Don’t ask; don’t tell.
As a New Yorker, I am predisposed to accept therapy as a proactive, even socially-acceptable means of attaining a greater sense of mental stability, health and self-confidence. And perhaps, these notions have been reaffirmed by the media and film industry’s portrayal/positioning of therapy in major motion pictures and popular TV shows, where big celebrities are seen throwing down 150-300 USD for therapy sessions of their own.
For instance, The Sopranos’ tough New Jersey mob boss Tony Soprano turns to psychiatrist Dr. Jennifer Melfi for his problems, and Analyze This’ cool and collected mob boss Paul Vitti confronts psychiatrist Ben Sobel to sort out his issues. And of course, there’s the “Games People Play” episode of Sex and the City, in which sexy and chic columnist Carrie Bradshaw takes her friend’s advice to go to therapy, as everybody does in Manhattan.
I was not aware that therapy takes on a very different face in other countries―specifically in Serbia―a face darkened by social stigma, painted with patterns reflecting abnormality, and illuminated in neon lights of “big problems,” indicating weakness and instability. I have come to think therapy for Serbians takes on the face of R.P. McMurphy from One Flew over the Cuckoo’s Nest.
Many people in other countries are reluctant to receive counseling or therapy, as they see them as signs of craziness, weakness or failure. These concerns are quite natural, considering our socio-cultural conditioning, explains clinical psychologist Dr. Dana Gionta, Ph.D., in her 2008 article “The Stigma of Therapy.”
According to Dubravka Radusinovic—a state-licensed clinical psychologist with a Master of Arts in psychology—these concerns manifest as a social pathological issue rather than a psychological one. Those who are outliers, discriminated against, or are suffering some type of injustice from the whole of society, are generally the ones who are more judgmental and/or perceptive of society’s “level of consciousness” and correspondingly, their lack of acceptance.
And because of this conditioning, many people with significant emotional, physical or mental distress decide not to pursue counseling in other countries, rendering many mental disorders under-diagnosed, under-treated and underestimated.
As Bosnian-born and current Belgrade resident Predrag explains, the public perception of therapy in Serbia is very much stigmatized: “You always have that look accompanied with the question, ‘What’s wrong with you? Are you ill?’ if you say you’re (seeing) a therapist,” Predrag states. According to Predrag, Serbians only see therapists and psychologists if they are overcoming serious problems (e.g. divorce, death of a loved one, war trauma, etc.). “I don’t think there are many people who do it on a regular basis (every week) as you (New Yorkers) do,” he asserts,” especially due to the cost of private therapy sessions.
Private care is available for those willing (and able) to spend a lot of money. For a 45-minute therapy session with a post-graduate student being supervised by an experienced therapist (Dubravka, for example), it can cost between 10-20 Euros, where a 45-minute therapy session with an experienced, well-established therapist can cost between 70-100 Euros.
As Predrag explains, many Serbians do not have the money to finance private therapy sessions. “People have more important things to spend their money on, and you have to consider the fact that the national average salary is 360 Euros per month (460 USD),’’ he states.
Ultimately, Predrag believes impressions of therapy are a matter of a social awareness level. “Unfortunately, (we are) still low on that scale,” he asserts. The same low level of awareness applies to the perceptions of yoga and meditation, older, unmarried and divorced women, and homosexuality.
As Serbian friend and colleague Alexander explains, “Therapy is never looked at as ‘ordinary’―regardless of one’s (socio-economic) status, or level of education, people feel the same about therapy in Serbia. Both Alexander and Predrag believe that therapy is a ‘last resort’ method―used by those who have experienced trauma. “We do support and accept therapy for those who have these serious issues,” Alexander asserts. “People here, respect those who need therapy; they feel that if you are unable to fix those problems with your friends and family, then you are worthy of therapy.” But even so, it remains a bit taboo: “If someone is in therapy, we will never ask that person about his or her problems or reasons for going to therapy; it remains private.”
According to Alexander, most Serbians rely on the support offered by family and friends, who are familiar with the person’s personality, lifestyle, strengths and weaknesses. In the circle of support and confiding, family invariably takes the first ring, friends the second ring and therapists the third/last ring. In Alexander’s opinion, it is outrageous to pay someone else for advice. “Why would I believe/accept a therapist’s advice when he or she is getting paid to help me?” he asks. If someone needs help, he or she should go to family and friends who will offer help without any pretense, where therapists have to be paid first and then they offer advice, Alexander voices.
Mental health is the key to building a healthy, inclusive and productive society, according to the World Health Organization (WHO), a specialized agency of the United Nations, concerned with international public health (WHO 2005a). However, the issue of mental health is of great concern in Central and Eastern Europe and the Newly Independent States (NIS), also known as the post-Soviet states, where rates of mental illness are rising, and the resources and facilities available―and the expenses attached to treating the condition (as well as the perpetuated stigmatic notion attached to receiving therapy)―pose profound challenges (the Global Initiative on Psychiatry, ‘Double stigma, double challenge,’2006).
According to Dubravka, there are mostly public resources in Serbia. There is one mental hospital available in Belgrade, as well as two institutes: the Institute for Mental Health and the Institute for Psychiatry. In addition, there are several public health institutions that function as separate entities as well as in schools (e.g. psychologists and counselors), all of whom are funded by the state.
Apart from the public resources, the other concerns lie with the rising rates of mental illness. According to an article in the Science Media Centre (2012), depression is actually the most common mental illness in the UK, and the third leading contributor to the global burden of disease. And while therapy is arguably quite effective and largely available, the largest impediment to treating depression, Science Media Centre argues, is the stigma and discrimination faced by those with depression and other mental illnesses.
In Europe, approximately one tenth of the adult population suffers from mental health problems and current predictions from WHO indicate that the number of individuals affected with depressive disorders will be higher than any other health problem within 20 years time. In Europe alone, 20 million people experience depression and its associated personal distress. Many people with depression (and other mental disorders) experience stigma caused by other peoples’ knowledge, attitudes and behaviours, states the Anti Stigma Programme European Network (ASPEN), which can lead to impoverishment, social marginalization and a low quality of life which impedes recovery.
In response to these statistics, Alexander asserts that people who live in, and/or migrate to, bigger, more populated cities (e.g. Belgrade, New York, London, etc.) from smaller cities, are generally more likely to be overwhelmed and experience feelings of depression. As he explains, the pressures and conditions of an urban lifestyle are conducive to a more strained and overwhelmed mental state. Therefore, therapy may be necessary, for people living under those conditions.
Alexander believes the term “depression,” however, is very often overused and abused in society. To many people in Serbia, depression is seen as an exaggerated, temporary ailment with a quick fix, Alexander explains:
“(In Serbia), you can tell people you’re ‘tired’ and ‘not feeling well,’ but to say ‘I cannot work, because I’m in depression’ is (inexcusable and misleading). If people use this complaint, others will say: ‘well, if you feel that way then you are not working hard enough. ‘Go fish! Go get a job, do something (productive).’”
ASPEN aims to make significant contributions toward the reduction of stigma of and discrimination against people with depression in the 27 EU member states. According to The ASPEN Project webpage, “ASPEN is an association of 20 EU partner sites in 18 European countries and a multitude of stakeholders from across Europe, including universities, governmental agencies, public health, mental health, and human rights groups, NGOs and charities.”
Apart from the ASPEN initiative, Dubravka is familiar with an NGO that provides workshops to individuals, families and friends coping with crises. The workshops are twofold: 1) providing proactive steps for the person in therapy to effectively cope with, and eventually resolve, his or her issues; 2) to educate and provide options for the family and friends dealing with a person in crisis. These workshops are crucial, as they work with everyone involved to resolve issues through communication, understanding and support.
Fortunately, perceptions on therapy are changing in Europe, partially as a result of western media. As Alexander explains, people respond to the way the film and television industry portrays therapy; they see it as a socially-acceptable, popular and even fancy activity exercised by celebrities. People in Serbia watch movies and TV shows, and are beginning to adopt the notion that therapy is an ‘in’ thing to do for people in big cities with a lot of power and money. “Just take a look at The Sopranos,” Alexander exclaims, “in which someone like Tony Soprano―a big, tough mafia guy- has his own therapist!”
Apart from the influences of western media, changing perceptions on therapy are most apparent with the younger generations who are exposed―via interactions and travels―to other types of people, customs and situations. As Dubravka wittily explains, in order to see (or understand) another’s standpoint, one must have the occasion to literally ‘stand’ on, or near the other person’s standpoint (and vice-versa). “Once it is presented in a ‘human way,’―a human story that becomes personal to you―it changes your opinion, your way of viewing things,” Dubravka states.
Our perceptions and prejudices could be the result of the absence of the experience or circumstance that allows us to relate to others, to understand others. If we have not been faced with a particular issue or situation, then how are we to relate to it? If we have not dealt with a personal crisis that warranted therapy, how could someone be expected to accept therapy? Therefore, we need to put ourselves in others’ shoes (or on their ‘standing point’). “This is the point where judgment ceases and change begins,” Dubravka states, for empathy and compassion are the two entities that can elevate us as human beings and as a society.
“The real voyage of discovery consists not in seeking new landscapes, but in having new eyes.”
~ Marcel Proust
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