Indian Journal of Medical Ethics

Book Review

Guiding the confidential into public discourse

Melvin Mathew Thomas

Published online first on July 14, 2023. DOI:10.20529/IJME.2023.045

Aruna Gopakumar, Yashodhara Lal, And How Do You Feel About That? Breakdowns and Breakthroughs in the Therapy Room, Penguin, December 2022, 376 pages, Rs 243 (Paperback) and Rs 230.85 (Kindle), ISBN-10: 014345742X, ISBN-13: 978-0143457428.

In recent years, popular media has made several attempts to allow its audience to be privy to interactions within the therapy room that are otherwise considered private and confidential. Some examples are Treatment (2008-2021), an American television drama series, or popular Indian films like Dear Zindagi (2016) or Kaasav (2017), among others. And How Do You Feel About That? Breakdowns and Breakthroughs in the Therapy Room is a compilation of 50 short fictionalised conversations that transpire between the psychotherapist and their patients during the process of therapy. Authors Aruna Gopakumar and Yashodhara Lal adopt a similar approach that involves fictionalising experiences and conversations that are inspired by real life encounters. The authors, both practising therapists, use a conversational style of writing while alternating between their individual and unique narrative experiences during clinical practice. The 50 vignettes are written from the perspective of the therapist and involve recreation and fictionalisation of the voice of the patient. The genre and the style, therefore, bring to light conversations that are otherwise hushed in India, largely due to the stigma that shrouds the process of seeking help for mental health concerns. In addition to puncturing existing social stigma, such an approach enables the demystification of mental health, making it vastly accessible and welcoming for those who wish to engage with such dialogues (p xiv). This approach, in turn, respects the larger ethical principles of privacy and confidentiality that remain sacrosanct to the treatment and study of mental health concerns.

Gopakumar and Lal rely on the psychoanalytical theory of Transactional Analysis (TA) ─ a term coined by Dr Eric Berne ─ which becomes the common thread that sews the individual stories together. Such an approach aids the authors to highlight and communicate the multifaceted nature of mental health concerns and their treatment. In this process, the patient is seen to create alternative meanings to concerns they face — by revisiting past discomforting experiences in new ways that make them feel safe (p xvi). By using such a method, the patient learns to address, empathise, and resolve concerns, by placing themselves in the shoes of others; or in this case, by confronting concerns by imagining the involved parties sitting across on empty chairs.

The diverse nature of narratives ranges from instances that highlight the scepticism of patients who are new to psychotherapy, to those who rely on therapy to make new meaning of their behaviour towards their partners, to those who use therapy to find closure to actions that were encountered by a younger version of themselves, and so on. By providing such a wide spectrum of concerns, the book aids the reader to identify and relate with several such fractured moments (p xiv). Readers are guided to witness the narrative organically developing within the four walls of the therapy room, by being a fly on the wall, even as the patients encounter a plethora of emotions such as pain, joy, suffering, closure, etc (p xiv). Such an attempt navigates through the ethical dilemmas of engaging and communicating information that cannot normally be disclosed without breaching confidentiality. The style, therefore, transcends the sensitive and private aspects of therapy and creates a pathway towards larger public discussions on the topic. In addition, by limiting the use of medical jargon (p xvi), this book becomes crucial in highlighting mental illness from a social understanding/model of disability.

An exploration of mental health and illness, especially through narratives, continues to be an unexplored topic in India. As the subtitle suggests, at a specific locus at which breakdowns and breakthroughs in the therapy room emerge, the book offers the readers several unique reflection points for personal growth. The nature of such a unique technique enables moments of affective identification for the readers — to comprehend, relate, reflect, and gain insights into their own lives. Therefore, the wide range of these short narratives allows the readers to relate with a peculiar emotional legibility that the book facilitates from multiple vantage points. It becomes important to point out that the book is neither clinical nor diagnostic in nature. Instead, the experiential, affective, and relatable aspect of the book that leads to the “breakdowns”, sheds light on the centrality of vulnerability in the therapy room. Similarly, the “breakthroughs” indicate the epiphanies that the patient encounters through guided professional therapy.

Future editions of the book could provide a more rounded understanding of therapy, especially for a beginner attempting to understand it, or for those who might use this book as a passageway to seek psychological help. As touched upon earlier (and found explicitly in the subtitle of the book), it becomes pivotal for future editions to mention that breakthroughs or epiphanies are momentary results that are neither guaranteed, nor are they the primary purpose of therapy. In other words, the purpose, process, and success of therapy should not be measured against the yardstick of breakthroughs or rapid epiphanies. Such a disclaimer holds more relevance in the Indian context, especially since the role of the therapist or any other medical practitioner is misconstrued to be one of tidying up concerns and confusions faced by the patient. Adding such a disclaimer would counter the possible power imbalance between patient and therapist that might otherwise be taken for a norm. The book could also have touched upon instances where a combination of pharmacological interventions along with therapy could have been seen as a necessity. Such combined treatments are common in practice, while both approaches carry with them their own set of stigmas that could have been briefly acknowledged in the book. Also, in addition to Transactional Analysis, the book could have listed, in its foreword, a few alternative approaches that are used in psychotherapy. A brief description of such practices could carry with it the potential to generate further awareness and interest amongst the general public.

In a country like India, where there is a dearth of mental health practitioners, and where stigma involving mental health is rampant, such a book provides a much needed entry point for those who are interested in conversations around the topic. The book remains true to its title and encourages its readers to seek therapy as a process of self-discovery. Such explorations of mental health that use illness narratives carry with them the potential to educate and support public deliberations, which might further aid policy makers, educators, medical practitioners, and most importantly, the general public, to engage with mental health concerns through a more relatable and empathetic lens.