An 18-year-old student, who spoke to the Post on condition of anonymity, has been battling borderline personality disorder for the past two years. Although she had been visiting a mental health counsellor, her condition saw little improvement during her time with her counsellor.

She feels her experience with the counsellor failed short of her expectations and that the treatment her counsellor offered had been ineffective.

She recalls her therapist giving her the most generic of advice. Although she had been taking purportedly exclusive therapy sessions for her condition, she says she was nowhere close to feeling better despite meeting up with her counsellor several times.

“I thought that going to a mental health counsellor would help me get better but it didn’t. My expectations from the counselling sessions were not in sync with the reality I faced at the clinic,” she said. “I would talk about my problems hoping she would provide me with guidance based on a thorough understanding of my problems. I had about 12 sessions with her, and every session felt like she was improvising with no concrete steps to cure me. Ultimately it was medication prescribed by my psychiatrist that got me to a better place mentally. I just wish I had received good therapy so that I could understand my condition better.”

The teenager is not the only one who has been struggling to find the right direction towards recovery.

Shiksha Risal, a 33-year-old NGO employee, who also advocates for mental health well-being, had been battling depression for three years. She recounts the lack of empathy she was dealt with by her psychiatrist and recalls being asked to bulldoze through her problems.

“My psychiatrist was indifferent to the problems I was suffering from. I would try talking about my problems, but I could tell that it fell on deaf ears. It is already difficult talking about mental health with the stigma attached to it in our society, and it is disheartening to be met with such disregard when we try to address our problems, especially by the very people who are supposed to heal us,” said Risal.

While both psychologists and psychiatrists study human behaviour and mental processes, the qualifications of a psychologist do not extend to prescribing medication for a given condition. Psychiatrists, on the other hand, are trained medical doctors, who are able to both prescribe medications and provide therapies.

Psychologists tend to lead a talk session using a number of cognitive and behavioural techniques, while psychiatrists are consulted for mental health disorders that reach a severity requiring medication. Both psychiatrists and psychologists may be consulted to treat a mental health disorder.

A special initiative of mental health situation assessment conducted by the WHO in 2021 revealed the precarious situation of mental health issues and the lack of qualified mental health professionals in Nepal. According to the assessment, the number of psychiatrists in the country is as low as 144 while the number of psychologists in private practice is estimated to be around 30. The gap between the number of mental health patients and qualified mental health professionals is ever-growing with the National Mental Health Survey conducted in 2019 and 2020 revealing that 23 percent of the Nepali population is seeking treatment for mental health disorders.

Despite growing mental health problems in the country, access to mental health resources remains a major problem. Efforts to maximise available resources remain limited to urban areas and that too with a gnawing shortage of qualified professionals.

The lack of properly trained and qualified psychiatrists, psychotherapists and psychologists in the country can be attributed to the government’s inability to make mental health a priority. Psychology needs to be a regulated profession, but the failure of the authorities concerned to systematise and monitor the mental health medical field has led to the absence of well-trained and competent therapists adept at handling the sensitive nature of mental health processes and delivering productive and fulfilling counselling sessions.

Sajina Bhandari, a psychotherapist based in Kathmandu, also cites the lack of proper monitoring and regulatory mechanisms as the main reason for the dismal production of psychological resources in the country. “There is no regulatory board in the mental health sector in Nepal which has allowed malpractice to thrive. Dealing with psychological issues is no easy task, these are issues that must be handled with the utmost care. When there are no standards and guidelines to be met to become a psychologist, psychological practice becomes unethical,” said Bhandari.

The lack of focus on mental health studies in the academic curriculum of the Nepali education system has also contributed to the dearth of qualified mental health professionals in the field.

Like the field of medicine is divided into various specialisations and sub-specialisations, so is the field of psychology. While M.Phil in Clinical Psychology and MA in Psychology focusing on clinical, counselling, and industrial psychology is offered by Tribhuvan University, several specialisations like addiction psychology, neuropsychology, and education psychology remain unexplored despite their importance as a solution to a wide variety of mental health problems.

This means that a therapist would have to navigate a particularly complex issue all on their own with little to no prior knowledge and experience, while also guiding their patients. Imagine a psychologist in a drug addiction rehabilitation centre, with no prior knowledge about addiction-related issues. It is a bleak thought.

“The absence of specialised fields means that therapists lack the kind of intensive and in-depth training that is crucial in handling the sensitivity and complexity of a particular mental health problem,” Bhandari told the Post.

When one therapist has to deal with a broad set of issues from a wide range of age groups, it can get overwhelming for the therapist as well, says Bhandari. In cases where a patient has received one-on-one care and undivided attention from their therapist, the results have been fruitful. Mental health counselling and therapy have come to the rescue of many seeking help.

A competent and compassionate therapist can make a world of difference, says Amira, who has been dealing with depression. She has asked her real name to be withheld for privacy reasons.

“After starting therapy, the anxiety that I had associated with my condition has reduced. It feels uplifting to have a therapist who cares about my well-being enough to take the time to truly listen to all of my conflicting feelings and understand my issues. When I was first given the BDI (Beck’s Depression Inventory), my score was high enough to be severe depression. But since I started the therapy, my condition is getting better. I am very happy with my sessions with my therapist,” said Amira.

Amira’s account of her experience shows that effective counselling sessions with qualified mental health professionals can help in curing mental health issues.

Despite growing mental health awareness, the stigma attached to mental health issues is a hindrance several young people face in their search for medical help.

“The thought that I will be met with prejudice and backlash once I start talking openly about my mental health issues fills me with dread,” said Amira. “I can only freely communicate about my state of mind with my therapist inside a closed room. I still haven’t gathered the courage to speak about my condition openly for fear of rejection and apathy.”

However, even if one chooses to speak freely about mental health issues they are facing, treatment for their condition is neither easily accessible nor affordable.

The cost of tailor-made therapy sessions is high. Patients are left to navigate through the web of cost-benefit analysis to ponder whether the costs of therapy are greater than their benefits.

According to Amira, a 45-minute therapy session with a professional therapist can cost anywhere above Rs 1,000 in Kathmandu.

Counselling is a long-term treatment process; patients have to have continuous contact with their therapist to ensure improvement and prevent relapse. With the costs of therapy as high as it is now, patients aren’t able to commit to their psychological development.

In Nepal, psychological services are mostly provided by private practices, NGOs, and INGOs. The journey towards better mental health conditions is filled with uncertainty for patients who first have to overcome their own self-doubts, accept they need help, overcome the fear of social stigma, find the right mental health professional and be able to afford treatment. Government intervention in the mental health sector vis-à-vis funding hospitals to provide mental health services is a step forward in improving accessibility and affordability of mental health treatment. Officials at the Ministry of Health and Population said the government plans to introduce mental health services in certain government-run institutions in future. Roshan Pokhrel, secretary at the ministry, said, “The placement of psychologists at hospitals could make a difference in opening accessibility to mental health services to all age groups from all backgrounds. The child psychiatry wing of Kanti Children’s Hospital provides both psychiatric and psychological services to children under the age of 15. We are currently in the process of adding new positions for psychologists at certain state-run hospitals in the country in the hopes of improving accessibility to mental health services.”

Efforts to develop and adopt dynamic and introspective policies can also go a long way in changing the landscape of mental health development in Nepal from the early stages to the implementation phase.

“The ministry has been working to develop a separate division for mental health for years now, but we have not been able to implement the plan,” said Pokhrel. “We have also included drugs for mental disorders like anxiety and depression in the list of essential medicines provided by the government, making it accessible and affordable to all. We plan to extend psychological resources in the country with a well-trained and dedicated set of psychologists in government hospitals. We have not been able to direct our resources to the mental health sector nearly as much as we should, but we are working on changing that.”

Highlighting the positives of aligning oneself with the right approach to mental health treatment through professionals, Risal says she is on her path to recovery after finding the right therapist for herself.

“I’m in a much better place now after undergoing CBT (Cognitive Behavioral Therapy). The therapy helped me understand myself better and I'm so much happier now,” she said. “But I’ve come across people who, despite wanting to start therapy, aren't able to afford it. The lack of government funding has made therapy expensive and inaccessible.”