Mental health and Counselling in India: Interview with Dr. Kusum D’sa, Part 2

counselling

Mental Health and Counselling

Last week, we aired the first part of our interview with Dr. Kusum D’sa, a counsellor from Mangaluru, where she talked about how counselling in India is a family affair. Today, in Part 2 of the interview, Dr. Kusum shares the warning signs that tell parents their children need to see a counsellor or a psychiatrist, the importance of attending to children’s grief and trauma, and adapting therapy to meet cultural expectations. And now to the interview with Dr. Kusum.

Dr. Kusum, can you give parents an insight into when they must reach out for professional help? What are some common warning signs that a child may need psychological intervention?

So, there are some red flags parents would have noticed but have not given that much of importance due to the perception issue that I just mentioned now. The severity of the problem is not understood by the parent. Some of the things that the parents should look for is change in behavior, especially in school. If the child goes to school, college…, you’ll see an immediate, dramatic drop in the academics. That’s the biggest sign. So, there is a drop in the academics, changes in the behavior – if the child is talkative but suddenly withdraws and become silent; there could be anger, excessive anger, irritability…, aggression. These are all the telltale signs when it comes to behavior.

You should look for emotional distress. Emotional distress is when the child suddenly has anxiety issues. I have lot of children who come for anxiety issues. They were fine, they are fine otherwise; but when there is exam nearing, they have these anxiety issues… and sudden crying for no reason. Mood swings, sudden mood swings! The child would like something and suddenly the child doesn’t want it anymore. There’s no logical explanation for a parent. So these are the signs when it comes to emotional distress. And as I told you already, academic issues; the child who would be doing rather well in studies has started dropping in grades.

Another thing which I don’t know if the parent notices, the changes in the sleeping pattern. The first question I ask every client is their eating and sleeping pattern—how is it? Has there been any changes? Because this is one of the early signs of onset of issues with mental instability. And isolation, the child who’s or anyone even an adult, they start withdrawing from social gatherings. They don’t want to go with their friends anymore. They are happy to be isolated and they themselves isolate. They don’t express feelings anymore. They also start saying that ‘there’s no one with me, I’m alone. I don’t want anyone! No one understands me!’  … these changes.

Because of all these things, the next stage is the physical symptoms. The child would have unexplained headaches, stomach pain, body discomfort, pain in different parts of the body. Because of physical symptoms, the mother or father would have definitely taken them to the doctor and the doctor says ‘she’s fine.’ So this is another red flag. In extreme cases you have self-destructive behavior. I have a client who pinches herself all over her body. There are dark marks, biting nails, pinching oneself, pulling hair, or this comes in the severe cases. It takes longer time for the child to come out of this, so I have a client who’s still doing it.

And of course, if it is younger children, they may have regression in developmental milestones. Like for example, they would be potty trained, but they’re still wetting the bed. Or they would have done everything and suddenly they start bed-wetting. Sometimes children, like thirteen years, teenagers also start bed wetting. This may not come to the notice of the parent if the child realizes the next day and tries to hide.

Most of the time these are not noticed when there is a lot of emotional gap between the parent and the child. Basically, it will have a big impact on the family relationship. So you will see changes in the family relationship. The child would no longer go to the parent for anything. These are the red flags that parents should notice in their children.

Is there an average length of time that you work with children? How long is treatment typically?

I recommend minimum five sessions to anyone who come to me because one cannot do anything with just one or two sessions. 5 sessions is what I recommend.

And what were the most common needs you saw in the children who came to you for treatment?

Issues would be anxiety. If the child has anxiety issues, it’s basically, they’re not able to get that secure and safety feeling in the environment that, that they live in. So that is one of the issues. A feeling of depression! Even children have depression! Even young children have depression that manifests in mood… change in mood, change in sleep pattern, change in appetite, change in not mixing with other children. So, these are the signs.

And then as I mentioned before, behavioral issues, aggression, defiance, attention seeking, impulsive behavior for no reason and you see that impulsive behavior either in the classroom or in the assembly or somewhere in the canteen. One couldn’t understand why the child behaves in that way. And most of the time it is trauma. Post traumatic disorder over violence or abuse, or neglect, or sometimes even accidents.

There are children who have witnessed severe violence inside the four walls of their own homes. So this comes out as  trauma related symptoms, especially in schools. And family conflict or transition. Just last week I had a family coming in. The father had hung himself. The mother is in deep grief and trauma, and the children are in a bewildered state because they feel they’re going to lose their mother as well. No one is concentrating much on the children because they appear to be fine compared to the mother who is crying and in a severe depression.

Now, severe depression is what we can see and cater, and handle. But no symptoms is something which is more dangerous because children are not able to talk about it… because they have lost a parent and they feel they are on the verge of losing another.

And of course, as I mentioned before, academic challenges. They would be fine doing work by themselves, but now they are not able to. I see children. They say they can’t remember. They would have done this before. They could do it comfortably a few months before, but they’re not able to function anymore when it comes to academics. Of course, peer relationships and social skills and self-esteem and identity issue.

These days I see so many children with this one single issue. Basically, they are pressurized than expected to do much more than their capacity, number one and number two, they are expected to do, which they are not even interested in. They have to fulfill the desire of their parents on the career issue or an interest issue. This is very, very sad to see. “I’m not interested in cricket, but I want to…, I have to learn cricket because my father wants me to be a cricketer.”

It leads to severe identity issues early in life, and of course later as well. As I told before, the major, major issue is in parent child relationship. On communication breakdowns. The child has to meet parents’ unrealistic expectations. This is a major trend that I observe these days.

Dr. Kusum, how do you approach treatment for kids who’ve experienced trauma?

I mentioned an example already about this last week, where the children lost their father and mother is in severe depression. They are traumatized, but they’re not able to express it. So, this is what I told the family members. Of course, we can treat the mother, she needs medical attention, but the children are the priority. They need to attend counseling session. The approach is similar.

First, establishing trust, educating the children on various aspects of life after establishing rapport and gaining the trust of the child, slowly introduce coping skills, process their trauma, basically. First identify the trauma and process it through the sessions and make them understand about attachments in relationships, in case of deaths and abandonment, or even abuse.

And of course… family involvement, family has to be involved. It is not a stand-alone therapy for one person, everybody involved be in the process. And certain techniques, of course, CBT will help. Empty Chair also will help. Empty Chair is very effective when it is trauma related. I’ve seen so many children transform after an Empty Chair. And of course, we need to collaborate when it comes to severe cases. Collaboration with other professionals is very, very essential. So, it’s not one therapy. We should have a team.

In your experience, have parents been open to therapy for their child who has experienced some form of trauma?

It’s very rarely that I am a first option. They would have exhausted other options and then come to a therapist. One out of ten would have come directly to me, but nine don’t. They go to every other option. Then they come and that is why it becomes more difficult because so much time has already been lost.

What steps do counselors take if they suspect a child is being abused or neglected?

See, if it is sexual abuse, it’s my duty to report to the authority. It’s a mandatory rule and a law that has come in, so I have to do that. And this will be done after taking the parents into confidence, taking the child into confidence, educating them about the act and everything, and then with their own knowledge and consent, this will be done.

When it becomes a police case, there is a procedure and they have their own counselors and the rehab homes. If the parents wish to see another professional like me, then of course there’s a long process of meeting the child and providing necessary care.

First, gaining the trust of the child, approaching the topic in a very indirect way until the child becomes comfortable and opens up and talks about it. In most cases, a child doesn’t even know it’s abuse. They would have accepted it because that’s the narrative that is built for the child. So, it is very sensitive to sit with the child and make the child understand.

And here again I have my own professional support system. If I feel that I cannot handle this anymore, I refer to other counsellors or other professionals who I feel would do a better job than me. So, this would be the last resort.

Have there been any disagreements with parents or guardians regarding treatment plans? How did you handle it?

My first hour when I gather information is the crucial time for me to understand the parents’ goal. So I see that the parents goal, my goal and the child goal are all on the same page. That’s the convincing that I have to do. I take it upon myself that it’s my job to see that there is no disagreement with the parents or the guardians regarding the treatment plan. Till now there is no disagreement, because even if there is disagreement or difference of opinion, which I welcome from the parents, I tell them why it is done, how it is done, and ask them if there is any better way to do. I’m definitely open to learn and change.

Do you have any suggestions for parents and caregivers on supporting their children through grief and loss?

We have a very old adage which says prevention is better than cure. So, if it is something that is known as in case of terminal illness, it’s always better to involve the family members. But if it is that which hits us with no warning, then again, the therapy process is very, very essential.

How much stress do you feel that parents’ ideas on career choices affect children’s mental well-being?

Most of the time, the big burden the child is carrying today…, I wouldn’t want to be a child of today’s generation because that poor child is carrying the expectations from the parents, the wishes of the parents!!! The parents who couldn’t do things in their life, they want their child to do it whether they like it or not. And that’s the cause of their anxiety, stress –this unrealistic expectation. We need to make it very clear that parents have to accept their children as they are, leave them free to fulfill their own dreams. I wish this would happen more and more.

Dr. Kusum, your clients must come from diverse backgrounds. How do they factor their cultural background into their treatment?

Cultural background…, I have clients from all religious background and cultural background. So I customize my therapy. For example, if they come from a Hindu background, I use a lot of metaphors and stories from the mythologies of the Hindu. Likewise, in the other religion, whether it is Christian or Islam. I do my homework when they tell me who they are.

With their names, I come to know which religious background or cultural background they come from. I do a bit of homework to use the metaphors and stories which is beneficial for them. In a way, this helps me to break the ice and build a rapport. This is what I have observed.

There are lot of people who like it when it is…, spirituality is included in the therapy, which I do. If they want to have a flavor of something that the…, spirituality to have a flavor of the religion, I do that for them because ultimately the goal is mental wellness. It doesn’t matter how you do what you do.

Dr. Kusum, what methods do you use to track progress in therapy sessions?

To track the progress, every session has homework for my clients and this has to be accomplished when they come to the next session. That’s how my sessions are planned. And once this is done only, we can move to the next session. That’s how it is built. So, it’s easy for me to track the progress as. Well, so some of them do come without the homework being done. Eventually I have realized that… what I would do is if they don’t do the homework, I make them do it in the next session, in front of me…so that we achieve the results which we’ve visualized.

They are all in my radar in my WhatsApp groups and I send them morning messages, motivational messages for their recovery, related to their recovery and I get very good feedback from them saying that the messages help them a lot. So, I also give them challenges basically for self-improvement. And this has also helped them a lot. And then, I have seen clients even after five sessions, they sign up for the next five sessions because they want more. Not in terms of recovery therapy as such, but more for self-care and self-discovery.

What kind of stresses and challenges do you come across on the job?

There will be something which is, in my perception, difficult in the first sessions. But I don’t know out of nowhere in the third or fourth, something works, and the clients come to a common ground where we can move towards recovery. So, over the period of time, I feel that “Ok, this is something in my mind! this is going on.” So, this is my own therapy when I feel “Okay, this is a difficult session!” Then I tell myself “No, nothing is difficult, and the client will definitely come around.” This is what has happened 100% of the time. So, it’s very satisfying. Eventually everything will be fine in the end. That’s what we say, right? In the end, everything is fine!

Dr. Kusum, what do you like or dislike about what you do?

I like everything that I do and it’s such a beautiful, cathartic experience for me. With each session, with each client I am different. I have grown and I have learned. That’s why I love this profession. There’s nothing that I dislike. I like every part of what I’m doing, so there’s nothing that I dislike, and I feel even that temporary discomfort is a blessing in disguise. It comes to me because I have something to learn from it.

What kind of stresses and challenges do you come across on the job?

In some cases, the wound is very deep. To peel off this wound is sometimes very challenging. But then, because my mind is dwelling on how to go about it, eventually I come up with the plan. So that is one thing. But when it comes to the external factor, sometimes what I cannot fathom is the parents’ apathy! I have seen children really suffering and parents not giving any heed even though they come…, bring them to the therapy. They still feel it’s a matter of attitude rather than other things which the parent must heed. This is something which is a little difficult for me to understand.

How did you handle situations where a child was resistant to therapy?

First of all, I don’t make it look like therapy to the child. When the child comes in the beginning, it’s all fun. It’s all building rapport. And my only goal in the first session is that they should come back to me next session. This is how I work with the children, and they do come. They like it, and the parents give me feedback, “I want to talk!” There are so many of them… even after therapy, they want to talk to me, we add value to the time that they spend with this. And as I told before, general love is what the children will catch immediately. So, I don’t look at them as a client. I love children and that’s what perhaps comes out.

What change would you like to see in how Indian society approaches children’s well-being?

As I mentioned before, in the children’s well-being, not pressurizing the children to live the dream of the parents. That’s one thing. Allowing the child to bloom in their own way. I think this is where things have to change.

In your experience, how approachable are doctors, teachers, and other school officials to working collaboratively with a child therapist? What changes would you like to see there?

This is the major issue. There is no team, especially in the place where I am. We all are in silos, working independently, pretending the other…, next one does not exist…, when the doctors, teachers, school officials, child therapists, psychiatrist… we all should be one single team. I am a very optimistic person. Someday it will happen!

Dr. Kusum, what strategies do you use to help children develop healthy coping mechanisms?

Basically, the child will be taught about how to express one’s taboo areas; like for example, child may express happiness but the other emotions—anger. How to express anger? How to express sadness? In those other areas teaching them to be emotionally aware. This is very important. And another very important thing is, this is what I do in most of the, not most, all of my therapies with children –teach them relaxation techniques.

I tell them, “All of us, I mean, everybody knows this. We cannot stop or avoid problems or issues in our life. But definitely, we can have tools and techniques to bring the gravity of it down. So, lot of breathing exercises, muscle relaxation, art therapies is what I teach. Many of them have given me good feedback and they tell me that, “Ma’am, this is what we do, and it is working.” So, this is one of the coping techniques I teach, and encourage children, of course, in problem solving skills; Make them aware that there is not one solution, there may be many solutions to the same problems and how they can use whichever they find beneficial for that point of time.

And of course, foster resilience. That’s what is lacking in most of us! We snap very easily. So teaching, persevering, accepting failures, learning from mistakes. This is what is lacking! This is not taught in schools, sadly. So, this is another thing that is included in the therapy. Of course, the basic thing is to provide a safe environment to express and model healthy coping behaviors.

This is what I tell in my sessions with the parents. “What is your reaction to anger? How do you express anger?” Say if we can teach this to the adults in the House and that’s how they model, and that’s how the children learn. So, this is how it goes. That’s why it’s a family session. It can never, never be one single person changing.

Another important thing which is underestimated is physical activity. If it is children, I tell ‘drain their energy.’ They have to be dead tired at the end of the day. That’s when you get a good sleep, and you start the next day. So, one hour of physical exercise or whatever the child loves must be given. And a ready support system to be given to the child. OK, when you are having this call, you should have this go list in the house itself. These are the places to go, places for you, and you need not have to suffer alone.

How did you approach cases where a doctor recommended medication for the child? Did you have to counsel the parents on following through with the treatment?

Yeah, we have this…, I don’t know why this happens, but we have resistance to taking medicines, especially when it is mental issues. Otherwise, we don’t have any… headache, we pop a pill as if we are eating candies. But when it comes to mental issues, we have so much misguided information. So if a doctor has recommended it, I tell them I would love to talk to the doctor. I have a discussion with the doctor—for what reason these medications are given. Is it medicine?

If it is scaffolding, I try and explain it to the parent. “It’s only for some time, not forever. It…, it only scaffolds and then after some time it’s…, your child is tapered off the medications.” This is what the doctor has to do. If the doctor has not done it, then I will do the needful. So, the doctor has recommended medications. I am sure it is for a purpose. And if the parent is not agreeing with it, then the parent has not been communicated properly. So, in that case I do the honor.

Your field is a very demanding one. How do you manage potential burnout or emotional stress in this profession?

First of all, my routine, my everyday morning begins with my own yoga, meditation, pranayama…mindful exercises. Things that I love doing. Apart from this, counselling and therapy is something which I love doing as well, so this is how I avoid burnout. If there is a severe burnout, which I haven’t had till date, but if there is something disturbing, I have a support system of fellow counsellors and therapists. I just call them, and we have a discussion and that within an hour of discussion, I am fine. I bounce back.

Dr. Kusum, thank you for joining us and sharing your valuable expertise with us at for all our kids. Many parents hesitate to seek professional help for their children. But we believe your insight will clarify their doubts about counselling and how the outcome will benefit their children. Thank you very much.

Thank you for the opportunity given to me. Thank you so much Rama, for this wonderful opportunity that you have given me. And thank you, listeners!

Read more on how unrealistic parental expectations contributes to mental health problems in children:

Rising parental expectations linked to perfectionism in college students

Listen to other episodes in this series:

Mental health and Counselling in India: Interview with Dr. Kusum D’sa, Part 1

OT and Early Intervention: Interview with Dr. Isha Soni Part 2

Occupational Therapy: Interview with Dr. Isha Soni Part 1

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