoods taken away from them at any point of time! 

Medicine and therapy would help manage his or her anxiety but the reason goes unattended, the cause behind the anxiety. This is not at all to say that medical attention and therapy is not important – this is to say that sometimes the reasons are far more complex and hence the interventions need to mirror that complexity. And it’s like we said last time, this is serious food for thought also for people urban planners, designers, public servants even to understand what goes into making healthier happier cities.

Deepika: Right because there are so many structural issues involved in how you are feeling right, I completely agree with what Aparna saying when she says you have to connect people to other systems like healthcare or access to livelihood and employment opportunities, any kind of network and system that helps alleviate and remove some of the constant  uncertainty and fear and anxiety around the basics and thats as important as individual conversations on emotion regulation and managing how you are feeling. 

Arpita: And in this sense, iCALL is really a very insightful project that i think brings great depth into a conversation on what a holistic mental-health care approach looks like. Yet i think what truly moves me, what I truly love about it is what is at the heart of the project – you know the basic thing of reaching out and bringing human support, love and connection back into the lives of those who are distressed, depleted and exhausted by the demands of life. 

It seems appropriate then to wrap our conversation of today with their advice and invitation to those hesitating to seek help. 

Aparna: I feel that if somebody who is listening to us has to be addressed, I think one of the first scripts that you need to look at is the script of weakness. That help seeking through a formal source is considered as a sign of weakness or as a sign of I am not adequate enough to deal with my own distress. So I think seeking help itself needs to be reframed as a sign of strength and a sign of wisdom, if I may call it, to know that you know now perhaps things need to be brought into a different reality where somebody else can be a part of my resilience journey. This is not to say that I am not resilient. This is to say that somebody else’s presence can complement your resilience. 

So I think and most importantly a service like iCALL is giving…see we call it iCALL and we say I can so it’s a message of hope, but if you call the call is within your control and the help is one call away and you make that call and you will initiate your journey towards your own wellbeing. 

We also want to say that don’t wait till the distress escalates to such a level …all of us have an innate wisdom to understand when is it that the distress starts, you know, surpassing my own resources. So the minute you realise that, this is a non-judgmental space. This is a non-stigmatising space.

We’re not even asking you who you are. If you are not willing to tell us your name identity. This is your space, so claim it and claim it for your well-being.

Outro:  If you’d like to learn more about iCALL visit the website icallhelpline.org. If you would like to access the helpline the number is 022-25521111, I repeat its 022-25521111. They are available Mon to Sat from 8am to 10pm. We’ll also shortly be sharing an extra on the inner workings of iCALL to understand who the patient and skilled people behind the phone lines are and how they manage to do this challenging work. 

To read further and access resources related to iCALL and the conversations around mental health in Indian cities visit our website http://www.thecuriocitycollective.org. 

Next TCC episode, we shift gears to another big topic in cities – garbage! We begin our four-part series called Trash Talk where we explore how individuals from different cities are engaging with the growing problem of garbage in cities across India. Don’t miss it!