Holding___Space: An interview with Cindy Emanuela, an Indonesian psychologist

August 31, 2023

I'm excited to announce Holding___Space — a new series of interviews with individuals who I believe are inspiring in the fields of mental health, wellness, and mindfulness. Through these interviews, I aim to bring a spotlight to the incredible work being done by these individuals and share their insights and experiences. I hope that by highlighting these people, I can guide both myself and you, the readers, on our own inner journeys and offer ourselves a source of inspiration as we work towards our own collective mental, emotional, and soul well-being.

For my first interview in these series, I am happy to share my interview with Cindy Emanuela, a psychologist (also termed "clinician-scientist") working at the Indonesian Psychological Healthcare Center based in SCBD (One Pacific Place and Pacific Place Mall), Jakarta. With an undergraduate degree in psychology and a masters in professional clinical psychology from Universitas Tarumanagara (UNTAR), Cindy's education and experience in the field of mental health is already impressive. But what seems to set Cindy apart is her grace and maturity, qualities that far exceed her years. Only being in her mid 20s, Cindy carries herself with a level of professionalism and self-assuredness that immediately gains trust. During this Zoom interview, I delve into Cindy's journey as a psychologist where she has administered 800 hours of psychotherapy across approximately 800 sessions, the challenges she has faced along the way, and her thoughts on the landscape of mental health in Indonesia.

Please tell me a bit about yourself, Cindy.

Cindy: Sure, I'm Cindy Emanuela and I've been a part of the IndoPsyCare team since December 2020. I specialize in helping people with Borderline Personality Disorder (BPD), Obsessive-Compulsive Disorder (OCD), Bipolar Disorders, and depression. Most of my patients are between 24 to 48 years old and come from all walks of life. I was drawn to IndoPsyCare because their vision and mission aligned with my own values and beliefs. I had the chance to meet one of the founders, Dr. Edo, at a professional seminar on psychosis and was thoroughly impressed with what I learned about the center. That's what inspired me to join the team as a practitioner.

How would you personally define mental wellness?

Cindy: When I think about mental wellness, I see it as more than just the absence of mental illness. It's about functioning optimally as a human being, being able to positively contribute to society, handling stress effectively, and realizing one's own potential as a unique individual. To me, that's what mental wellness truly means.

So, why did you decide to get into the mental health profession?

Cindy: Ever since my high school days, I've always been known as the 'listening ear' among my friends. I was often sought out for advice and saw the need for psychological help among those close to me. This sparked my interest in psychology and delving deeper into understanding the human mind. I never had a fascination for numbers, literature, or other subjects, but the understanding the intricacies of the human mind have always captivated me.

That's really great, it sounds like a real calling for you! Can you also share why you chose to work at IndoPsyCare?

Cindy: One of the things I really like about IndoPsyCare is our commitment to evidence-based treatments. For example, when it comes to Borderline Personality Disorder (BPD), we recommend and provide Dialectical Behavior Therapy (DBT) instead of Cognitive Behavior Therapy (CBT). This decision is based on the latest scientific research and evidence on DBT, which has been shown to be effective in efficiently reducing BPD symptoms and is recommended by the international bodies, such as Cochran and NICE Guidelines. We also follow a person-centered approach —where we aim to gain an understanding of the patient's condition, including their strengths and weaknesses, as this plays a central role in the formation of a treatment plan.

What also sets us apart is that we are one of the few centers that provide a diagnosis. This is important because it helps us determine the necessary treatment. We believe in being transparent with our patients, so they understand their diagnosis, the core issue, and the treatments we provide. Unlike counselling-only approaches, our goal is to address the core problem, not just the symptoms. Think of it this way - our aim is to tackle the core issue, not just the symptoms. It's like visiting a doctor who gives medicine to cure the illness, rather than just symptom relief through supplements.

That's really interesting, what you just said resonates with me. In Australia, I received help from a counselor to work through my personal and work-related struggles. While the sessions were helpful, I felt like I was only addressing the symptoms. Like she was only giving me supplements. But when I moved to the Netherlands, I had to go through a thorough intake process, which resulted in a formal DSM diagnosis. Now, I feel like I'm finally getting to the core of my issues instead of just treating the symptoms, which is very helpful.

Cindy: I'm really glad you have experienced this yourself!

Can you also give me an idea of what it's like to seek psychological help at IndoPsyCare? I understand that many people might be unsure of what to expect when they first seek therapy, and I think it would be great to get a clearer understanding of the process.

Cindy: Of course, the process we follow here is a three-step one. Firstly, we go through Evaluation and Diagnosis. Like I mentioned earlier, we assess the individual through 3 to 4 sessions and a comprehensive questionnaire. After that, we have a casual, yet structured interview with the patient. Most people prefer to have it in person, but if need be, I can also do it over a video call.

The second step involves formalizing the diagnosis. At this stage, I'll let the patient know their diagnosis and how it affects them, and see if they can relate to it. I think it's crucial as it helps them separate themselves and their condition. From here, I'll create a treatment plan based on the NICE (National Institute for Health and Care Excellence) and IPK (Ikatan Psikolog Klinis Indonesia) guidelines. I'll explain to them my approach and give an estimate of how many sessions it'll take, keeping in mind that therapy is an out-of-pocket expense in Indonesia.

Finally, there's the Termination stage. This is what sets us apart from other centers, in my opinion. We determine that the treatment plan has come to an end when the individual has either recovered or reached remission. Recovery means the symptoms are still there, but mild, while remission means the symptoms are barely noticeable.

Another thing I wanted to clarify - which has been quite confusing for many Indonesians - what’s the difference between a Psychology Center (like the one you work at) or a Psychiatric Hospital (Rumah Sakit Jiwa)? 

Cindy: Firstly, it always begins with the diagnosis. If the situation calls for it, I'd direct a person to a psychiatrist for medication to help regulate their condition. The severity of their struggles also plays a role. For instance, I've seen individuals who are so far gone that they're no longer in touch with reality or haven't slept at all in a week, and in those cases, traditional psychotherapy isn't feasible. In Indonesia, I'd say that psychiatry is typically reserved for more chronic, severe cases that often require medication - kind of like an emergency room in a hospital. On the other hand, psychologists may be more suited for the treatment of conditions that benefit from repeated interactions over prolonged periods. Psychotherapy typically involves longer sessions, which allow psychologists to get to know the patient on a deeper level. And, it's worth mentioning that psychiatrists are medical doctors, while psychologists are not.

Thanks, that's really helpful. My next question is a bit more culture-specific to Indonesia. I've heard from friends that some people can be worried about their privacy when seeking therapy, especially if they are public figures or come from well-known families. They're concerned that what they share in therapy might become public knowledge. What do you think about this, and are there any privacy laws in place to ease these fears?

Cindy: Definitely, I make it a point to emphasize to each of my patients that what we discuss in our sessions is completely confidential. I cannot disclose any information, even to their own family members, unless the patient gives their specific consent. For example, if a teenage patient allows me to share their diagnosis with their parents, but not any other details, I will respect that boundary. However, there is a caveat in case of a matter of urgency, like if the patient expresses a plan to harm themselves or someone close to them. Even then I would still request their consent to do so. 

Also as psychologists, we have a strict code of ethics that requires us to keep our patients' information confidential, even with our friends and families. But that doesn't mean we can't get support when we need it. To maintain our own mental well-being and handle tough cases, we also have access to psychological supervision where we can share aspects of our work and receive guidance with our supervisor. So, any sharing we do is strictly within a professional context and always with an eye towards protecting our patients' privacy.

What are the highlights of your job, the elements that you most enjoy and that makes it all worth it?

Cindy: Working with patients can be both a challenging and rewarding experience. While some patients are open to change and eager to follow through with the exercises and advice I give, others can be resistant. But for me, those "difficult" patients bring a special kind of energy and excitement. I love the challenge of finding new ways to connect with them, build rapport, and ultimately earn their trust. To me, this job is so much more than just earning a paycheck. It's about breaking through those barriers and helping my patients be vulnerable about their emotional struggles. Seeing them make positive shifts in their lives is what truly makes it all worth it. 

Honestly, they don’t just learn from me, but I also learn from them. My patients often have their own unique perspectives and insights that they share with me, and I'm always amazed by what I can learn from them. At the end of our sessions, I like to ask what they got out of it and it's fascinating to hear their own understanding of their problems or even deeper insights about others' struggles. It's a reminder that everyone has their own wisdom and I'm also grateful for the opportunity to learn from my patients.

What are some of the current biggest barriers or challenges to providing psychological care in Indonesia?

Cindy: Well, as a developing nation, the adoption rate of seeking psychological care is still quite low in Indonesia. I think these are some of the reasons why: 

Firstly, the availability of psychologists isn't quite there yet, whether it be in the public or private sector. A lot of healthcare centers or hospitals still don't have dedicated psychologists.

Secondly, the number of people working as psychologists is still low. We have close to 300 million people in Indonesia, but only about 1,500 professional mental health providers to serve them, and most of them are located in big cities, leaving those in smaller provinces with limited access.

Thirdly, awareness about mental health is also still lacking compared to Western countries where it's widely recognized as a legitimate concern.

Fourthly, patient satisfaction with care can be an issue. Some people who've started seeing a therapist don't feel like they're making progress just by talking and they're used to the medical system where a pill is prescribed for their physical ailments. Trust in the effectiveness of psychological treatment, and having to do the work themselves, can be a challenge.

And lastly, financial constraints can also play a role, especially for those with limited income who understandably prioritize their immediate needs over investing in their mental health.

That’s really interesting. To your second point, why do you think there’s so little practicing psychologists in Indonesia?

Cindy: It's sad to say, but many parents in Indonesia still aren't on board with their children pursuing psychology as a career. They view it as a less secure field compared to something like medicine, where a job at a hospital is more guaranteed. There's a common misconception that psychologists will end up working in HR or teaching, both of which aren't known for high salaries. But the good news is, I've seen an upward trend in mental health awareness through social media, and I believe this will change in time. The certification process to become a practicing psychologist also can be quite rigorous, including the need to renew licenses, but it's all in the interest of ensuring we provide the best care possible to our patients. It's true, we may not make as much money as some other industries, but as a professional clinical psychologist, I see it as a rewarding line of work nonetheless. I work on a per-patient basis, but some centers do offer a regular salary.

What are you doing to address these barriers or challenges?

Cindy: Well, there are a few factors to consider. Firstly, the perception of mental health and seeking psychological help needs to change. People need to understand that just like seeing a doctor for physical ailments, seeking help from a psychologist for mental health is just as important and normal. That's why we try to educate the public by hosting free online webinars and spreading the word about the importance of mental health. Secondly, as psychologists, it's crucial that we stay knowledgeable and up-to-date on the latest evidence-based treatments. This not only benefits our patients but also strengthens the field as a whole. By participating in research studies and publishing peer-reviewed papers, we can continually provide mental health help to those who have put their trust in us.

I’m curious, what's your take on the recent surge in mental health Instagram pages? Do you believe it helps with raising awareness?

Cindy: I think by shining a spotlight on mental health on these platforms, we're making the conversation more accessible to the general public. This increased visibility can help people recognize when they're struggling and seek help, but it also has the potential to lead to self-diagnosis. People may read something online that sounds familiar to them and jump to conclusions about what they're experiencing. That's why it's still always a good idea to consult a professional for proper evaluation and advice.

I have another cultural-specific question. What is the relationship between religion and mental health in the context of Indonesia?

Cindy: Religion definitely plays a big role in Indonesian culture. And when it comes to mental health, there's a connection worth exploring. A study I read by Soebandi (2015) showed that religion has been show to have a link to schizophrenia. For example, if someone drinks alcohol but feels guilty because their religion considers it a sin, it creates a moral conflict in them, which can get so severe that the person becomes a social recluse or start suffering from psychosis. Sadly, in some communities, people with mental health issues like schizophrenia or depression may be ‘prescribed’ to seeing religious leaders for help instead of seeking professional help first. This has resulted in negative outcomes, like being physically restrained with chains (pasung) or labeled as insane, when sometimes all they need is a different perspective. While I believe spirituality can be helpful, issues with mental health are best handled by mental health practitioners.

As psychologists, we are also bound by ethics to not impose any religious beliefs during therapy sessions. Despite being a religious country, I believe that people's choices are their own and their human right. I truly believe in each person's right to free will.

That’s really great to hear, Cindy. It leads me to the next question, what are some of the biggest stigmas related to getting mental health support in Indonesia? And why do you think these stigmas exist?

Cindy: Shame is a huge factor. People are often afraid of being labeled as "crazy" or "insane" by others. They also fear social isolation, where friends may talk behind their back and eventually stop being friends with them due to their struggles. Also, some people worry that a mental health diagnosis may negatively impact their chances for professional employment. 

Many of my patients are also hesitant to reveal that they are seeing a therapist to others, and those who do are sometimes met with unhelpful advice such as "just pray more" or "be more spiritual." Some families may even brush off their struggles and suggest they just need more socialization or take traditional medicine that has no correlation with their mental health. This lack of validation and support can be incredibly discouraging and only adds to the shame they already feel. Overall, I believe that shame is the biggest stigma associated with mental health in Indonesia, as it prevents or delays people from seeking the help they need. This delayed response could affects their prognosis.

There is also still a common stigma surrounding mental health care and treatment, with many perceiving it as a luxury only accessible to the privileged, or even being a non-issue, especially when taking into consideration the ongoing struggle for basic survival needs in the country. Do you have any thoughts on this?

Cindy: For sure, there are still many people in Indonesia who struggle with their basic needs. And with such a diverse country, with different cultures and languages, we have not been able to properly educate everyone on the importance and legitimacy of mental health struggles.

I also believe that more research needs to be done to tailor mental health approaches to the Asian population, as a lot of current research and approaches can be heavily influenced by Western perspectives, which could also help some of the solutions to be more culturally-relevant in Indonesia. 

Also, it's not always easy to simply "talk to your friends" about mental health struggles. Being open and vulnerable with those closest to you can be challenging, as they may have their own biases and agendas. That's where a trained psychologist can step in to offer a neutral, outside perspective and support you in uncovering your true emotions and needs.

In your view, what are the negative consequences of untreated mental illness or unaddressed mental health issues within our communities?

Cindy: Some of the obvious negative consequences are interpersonal issues. If they’re studying, their education will suffer. If they are employed, their work performance will suffer. They are unable to show up fully and presently with either their friends, family, or acquaintances. As a result, this might lead to severe depression which might lead them to suicidal tendencies. Pain also causes pain. There are cases where patients have had violence or pain inflicted on them, and through that anger, they inflict that pain on other people. It perpetuates a cycle of pain. 

I have seen this cycle play out around me myself. How do we personally help people around us who are going through challenging times?

Cindy: When a friend is going through a tough time, it can be hard to know how to help. But sometimes, the most powerful thing you can do is simply be there for them. Just sit with them, listen to them, and show that you care. Trust me, that can make all the difference.

Sometimes it’s enough to sit and be present with people. 

Cindy: Exactly. In the end, we are all social creatures. We all want to feel loved, and that we are all cared for. Sometimes just being there and present for someone is enough. But if you sense they need more help from a therapist, it's okay to suggest it to them. Just do it gently and patiently so they don't feel judged or pushed. 

Earlier you said that finances are a big barrier for people seeking mental health help. In some countries, like where I live, therapy is included in basic health insurance. Do you think the Indonesian government provides enough support for mental health treatment and care? And if not, what can be improved?

Cindy: So, there's already a national policy in place that's meant to provide psychological support to our citizens. This includes funding for therapists and healthcare workers, as well as to purchase the tools they need to do their job. However, it doesn't seem like the implementation of this policy is running optimally. For instance, there have been reports of a shortage of hospitalization support in some areas, especially for those who are in a suicidal state and need to be monitored in hospitals. The support system could use some improvement. 

Another area for improvement is making it easier for people to access mental health coverage through the national health insurance (BPJS) system. Currently, you have to go to your GP, get a referral, and then see a specialist. This might be too complicated for many people.

And of course, another thing the government could improve on is putting more emphasis on prevention rather than just cure. 

My final question is ⁠— what is the ideal state of mental health in Indonesia, and how can we get there?

Cindy: Ideally, of course, where everyone has optimal mental health, and clinician-scientists like myself are no longer necessary. According to the World Health Organization, the ideal ratio of psychologists to citizens is 1 to 30,000. But in Indonesia, we fall far short of that. In fact, we only have around 400 clinical psychologists and 800 psychiatrists serving a population of nearly 300 million people.

Many psychology grads don't end up as clinical psychologists, opting for fields like organizational psychology instead. The road to becoming a clinical psychologist is tough, requiring a specialized Master's Degree after a Bachelor's. The training residency and thesis process can be rigorous and not everyone succeeds. And with stricter licensing requirements, the government's aim is to enhance the quality of psychologists in the country. Unfortunately, this has resulted in a continued shortage of mental health providers in Indonesia. 

I believe the ideal scenario for mental health in the country is one that raises awareness to end the stigma, but also provides access to trained professionals. So as a society, one of the ways we can make a difference is by producing more graduates in clinical psychology. If you're a student or someone with a passion for helping others, consider pursuing this field. By doing so, we can work together to improve the mental wellbeing of our country.

Beautifully said. Thank you for taking the time to give sincerely to this interview Cindy, it’s been a great pleasure. 

Book: IndoPsyCare's appointment page

Follow: IndoPsyCare's Instagram