Prabal K. Chattopadhyay
CLINICAL PSYCHOLOGY IN THE NEW MILLENNIUM
Human society today is experiencing the most rapid technological advancement due to the phenomenal development in computer science and information technology. Such materialistic progress, no doubt, has improved our standard of living, making life easy and full of comforts, yet has robbed us of our mental peace.
Not only psychiatric patients but normal people nowadays are also constantly exposed to certain stress-inducing situations, such as the threat of war, unprecedented use of nuclear energy, rapid political and economic upheaval in general, and, at a more personal level, psychological conflicts and confusions regarding the values that all hold essential to their existence. Ancient Oriental ethical values are being substituted by occidental ones. The young generation is the worst victim of such transition. There is unrest everywhere. Violence is on the rise and society's stability is under threat; it signals a spell of horror to the peace-loving citizen. This has brought an unprecedented number of issues and challenges to clinical psychology with emphasis on the preventive and promotive aspects of mental health.
In recent years, subjective well-being is the focus of research attention. Since psychological well-being is a matter of personal perception, variables that influence such evaluations do vary across cultures. Yet, little attention has been paid to such cultural variables in our research. There is a dire need to employ assessment and intervention strategies that are culturally sensitive in order to enhance the quality of clinical services and, thereby, improve the quality of life (QOL). Thus, at the dawn of this millennium, it seems appropriate to consider the advent of the science and profession of clinical psychology in India.
Based on previous research reports and reviews, this chapter focuses on the changing and emerging trends noted in the areas of clinical assessment and intervention together with the other activities of clinical psychologists in India. For the sake of brevity, and keeping in mind the problems of rural development in India and the role of cultural and sub-cultural factors in psychopathology and interventions, assessment tools and strategies that are found sensitive to our culture have been considered in greater detail. Omission of a research article, however, should not mean that its importance has been ignored; rather, I have focused on the new and challenging frontier areas and on the means by which we may improve our quality of life in future.
Clinical Psychology in India
As clinical psychology (CP) enters this new millennium, it faces an unprecedented number of issues and challenges. To keep pace with the demands of society, CP has to change its perspective in almost every aspect of the field starting from imparting training to clinicians to provide service to the community. Though psychological services in India are on the upsurge, doubts and apprehensions persist regarding the quality of services rendered, particularly relating to issues of sensitivity to culture (Kakar, 1997). However, the Indian Association of Clinical Psychologists (IACP) has made several valiant attempts to avoid such confusions and to ensure high quality of services (Prabhu, 1997; Verma & Kaur, 1998, 1999; Verma & Puri, 1996).
The frontier areas of CP, namely, health psychology (including malnutrition, women and stress), school psychology (including adolescent criminal behaviour, gender equality) (Prabhu, 1997; Prasad, 1996), gerontology, forensic psychology, rehabilitation (Thapa, 2000), sexually transmitted diseases, crisis intervention in terminally ill patients (Mehrotra & Mrinal, 1996), and suicidal behaviour (Prasad, 1998) require attention in the immediate future. In addition to understanding the relationship between stress and illness, and identifying risk factors for illness, attempts have been made to implement interventions. Though findings concerning the association between meta-psychological belief and recovery in Indian patients have been inconsistent (Kholi & Dalal, 1998), many intervention techniques (depicted in the section on therapy) have been successfully employed in the area of behavioural medicine (Thapa, 2000). Likewise, there has been progress in the application of neuropsychological methods of assessment. Certain gaps and lapses in the theory become evident when the tools developed by academics are put into practice by clinical psychologists for quality assessment. These gaps are to be minimized by the clinical psychologists. However, the focal theme for clinical psychological research, in the context of our culture and particularly for rural development, would be to generate certain instrumental (self-control) and terminal (salvation, freedom, longevity) values (Tiwari et al., 2002) for implementing quick and need-based effective management, and formulating adequate prevention programmes.
Clinical Psychologists in India
The scope of work for clinical psychologists has grown enormously over the years. They now work in different settings, which have paved the way for the emergence of new directions and horizons in CP.
In clinical settings, the specific functions of a clinical psychologist are psychodiagnosis, psychotherapy, and teaching. In rendering these services, what is needed is a change of attitude—to move from a dependent, subordinate, technician-like role (Murthy, 1982) to that of an independent decision-making professional. In hospital settings, services are to be extended beyond the psychiatric unit. That is to say, he has to serve even in the departments of neurology (including neurosurgery), obstetrics-gynaecology, physical medicine, paediatrics, etc., as a neuro-psychodiagnostician as well as therapist/counsellor for complicated cases, for example, those requiring hysterectomy and the termination of pregnancy. It is the demand of the day that psychodiagnostic assessments should shift from assessment of symptoms to elucidation of basic psychopathology of each condition, namely, borderline states; they should be aware that they are dealing not with disease, but with behaviour. Clinical psychologists should be interested in the process, not in labels. A particular pattern of the behaviour may stem from wide-ranging psychological causes, and that a diagnosis on a purely descriptive level without regard to the patient's thought content is no diagnosis really.
Services of the clinical psychologists for children in India have been limited to child-guidance clinics. The clinics must be equipped with more descriptive and experimental procedures, namely, psychophysiology, neuropsychology, and neuroendocrinology for the appraisal and treatment of individuals and families, applying biofeedback and behaviour modification techniques for children, including special children. The requirement for the extension of their services is most immediate in the paediatric setting, in social service departments, and with general physicians (GPs).
Mental health professionals in general and clinical psychologists in particular, have contributed to the management of mentally retarded persons. Since the declaration of the International Year of Disabled Persons (1981), clinical psychologists were encouraged by the Ministry of Social Justice and Empowerment (formerly Ministry of Welfare), Government of India, to join the national institutes for disabilities in different parts of the country, namely, National Institute for the Orthopaedically Handicapped, Kolkata; National Institute for the Visually Handicapped, Dehradun; National Institute for the Mentally Handicapped, Secunderarbad; and National Institute for the Hearing Handicapped, Mumbai, as professional caregivers and faculty members. Clinical psychologists would thus serve the disabled population by way of assisting family members as special educators, developing service models for nationwide replication, and as Master Trainers to impart training to people to serve in this field, and to conduct need-based research. Thus, their contribution has been acknowledged not only in the area of mental retardation but also in other areas of disability.
Some of the most important duties of clinical psychologists are to provide educational and vocational guidance to the students, counselling, the appraisal of cognitive (both IQ and aptitude), learning (e.g., ADHD, dyslexia), and emotional (e.g., conflicts) problems, collecting and disseminating occupational information (Srivastava et al., 1996). About 15–20 per cent of students fail to maintain satisfactory progress in school (Prasad, 1996), but the mental-health services available in our country are very meagre. There are around 140 counsellors working in 200 schools of Delhi (Bhatnagar, 1994) and in a few other centres like the K. G. Medical College, Lucknow; some schools situated in different parts of the country are providing excellent services but there is a significant gap between demand and supply.
Another problem that clinical psychologists require to address is the unhealthy academic competition, mostly among parents and thereby among their children, added to the burden of the syllabus. The Yashpal Commission, appointed by the Government of India (Prasad, 1996), recently expressed great concern over such a burden. Clinical psychologists must prevail upon the authorities concerned to solve such problems.
Gifted children mostly fail to receive adequate attention. Clinical psychologists functioning in schools as programmers and behaviour modifiers have to innovate new techniques to identify such children and institute special programmes for them.
As consultants in schools, clinical psychologists have to organize workshops on effective parenting (namely, developing communication style), and effective teaching methodologies (aiming at enhancing the power of concentration), they have to educate students about sexual problems and value conflicts, etc., and thus assist students in their desired academic pursuit while also guiding parents to cope effectively with stress. Many a time teachers and parents show resistance to come forward for consultations because of social stigma. It is again the responsibility of clinical psychologists to help them to overcome such initial resistance and to accept the fact that emotional problems are like physical ailments and, therefore, curable. Thus, as both consultants and counsellors in academic institutions, clinical psychologists can bring parents and teachers closer to each other to form teams. They can train them to help students of different grades to develop group morale, build character, leadership and such other desirable traits; they can train parents and teachers in early detection of disordered behaviour and to have the requisite information about the sources of the remedies available.
In organizational establishments, clinical psychologists have to motivate workers through psychological methods as well as deal with problems like industrial unrest and lowered productivity that arise due to violation of psychological contracts. Psychological contract (PC) is a belief about reciprocal obligation between employer and employees. This specifies what each one expects to give and receive from the other in the relationship. A violation occurs when one party in a relationship perceives another to have failed to fulfill promised obligations (Rousseau, 1989). They have to motivate workers using psychological methods to improve production, to improve communication skills, to initiate higher need for achievement. By providing counselling in the various psychological problems in industrial establishments, clinical psychologists can help enhance overall healthy interaction, both at the personal and interpersonal levels.
Clinical psychologists must be aware of and concerned about the detection of toxic chemical etiologies, if any, and successful implementation of measures to prevent tragedies (Gupta, 1998). These problems are of serious concern in India, for example, the Bhopal gas tragedy that occurred in December 1984 (ICMR, 1986). Workers in India, by and large, are illiterate and, thus, unaware of the harmful effects of the toxic substances in their work environment. Furthermore, the Indian climatic condition has certain special problems. Research reports show that toxicity of almost all the substances increases with the rise in temperature and humidity. Likewise, malnutrition and protein deficiency enhance the toxic effects of various substances. The role of clinical psychologists in crisis intervention, namely, in situations like Kargil and Kandahar, has not been acknowledged. Though services of physicians and neurologists were requisitioned, the services of clinical psychologists were largely ignored. IACP has to sensitize the authorities concerned on such issues for the future well-being of victims and the welfare of the community.
A SHIFT IN FAVOUR OF USING PSYCHOLOGICAL TESTS FOR SCIENTIFIC PURPOSES
There has been tremendous growth, over the years, in the number of specialized institutions that are devoted to selection of personnel for different positions. The National Institute of Bank Management, banking services selection boards, Services Selection Board, and special wings of the Defence Research and Development Organisation (DRDO) are some of such organizations. Likewise, the Union Public Service Commission (UPSC) and state public service commissions conduct tests for the recruitment of personnel for various services. Almost all large organizations have personnel or human resource development (HRD) departments for this purpose. Mostly verbal tests are employed, though the use of performance tests is increasing (Misra et al., 1999). This is a reflection of society's acceptance of the system of psychological assessment, particularly of their commitment to the belief that aptitude predicts future performance. In addition, overall personality assessment can help to discriminate between competent and less competent incumbents. This has no doubt increased responsibility of clinical psychologists for providing valid assessment of psychological attributes, as the demand for tools for assessment of individual differences will continue to increase for selection, placement, training, counselling, and diagnosis.
Of late, in India, many high-profile corporates, like Tata Consultancy Services, have started taking the help of clinical psychologists in this regard. The need for stress management programmes for employees has been recognized by some other organizations, like Hindustan Lever. Clinical psychologists act as consultants for many relevant issues of the day. They have important roles in developing communication skills, creating awareness of emotional quotient, spiritual quotient, and mental health issues, of balancing work and personal life, of establishing harmony in personal life and interpersonal relationships, and in lifestyle interventions in stress management (anger management, emotion management, relaxation training, etc.).
For training and recruitment of personnel, clinical psychologists have a significant role to play in military and police training institutions, for example, clinical psychologists can help to equip them to tackle problems psychologically; thus, their services extend to forensic psychiatry and criminology. Likewise, clinical psychologists must modernize their methods through rigorous research to keep pace with the recent emergencies in military and defence services, including terrorism consumerism, and other menaces (Kaliappan, 1994).
Clinical psychologists have been engaged in developing diagnostic tools suitable to the needs of our community. Indigenization of tests is necessary for providing unbiased and valid assessment in analysing our well-being and our woes (Mohammed, 2002). However, there is need to ensure quality control in the production of tests being supplied by Indian manufacturers. Sahay (2001) cautioned that stimulus materials of many tests are changed arbitrarily by the manufacturers, like Bender-Gestalt Test's figures are shrinking; the same is the case with Raven's Progressive Matrices. Some of the cards with stimulus figures also mention the name of the manufacturer on the top. This is considered highly unscientific. It is time to exercise adequate quality control and to communicate this major concern of the profession to the manufacturers of tests in the country. Clinical psychologists are the most suitable professionals for such quality control.
At the larger community level, clinical psychologists have to intervene in matters concerned with fertility regulating practices, choice and use of contraceptives, change of attitudes about sex, mental disorders, etc., and also in matters related to psychosocial intervention strategies that are culturally sensitive.
In India, traditional healers play a significant role in the restoration of mental health, so much so that it has been designated as cultural preoccupation (Kakar, 1997). Implementation of modern treatment methods, particularly in rural areas of India requires brain storming sessions through clinical psychologists in line with the cultural and social cognitions (Misra, 1997) of our population.
The media have taken a leading role in disseminating information related to mental health. Availability of a helpline in any magazine or newspaper necessarily signifies the popularity of mental health issues in periodicals published in India. However, the Internet and cybergames have brought a new set of challenges to the clinical psychologists particularly for amelioration and prevention of problems that our children, adolescents and young adults face. The helplines (Duggal & Singh, 2002a, 2002b; Verma & Bhargava, 2001) offer services to the distressed but mostly are not staffed with professional experts. As such, services of clinical psychologists must not be substituted by the commonsense exercise of non-professionals. Thus, cybercrime arising out of Internet addiction is another of the new challenging issues with which clinical psychologists must contend.
A POSITIVIST PARADIGM
Clinical psychologists are not merely concerned with problems of pathology. Their repertoire of activities must include helping people identify their potentialities to utilize them to enhance their quality of life. For example, the role of clinical psychologists in premarital and marital guidance, counselling, career guidance is well recognized. In Indian society, most marriages are arranged and, more often than not, partners are strangers to each other. Indian social fabric does not usually permit a period of courtship. Though some youngsters nowadays date, several affairs end abruptly and in some cases marriage ultimately breaks. This is because such affairs are based upon false communication and physical attraction. Clinical psychologists can prevent such situations by helping partners to gain a fuller understanding of themselves, which is the basic criterion for happy marriage. Likewise, to make marital life satisfactory, problems centring on sex conflicts, women's liberation (higher education, employment), male domination, etc., have to be skilfully dealt with along with the underlying psychological problems in a relationship.
Career guidance provides the rational decision that helps to logically match individuals to suitable occupations. The principle of career counselling is to equip the individual better to make occupational plans after understanding his/her own abilities and characteristics. Thus, the aim of clinical psychologists in career counselling is not just to assess the client's qualities and capability to match them against a job profile. Clinical psychologists must also provide thorough and effective individuation (Sanyal, 2003a) of the counselling experience to develop a self-evolved career plan and the initiative to fulfil one's ambition.
Indian players and their policy makers have felt the need to consult clinical psychologists who are experts in sports medicine/sports psychology. To obtain a desirable training outcome in football performers, the Sports Authority of India have requisitioned services of clinical psychologists (Saha et al., 2001).
Of course, to make a mark in new directions in the new millennium, efforts must be made to strengthen the hands of these professionals through licensing/registration (Prasad, 1997; Thapa, 2000) and establish a strong sense of professional identity and (Rao & Mehrotra, 1998) responsibility.
Clinical psychologists must be determined to retain the success (Thapa, 2000) with challenge (Prasad, 1998) that they have achieved after their long struggle for autonomy in independent practice (Nathawat, 1999). An independent council/board for clinical psychologists, analogous to that for allopathic, ayurvedic, homoeopathic professionals, is to be formed for consumers’ protection against quacks (Singh & Nathawat, 2000, 2001) and for quality control of professional services.
For advancement of clinical professional practice, there is an urgent need to expand the sources of information dissemination to our clinicians to meet the growing demands thrust upon them by the community. For example, UGC-sponsored (University Grants Commission) refresher courses should be available for clinical psychologists separately, instead of the same under the rubric of behavioural scientists.
PSYCHOLOGICAL DISORDERS: EPIDEMIOLOGY AND DEMOGRAPHIC VARIABLES
The national prevalence rates per 1,000 population for ‘all mental disorders’ is reported to be 70.5 (rural), 73 (urban), and 73 (rural + urban) (Ganguly, 2000), of which the prevalence of schizophrenia is 2.5/1,000, which is consistent across cultures over time; rates of depression, anxiety, hysteria, and mental retardation are also provided. Of the epidemiological studies of psychiatric morbidity carried out since 1960, 15 have been reviewed by Ganguly (2000) to classify the following: (i) all-India prevalence rates for ‘all mental disorders’; (ii) national prevalence rates for specific disorders; (iii) rural-urban differences; (iv) morbidity in urban industrial population compared to rural and urban general population; and (v) the stability of rate of schizophrenia.
With the exception of a few studies reported on etiology, for example, defensive styles in different groups of neurotics (Sanyal et al., 1993), ‘identity vacuum’ (Bhushan, 1993) in the modern youths, and coping strategies in young males (n = 150) and females (19 to 21 years) (Sanyal et al., 2002), relatively greater number of studies have been reported on intervention methods for anxiety and anxiety-related disorders. Atypical, rare cases like haemophilia (Basu & Bhattacharya, 1995), alexithymia, and patients with cancer (Sinha & Nigam, 1993) have been studied from the psychiatric perspective (Pandey et al., 1996). Epidemiology and demographic variables of different disorders are reported below.
Classification: Present Status with Regard to Indian Culture
Unlike general medicine, classification in psychiatry is complicated. Psychiatric classification attempts to bring some order into great diversity. Still, the use of psychiatric classification has been criticized as inappropriate, particularly by some psychotherapists. According to them, diagnostic category distracts from understanding the unique personal difficulties of patients. However, contradictory views also exist. Classification may be harmful in our culture from social stigma point of view. Instead of using categorical classification, some have advocated dimensional classification (Eysenck, 1976), and thereafter the multiaxial approach; the latter also has obvious limitations. Some of the classifications are so complicated that there may be difficulty in applying them in every case. Moreover, the classification system of developed countries has not been wholly satisfactory in developing countries (Walker, 1981). In developing countries, acute psychiatric symptoms may present difficulties of diagnosis. Such difficulties can be overcome only when we consider important cultural factors and the varying use of language to describe emotions and behaviour (Kapur, 1987). The impact of culture in symptom manifestation has been discussed later in this chapter.
Disorders of Childhood
Information about childhood mental disorders in India is scarce, and epidemiological research reports on prevalence rates show wide disparity ranging 69 to 171.7/1,000 (Seshadri, 1993). School-based studies show prevalence of 64.2 to 196.2/1,000. Clinic-based studies (Basu et al., 1996; ICMR, 1992) showed a total prevalence of 28 per cent neurosis. In 1995, Singh, Manjhi, Shukla, and Banerjee reported that more than one-third of the total number of patients attending child guidance clinics were diagnosed as schizophrenic, hyperkinetic, and mentally deficient; 23 per cent of the cases were diagnosed as hysteria, where a large discrepancy was noted with the findings of ICMR (1992) in ‘collaborative study on pattern of child and adolescent psychiatric disorders’. Khanna and Singh (1994) reported the preponderance of males in a sample of 222 children of which 53 per cent were adolescents and manic depressive psychosis (MDP) was the most common diagnosis. However, A. R. Singh et al. (1995) provide comprehensive information about socio-demographic variables and the diagnostic pattern of child cases (n = 260) who attended psychiatric unit of the Central Institute of Psychiatry (CIP), Ranchi. Prevalence was higher among male children in the age range 6 to 13 years, hailing from the families of lower socio-economic status (SES), with about 50 per cent from urban backgrounds. Boys outnumbered girls in almost all the diagnostic categories except in mental deficiency, hysteria, and yet-to-be diagnosed categories.
Child-rearing styles and environmental stimulation have drawn the attention of researchers. Parental deprivation (Chattopadhyay et al., 1993; De et al., 1993; Mukhopadhyay et al., 1996; Mukhopadhyay et al., 1997; Sinha, Sharma & Bhargava, 2000), family pathology, namely, poor involvement and of parents, poor disciplinary practices (Vidya & Tripathi, 2001), and parental alcoholism (Kodandaram, 1995) have been associated with childrens’ behavioural problems, namely, pathological aggression, truancy (Sreelekha Saha et al., 1998) and higher autonomic nervous system (ANS) arousal (Duttagupta et al., 1998), and problems of adjustment (Roychowdhury & Chattopadhyay, 1995). Psychoticism as a dimension of personality was found to be present in those who develop anti-social personalities later in life (Basu & Basu, 1998).
Early age gender discrimination and related behavioural expectations in Indian society cause increased need persistence in girls and greater aggression acquisition in boys (4 to 7 years), irrespective of social class and age (Tripathi et al., 2001, 2002). Though social class level did not emerge as a major variable affecting the adjustment, it produced an interaction effect. In the disadvantaged social class, the expectation with regard to socially desirable behaviour is lower, but due to economic deprivation females get fewer opportunities for interaction with other people; which in turn causes psychological starvation and weak ego strength in female children of this particular class. Male children of this particular class have to carry the extra economic burden of the family right from childhood and are automatically deprived of an adequate model to emulate for the development of sufficient ego strength. Pressure of domestic work and the expectation of adult behaviour from them without an adequate model cause negative ego strength. This study employed the picture-frustration test; however, until the inter-rater reliability of the results is not worked out subjectivity in its interpretation cannot be ruled out.
Frequently reported problems in children are: impulse control disorders, autism, feeding and eating problems, problems associated with elimination, reading and writing problems (e.g., dyslexia), etc. Epileptic children sometimes show sexual misbehaviour, cruelty, stealing, fighting, lying, and destructiveness. Psycho-behavioural interventions have shown promising effects in alleviating such problems.
Of late, this behaviour has drawn the attention of clinicians and researchers. Several causative factors have been identified: (i) avoidance behaviour, (ii) seeking comfort, (iii) escape from demands of school, and (iv) occurrence of some stressful life events giving rise to physical complaints namely, headache, giddiness, nausea, vomiting, fainting, abdominal pain, difficulty in breathing, and other anxiety features. Truants (n = 73) of VII to X standards in private schools in Punjab showed lower achievement motivation and poorer life adjustments than non-truants (Irfan et al., 1993). Both teacher- and parent-centred factors are responsible for this. In the former, lack of attention to the individual needs of the pupil, authoritarian attitude of teachers, disturbed peer group relations, too high a work load and insufficient self-estimation, are some of the important factors. In parent–child interaction, emotional instability of the parents, violent quarrels, prolonged illness, parental disinterest, and lack of opportunities for the child to be positively evaluated (either by himself or by others) are some of the important factors for causing lower achievement motivation leading to truancy. A stimulating environment conducive to nurturing maturity (Sen, 1996) is required both from teachers and parents.
Every year, about 10,000 to 20,000 children are physically or psychologically abused (Das, 2003). Child abuse may broadly be divided into sexual abuse, emotional abuse, neglect, and physical abuse—of which sexual abuse is one of the gravest forms. Childhood sexual abuse acts as a self-mediation strategy for substance abuse in later age (Pekala et al., 2000), along with other behavioural problems, like becoming a recluse, a loner with hatred and anger towards one's parents. Substance abuse in such cases helps suppress memories of such abuse and to cope with emotions such as a sense of powerlessness, lower self-esteem, lost sense of self-identity, and inability to trust others. However, research findings have been inconsistent with regard to child abuse as the precursor to and cause of dissociated disorders.
Children with conduct disorders perceived their parents and parenting style negatively compared to that of normal children (Singh et al., 2004). Accordingly, parental guidance, counselling, and play therapy are found essential to help children with aggressive behaviour (Dogra & Veeraraghavan, 1994). Likewise, impulse control disorders in children have been successfully treated with psychotherapeutic packages comprising different behavioural and cognitive techniques (Arun & Kaur, 2002). A combined approach (parental training and individual therapy programme) (Basu et al., 1996) was found effective in treating five children (5 to 7 years) with attention deficit hyperactivity disorder (ADHD) in 35 sessions (Basu et al., 1996). Of late, physical exercise, namely, swimming (Biswas et al., 1998; Chakraborty et al., 2001), and games and sports (Chattopadhyay et al., 1994; Saha et al., 2001) have been effective in anxiety amelioration in children.
Due to inadequate intake of proteins, vitamins, and calories, rural children in India are the slowest in almost all aspects of development. The promotion of adult education, like that of Integrated Child Development Services (ICDS), is required for identification and fostering of creativity in children as the appropriate strategy for effective human resources in our country.
Disorders of Adolescence
Epidemiological studies in the Indian context have shown a wide range of prevalence rate (2 per cent to 30 per cent) for psychological problems amongst adolescents (Bhola & Kapur, 2000), of which more than 8 per cent prevalence of psychological disturbances and nearly 6 per cent prevalence of emotional disturbances were noted (Kapur et al., 1994; Sinha & Kapur, 2001) in adolescent boys. A prevalence rate of 10.9 per cent for emotional problems in adolescent girls has been reported (Bhola & Kapur, 2000), implying higher prevalence in girls (Gaur et al., 2001; Sinha & Kapur, 2001); of about 1.5 million brown sugar addicts in India, 12 per cent are females.
There is a remarkable convergence of clinical observations pointing to these striking gender differences in adolescent symptomatology. Adolescent girls constituted a vulnerable group that clearly has a proclivity towards internally turned symptoms such as anxiety, depression, and somatization disorders, whereas for adolescent boys conduct disorders, hyperactivity, attention difficulties, and school refusal and/or truancy show an increase in rates (Bhola & Kapur, 2000; Ollendick & King, 1994). Prior to adolescence girls are mentally healthier than boys, whereas the opposite pattern emerges after adolescence. Girls usually in our country are targeted as they are believed to be non-expressive, more so during adolescence. Therefore, they are at risk (at 11 to 16 years) of having problems that others fail to recognize. There is remarkable confluence of evidence suggesting that girls are particularly vulnerable to developing emotional disorders that are likely to continue into adulthood (Bhola & Kapur, 2000).
Boys appear to be motivated more by the need for power and recognition while girls by the need for affiliation. Research reports show that majority of the boys wished that their parents were wealthier with high social positions (Bhola & Kapur, 2000), while girls on the other hand longed for greater love, attention, and encouragement from their parents. Some of the reported studies have limitations in terms of sample size, socio-demographic representations and lack of multi-informant data. For example, prevalence rates may vary depending on whether information obtained is based on parents, teachers, or a self-report (Bhola & Kapur, 2000), of which self-report is the best source of information. Present-day adolescents face ‘achievement press’ from their families and schools. Though Sinha et al. (2000) reported the absence of obsessive-compulsive phenomenon (OCP) in Indian adolescent boys, many other studies have contradicted this finding (Sinha & Kapur, 2001). Sexual guilt, leading to obsessive-compulsive disorders (OCD) particularly in adolescent boys, and somatic complaints in adolescents irrespective of their gender (Sinha & Kapur, 2001), are evident. Poor academic performance, sex guilt, and negative social interaction are important correlates of attempted suicide in adolescents (Kar et al., 1996).
Emotional disturbances in adolescents negatively affect their adjustment. This leads to a variety of psychological problems (Kiselica et al., 1994), namely, academic under-achievement, peer dislike, loneliness, poor compliance with teachers and poor self-concept, lower stress-tolerance (Sinha, 2000), lower competence and personality deterioration, (Rao & Parthasarathi, 1993), anxiety, aggression, and depression (Sanyal, 2004). Bhandari et al. (2002) at Panjab University, Chandigarh, studied 600 (300 males) university students to examine the role of negative cognitions and personality in depression at different levels of stressful events. Results showed that maladaptive cognitions do not act synergistically with stressful events to explain depression.
There are wide cross-cultural variations found at the onset of adolescence. Applying psychological, psychophysiological (ANS and central nervous system, CNS) and endocrinological measures, the onset of adolescence amongst our subjects (n = 250 boys) appeared to be around 12 years and its duration extended upto 12 to 17 years, with a peak level of anxiety and adjustment problems around 15 to 16 years. On hormone measures, peak anxiety was evident around age level 11 to 12 years (Mallick et al., 1986).
In our country, poor mental health awareness, limited clinics (e.g., 100 child guidance clinics in India till 1999, Sethi, 1997), inadequate numbers of trained mental health professionals (Prasad, 1996), and other community-based services along with the perceived stigma make adolescents an underserved population. Further, there is a gender difference in the use of child guidance services in India, with boys far outnumbering girls (Sethi, 1997). Such a sizeable mismatch between the need for and the availability of services (as also its utilization) suggests that community-based programmes for public awareness and school mental health programmes are urgently needed, with particular focus on the methods suitable to unveil the hidden emotional problems/disorders in our teenagers. In this context, Chattopadhyay and Duttagupta (1999) have delineated the importance of objective measures (psychophysiological).
Paintal and Pandey (1996) in a study on 313 (168 boys) adolescents (15 to 16 years) reported that gender differences prevail with regard to conflicts and attitudes of adolescents towards their parents. In Indian families, the mother is ordinarily perceived as more punitive than the father; still, she is the major source of affection and care and is more influential than father whose role is culturally ill-defined (Paintal & Pandey, 1996). However, this attitude has changed considerably with the advancement of women particularly for working women. Importantly, the attitude of adolescents towards their parents is vital in providing parental guidance. Services in general for emotional problems are almost negligible compared to those for behavioural (Rangaswami, 1995) problems, like hyperactivity, problems of conduct, attentional difficulties, school refusal, and truancy (Khanna & Singh, 1994). The specific factors responsible for greater discordance in the families of adolescents need to be spelt out in order to check increased crime, delinquency, and violence among young adults.
Awareness programmes for parents and teachers are necessary. Clinicians must bear in mind the implications of negative cognitions (developed through negative conditioning during upbringing); treatment formulations should emphasize measures to reduce such negative bias with which the adolescents perceive the world and self.
In view of the National Policy on Education (NPE-1986) in HRD, our schools should undertake enrichment programmes (Hemantakumar, 2002) like sensitivity training, personality development programmes, for raising QOL in general and for girls and women in particular.
School-based brief supportive psychotherapy for adolescent girls (n = 40) with emotional disturbances was found effective (Bhola & Kapur, 2002; Sinha & Kapur, 1999) in Indian society. Clients showed clinically significant changes in internalizing their problems, self-esteem, and adjustment. The relatively small sample size and inclusion of only girls and that too from schools, limit the generalizability of the findings. Also, only self-reports were used as the indices of outcome evaluation making the results susceptible to common method variance and response biases. Again, for some of the measures employed, normative data was not available. This led to some difficulties in interpreting the rates of clinical significance. This study, however, emphasizes the need to broaden the question of therapeutic effectiveness beyond statistical significance—a long-standing issue, whether statistics can be always applicable to biological sciences. This study also emphasized the inclusion of indices like different domains of adolescents, parent functioning. However, further research is needed to collect normative data for tools used as psychotherapeutic outcome indicators.
Disorders of Adulthood
Depression is projected to be the second prominent cause of disability by the year 2020 (Murray & Lopez, 1997). Clinically identifiable depressive disorders have been found to be as common in India as in the West (Sen & Williams, 1987). Seriousness of depression increases when it is accompanied/followed by physical illness/ailments (e.g., infertility, menopause).
Sharma et al. (2001) at NIMHANS, Bangalore, explored the issue of vulnerability to depression (n = 18) by examining both state and trait markers and reported that vulnerability is present at both levels. Remitted depressives (n = 19) used lesser than normal (n = 24) problem-solving coping in stressful situations and appraised the future as negative, particularly in the interpersonal domain. This highlights the importance of cognitive therapy in relapse prevention. The sample size investigated may not be truly representative of the general Indian population. In addition, the study was cross-sectional in design and subjects responded to a hypothetical stressful situation. Vulnerability can be best examined in longitudinal studies.
Theorists differ in their opinion on whether interpersonal difficulties in depression are associated with perceptual impairment or with emotional bias (Banerjee & Chattopadhyay, 2004). That is how recognition of facial expression has been found to be either biased or impaired in depressives. Negative bias refers to a state in which there is flood of certain unpleasant emotional experiences, and impairment refers to a perceptual deficit (Dutta & Mandal, 2002). Asthana et al. (1998) examined whether interpersonal difficulties in depressives are associated more with perceptual impairment or with emotional bias. They found a general impairment in major depressives’ ability to perform visuo-spatial as well as affective tasks. They also suggested that major depressives’ deficit in judgement of emotion stems from their cognitive/perceptual deficit, that is, due to the right hemisphere dysfunction (Asthana et al., 1998; Mandal & Asthana, 1999). Thus, major depressives’ perceptual deficit is pervasive and not specific to affective categories. Institutionalization of psychiatrically depressed patients might have reduced or retarded mental operation of depressives. In addition, there is invariant information processing in depressives that results in ‘over-generalization’ and ‘blurring’ of discrimination (Beck & Shaw, 1978). However, the small sample size of Asthana and others does not allow comparison of this study with other psychiatric cases.
Gender differences show that women are twice as likely as men (due to hormonal differences and personality variables) to suffer from depression (Dixit et al., 1999, 2001).
Effects of REM sleep deprivation on cholinergic receptors (Prathibha et al., 2000a) and models of depression have been described by Kumar and Raju (1998), and Prathibha et al. (2000b).
Though ego functions could differentiate well between neurotics and psychotics, amongst neurotics and normals conflicting research evidences are reported, for example, differences between normals and depressives and between normals and anxious patients in terms of ego functions are almost similar (Basu et al., 2002). In one study, Basu and Chakraborty found that (1996) normals and depressives differed significantly on all ego functions, except the synthetic-integrative function, whereas in another study (Basu et al., 2002) object relation (OR) was found to be better in normals than in depressives, unlike between normals and anxious patients. OR refers not only to the degree and kind of relatedness to others, but also to the ability to enjoy interpersonal relationships and to tolerate separation, which is obviously low in depressions.
In general, however, ego functions of depressive patients show that OR, thought process, adaptive regression, defensive function, and synthesis in integrative functions are contributory to depression (Basu et al., 1997). The better these functions are, the lesser is depression (Basu et al., 1999a, 1999b). This study was of 60 patients (19 to 40 years) with depression (ICD-10). The age range was quite wide and it is not known whether the authors controlled the menstrual status of their female subjects at the time of investigation, which can contaminate the obtained findings (Basu & Chattopadhyay, 1999). This study also revealed that the amount of total presumptive stress had inconsequential effects on depression; the combination of the total presumptive stress and some of the ego functions played a significant role in determining the overall psychopathology of depression. This finding is valuable in planning therapeutic programmes for depressives.
Knowledge of comparative roles of psychological functions in other clinical groups is necessary for formulating psychological intervention programmes.
There has been a significant shift in research interest toward cross-cultural, sub-cultural, and neuropsychological comparisons; also a shift from intra-individual to inter-individual approach (Sovani & Thatte, 1994) in the management and recovery of schizophrenia as noted in a recent research.
Emphasis on standardized approaches to diagnosis and assessment, embodied in the DSM and ICD nosology, has stressed features that are culturally invariant (American Psychiatric Association, 1994). Although features like neurocognitive deficits, brain abnormalities, and the effects of family interaction patterns appear culturally invariant, many features, such as cultural differences in presentation, severity, course, and medication affects, do show substantial variance with culture. Emotional processing in schizophrenia was measured cross-culturally on three groups of patients, namely, on Americans (40 patients and 40 controls), Germans (24 patients and 24 controls), and Indians (29 patients and 29 controls) (Habel et al., 2000), to see whether ethnic background could be associated with it. Although some variation in performance was observed among cultures, similarities were more prominent than differences. Such emotional impairment, however, is supportive of a common neurobiological bias in schizophrenia, but small differences in affective impairments with respect to emotional valence probably reflects the influence of culture and demographic variability among the samples. However, applying these proofs in larger and more diverse samples and combining them with structural and functional imaging will help to know more about the neurobiological phenomenon of affective symptoms in schizophrenia and also psychopathology and psychophysiology of patients suffering from it.
Psychophysiological research studies have been relatively fewer in number during the period covered in this survey compared to the previous decades. Mishra and Sharma (1995) found higher heart rate and diastolic blood pressure in schizophrenia (n = 138) compared to normals and first-degree relatives of schizophrenics. Of the various psychophysiological measures, Galvanic skin response (GSR) has been employed extensively by the researchers in assessing stress-related problems, namely, menstrual distress (Basu & Chattopadhyay, 1999), functional infertility (Mukhopadhyay & Chattopadhyay, 1994) and also in determining behavioural inhibition systems and personality interrelationships (Mukhopadhyay & Mukhopadhyay, 2000). GSR in comparison to other psychological and hormonal measures was found to be by far the best in determining arousal of the subjects. However, the number of subjects investigated was small in all the above-mentioned studies and thus these require replication. The methodology also requires standardization so that discrepancies in the results can be avoided. Interestingly, the concept of LIV (law of initial values)—a crucial and significant basic concept in psychophysiological research—is found to require a revisit by both Indian (Mukhopadhyay & Chattopadhyay, 1995) and Western researchers (Bernstein, 1973). This issue is detailed later in this chapter.
Ego functions and stressful life events of schizophrenia have been associated with severity of psychopathologies (Basu, 1993; Basu & Banerjee, 1998; Basu & Basu, 1996; Basu et al., 1999a, 1999b, 2002, 2003; Basu et al., 2000). In contrast to Bellack's original work, these authors have found a non-linear trend, that is, dysfunction of ego in different clusters. For example, reality testing and judgement factors of ego functions constitute a cluster for psychotic patients, whereas drive control, defensive functioning, stimulus barrier, thought process, and autonomous functioning formed a cluster for patients with generalized anxiety disorder (GAD). Paranoid schizophrenic subjects and normals did not show any difference in adaptive regression function of the ego (Basu & Basu, 1996), which requires clarification. Again, OR of the ego function unlike those of the patients in the West, does not give a clear picture in the context of patients of our culture; a finding that emphasizes the need for cross-cultural investigations.
Deficit in emotion recognition has been found to be a characteristic feature of schizophrenia pathology (Mandal et al., 1999). Schizophrenic patients with positive symptoms when compared with non-patients controls have shown a recognition deficit in negative emotions but not for positive or neutral facial expressions. This may suggest that schizophrenia patients with positive symptoms suffer from some kind of interpersonal difficulties by which they tend to see others happy because of their own style of coping. Their style of functioning renders it possible for them to keep arousal-provoking perceptual cues from entering into subjective awareness. Brief visual stimuli enter into a cognitive storage system of large capacity but for a short duration (iconic image, Neisser, 1967). A schizophrenic's icons are intact but the integration of iconic storage into more complex cognitive operations may be deficient. However, many such interpretations, particularly with schizophrenia, are still speculative in nature. More studies, especially with meta-analysis of earlier findings and a comparison of studies that used differential deficit designs are required to permit definitive conclusions to be drawn. A critical review on facial expressions of emotions in schizophrenia is available (Mandal, Pandey et al., 1998).
Literature on the issue of handedness in schizophrenia has been full of contradictions in the sense that left bias, excess of dextrality, mixed handedness, and even no difference in handedness from controls have been reported. Studies which accounted for other forms of sidedness bias indicated confusion in lateral performance of earedness, eyedness, and footedness along with handedness in schizophrenia. Because pathological brain functioning is interpreted as the causative factor for both senistrality and dextrality in schizophrenia, it is possible that these patients initially show confusion about their lateral performances following a structural damage or a neurodevelopmental disorder. Later on, disturbances in lateral performances move towards an excess of sidedness bias as a result of socio-cultural pressure, chronicity of illness, sub-type character of the disorder, etc. In sum, out of inconsistent results what is apparent is that lateral performance is less overtly expressed in actual hand performance of patients with schizophrenia (Mandal & Singh, 1993), though right ear advantage and normal lateralization patterns emerge when acuteness subsides (Shukla et al., 1993).
On the neuropsychological (NPL) perspective (Mandal & Singh, 1993; Tiwari & Mandal, 1998), lateral transfer deficit was considered to be a trait marker in schizophrenia. Deficits in interhemispheric (bilateral) transfer in schizophrenia have been examined both with structural and functional measures. The former approaches involve rather a postmortem measurement of corpus callosum size, and the latter approaches include perceptual studies with visual split-field and auditory tichotic-listening technique and studies of ipsilateral/contralateral tendency differences in somatosensory-evoked responses (Biswas et al., 1996). Earlier studies, however, shed little light on whether such bilateral transfer deficit is differentially associated as a trait characteristic of schizophrenia, irrespective of the sub-types, or is contingent upon the stage of illness (acute vs remitted) (Shukla et al., 1993). Left hemisphere deficits in non-paranoids (n = 10) compared to paranoids was reported by Gupta (1993).
In a later study on mirror drawing tasks (Biswas et al., 1996), male patients with schizophrenia (n = 14; mean age 28.5 years; SD 6.1 years) were compared with their first-degree relatives (n = 14; mean age 29.6 years; SD 3.5 years) and normals (n = 14; mean age 22.5 years; SD 3.5 years), and it was found that deficit is an enduring functional loss in schizophrenia because, patients who have showed improvement over a six-week treatment period displayed no fluctuation in transfer tasks with clinical changes (state marker).
Pharmacotherapy is effective in treating acute symptoms but not in removing the residual cognitive and social deficits (Penn & Mueser, 1996). Psychoeducation and vocational rehabilitation approaches combined with maintenance pharmacotherapy have reduced (Rangaswami, 2000) the risk of relapse, improved social adjustment and QOL of patients. Sample size (n = 6) was too small and only six months of follow-up was reported. Long-term follow-up is warranted. However, this study highlights that for the patients with bio-psychosocial etiology, combined pharmacotherapy and psychosocial interventions increases the functional capacity to a great extent.
Cross-cultural and sub-cultural research to compare interrelationships among biological and environmental variables is needed. Such studies afford a large arena where both unique and familiar behaviour pathologies can be examined for the light they shed on etiology.
Disorders of Old Age
Chronologically gifted age (ageing) has become a global demographic revolution since the latter part of the 20th century, and in the new millennium one of our achievements is stretched life span. The concept of successful ageing has been currently a dynamic area of research interest in gerontology.
The world's elderly (over 60 years) population is rapidly rising and is expected to touch 14.55 per cent of the total population by 2025 and 20.69 per cent by 2050 (UN reports). The elderly growth rate is reportedly higher among developing countries, particularly in India and China (Ramamurti, 2002). India recorded an elderly population of 5.7 per cent of the total population in 1960, which rose to 6.5 per cent in 1980, and 7.3 per cent in 1990, and is expected to reach 12.6 per cent by 2020 (Chao & Chadha, 2002). India ranks fourth in the world in terms of the absolute size of elderly population (Sanyal, 2003a).
Scientific study of ageing in India started in late 1950s to 1960s. The Association of Gerontology (1979) and the Geriatric Society (1982) were established. The Department of Psychology, S. V. University, started a Centre for Research on Ageing (CRA) (1983 to 1984) and a P. G. Diploma in Gerontology (1993). This department was recognized by the UGC for the departmental special assistance programme (DSA) in Ageing and Lifespan Development (1990). The ICSSR Helpage (India) and the CRA are the documenting centres of research in ageing. The UGC, ICSSR, and ICMR, have made ageing a priority area for research. Academic journals, popular magazines, and critical reviews on ageing are available (Ramamurti & Jamuna, 1993a, 1993b, 1995, 1999). In 1999, the Government of India promulgated the National Policy for the Elderly and provided various occasions and subsidies for the senior citizens.
Ageing may broadly be categorized into: (i) primary ageing, (ii) secondary ageing, and (iii) tertiary ageing. Birren and Schroots (1996) further differentiated three aspects of ageing: (i) social, (ii) biological, and (iii) psychological.
Epidemiological studies have demonstrated depression (alienation, isolation, loneliness), hypochondriasis, and somatic problems as the most common complaints in this group though these are found to vary with basic personality factors and socio-cultural variables of being either at home or in the home for the aged. There are gender differences in case of a few symptoms; for example, more physical symptoms—approximately two times higher depression—are reported in females (Sinha, 2002), while more psychological symptoms are reported in males. The lack of adequate support systems including social, emotional and financial support has emerged as a very significant factor in this regard. Though no gender difference was observed for the ‘wish to be dead’, suicide plans and attempts were reported to be more common in males. Contrary to these, Quraishi and Arora (2000) in a study on 96 males and females (65 to 94 years) found that degree of depression, sex, and age are not related with suicidal tendencies. Similarly, Chao and Chadha (2002) reported that sex difference does not have much influence on loneliness and happiness. However, crying spells were reported more by female patients irrespective of culture they belong to. Cross-cultural differences are reported in overall symptom manifestations (Sinha, 2002). While in the West, a higher prevalence of MDP in the upper social classes was reported, in the study in India and its continent, higher prevalence of depression in middle-class socio-economic status was reported (Sinha, 2002).
An overall impression from the Indian literature on the relationship between SES and depression appears to be inconsistent. When compared with the Western literature, namely, those from Liverpool and Zaragoza, Sinha (2002) found significant qualitative differences in symptom profiles. The symptoms which ranked first in the Kathmandu sample, ranked last in the two Western subjects. Psychological symptoms were given more importance in identifying and reporting depression by older people of the two cities than the physiological/somatic complaints in contrast by the old age subjects of Kathmandu. The possible reasons for such significant differences in the psychological mindedness of the people of these two cultures have been detailed by Sinha (2002). However, symptoms which are influenced by cultural differences and are equally present in all cultures are—fatigue, loss of interest, energy, anhedonia, tension, and worries. Likewise, convergence in research reports was noted amidst all the divergences between Oriental and Occidental cultures, that is, irrespective of culture aged women report more emotional problems than old men and aged women are less satisfied with life compared to aged men (Nathawat & Rathore, 1996).
Report on health and morbidity in old age in India (Prakash, 1997, 1998b) showed that 5 per cent have difficulty in physical mobility; the chronically ill rise from 39 per cent in 60 to 64 to 95 per cent in people over 70 years; hospitalization rates ranges between 8 to 11 per cent, out of 40 per cent diagnosed as ill and only 10 per cent seek medical help (Dandekar, 1996), of which males avail greater medical facilities at public hospitals. Psychiatric morbidity in rural elderly Bengalis has been reported (Nandi et al., 1997). The latter requires replication in other sub-cultural communities in India.
Geographical variations and the rural-urban setting impose different intensities of impact upon the elderly. In most developing nations, the elderly face more severe consequences due to industrialization and modernization processes (Ramamurti, 1994, 2002) than the elderly in the developed nations. The urban male elderly living with spouses, and pensioners have better QOL than the female, widowed and elderly non-pensioners (Chao & Chadha, 2002). Women were found more disturbed regardless of age and the place they live (Prakash, 1996). The rural environment has been identified as a stressor (Eswaramoorthy & Chadha, 1997; Shirolkar & Prakash, 1996).
Social support, particularly family support, is a major source of life satisfaction in the Indian elderly (Nathawat & Rathore, 1996). Furthermore, very hardy old people reported more life satisfaction with more positive affect than the ones who were not as hardy. The institutionalized elderly (n = 100) (60 to 70 years) (Sanyal & Sinha, 2003) showed greater loneliness and poorer adjustments than those not institutionalized. This is because in the past extended families in our society could provide a sense of belonging (emotional and familial ties) to their aged members. Owing to industrialization, the traditional extended family system is breaking down rapidly and, as a consequence, the life and position of the aged in the present family system is becoming more precarious. Institutionalization generally comes about as a function of disabilities of the elderly and the insufficient social support available to maintain frail older persons in the community.
Though there is controversy with regard to locus of control (LOC) in the institutionalized elderly, there is agreement amongst researchers in India that in our socio-cultural context, the institutionalized aged despite living with others of their own age group in a residential setting do not experience the same level of kinship felt by the family-based aged (Kanwar & Chadha, 1998; Sanyal & Sinha, 2003). Similar was the view of Priya and Chadha (1998).
Prakash (1998a), in a large sample of 316 (aged over 60), found differences in functional competence, social support and well-being, where urban males appeared to be in a more advantageous position than women. Extensity of and satisfaction with the social support system varied depending upon the urban-rural milieu. While networks of both men and women in India are family-based, men have larger networks (Shankardass & Kumar, 1996; Prakash, 1998b). With the changing demographic scenario, more attention is focused on factors that add to the vulnerability of women as they age. These findings have serious implications in the future planning care and welfare of the elderly in our society particularly for women, since informal social supports are waning (Prakash, 1996).
Comparing ‘geropsychology’ in the East and the West, it has been found that several ‘modern’ developments and ‘changed’ cultures of the West have affected the process of ageing and made the life of the elderly more difficult to live (Ramamurti, 2002). Keeping in view the traditional Indian lifestyle and coping with ageing, some modifications necessary to keep pace with changing times and technology would appear to provide a better way of coping with the problems of old age (Channabasavanna, 2000). Thus, we can enjoy the ‘chronological gift’ (Ramamurti, 2002) without (Sanyal, 2003b) apprehensions. Ageing is not something that should cause one apprehension or shame. If successfully managed, care for the elderly is to enable them to enjoy ageing with a satisfied smile and its real sombrences. This calls for attitudinal change on the part of the younger sections of society which demands respect for, obedience to and care for its elders; this, of course, cannot start unless one shows respect, obedience and care for one's parents.
Substance Abuse Disorders
In the late 1990s, the total number of drug users was estimated to be 180 million (United Nations Drug Control Programme), equivalent to 3 per cent of global population or 4.2 per cent of population aged 15 and above (World Drug Report, 2000). Asia's heroin using population represents one-third of the global drug users (Pant & Bagrodia, 2003). The highest drug abuse is in India with mean estimates of around three million people—slightly more than the total estimate for Europe as a whole (World Drug Report, 2000). Of these three million drug abusers, 15,000 were reported to be women by Ministry of Social Justice and Empowerment (Pant & Bagrodia, 2003).
Of the 1.5 million brown sugar addicts in India 12 per cent are female (Pant & Bagrodia, 2003). The abuse of benzodiazepines and barbiturates is on the rise and dependence on prescription pills is not uncommon among women (Kapoor, 1992). Research on drug abuse/dependence in the Indian context points to a serious limitation when it comes to the issue of gender (Shankardass, 1997). Studies on such women subjects are inadequate and male experience has been presented as a general one. Pant and Bagrodia (2003) investigated 15 male and 15 female drug addicts from a residential rehabilitation programme in Delhi. Findings revealed that women differ from men with respect to the variety of drugs and mode of usage, reasons for initiation, motivation for seeking treatment as well as in their treatment history, in overall adjustment patterns to home, health, social, and emotional spheres of life. Female addicts were found to be more ‘retiring’ in social adjustment, and in emotionality they showed very unsatisfactory adjustment compared to men. Women addicts showed greater vulnerability to succumb to tensions, frustrations and emotional upsets. This difference might have been due to their fear of greater stigmatization than men addicts. This, perhaps, led the women addicts into revealing their emotions to others that in turn increased their feelings of depression, built up self-consciousness and worries. Furthermore, the culture of ‘drug dens’ where men addicts gather for consuming drugs, has not been open to Indian women addicts. This could be a reason for their greater feelings of social isolation. However, about 86.6 per cent of the females in this study were housewives and most of their husbands were also addicts hence, it is not known whether same results will be evidenced with regard to employed female addicts whose husbands are not addicts.
The malady of illicit drug use has spread to the student community of a developing country like India. From the socio-demographic point of view, drug addiction in India was found common amongst urban educated youth (Goldberg, 1995). Hostel environments as well as influence of the husband (79.9 per cent) and husband's friends (13.3 per cent) (Pant & Bagrodia, 2003) and the wife's personality (Kodandaram, 1996a, 1996b) are some of the important factors that initiate addiction.
The family members of alcoholics are characterized by moodiness, tension, unhappiness, and irritability. Communication problems and incongruent perceptions between spouses, low cohesion, low expressiveness and recreational orientation, incidents of family violence and increased psychological distress in children are evident.
Suman and Nagalakshmi (1996) in a study of 40 male alcoholics (mean age 39.4 years), found that the spouses would ideally like the alcoholics to be more assertive and competitive, more affiliative, warm and friendly. Alcoholics falling short of these expectations of their spouses results in family discord.
Family intervention (Kodandaram, 1999, 2000), in addition to pharmacological- and cognitive behavioural treatments can prevent addicts and their vulnerable children from developing psychopathology (Suman & Nagalakshmi, 1993, 1995, 1996). Family-based treatment can help addicts in asserting appropriately in interpersonal situations through understanding and implementing a balance of power.
Some of the researchers have forged progress in understanding the biochemical and pharmacological aspects of addiction but an understanding of psychological sub-strata (predominantly anchored to earlier psychoanalytic theorizing) remains embryonic. Frustration-aggression patterns do not reflect the choice of drug that leads to dependence (Gaekwad & Parimu, 1994). Whether specific personality traits, characteristic of addicts are indicative of a personality proneness to addiction is not known.
Chain smoking is a symptom of some inert psychopathology (Mitra & Mukhopadhyay, 2002). A carefree approach towards social expectations and avoidance of social conformity, coupled with anxiety of negative evaluation, are some of the highlights of the personality correlates of chain smokers. Whether personality characteristics have anything to do with the selection of type of the substance is not yet known. These can be verified by longitudinal type of studies, whereas most of the reported studies are cross-sectional in nature.
An important cognitive construct related to alcohol expectancies is drinking refusal self-efficacy. Expectations of self-efficacy determine, in actuality, whether coping behaviour will be initiated and how such efforts will be sustained in the face of obstacles and aversive experiences.
Western studies on relapse prevention in addicts pertaining to self-efficacy give a mixed picture and there is not much focus in Indian research on this area. To assess the role of self-efficacy of addicts in relapse prevention in the Indian scenario, Rejani and Kodandaram (2002) conducted a study at NIMHANS, Bangalore. In a drinking refusal self-efficacy questionnaire, early relapsers (n = 30) showed more social pressure compared to late relapsers (n = 30) in self-efficacy. These authors suggest the need for specific treatment strategies for early and late (30 to 50 years) relapsers with alcohol-dependent syndrome (ICD-10). Research on relapse prevention measures in addiction show more relapses in the initial period following the treatment but gradually decreases over time (Desai & Ray, 1989).
Social pressure may be direct (as when offered drinks/cigarettes) or indirect (i.e., when in a group where many others are drinking). Rejani and Kodandaram's (2002) study shows that the capacity to deal with social pressure is higher in the early relapse group. It may be that over-confidence in their ability to deal with social pressure contributes to the frequent relapses in the early relapsed group.
Previous studies have been mostly anecdotal and unsystematic therefore client matched and gender matched intervention strategies are needed. Also studies need to be made that whether personality characteristics of the addicts could be used as predictors for the selection of and mode of intake of, the agent. Beyond the institutional setting, greater teamwork and outreach intervention needed to initiate behavioural changes in addicts (Kamel et al., 1996) be implemented.
Organic Brain Dysfunctions
A multivariate approach has been employed to study organic brain disorders namely, brain damage and deterioration in cognitive functions. In severe forms of Parkinson's disease (PD), significantly higher problems in motors, cognitive, and psychological domains (e.g., depression) have been evident (Gupta, 2000; Gupta & Bhatia, 2000) than in the moderate form of PD.
Somatoperceptual impairment in focal brain damaged patients has been reported (Pandey et al., 2000); findings based on NPL tests have not been consistent.
Over the decades, there have been numerous studies applying NPL methods to examine the perception of facial emotions. These studies have generally adopted two approaches: in the first, tachistoscopic and prefield viewing paradigms have been employed with normal subjects, where visual-field advantages and hemisphere biases are examined. In the other approach, subjects with unilateral brain damage to either right or left cerebral hemisphere (i.e., the lesion method), have been examined to assess their level of performance on perceptual measures. Patients with focal brain damage, both right hemisphere damage (RHD) (n = 10; mean age 30.5 years; SD 10.1 years) and left hemisphere damage (LHD) (n = 10; mean age 28.0 years; SD 9.2 years), were compared with normal controls (n = 10; mean age 28.5 years; SD 5.8 years) on facial expression identification tasks (Mandal et al., 1996; Mandal, Asthana et al., 1998), where impairment in facial expression processing ability in RHD patients became clearly evident with such a visuo-spatial load of task structure. This is probably because the right hemisphere plays an important role in the initial stages of cognitive processing, particularly in face perception. Because both visuo-spatial and emotional processing functions are subserved by the right hemisphere, double dissociation may result in significant impairment (Mandal, Asthana et al., 1998) in the matching performance of RHD patients. Contrary to this, Mandal et al. (1996) observed that RHD patients (n = 11) may be better identified by the assessment of their correct responses to facial expression of emotion and LHD (n = 11) patients by their incorrect responses. Still later Mandal et al. (1999) found that RHD (n = 30) subjects were significantly less accurate in identifying facial emotion than LHD (n = 30) patients. In the emotional type, RHD were significantly less accurate for negative and withdrawal emotions than for positive and approach emotions. The size of the lesion was not significantly related with performance on the measure of emotional perceptual accuracy. On groups of focal-brain damaged patients, Pandey et al. (1999) found that tactual recognition of cognitive stimuli was slower in left-right hemispheric damaged patients. These findings require replication on larger numbers of subjects and several methodological caveats are to be borne in mind while comparing the estimates of disorders across studies.
On 250 adult subjects with mild (n = 100), moderate (n = 100), and severe (n = 50) head injuries using the PGI battery of brain dysfunction and dysfunction analysis questionnaire (Kak et al., 1995) it was found that some amount of dysfunction (IQ, memory, and other psychosocial functioning) continues to persist depending upon the severity of trauma. However, absence of pre-illness data and lack of adequate follow-up make findings inconsistent when studies are compared with each other. Masroorjahan et al. (2000) reported that out of the 120 epileptic patients, 35 per cent did not show any appreciable neuropsychological deficit. The mean age of the patients was 24.20, SD 8.12 years. Unlike previous studies where only a few specific functions were assessed, in this study assessments of both convergent and divergent functions were done.
The main deficits in epileptic patients were impairment in smooth coordinated movements, praxis, visuo-spatial abilities, acoustic analysis, use and appreciation of grammar, nominative speech, dynamic flexibility, and regulation of mental processes. Complex forms of arithmetical operations, memory with interference, and logical memories and abstract organization through verbal association were impaired. In a recent study (Dutta et al., 2001) on 27 neurological patients with specific brain lesions (22 to 27 years) it was found that immediate memory is subserved not by isolated areas of the brain but by widespread areas concerned by a network system. Disturbance in immediate memory may result from cortical pathology or from an interaction between cortical and sub-cortical pathology. Most studies on this issue have used a haptic method for perception and recognition of stimulus material. However, Pandey et al. (2000) opined that the dichhaptic method is more appropriate with control for hand performance in focal brain damaged patients. These authors conducted two studies—one in an experimental framework and another with clinical orientation to examine somatolateral asymmetry in the recognition of verbal (letter) and visuo-spatial (nonsense shapes) stimuli. For study 1, 30 neurologically intact normal males (n = 15, mean age 21.86 years, SD 1.35) and females (n = 15, mean age 23.06, SD 1.18 years) subjects were selected who were blindfolded during the experiment and were required to explore two stimuli dichhaptically. They were instructed to haptically identify the target stimulus in a set of test stimuli. Fewer trials were required to recognize nonsense shapes when they were presented to the left hand, whereas fewer trials were required for the letters when they were presented to the right hand. The performance of study 2, which was on brain-damaged patients, showed that performance of the hand ipsilateral to the damaged left hemisphere (LHD) was better for nonsense shapes than for letters, and performance of the hand ipsilateral in the damaged right hemisphere (RHD) was better for letters than for nonsense shapes. However, for study 2, only six patients with RHD (mean age 40.6 years) and six with LHD (mean age 46.4 years) and six non-neurological general medical patients (mean age 42.9 years) were examined thus it requires replication on a relatively greater number of patients. A detailed review of studies that examined the hemisphere focus of emotion processing on focal brain damaged patients is available (Mandal & Asthana, 1999).
Inconsistencies found in somatoperceptual studies may be resolved by incorporating findings with clinical populations which has hardly been done by Indian researchers. Paucity of clinical studies may be possibly because: (i) impairment in performance following brain damage does not necessarily indicate the function of that area in the intact brain (Sergent, 1988), and (ii) the dependent measure of performance in an experimental approach is not analogous to the dependent measures of impairment in a clinical approach (Mandal, Mohanty, et al., 1996). These methodological problems arise when findings from two different approaches are treated with a single analysis. For example, it is difficult to compare the findings obtained using the dichhaptic method with those obtained using the haptic method. The dichhaptic method is more appropriate with control for hand performance (Pandey et al., 2000) in focal brain damaged patients.
Researchers examined whether hemispheric superiority is determined more by stimulus type or content; no hemispheric effect was observed for stimulus content. Also, asymmetry in emotional face was rated by normal subjects in intensity of expression where the right side of the face was more expressive for more intense expressions of happiness and sadness (Mandal et al., 1995). Side-bias and vehicle accidents were also related (Mandal et al., 2001). Cultural-specificity was observed with respect to hemifacial asymmetry and valence of emotion expression (Mandal et al., 2001).
During recent years, considerable emphasis has been given to the study of psychosocial stress in the etiology of psychosomatic disorders. Excessive tension and worries are held responsible for many psychosomatic disorders like psychosomatic gastrointestinal, psychosomatic respiratory, psychosomatic skeletomuscular, psychosomatic endocrinological, psychosomatic sexual. Anxiety inhibits aggressive endeavour and also impairs problem-solving and coping abilities. Anger increases outward defensive aggression and inhibits alternative channelization of aggression (Sanyal et al., 2002). A close relationship between personality patterns and emotional discharge, coping styles, locus of control (LOC), and psychosomatic problems have been reported in men and women (Koradia, 2002) in different spheres of life, namely, occupation (Helode, 2002), and academic (Dharitri, 1996). Most commonly reported psychosomatic disorders in India are:
Somatoform Disorders (SFD)
SFD is of relatively recent interest in both theoretical and clinical research literatures. Occurrence of stressful life events (SLE) in the previous year is significantly higher in depressives and in anxious patients than in schizophrenia subjects and normals (Basu et al., 1999b). A weak relationship between SLEs and schizophrenia may represent the schizophrenic patients’ greater detachment from reality, and thus such relationships in schizophrenia should be viewed in a different manner than those for other psychiatric disorders. Due to prodormal phase, the registration and recall of events in patients with schizophrenia in a defined time period is influenced by diminishing OR and interest (Basu et al., 1999b) in the outer world. Even children facing problems with their family environment exhibit symptoms like headaches, vomiting, giddiness, abdominal pain. This has been detailed in the section devoted to childhood disorders.
Irritable Bowel Syndrome (IBS)
Since the recognition (Powell, 1818) of irritable bowel syndrome (IBS) as a functional gastrointestinal problem (Thompson et al., 1992) till 1978 observations have been descriptive and largely retrospective in nature. Some of the negative SLEs are for example, death of close relatives, separation, physical trauma, financial loss (Singh et al., 1991). In 30 patients with IBS, compared with 30 matched normals Arun, Kanwal, Vyas and Sushil (1993) have found that 190 per cent of the patients perceived three or more reported life events as compared to controls (43.3 per cent) as stressful. The most frequently reported life events were major purchases, construction of house, death of relatives, change/expansion of business, sexual problems, and family conflicts. However, scanning available literature gives an impression that life events do play a significant role in the onset and exacerbation of IBS (Pathak & Srivastava, 2002), though it has not been possible to identify a definite set of stressors as yet.
Pain Syndrome (PS)
In functional pain (‘Psychalgia’, Reber, 1985), higher levels of anxiety, depression, and suspicion are evident than in patients with organic pain (Bhaduri & Chattopadhyay, 1994; Chattopadhyay et al., 1990). Higher levels of somatopsychic anxiety, muscular tension, lower level of monotony avoidance and social desirability (Nathawat & Gupta, 2000), and even some psychotic-like aspects of personality components in patients with low back pain and headache have been reported. In this study, 90 subjects of both sexes (age 25 to 50 years) were divided into three groups, namely, patients with functional pain (FP), patients with organic pain (OP), and normal controls (NC). The FP group showed vague distress, panic attacks, and autonomic disturbances when compared with the OP group. The FP group was also found to be prone to worrying, cognitive social anxieties and preferred social aloofness. However, no significant differences were observed among the three groups in impulsiveness, guilt, and inhibition of aggression. Conversely, guilt and inhibition were found to be present in patients with FP in another study (Bhaduri & Chattopadhyay, 1994). The later study was on a small number of subjects (10 each in PF and OP groups), and thus generalization of its findings is not possible at this stage. Interestingly, in Chattopadhyay et al.'s previous study (1990), a group of patients with anxiety neurosis was compared with an FP group and the level of anxiety and neuroticism observed in the FP group was found exactly similar to those found in the patients with anxiety neurosis. Personality factors are found to be important in causing FP. Verma et al. (1986) found no association between pain and socio-demographic characteristics. Methodological differences may be responsible for such discrepancies in the findings.
Coronary Heart Diseases (CHD)
Industrialized societies have suffered a marked increase in CHD in the twentieth century. Hurry, worry, tension, irregular habits, promiscuity, etc., are some of the factors associated with CHD.
Numerous behavioural (indulgence of drink, drugs, smoking, sedentary life, dietary intake of cholesterol-rich and highly saturated fat/high calorie food, etc.), biological (hypertension, salt sensitive and overweight) and socio-cultural (highly competitive society, prestige, fights, social isolation, etc.) factors have dominant causal role in increasing CHD. Of the psychological factors, in addition to worries and tension, depression has been associated with an increased risk of myocardial infarction (MI) both at the pre- (Gupta et al., 2002) and post-MI phases (Bhattacharyya, 2001). Though Bhattacharyya (2001) makes mention about Type-A behaviour's contribution to CHD (n = 100, CHD patients in the age range of 35 to 55 years) where more rapid development of arteriosclerosis and with more frequent bursts of non-epinephrine secretion lead to MI, ischaemia and chest pain, the recent concept has been to consider good Type-A and bad Type-A. In fact, Bhattacharyya's (2001) results do indicate such a differentiation in the experience of stress where he reported that the patients who score higher on Type-A were found to be more competitive, hyperalert to the extent that they experience greater tension (causing distress) in comparison to low scorers (good Type-A) who accept the approach coping style as the form of logical analysis with positive appraisal and problem solving behaviour (Hardy Type-A) (not distress, but ‘U’ stress). CHD patients with internal LOC blame themselves for their disease (causing more depression) as opposed to those with external LOC. Currently, researchers have thrashed out most toxic factors in Type-A, such as antagonistic hostility and anger hostility. The weight of evidence suggests that antagonistic hostility is predictive of heart disease (Rai, 2000). This finding is important for intervention strategies of patients with CHD.
Social support research in CHD has given a mixed picture in the sense that lack of social support does not necessarily cause stress in every patient with CHD. Gupta et al. (2002) in a group of 81 male MI patients (45 to 60 years) found that social support measures in general are inversely related to stress, anxiety, and depression. However, the belonging component of social support significantly predicts stress while the self-esteem component of social support significantly predicts depression in patients. The combination of self-esteem, belonging, and appraisal components of social support is the best predictor of stress while the combination of appraisal and belonging components is the best predictor of anxiety in normals. The buffering role assumed to be played by social support in attenuating psychological stress, like anxiety and depression (Bhattacharyya, 2001), from the results of the latter study, appears to be limited. However, this study selected 59 volunteers as controls who were waiting to meet the patients admitted to the hospital with CHD which obviously is subject to criticisms because relatives of the patients with CHD waiting to meet the patients are not free from tension and worries; thus, they might not have been calm normals. Secondly, this study was cross-sectional in nature and thus the direction of causality is not implied from the findings obtained at this stage.
Peptic ulcer is a general term referring to an ulcer either in the stomach or duodenum. The most common form of peptic ulcer is duodenal ulcer. Studies in the USA and UK estimate the prevalence of duodenal ulcer between 6 per cent and 15 per cent with three-to-one male predominance (Grossman, 1981) whereas, in international comparison south India has higher incidence (Grossman, 1981).
Psychological factors that have been implicated in the occurrence of duodenal ulcer (DU) disease include personality variables, namely, high neuroticism, higher introversion, dependency, anxiety, low ego strength. Previous studies though have been consistent in designating one particular personality as ulcer-prone in general, however, ulcer patients have been found to show immaturity and impulsivity in their personality.
Type-A has not been disease-specific to CHD only. Higher scores on high drive and competitive components factors on the Jenkin's Activity Survey Form-C (Thankachan & Mishra, 1996b) were observed in patients with DU. This study was of 30 male cases (mean age 33.90, SD 8.87 years) and the group of patients was a mixture of married (n = 24) and unmarried (n = 6), employed (n = 25) and unemployed (n = 5), and also with (n = 3) and without (n = 27) family history. With regard to diet also 23 cases were non-vegetarians and rest were vegetarians. These results, however, cannot be generalized due to the absence of control group and non-availability of Indian percentile scores on the tools used.
Indian studies give an overall impression that current understanding about the relationship between Type-A behaviour and DU is limited. Not many studies reported showing a potential link between DU and Type-A behaviour, even though researchers expressed such possible links because hormonal levels (gastrin) that stimulate hydrochloride acid secretion correlated with personality factors such as striving for independence, achievement, etc.
In a study on endoscopically confirmed cases (n = 30) of peptic ulcer (PU) and normal controls, Kumar et al. (1996) found that distressful life events are three times more frequent in PU patients, and a majority of these stresses had occurred prior to the age of 30 years, the next period being 31 to 40 years. Three-fourths of the stressful events had occurred more than four years earlier (i.e., accumulation of effects), and severity of stressful events was significantly higher in the PU group compared to matched control group.
From our cultural point of view, what is important in this type of study is that social support during exposure to stressors plays the effective role of buffer and as such it should be given due weightage in the psychopathology of PU cases.
During recent years, one of the most striking findings in the field of immunology and neurosciences is that the cells of the immune system and of the nervous system are identical and can presumbly communicate directly with each other (Kumar et al., 1996). Psychoneuroimmunology has made a recent breakthrough that the relationship amongsts these three branches of science are interactive. However, in the present perspective, longitudinal studies with long-term follow-up could provide more reliable information.
Bronchial asthma (BA) is perhaps the second most important problem after pulmonary tuberculosis which is of concern to chest physicians in India (Jindal et al., 2000). It is a chronic respiratory problem characterized by recurrent attacks of airway obstruction. It causes anxiety and depression in patients and disrupts social interaction. Absenteeism from school and work due to this problem is not very uncommon. At the beginning of scientific medicine, an association between stress and asthma was reported, but a causal link between these two was established in the 1970s. Research in the 1980s and 1990s reported association between emotionality (excessive insecurity, anxiety, depression) and asthma (Chatterjee & Chattopadhyay, 2004). To gain a better understanding of the pathophysiology of asthma, one needs to be in touch with the advances made in the field of psychoimmunology in the past two decades or so—an issue that has been discussed earlier in this chapter.
Diabetes Mellitus (DM)
According to WHO, in India there are about 37 million of patients with DM, which is likely to rise to nearly 57.2 million by 2025. Psychological stress and DM have been associated in a study (n = 100) by Parveen and Singh (1994). These patients were compared with matched control (n = 100), and a non-psychosomatic group of patients (n = 100). It was found that on the SLE scale, total stress of the lifetime and event of the stress of previous one year have significant rols to play in DM.
In ego functions, DM patients scored poorly on drive control (DC), adaptive reaction (AR), and in stimulus barrier (SB) than the normals, but showed overlap with the depressives in some of the ego functions (n = 10 in each group; mean age 30 years) (Basu et al., 1998). DC refers to the ability to inhibit impulsive acting out. In DM patients, this control might be loosened due to constant distress. Low AR refers to lack of flexibility required for delving deep into fantasy activity and to bring about an adaptive configuration. Probably preoccupation with their health status in the DM causes rigidity which inhibits the free flow of the intrapsychic energy. Low SB indicates the constant stress and due to free-floating anxiety even negligible stimulus input is internally magnified to bring about an elaborate protective mechanism (Basu et al., 1998). Reaction to stress by patients with DM appears rational to society, but in dysthymia the reaction to stress tends to far exceed the normal limit. Thus, in depressives impairment is far more pervasive. However, generalization of these findings not possible till it is replicated on a large number of subjects. This study however, brings out how psychological predisposition influences the way patients with DM react to their disease, handle medicational requirements, and monitor their involvement in other activities; there is considerable psychomotor retardation in them due to depression. Thus, disease itself is a source of continuous stress to these patients and to their families. This implies the need for psychological intervention in such cases.
The exact causes of hypertension are unknown, although risk factors include family history of hypertension. Hypertensives show heightened reactivity to stressful events. Hostility and suppressed rage affect their ways of coping with stress. In a study on patients with idiopathic hypertension (n = 25), significantly higher levels of anxiety and depression compared to normals (n = 25) and normotensive hospitalized non-psychosomatic patients (n = 25) were evident (Chowdhury et al., 1994).
Hypertension is typically treated by diuretics or beta blockers that often have adverse side-effects. Cognitive behavioural treatments, including stress management, have been used to reduce dosages. Newer antidepressants combined with behaviour therapy and supportive psychotherapy (Chowdhury et al., 1994) may be best suited for this purpose. Relaxation has also been useful for such patients.
Heightened anxiety and depression like that of hypertensives are also equally present in patients with other psychosomatic disorders and with neuroses, the only difference being organ vulnerability, an issue which has not been focused in Indian research so far.
OTHER STRESS-RELATED DISORDERS
Post-Traumatic Stress Disorders (PTSD)
Persons suffering from PTSD have typically undergone a stressor of extreme magnitude. One of the reactions to this is stressful event is psychic numbing, such as reduced interest in one's daily life activities including constriction in emotions. Other symptoms include excessive vigilance, sleep disturbance, feelings of guilt, impaired memory, lack of concentration, and an exaggerated startled response to loud noises so much so that it may sometimes lead to psychological illness (American Psychiatric Association, 1994).
The impact of the Orissa supercyclone on survivors’ LOC, depression, and stress was assessed through interview, 3 months after the trauma. The affected people (n = 65) who were close to the epicentre of the supercyclone experienced more anxiety, depression, and stress; the magnitude of loss experienced by the survivors significantly increased external LOC than those unaffected (n = 65) (Suar et al., 2002).
PTSD has been tied to changes in immune measures, especially natural killer cell cytotoxicity, following a natural disaster (Ironson et al., 1997). Of late, research evidences suggest that survivors of PTSD may experience permanent changes in the brain involving the amygdala and the hypothalamo-pituitary-adrenal axis, though full understanding of the implications of such changes are unknown. PTSD sufferers show enhanced cortisol, norepinephrine, epinephrine, testosterone, and thyroxin functioning. Whether such hormone changes result from PTSD or represent a vulnerability to traumatic effects of stress is a question yet to be answered. However, a combination of pharmacological, psychological, and also psychosocial treatment into a multimodal intervention programme seems to be the best way to help such persons to alleviate their crises.
Women and Stress
The problems related to premenstrual tension (PMT), menstrual tension, and dysmenorrhoea have been extensively studied from both behavioural and clinical viewpoints, but little attention has been paid to ameliorate the physiological problems of normally menstruating women who do not report problems at a clinical level. Of course, our cultural/social stigma causes strong inhibitions in Indian women for medical consultation (Mukhopadhyay & Chattopadhyay, 2000; Koradia, 2002). Menstrual problems have been designated as ‘at risk time’ (Parvathi & Venkobarao, 1972) and menopause is often called ‘the change of life’—both have contributions to adjustment problems (Jamuna, 1987). Temperament of the person is important (Basu & Chattopadhyay, 1999) in symptom manifestations as well as in intervention outcomes (Mathur & Jani, 2002). Psychological characteristics, namely, anxiety, mood, etc. make some women susceptible to menstrual distress. Job anxiety does not contribute to menstrual distress, rather commitment to job helps women to perceive such distress to a lesser extent than those by unemployed women.
Sixty normally menstruating women (mean age 25.8, SD 3.96 years) were investigated (Mukhopadhyay & Chattopadhyay, 2000) in different phases of of a cycle, namely, menstruam (M), intermenstruam (IM) and premenstruam (PM), applying psychological (state-trait anxiety inventory, mood-rating scale, depression inventory), psychophysiological (GSR) and hormonal (prolactin, cortisol) measures, and it was found that on all the measures significantly greater menstrual distress was experienced by women on the M and PM phases compared to their IM phase. Higher consistency in the findings was also noted in psychophysiological and hormonal measures than those obtained in psychological measures. Inadequate level of attentiveness and vigilance observed in the M and PM phases clearly indicates relative impairment in the frontal lobe functions in these phases. Discontentment, depression, restlessness, and anxiety are also noted in the M and PM phases. Such changes in affective tone may be the adequate cause of inadequate frontal lobe functioning.
Contradictory findings noted in the previous literature in this regard, may be due to wide methodological variations in different studies, for example, unlike the study mentioned above, most of the studies have applied only subjective measures to assess distress, which obviously can cause confusion.
In ameliorating such problems, a clear understanding of the cognitive and affective changes that women experience over the phases is essential. Biofeedback (BFB) was found effective in self-regulating women's heightened level of distress.
Labour pain and delivery, in both normal and caesarean cases, cause severe stress in women (death anxiety in extreme cases) with higher magnitude in caesarean cases (Sinha & Nigam, 1993), particularly for those who develop a negative attitude towards delivery. Women suffering from depression due to labour pain, and chronic pelvic pain show differences in their personality characteristics compared to those suffering from menopausal syndrome (Dixit et al., 2001). Depression in infertility and menopause has shown a different trend in women suffering from some kind of delivery problem. In general, however, seriousness of depression in women increases when accompanied or followed by some kinds of physical ailments. This emphasizes the need for psychological intervention even while women undergo treatment for physical ailments. Unfortunately, recently available promising treatment procedures are not widely disseminated for their use in applied settings, for which matter physicians are to be aware of the importance of psychological intervention so that the patients with such problems can be put on a joint treatment approach.
Destitute women show overlapping with depressive patients on a number of personality aspects (Basu & Chakraborty, 1996), though the destitutes are reported to be more flexible and creative.
Sexual offences have received much attention as one of the fast growing crimes of violence against individuals, particularly women in India. During recent years among sexual offences, rape is considered to be the most serious offence. Rape is also a psychiatric problem in the sense that the symptom has an underlying psychopathological state; the victim is likely to suffer from PTSD. Agarwal et al. (1987) in a study on 30 rapists drawn from the Central Jail, Jaipur, found that rapists, like other criminals, are highly extroverted as well have higher scores on neuroticism and psychoticism. Dynamic factors reveal that rapists are extrapunitive, thus they direct their aggression outwardly by inflicting sexual offences on persons of the opposite sex, usually those who are younger in age. These findings require replication on larger samples and various personality factors need to be studied in greater detail.
Effects of multiple roles on women's health have been the concern of some Indian researchers (Waldron & Jacobs, 1989). This has been dealt with later in this chapter.
Pollution and Stress
In recent years, increasing attention has been paid to environmental neurotoxins that affect our mood and cognition. Gupta (1998) has given a detailed account of the various psychological techniques that have been employed to study the NPL deficits associated with chronic exposure to low levels of environmental pollutants, such as, organic involvement (manganese, lead) pesticides, metals, and other industrial chemicals. Higher levels of exposure to manganese, for example, lead to toxicity marked by profound disturbances of the CNS, ranging from bizarre psychological symptoms (anorexia, apathy, lathergy, depression, weakness, inability to concentrate, sleep disturbances, sexual disturbances, emotional instability like inappropriate laughter or weeping) to disabling neurological ones (such as, gait disturbances, clumsiness, dysarthria, and muscle cramps).
Likewise, the ability of lead to cross the placenta is well known. Infants poisoned by lead in the uterus have been reported to be less mature at birth and display a high frequency of neurological impairment/developmental delay, where their mental age is several months below their chronological age; they also show deficit in language development (Singh et al., 1978). IQ and behavioural differences between lead-exposed and control children are typically regarded as ‘end-points’ rather than ‘snapshot’ (Gupta, 1998) measurements of dynamic process.
Besides metals, insecticides in common use also entail some neurotoxicity, particularly some of the organophosphate compounds, that can cause adverse affects like, hallucinations, ataxia, memory difficulties, drowsiness, and anxiety so gradually that workers in industries may not be able to detect it immediately. It requires awareness of occupational health hazards. In the Bhopal tragedy in India (December, 1984), widespread multi-organ involvement in those exposed to pollution was observed (ICMR, 1986). The substance leaked was methylisocyanate (MIC) and nearly 100,000 residents were the victims with complaints like respiratory distress, eye irritation. Also, India's climate conditions, namely, humidity and other factors such as, malnutrition, protein deficiency, enhance the toxic effect of various substances (Gupta, 1998). Early detection of such adverse effects through NPL tests is essential for successful prevention.
Interdisciplinary research shows that ambient concentration of air pollution causes disturbances in the physiological (ANS functions), biochemical (lead concentration, carboxyhaemoglobin (CoHB), and sulphanoglobin (SHL) in the blood and psychological (irritability, aggression, suspicousness) functions, more in the people in industrial areas than those of inhabitants of residential areas, whereas people of commercial areas fall in between in all the variables (Chattopadhyay et al., 1993; Chattopadhyay et al., 1995). Twenty male subjects (mean age 36; SD 1.5 years) in each of the three areas of Kolkata metropolis were investigated. Owing to the small number of subjects, the findings were not conclusive at that stage but findings do reveal that air pollution has deleterious effects on physical and mental health of individuals.
To study the effects of subtle neurotoxicity, various NPL tests, for example, WAIS, WISC, Wechsler Memory Scale, Benton Visual Recognition Test, profile of mood tests, Wisconsin Card Sorting Test (WCST), Minnesota Multiphasic Personality Inventory (MMPI), reading comprehension test, have been used (Gupta, 1998). A profile of one's abilities and liabilities can be drawn using these NPL tests. Some methodological issues are important in this type of research. For example, many factors influence the course of child development, and some of them may be correlated with lead exposure; if they are overlooked, they will lead to Type 1 and Type 2 errors.
It is evident that toxic chemical etiologies are not to be ignored by psychiatrists and clinical psychologists. Even vague, subjective complaints require proper attention to save future severe damage to such exposed persons. Clinical professionals should keep in mind that early effects are usually vague, unspecific, and difficult to discriminate from normal conditions, and also that awareness of changes of one's own behaviour patterns, well-being, and willingness to speak about them varies across individuals and across situations.
Stress in Terminal Diseases (TDs)
Research in oncology shows a relationship between psychosocial factors and cancer (CA) in terms of initiation (behavioural factors, namely, consumption of tobacco, fatty diets, exposure to stress) and progression (behavioural factors, namely, non-adherence to risk for treatment, failure to use screening for early detection etc.) of the diseases (Sinha & Nigam, 1993; Urs et al., 1997).
The CA-prone personality (Type-C) has been described as inhibited, conforming, compulsive, depressive with the potential of learned helplessness (muting of negative emotions), though contradictory findings are also available to the extent that some studies have failed to identify any psychological predictors of CA. This is because the studies on CA-prone personality traits have suffered from methodological problems that make it impossible to determine whether such personality traits lead to development of CA, or those personality factors develop as a consequence of CA.
There has been a great deal of speculation about the possible role of personality and stress as risk factors in TDs. Though patients with cancer (CA) and those with CHD perceived their parents as rejecting, CA patients showed proneness to regression, and CHD to sensitization; CA patients were more emotional, submissive, timid, and placid than CHD (Nair & Mandal, 1996) patients.
CA patients use denial and repression as defences, and major SLE and lack or loss of social support has been associated with onset of CA, though other studies have found no such relationship between life events and onset of CA. On the whole, evidence relating psychosocial factors to the progress of CA is somewhat more convincing than that attempting to tie/psychosocial factors to its onset. In both cases however, additional research is needed on patients of different age and sex, and particularly in context to our culture (Kholi & Dalal, 1998).
In a series of studies in interdisciplinary framework, higher than normal neuroticism, ANS arousal, and levels of blood cortisol and prolactin (which were almost similar to those of the patients with clinical anxiety), were found in different categories of CA patients, namely, esophaegal, laryngeal, cervical, lung, and oral (Chattopadhyay et al., 1989). Psychogenic disturbances in patients with different categories of CA have been updated (Chattopadhyay & Bandyopadhyay, 1996) and importance of psychosocial intervention for CA patients has been emphasized (Urs et al., 2002).
In personality disposition, CA patients were reported to show a greater recurrence of loss of love objects, unstable, disurgent in communication, tense and their scores for Factor ‘C’ on the 16 PF tests were found to have a high positive correlation with those on the depressive-sensitization scale (Nair et al., 1993), but anxiety and depression were found to decline substantially within a week, especially when active treatment had been initiated quickly (Mehrotra & Mrinal, 1996).
A broad array of psychological interventions have been undertaken with CA patients to enhance the QOL, such as informational-, educational interventions, counselling and therapy, cognitive-behavioural interventions to manage the side-effects of chemotherapy. Intervention will be discussed later in this chapter.
Psychosocial interventions can be a very useful adjuvant treatment for CA patients, together with other interventions, such as pharmacotherapy, stress reduction, and social support groups. This helps improving perceived social support of CA patients.
However, application of psychosocial therapy is underutilized and is inadequately documented in psychiatric literature so far in our country. Thus, there appears to be serious gaps in our understanding regarding applications of such intervention strategy in our treatment of patients with CA.
Special Category Disorders
When infertility cannot be explained by usual diagnostic procedures and patients become refractory to routine medical treatment, such a condition has been designated as psychogenic/functional/idiopathic/normal/unexplained infertility. Around 11.5 per cent of the patients attending OPDs of infertility, turn out to be idiopathic (Mukhopadhyay, 1992; Mukhopadhyay & Chattopadhyay, 1997). Their formal medical treatment outcome (not referred for psychological intervention) was unsatisfactory and as a consequence many couples opted for legal separation. Research reports, particularly from the psychological perspective, are very scarce in India.
Interdisciplinary research employing psychological, psychophysiological, and endocrinological measures, revealed higher ANS (GSR) arousal in individuals (25 to 29 years) with idiopathic infertility (n = 20) than those with organic infertility (n = 20) (Mukhopadhyay & Chattopadhyay, 1994, 1997) and fertile women (n = 20). On laboratory examination, their husbands were also found free from any organic pathology. Clinical and pathological investigations of these women showed that their cycle was ovulatory and free from any aberration. The hormone profile of idiopathic infertile (II) group did not show any difference with the fertile group. The organically infertile (OI) group, however, showed estrogen overactivity throughout. Higher-than-normal anxiety, neuroticism, introversion, and psychoticism, were the personality predispositions of the II group. Psychotherapeutic intervention did help the II group not only to conceive quickly within a few months’ sessions but also helped them to have a second baby (wanted) within the next two years.
Sexual Dysfunctions and Deviance
Considerable interest has been recently shown in the understanding of sexual problems. Since the pioneering work of Masters and Johnson, the treatments of sexual inadequacy came into limelight. Socio-cultural and religious factors have significant impact on such problems.
From the psychological point of view, parental upbringing, which does not allow the child to develop an adequate self-image, adequate self-confidence, causes sex conflicts and sex guilts, and feelings full of inadequacy in role-playing. These are some of the important matters that need the attention of professionals and would help reduce such undesirable behaviour and feelings. Inhibition, misconceptions, and poor knowledge about sex cause numerous problems in our adolescents and youths.
Types of Sexual Dysfunctions
The commonly reported dysfunctions in men are premature ejaculation, erectile dysfunction (impotence), retarded ejaculation, and male dyspareunia. Likewise, female dyspareunia, orgastic dysfunction (anorgasmia), vaginismus, and frigidity have been reported.
In therapy, there is a shift from traditional re-educative psychotherapy to behaviour therapy, in general, mostly following the techniques given by Masters and Johnson. The results of brief sex therapy are encouraging.
Unwed motherhood, as a problem, is on the increase in India. In a study of 56 unwed mothers (Singh & Singh, 1981) broken from (42.85 per cent), forced sex/rape (14.28 per cent), promise of marriage (32.15 per cent), sex curiosity (21.43 per cent), sexual pleasure (16.08 per cent), economic gain (14.28 per cent), and lack of knowledge were found to be the causative factors. Persons reported to be responsible for pregnancy were found to be fiancés (25 per cent), friends (16.08 per cent), employers (8.92 per cent), neighbours (8.92 per cent) and relatives (5.36 per cent). Agarwal et al. (1987), in a study of 30 patients in the Central Jail, Jaipur, found that they showed high scores on psychoticism, neuroticism, extraversion, and extrapunitiveness like those reported by Singh and Singh (1981) in the case of unwed mothers. Such similarities, in personality characteristics between the rapist and his victims, are very interesting. Most of the rapists (70 per cent) in the study were in the young age group (15 to 24 years). This finding is very close to those of Western studies. But contradiction is noted with regard to marital status of the rapists where, unlike in Western studies, this research found that majority of the rapists (75 per cent) were married. This particular finding highlights the importance of dynamic factors, namely acting-out hostility, delusional hostility, delusional guilt, and self-criticism. However, due to paucity of studies on defensive factors of guilt and hostility, comparative data is not in hand at present. It is difficult to generalize the significance of sociodemographic variables in rapists based on such a small sample. The confirmation of these findings on larger populations would be helpful for further probing into the matter.
Impulse Control Disorder (ICD)
ICD of the obsessive compulsive disorder (OCD) spectrum covered trichotillomania, pathological gambling, self-injurious behaviour, kleptomania, compulsive lying, and sexual compulsion. Moral implications, particularly in Indian culture, cause severe depression and anxiety as combined features. Compulsive masturbation (causing guilt in adolescents) and repetitive promiscuous sexual behaviour are addictive in nature. In a 22-year-old unmarried female graduate, with the complaints of compulsive public masturbation, Rangaswami and Kaliappan (1995) managed with pharmacotherapy jointly with multimodal behaviour therapy. Follow-up for six months showed the maintenance of the treatment gain with no complaint of relapse. Relapse has been reported in some Western studies, but that could be due to differences in the therapeutic strategy employed. The present strategy of behaviour therapy, with the combination of pharmacotherapy, probably explains this aspect better.
Sexual Orientation Problem
HIV was first recognized in 1983 in the Pasteur Institute of Paris, and thereafter in 1985 in the National Cancer Institute in Bethesda, USA. HIV is believed to cause the dreadful disease AIDS (Mani, 2002). Kowlas (2001) has recently developed a database on HIV/AIDS in the sub-Saharan African Region.
The initial AIDS cases reported in India were from the sexual partners in Chennai (1986) and Mumbai. In the past two decades or so, HIV infection has rapidly spread all over the country. In March 1998, the National AIDS Control Organization had reported, based on a survey, that 1,400 were having HIV infection as was evident from among 3.2 million people who were examined. The 1999 Health Update (cited by Mani, 2002) reported that a total of 5,145 cases have been reported to have developed AIDS (80 per cent males). Almost 89 per cent of these victims were in the age group of 15 to 24 years. Maharashtra has reported the maximum number of HIV infections, followed by Tamil Nadu and Manipur (Health Update, 1999, cited by Mani, 2002).
Primary involvement of CNS in HIV brings two types of neuropsychiatric sequelae: AIDS dementia complex and mild neurocognitive disorders. Of the plethora of cognitive disturbances noted in seropositive patients (Gupta, 1999), through neuropsychological testing, mental slowing occurs very early which can be used as a potential diagnostic marker (Sabhesan & Nammalvar, 2000). Along with the neuropathological changes and cognitive decline, there are increased psychosocial disturbances (Gupta, 1999). Early defects are frequently accompanied by behavioural changes and adjustment problems. Attentional deficits being early indicators of cognitive decline should be taken as markers for neuropathology, and also as predictors of behavioural sequelae, therefore, attentional deficit is the central point to neuropsychological and psychosocial rehabilitation.
In India, the national AIDS campaign has provided condoms to sexual partners for protection against AIDS (Mani, 2002). There is a need for awareness programmes and AIDS prevention measures (Mani, 2002), and to overcome resistance to psychotherapy arising from cultural biases (Gupta, 1999).
This can be due to fear or avoidance of heterosexuality. Anticipatory avoidance technique was quite helpful to treat a married homosexual of 36 years (Rangaswami, 1982). Replication is necessary for generalization.
Another important issue that requires mention here is the treatment possibilities of gender dysphoria. Most of the reported studies on the hijra community are sociological in nature. In 1970, the Tata Institute of Social Sciences (Mumbai) conducted a survey, and thereafter some sporadic articles of scientific and semiscientific nature have been published (Mondal, 1989; Mukherjee & Chatterjee, 1995). In a study on three categories of eunuchs, namely, castrated (n = 34), transvestite (n = 10), and zenana (n = 13) in Kolkata. Sanyal et al. (1997) reported that the former two groups openly manifested feminine urge to enjoy female sexual identity/role, whereas zenanas with true masculine identity showed a complete lack of such urge. Basu (1996, 2000, 2001) has depicted well the dilemmas that mental health professionals encounter in working with such persons. Basu and De (1997) presented a succinct review of the diagnostic and therapeutic status of transsexuals in India. Cases of transsexualism, secondary to schizophrenia, have been reported where transsexualism developed after an acute psychotic episode (Banerjee et al., 1997). Also in another case, the delusion of ‘sex change’ was found to be the major symptom (Jiloha et al., 1998). In none of the cases, successful reversal of sex role has been reported (Nihalani et al., 1998). The latter authors also reported a case of an (over 35 years) eunuch with positive HIV. Unconscious guilt present in them (Basu & De, 1997; Sahay & Srivastava, 1994) may be ameliorated through psychotherapy, but their unwillingness to continue the treatment causes hindrance to progress (Nihalani et al., 1998). Lately, psychological management of sexual dysfunction, in general, has been detailed by Kumar (2003).
Recently, in connection with the AIDS disaster throughout the world, interest in haemophiliacs has been renewed, though the psychological characteristics of haemophiliacs were pointed out as early as in 1949.
Haemophilia is a congenital blood coagulation disorder, specifically in males, resulting from the genetic deficiencies of specific plasma factor within. Eighteen patients (20 to 38 years), residing in the Kolkata metropolis, were identified with the help of the International Hemophilia Society, Kolkata chapter. They were suffering from Type A haemophilia (Factor VIII deficiency). Though they were diagnosed before the age of two years, none of them was permanently crippled (Bhattacharyya et al., 1995). They were compared with 18 matched normal controls. Though personality questionnaires did not reveal any difference between the two groups, Rorschach profile tests indicated neurotic constriction and emotional difficulty in the patients. This shows that they consciously do not feel they are psychologically sick, though psychologically they are half-way between health and sickness.
The patients’ group in the study was divergent in terms of severity (four: severe; seven: moderate; and eight: mild) and in terms of a number of demographic variables. However, findings reveal that such a mental state has significant therapeutic and social implications.
While India is undergoing a major change in socio-economic development, overpopulation is one of the main barriers of overall development of the country.
Being the second-largest populated country in the world—India reached the one billion mark on 11 May 2000 (Deb, 2003))—the Government of India has taken various measures, but by and large such measures are found to be less effective, perhaps because of illiteracy coupled with deep-rooted prevailing cultural beliefs and practices (Deb, 2003; Karra et al., 1997; Kartikeyan & Chaturvedi, 1995).
Research reports are not many that can document the knowledge, attitudes, and behaviour of cross-sections of people of India about the adoption of different family planning methods. A study spanning five generations of a south Indian family (Karra et al., 1997) reported that male involvement in family planning and use of male methods are associated with fertility decline, and resulted in long-term benefits for women. Another study on rural women revealed that (Kartikeyan & Chaturvedi, 1995) many women were concerned about child survival and viewed children as a source of support in old age. In Bhubaneswar and Balasore, in a recent study of 341 male workers from industry, it was found that (Deb, 2003), despite industrial workers’ knowledge about family planning methods, the use of condom was low (31.5 per cent). About 9 per cent reported their inability to afford it since it is expensive. Misconceptions, like the use of condoms diminishes sexual pleasure (74 per cent), it is harmful (10.4 per cent) for health, causes irritation of the genitalia (9.3 per cent), still prevail. It was also found that majority of the workers (69.6 per cent) were not in favour of vasectomy because they believe, it makes people weak and fatigued (5.6 per cent), diminishes sexual vigour (19 per cent), makes people impotent (18.3 per cent) and may cause health problems (6 per cent), namely, poor eyesight, infections, abdominal pain, etc.
Intervention programmes need to be taken up urgently with the help of mental health professionals and NGOs to disseminate correct and complete information; to remove misconceptions regarding sex, contraceptives, vasectomy/hysterectomy etc.; and to stabilize the country's population in order to enhance the overall socio-economic development of the country.
The Government of India has set up a committee to review the population control policy. Indian research reports reveal (Deb, 2003) that, in general, knowledge of rural people regarding family planning methods, for example, medical termination of pregnancy (MTP), safe period (natural method), abstinence, and coitus interruptus, is very poor. This could be the starting point for intervention. By providing adequate information on these methods, maternal deaths during pregnancy, and unwanted pregnancies could be avoided.
Psychosocial Correlates of Psychological Disorders with Special Reference to Family Assets and Liabilities
The model of stress and coping emphasizes the active role that parents play in dealing with the stressors associated with caring for their child (Nandawana & Ranga, 2002; Vidya & Tripathi, 1998). Family pathology and childrens’ behavioural problems (Tripathi et al., 2002), namely, aggression (Vidya & Tripathi, 2001), delinquency (Maniyar, 2002) have been associated.
Previous studies on relationship between family constellations and personality have focused mainly on birth order and certain other variables, like creativity and narcissism. The findings have not been consistent, probably because most studies have been piecemeal and largely ignore the multidimensionality of the phenomena involved.
In a sample of 694 (one to eight months of age) infants from six states (Karnataka, Andhra Pradesh, Himachal Pradesh, Uttar Pradesh, Maharashtra and Punjab), it was found that infants from poor home environments were significantly lower in psycho-motor and mental development than infants from congenial home environments. Intervention in the form of educating mothers had a significant impact on enhancing the home environment and the developmental outcomes of the infants (Verma et al., 2002).
The importance of mental health education has been stressed in Indian research for family members of mentally sick persons, to help them in understanding the problems of psychiatric patients and their involvement in their comprehensive care. The utility of the psychiatric nurse in educating the families of such patients has also been advocated (Prema & Kodandaram, 1998). An experimental sample consisted of 30 chronic schizophrenic patients and 30 key relatives of these patients who were given psychoeducation. An equal number of cases were taken as control group who were devoid of such intervention. Results showed that the experimental group benefited from mental health education. Similar were the findings in a later study on 60 chronic schizophrenics’ family members (Prema & Kodandaram, 2001). These studies go to show that systematic and planned mental health education for the families of mentally ill patients is required.
Gender discrimination and related behavioural expectations take place at a very early age in Indian society (Tripathi et al., 2001), which has a negative impact on adequate development of personality later in life.
Family Factors and Scholastic Backwardness
Academic achievement has become the sole yardstick of self-worth and success. Students are made to feel unworthy and guilty for performing poorly at school. Academic under-achievement, dropouts from school and failures at various levels of education are some of the major problems of the present system of education. Low achievement may cause deterioration in personality, instil negative self-concept, and inhibit social adjustment. Many a time such self-concept causes the development of physical symptoms like asthma, headache, etc. In severe cases depression and even suicide have been reported.
Cut-throat competition, mostly injected by parents into their children, compels every child to grapple with the need to achieve more to be successful (according to the criterion imposed by the parents/society) in life. The net results of such unhealthy, damaging competition are: severe aggression and frustration in our children/students (Sanyal et al., 2002). This study was of 300 college students (150 male) in the age range of 14 to 21 years, they were administered questionnaires to assess their emotionality. It was found that male students were more aggressive, ego defensive than female students. While male students expressed aggression outwardly, female students, on the other hand, were prone to suppress, that could cause several physical and psychological problems for them. This has been dealt with in detail earlier in this chapter while depicting roles and functions of clinical psychologists, particularly in school/academic settings, and how these professionals can help students find predictors of aggression and efficient control.
Research on families shows that the family is of paramount importance to the child and his achievement. In a study in Hyderabad city, 100 low-achieving students (50 per cent boys) of classes IX and X from 10 private English-medium schools were selected and the interviews scheduled were used to elicit family factors related to scholastic backwardness (Saradadevi & Kiran, 2002). Large family size, low educational status of parents, low parental involvement and encouragement were found to be the major family factors associated with scholastic backwardness. To improve the quality of achievement, parent–child relationships need to be strengthened, and children motivated and encouraged to perform better in school, instead of discouraging them.
Family Attitudes and Disabilities
Mental Retardation (MR): A recent meta-analysis shows that the prevalence of MR in India is about 5.57/1,000 (Reddy & Chandrasekhar, 1998). In a community study in Ranchi District (Singh et al., 2002), MR was found more in males (below 10 years) with the first born and those belonging to larger and lower SES families. This study was on purposive sampling, and diagnosis was wholly based on clinical grounds only, thus, it may not be free from recollection bias. Both negative (Ramgopal & Rao, 1994) and favourable (Singh et al., 2002) attitudes, towards MR subjects and resistance to receive medical advice (Chaturvedi & Malhotra, 1982) are reported but differences in the anxiety of the parents of autistic children and those of Down's syndrome children were not apparent (Kunder & Julius, 1996). Psychoeducation (Prema & Kodandaram, 1998, 2001) of parents (Rangaswami, 1995; Singh et al., 2002), particularly of mothers (Nandawana & Ranga, 2002; Verma et al., 2002) and need for inter-disciplinary research (Maniyar, 2002; Nagamani et al., 2003) have been suggested.
Epileptic Children: A considerable number of young epileptic children manifest behavioural problems such as violent/disruptive behaviour, temper tantrums, etc., due to parental overprotective attitudes (Sinha et al., 2000).
Physically Challenged and Emotionally Deprived Groups: Emotionally deprived children, for example, orphans, those auditorily challenged and subjects with speech problems, showed higher-than-normal physiological arousal and more self-conflicts, higher apprehension level, poor societal, emotional, family, and sex role adjustments (Chattopadhyay et al., 1993; De et al., 1993; Mukhopadhyay et al., 1996).
Compared to normative families, families of youth having substance abusers tend to be lower on cohesion and expressiveness, and higher on conflict and control (Bhatia, 1998), a finding which corroborates Western research reports (Andrews & Duncan, 1997).
Autistic Children: Parents of such children usually blame each other for giving birth to such a child, which makes their life interaction highly unsatisfactory. Such an unhealthy home atmosphere in turn, causes mental pressure on the child. Parents sometimes suffer from severe guilt and frustration. Sometimes parents fail to prepare themselves to accept such disability in their child, and as such take long time to go for scientific consultation and adopt a scientific procedure to impart training to such children. Parental education and counselling are highly essential in this regard. The definition and characteristics of autism and its causes, and the training procedures to be imparted, have been given by Bandyopadhyay (2000).
This book provides some information on the necessity for early detection, and the signs and symptoms that could help parents detect such disability in their children. Some information is also available on remedial measures that could be applied through the parents themselves. Of course, parental education and training are necessary in this regard, an issue on which the author has also focused. But the book does not provide any experimental/clinical research data-based information that could be of practical value in the management of such cases. Future research in experimental framework is necessary to formulate detection and management programmes for such cases.
Family Constellation as Personality Predictors
The neo-Freudian personality theories are mainly characterized by social factors, as opposed to the Freudian emphasis on biological factors. Family constellation refers to the operative forces in the family structure and its dynamics. Previous studies mainly focused on birth order and certain other variables, the approach was mostly piecemeal and ignored the multidimensionality of the phenomena involved. In a recent multivariate framework study on 258 (205 males) middle-level managers in the age range of 24 to 59 (mean age 37.37 years) drawn from industrial sites in Madhya Pradesh, it was found that (Srivastava & Singh, 2002) family dynamics/constellation may be used as a predictor of personality and adjustment of the managers. Perceived warmth and affection, perceived aggression and hostility, perceived neglect and indifference, perceived rejection along with the family constellation variables, such as, average birth space adopted by the parents, and birth order are important predictors of personality.
Characteristics of the family can affect how adults react to their work and career. More job satisfaction, less job-related frustration and tension (Paruthi & Bhardwaj, 1985) and more stress tolerance (Helode, 2002) were found in employees in an Indian engineering factory, who came from supportive, independent and well-organized families (Khan & Mishra, 2002). Job satisfaction and job adjustment in schoolteachers (Bharathi et al., 2002; Chattopadhyay & Bhattacharyya, 2003) have been studied. For interventions in job stress, the importance of the personality of the employees has largely been focused on. In a sample of 258 managers (205 males), drawn from industrial sites of central Madhya Pradesh, it was found that family constellation factors were meaningful predictors of personality and adjustment of the managers (Singh et al., 1999; Srivastava & Singh, 2002). Chandriah et al. (1996) investigating 255 managers (132 junior and 123 senior) from upper and middle management, in different industries around Kolkata city, found that junior managers who came from tension prevailing home atmosphere, expressed higher job-related tension. Need for psychological interventions to uphold organizational commitment of Indian Railway drivers in particular (n = 150, 26–35 years) (Khan & Mishra, 2002), and industrial employees in general (Sanyal & Basu, 1994), has been emphasized, as this has not yet received adequate attention in different parts of India and her continent (Kausar & Farooq, 2001). Psychological stress and health, particularly with HRD in the Indian perspective have been delineated (Mathur, 2001).
The transition from the joint to the nuclear family system is again causing confusion in our youth; individuals coming from joint families show higher anger control than those coming from nuclear families (Sreelekha Saha et al., 1998). Males of nuclear families display greater anger than females of the same family size (Iqbal et al., 1993). To resolve such confusion and its related symptoms, psychotherapy/counselling of both the individual as well as the family is necessary.
Home Role Attitude and Employment Role Attitude in Women: A Conflict
Recent shifts in family patterns may be changing the ways in which women and men are defining marital and parental roles. In the wake of the women's movement, wives’ expectations for sharing and cooperation from their husbands are also changing, especially among employed women. This does cause work-family conflicts in women. The attitude of Indian society towards women engaged in outdoor works is dualistic and influenced by social class and the caste system.
Married (n = 150) and unmarried (n = 100) working women were found to differ in occupational adjustment-related personality factors (Mallik, 1999). Placid and confident married working women are better adjusted in work situations. Emotionally mature unmarried working women also have satisfactory occupational adjustment. Mallik, in another study (1996) on 100 Bengali unmarried graduate working women (mean age 25.50 years), found low scores in occupational and high scores on home role adjustment. The author interpreted that unmarried working women with favourable attitudes, towards both home and employment, have good adjustment in their work situation, a finding which corroborates a previous research (Mallik, 1994). This shows that adjustment is highly influenced by attitude. Further study is required on personality vis-à-vis the attitude of women in home role adjustment with women of different age, education, and academic backgrounds. Sanyal and Bandyopadhyay (1996) observed that though high state-trait anxiety is a common personality characteristic of both older (55 to 60 years) and younger (30 to 35 years) groups of working mothers, younger mothers showed higher rate of boredom and proneness to loneliness. The study was of 33 upper and 37 lower age groups of subjects of nuclear families and they were all schoolteachers. Generalization of the findings may not be possible. However, younger mothers, may be owing to the materialistic demands of life, become the victims of greater loneliness. Working women and their application of defence show that (Sanyal et al., 2003) projection as a defence is significantly used more by non-working mothers in their actual life situations. This study was of 100 working mothers and 100 non-working mothers (34 to 35 years) with one or two children married for 5 to 10 years and clerical post holders in different government and non-government organizations. Working groups hold themselves responsible to overcome anxiety, and may be remaining outside home creates guilt in them. Regarding the dynamics of role conflict among Indian women (Misra, 1998), spouse support, age, duration of marriage, the number of children are significant, but not the types of occupation. These findings are important in programming marital counselling sessions (Mallick, 1998).
In recent years, there is dramatic increase in the divorce rate in India. Not many studies depicting relationships between divorce rate and psychopathology are available in our cultural context. Nathawat and Botre (1998) in a study of 60 divorced couples (30 men) at the matrimonial court, Mumbai, found that pathological personality disorders and transient clinical syndromes were more prominent in divorced couples than in happily married couples. Narcissistic, anti-social, drug dependent, delusional disorders were mostly present in divorced couples.
Research findings on gender differences in marital happiness have been inconsistent across cultures. While in American and Canadian subjects, marital adjustment in men is greater than in women (Bernard, 1972; Rhyne, 1981), Indian samples have failed to confirm these findings (Kumar & Trivedi, 1990). This shows that gender differences and marital happiness are culture-specific. A number of studies have identified factors contributing success/failure of marriage in contemporary society, for example, feelings of loneliness and insecurity (Goyal, 1997), influence of pathological personality (Nathawat & Botre, 1998), non-cooperation by in-laws (Mallick, 1998), satisfactory communication between partners (Dutta & Mukherjee, 1999), duration of marriage (Pramod Kumar, 1994), and wife's employment (Chaudhuri et al., 2002). In a recent study (Duggal et al., 2001) of 25 couples (22 to 68 yrs) of middle SES from Delhi City, understanding, tolerance, loyalty, and respect for each other, and extraverted personality were found to be the chief determinants of marital compatibility. This requires replication on subjects from different provinces of India, with different age groups and educational and social backgrounds.
Women's identity, largely in India, is wholly defined in terms of their interaction with others, namely, as a daughter, as a wife, and as a mother (Kakar, 1982). Such observations, no doubt have contributed significantly in our understanding of the dynamics involved, but the task of translating them into operational terms for empirical purposes needs to be addressed (Bhushan, 1993). Methods of resolution of identity confusion need to be explored, with special emphasis on the socio-economically disadvantaged, rural and out-of-school/college samples.
There is a need for long-term prospective studies on the adaptation process of individuals and families in life crises. Future research should focus on identification of characteristics of growth-promising families, identification, and examination of determinants of family climate, and to examine how families function in a broader ecological context.
PSYCHIATRIC SYMPTOMATOLOGY IN THE INDIAN CULTURAL CONTEXT
In psychiatric symptom manifestation, wide cross-cultural and sub-cultural variations have been reported. Auditory hallucinations occur more frequently in Western schizophrenic patients, whereas, visual hallucinations are common in cultures other than Western. Likewise, Indian patients were reported to experience more of delusions of bodily control and of being poisoned (Kala & Wig, 1982) than Western patients. People endeavour to keep their culture intact in symptoms, even after migrating to other cultures. The delusion of ghost possession, which is uncommon in Britain but common in South Asian countries, has also been reported in Asians living in the UK (Bose, 1997; Hale & Pinninti, 1994). Contents of the delusions have shown a significant change over the decades in both Indian (Sharma & Agnihotri, 1986) and Western culture. Suhail (2000) reported that Indian schizophrenic patients (n = 60) living in Britain, experienced persecutory delusions (content being harmed, attached, as well as black magic), whereas white (n = 50) patients had greater themes of telepathic communication. British-Indians, on an average, developed delusions related to their family members; white patients reported greater frequency of verbal hallucinations—hearing voices ordering them to commit homicide or suicide. In Suhail's (2000) study, compared to the whites (16 per cent), the delusions (control, reference, and persecutory) of twice as many British-Indian patients (39 per cent), revolved around their family members. The persecutor, however, varied from one study to the other. In some studies, persecutors were elder brothers (in case of males) and sisters-in-law (in the case of females), and also one's own parents and siblings and in-laws.
Although, the traditional extended family system is generally disappearing in Indian families living in Britain, all kith and kin keep close contact with each other. While, such close contact provides them with a unique opportunity to share, it may also burden one with tensions in the family, worry over responsibilities, break-ups, property disputes, etc. (in about 20.5 per cent of the cases, domestic tension causes mental illness in India) (Rao, 1966). Involvement of family members in the aggressive and persecutory themes in Indian patients, indicate that during the process of socialization a high premium is placed on obedience to elders and aggression receives hardly any encouragement. The authority of the elder brother or the mother-in-law is supported by moral injunctions. It may be that direct hostility or aggression is repressed or reappears in the form of delusions of persecution (Suhail, 2000).
Differences between British-Indians and white patients is another dimension of delusion, that is, theme of delusions could be because white patients believe in extrasensory perception and the power of their own mind (telepathic communication), whereas British-Indians seem to perceive power in external sources (Suhail, 2000), magic, for example. Preponderance of magic themes in British-Indian patients supports the hypothesis of a lower threshold of culturally sanctioned experiences (Al-Issa, 1995). In other words, this is a way to throw the responsibility for misfortunes on some culturally accepted external source. This also refers to the prevalence of suspiciousness in inter-personal relations, as the patients who reported magic themes were suspicious that people were using black magic or cult to harm them. Due to the small amount of data, it was not possible to split these into first and second generations in Suhail's study. However, it has been indicated that although beliefs in spirits, possession, and witchcraft were observed in the first generation of migrants, it cannot be assumed that they will not be retained in the subsequent generations who have spent their formative years in Britain (Bose, 1997). There is evidence that in societies undergoing rapid social change due to industrialization, indigenous beliefs continue to be held among those educated in the Western way (Bhattacharyya, 1986).
In the rural population of India, a preponderance of hallucinatory themes of magic and religion (jadu-tona, witchcraft, evil spirit) has been noted, particularly in less-educated females (Sharma & Agnihotri, 1986). In some parts of West Bengal, juju is the term used to express fear of some supernatural power, which may even lead to manifestation of psychiatric symptoms (West Africans also use the same term, i.e., juju). But the content of fear varies over culture. In India, such fear is mostly due to internal insecurity of losing some object of dependency, as a punishment that is imposed by the supernatural power because of the person's guilt feelings, for example, sex guilt, whereas for Western patients it is on account of the expression of aggression. In the rural population of Rajasthan, the possession syndrome is reported (Kapur, 1987) to be a culture-bound reaction to stress in the beginning and it proceeds to work as community therapy. Attitudinal differences exist amongst different cultures with regard to mental illnesses/behavioural problems, namely, homosexuality, and use of mind altering drugs, for example, ganja. Cultural differences exist not only in identifying symptoms and understanding their hazardous consequences, but also in reporting to the consultants for adequate treatment of such symptoms. Among the Yoruba tribe, phobia and OCD are very infrequently noticed, whereas, in our culture these are very frequently reported, particularly among adolescents and young adults. Some of the culturally determined abnormal behaviours (for example, amok, latah, and kora) prevalent in South East Asia, mainly in Malaysia, Indonesia, Singapore, Borneo, and the Philippines have been discussed, citing case reports by Sarbadhikary (1999).
Apart from hysteria in some parts of the country, three syndromes (based on sex guilt) commonly reported are dhat (seminal loss) (Singh, 1985), koro (dysphoric penile erection) (Chowdhury, 1992), and jhinjhini (numbness, fear of paralysis, and impending death) (Nandi et al., 1992). In some villages of Nadia district in West Bengal, jhinjhinia is the term recently used by victims to express a peculiar, sudden onset of numbness over the penis or breasts (as the case may be) so much so, that the respective organ shrinks into the patients’ abdomen. Local people form a rescue squad to pull the affected organ in the opposite direction and by the use of massaging oil, etc., it subsides. Jhinjhinia of Bengalis resembles closely to the koro that almost exclusively occurs among the Chinese (referred by them as suk-wang). Chinese people believe that the loss of sperm through excessive sexual intercourse/masturbation may result in improper balance between win (female) and wang (male) humours in the body. Koro occurs most often in immature and anxious adolescents and young adults who have been troubled by anxiety, guilt and panic over their virility (Sabadhikary, 1999).
The dhat syndrome, first discussed by Wig (1960) in India, was recognized by the WHO (1992) for classification of mental disorders under ‘other specific Neurotic Disorders’ (Bandyopadhyay, 1999). Researchers prefer to classify patients with dhat as ‘Undifferentiated Somatoform Disorders’ (DSM-IV, APA, 1994). In a study of 63 male patients with dhat syndrome (taken from the Institute of Psychiatry, Calcutta), different cognitive aspects were examined and compared with normal controls, and also with psychotics (n = 15) and neurotics (n = 15) patients. Questionnaire-based data revealed high levels of anxiety and preoccupation of having a disease that does not exist in reality in the patients with dhat syndrome, but not in other control groups. Therefore, loss of I (dhatu/semen) in an anxiety-prone individual makes him hypochondriacal (Bandyopadhyay, 1999). The number of neurotics and psychotics examined in this study was small. Moreover, their age, marital status, education, and employment status were not known. This study requires replication on large number of subjects matched in the variables mentioned above.
The dhat syndrome is accepted as a ‘culture-related’/‘culture-specific’/‘culture-bound’ psychiatric problem, particularly in India (Bhatia & Malik, 1991) and her sub-continent (Akhtar, 1988), but there is still ongoing debate regarding the possibilities of cultural expression of known psychiatric disorders in such syndromes. However, these require further study to stop speculation on its etiology (Kapur, 2001).
The coexistence of other psychiatric morbidity with dhat discharge needs special mention. Depression, like that of the neurotic or psychotic, is seen to be commonly associated with this problem along with anxiety and hypochondriasis. Such patients usually respond well with antidepressants (Bandyopadhyay, 1999). An eclectic approach is required for its management (Kapur, 1987). Relatively fewer numbers of studies on such phenomena have been reported in recent years.
Culture plays a strong role in the development and also in the course of patients with schizophrenia in developing countries like India, Colombia, and Nigeria, and they are less likely to remain incapacitated by the disorder for the long term than those who have schizophrenia in developed countries such as, the United States and Britain. It may be partially due to variations in the genes for schizophrenia across cultural groups, and differences in how cultures treat their patients that probably play a strong role in this regard. In developing countries, patients with schizophrenia, for example, are more likely to be cared for at home by a broad network of family members who share responsibility for the individual. In contrast, in developed countries, it is less likely that the persons with schizophrenia live with their families or that their immediate family has other members nearby who share in the care (Jablensky, 1989). Caring for a family member with schizophrenia is a huge burden. When it is shouldered by only a few persons, there can be tremendous conflicts in the family that may exacerbate the symptoms of the patients.
Cross-cultural comparisons of hallucinations and delusions have mostly been made by comparing results, with findings reported from other countries. Such comparisons lack empirical evidence because of methodological differences. Suhail's (2000) study is free from such a limitation. But the major weakness of this study is its retrospective design. Nevertheless, it is a very important study that depicts how cultural values and expectations affect the way the distress is perceived and expressed. Apart from inherent cultural values, shared cultural values are important because the sharing of two cultures may make a demanding impact on one's mental health.
Analysis of such contents is essential in the treatment of these patients, an issue which has been detailed in the section on therapy.
PSYCHOTHERAPEUTIC INTERVENTION: THE INDIAN SCENARIO
Discontentment has been raised by clinicians and academicians (Patel, 2000) on the application of Westernized explanatory concepts of psychotherapy to the Indian context. The concern of Third World countries, in this regard, was raised by Sinha and Holtsman (1984) long ago, and attempts were also made for indigenizing psychotherapy (Neki, 1973, 1976). A comprehensive review on this is available (Rangaswami, 1996). Andrew et al. (2000) described the rationale, development, and piloting of counselling intervention for general/common mental disorders seen in general health care units in India.
Intervention techniques so far applied to our population may broadly be categorized as: analytically oriented psychotherapy (less frequently applied in recent years), behaviour therapy, cognitive behaviour therapy including biofeedback (BFB), cognitive therapies, meditation and yoga therapies including asanas, guided somatopsychic relaxation including Progressive Muscular Relaxation (PMR), supportive psychotherapy (combined with medication), pharmacotherapy, and community rehabilitation programmes.
Rational emotive therapy (RET) has been effective in treating pathological anxiety and in reducing occupational stress (Helode, 2002), whereas RET conjointly with PMR was helpful in the treatment of menopausal syndrome (Mathur & Jani, 2002). Likewise, EMG, BFB and PMR jointly were effective in stress inoculation programmes (Abraham & Kumaraiah, 1993), rather than any single technique. However, Mukhopadhyay and Chattopadhyay (2000) claimed that BFB alone was effective in reducing pre-menstrual and during menstrual symptoms. BFB also reduced symptoms significantly for psychosomatic patients, namely, essential hypertension (n = 14; 45 to 60 years) (Mukhopadhyay & Turner, 1997), coronary heart disease (CHD) and related disorders (Agarwal et al., 2000). The efficacy of alpha and theta neurofeedback training in the treatment of GAD has been reported (Vanathy et al., 1998). Similarly, BFB was claimed to be by far the best technique in treating GAD, compared to cognitive behaviour therapy (CBT) and pharmacotherapy (Biswas et al., 1995). Also, the efficacy of BFB intervention in mental disorders, in general, has been claimed (Mukhopadhyay et al., 1994). However, these findings require replications on larger number of subjects and with longer periods of follow-up.
Though there was no structured evidence for the role of cognitive behavioural interventions prior to the 1970s for patients with psychosis, the current literature consistently shows that these strategies play important roles in the amelioration of psychotic symptoms, such as hallucinations. A progressive shift is noted in understanding psychopathology and interventions in schizophrenia from completely behavioural and cognitive and thereafter to cognitive-behavioural perspectives (Prasadrao, 2000). Further research is needed to identify such method of treatment, which could be patient-specific. There is need to assess the cost effectiveness of these interventions and also to find out the critical components of the treatment, so that the predictors of treatment outcome (Mitra & Chattopadhyay, 2003) can be identified. A detailed review on this issue has been given by Prasadrao (2000).
Cognitive therapy (CT) has been effective in treating patients with gynaecological problems and with depression in women having physical health problems (Dixit et al., 2001). CT (reassurance, restructuring, reconstruction of dysfunctional assumptions and verbal reattribution of self corrective scheme) was found effective in treating patients IBS (10 males and 4 females; mean age, 31.07, SD 10.75 years; chronicity mean 7.5, SD 5.36 years); a two-year follow-up shows maintenance of therapeutic gains (Pathak & Srivastava, 2002).
A comparison of CT with relaxation and meditation was done (Singh & Kaushik, 2000) on middle-aged women at risk with depression. A one-year follow-up revealed that relaxation and CT do replace the problems to some extent but the meditation technique was found most effective in enhancing stress coping skills in depression. However, only three patients were investigated and thus it requires replication on a large number of subjects.
CT compared to pharmacotherapy was found effective, if conducted for longer durations (28 sessions over the period of 12 weeks) to increase strength acquisition, and lowered relapse along with meditation for immediate symptom relief in patients (n = 14) with IBS (Pathak & Srivastava, 2002). The patients of both the sexes (male 10, female 4) were taken together and the age range was quite wide (18 to 55 years).
CBT was found effective in dealing with hostility in patients with CHD, and in 30 sessions (75 minute duration for each session) over a period of six weeks for a 45-year-old married male (Prasadrao et al., 2000). CBT could form an essential part of rehabilitation programmes for other cardiac patients. However, there is need for further research in this area using larger samples with long-term follow-up to see how far such intervention techniques help in maintaining health and enhancing positive lifestyles. Peptic ulcer patients (five males, 20 to 41 years) were treated with PMR and behavioural counselling; comparison of pre- and post-endoscopic findings showed significant improvement in each patient even after two years of follow up (Thankachan & Mishra, 1996a).
CBT was effectively applied on patients of bulimia, and asthma (Grover et al., 2002), and on patients (50-year-old female) with somatoform disorder, over 31 sessions with one-month follow-up (Akoijam & Rao, 2002). Since it is a case study and without long-term follow-up, generalization is not possible at this stage. CBT along with behavioural counselling for patients with OCD (Yogananda & Prasadrao, 2001) and CBT with personal psychotherapy for patients with depression (Mitra et al., 2003) and cases of deliberate self-harm (Raj et al., 1997) have been suggested as effective by the researchers. The cognitive behavioural model and psychophysiological model for the treatment of panic disorders have been updated by Rangaswami and Kaliappan (1995). An observation of the cross-national collaborative panic study on drug treatment (1992), cited by Rangaswami and Kaliappan (1995), is that for the treatment of panic disorder, in addition to pharmacotherapy, behavioural therapies have also proved effective. Prasadrao (2000) has given a critical review of the existing literature on the utilization of behavioural and cognitive behavioural strategies to deal with auditory hallucinations in schizophrenia.
Behaviour therapeutic (BT) techniques were applied (Ghosh & Chattopadhyay, 1993) in the treatment of ADHD (a seven-year-old boy); a five-month follow-up showed satisfactory and improved academic performance in school. Five children (8 to 14 years) with abdominal pain have been treated successfully with BT applying extinction and self-control training techniques (Rastogi et al., 1993). Training programmes for parents, along with behavioural intervention, were found effective in the management of five boys with ADHD aged 7 to 10 years (Basu et al., 1996). However, application of these techniques on larger samples and long-term follow-up are warranted on comparable groups to assess long-lasting efficacy. Coping skill developing technique is helpful for students with excessive tension and awaiting examinations (Dharitri, 1996). Comparative evaluation of three BT techniques in the treatment of different disorders has been presented succintly by Das and Chattopadhyay (1998). A multi-modal approach in the management of emotional disorders in children has been formulated by Roy and Som (1996).
Modelling procedures bring a satisfactory change in the level of aggression in 12- to 14-year-old delinquents (n = 10) of the Government Certified School, Bangalore (Vidyasagar & Mishra, 1993). Kaushik and Singh (1993) successfully treated a 12-year-old girl with a history of six years of trichopezoar (ingestion of hair/fibre) with behaviour modification techniques. Follow-up for six months revealed maintenance of treatment gains.
Chain smoking is a symptom of inert psychopathology (Mitra & Mukhopadhyay, 2002). Negative self-evaluation, high anxiety, and avoidance of social conformity, are some of the personality highlights of chain smokers.
Smoking behaviour was controlled applying BT. A number of BT techniques, including relaxation training to modify/control smoking behaviour in two volunteers (male in the age range of 26 to 30 years) with five-and-a-half years duration of smoking (15 cigarettes/day) was found effective. A time-lagged, non-concurrent type multiple baseline, across subject design, with two baselines of one-week and four-week durations were used (Kumari et al., 1993). This study suggested that factors in participants, for example, unassertiveness in not refusing cigarettes when offered, are important in preparing a behavioural package for the control/modification of smoking behaviour. In a later study (Kumari et al., 1996), the same authors claimed efficacy of BT in helping smokers to give up the habit. Self-monitoring stimulus control, relaxation training, assertive training, refusal skill training, and family support, were helpful to control smoking of willing subjects using the time-lagged, non-concurrent type, multiple baseline across individual design. Only two cases were studied, therefore generalization of the findings is not possible at this stage.
Response prevention, exposure, and modelling helped to treat a mentally retarded person with OCD within three months; a six-month follow-up showed maintenance of the treatment gain (Rangaswami, 1994). Since it is a case study, it requires replication on larger samples. Prasad et al. (1993) have provided a few guidelines regarding BT for helping problem children.
Guided somato-psychic relaxation is found effective in management of essential hypertension (Joy & Sreedhar, 1998), and its related psychological factors, namely, anxiety and depression, and also in management of paranoia and feeling of alienation in the elderly (65 to 75 years) (Anjana & Sreedhar, 2000).
Yoga therapy (YT) proved effective in treating patients with gastrointestinal and upper respiratory complaints, muscular twitching, numbness, and pain in the abdomen (Venkatesh et al., 1994). The patients studied were not matched in certain relevant variables, for example, age, education, occupation, etc.
Physiological changes occuring during psychosomatic illnesses can be regulated through continuous savasana. Savasana can be used independently of yogasanas. Duration of treatment has a positive relationship with therapeutic gain (Kumar et al., 1993). This study was on 50 female university students (20 to 25 years) of severe depression (for two to three months) (Bharathi et al., 2002). This technique has to be applied on patients with other categories of illnesses, and adequate follow-up is necessary to ensure its effectiveness. Significance of school-based supportive psychotherapy for emotionally disturbed girls (n = 40; 13 to 16 years) has been reported (Bhola & Kapur, 2002). But a relatively small sample size, and with only school-based girls as subjects, limits the generalizability of the findings.
An intensive multi-modal BT (diversion, scheduling of activities, relaxation, response prevention, imaginal desensitization and aversion therapy) and pharmacotherapy for a case of 22-year-old unmarried female, with the complaints of compulsive masturbation, resulted in complete recovery within six months and another six months’ follow-up showed maintenance of the treatment with no relapse (Rangaswamy & Palaniappan, 1995).
Drug treatment is not without unwanted effects and critical controversy (Rickles, 1981). To overcome controversies regarding the efficacy of any treatment, what is required is to establish treatment outcome predictors (Mitra & Chattopadhyay, 2001, 2003; Mitra et al., 2002) that can essentially contribute to identifying factors important for intervention. On 28 OCD patients, pre-morbid personality traits were seen to be sound predictors for response to treatment with combined behaviour therapy procedures (Sahoo et al., 2002). Client characteristics, namely, age, rigidity, depression, and anxiety emerge as two functional units, primary cluster (anxiety, rigidity, and age) and secondary cluster (depressive trait, age and anxiety) for serving as sound predictors of response to BT in patients with OCD. Similarly, ego functions have been claimed to be reliable predictors for determining therapy outcome in psychotic patients (Basu et al., 2002).
In sum, using neuro-behavioural approaches, we find that BFB, cognitive retraining, aphasia retraining and various other attempts in alleviating dyslexia (Gupta, 2002), post-operative disabilities, stroke, epilepsy, Parkinsonsism, and PTSD are frontiers. Other than this, in the medical sphere, a clinical psychologist's contribution is of far-reaching help both in intervention and prophylaxis. Most interventions are based on modulation of stress starting from cancer, going on to cardiac problems, asthma, peptic ulcer, diabtes mellitus, HIV/AIDS to many other psychological disorders—all can be treated, prevented, or arrested in their proliferation by intervening with psychodynamic- and cognitive-behavioural approaches.
Future research, to suit our clinical settings needs to be designed in such a way that it can facilitate identifying cognitive contents and themes specific to Indian culture. Steps have also to be taken to educate family members to overcome their resistance to psychotherapy due to cultural bias.
CRISIS INTERVENTION (CI)
CI aims at entering into life situations of an individual/family or a group, for the emergency purpose of ameliorating the effects of traumatic stress. It has a dual purpose—(i) to reduce the impact of the stressful event and, (ii) to utilize the crisis situation to help the victims resolve their present and future problems. In most cases, a stationary clinic or a centre meant for this is the place where intervention services are rendered. Not many such centres are available in India according to the need. However, setting is not the only important feature.
In India, over 90,000 people commit suicide each year (National Crime Records Bureau, Government of India, 1994; cited by Latha, 2000). There has been a 9.2-fold increase in attempted suicides in India in the last decade (Srivastava & Rao, 1996), with the majority usually being under 30 years of age. Retrospective studies reveal that amongst these, about 66 per cent had past history of ‘suicide attempts’ (Kumar & Pradhan, 2003).
Despite the enormity of the problem, there have been only a limited number of studies on completed suicide. Most of the reported studies were based on data from police records, with the exception of one or two that utilized (Latha, 2000) data from extensive psychological interviews of the patients who had either a contact for psychiatric services in the past or were being treated psychiatrically. Psychological autopsies of 30 patients (mean age 30 years, SD 3.8 years) at the KMC Medical College, Manipal, south India, suggested some of the characteristics that may be specific to our culture (Adityanjee, 1986). Gender differences in the profile of suicide completers were noted (Latha, 2000). Contradictory research findings are available where no gender difference was noted amongsts 90 subjects (median age 73 years) drawn from an old age home (of 48 males) (Quraishi & Arora, 2000). Also, depression and age were not found related to suicidal tendencies. These two studies differ a lot in the age and status of the subjects investigated, where the former was on young adults and the latter on old subjects; the former was on subjects residing in their own home situation, whereas the latter was in a home for old people. Provisions should be instituted to assure satisfactory drug compliance and regular follow-ups. Most of the samples in Latha's study were from either lower, or upper middle class families, and there was no provision for social security or health insurance which institute free treatment for this class of people. Of course, the majority of the Indians, according to socio-economic status fall into this group. Regular treatment availability might have reduced the risk factor. Amongst other problems, the most important in our culture is the patient's reluctance to comply with treatment and, therefore, potentially these are the most lethal patients.
Deliberate self-harm (DSH), though, is a complex phenomenon from the personality point of view (Kannapiran et al., 1997), and increased stress, poor coping, hopelessness, cognitive-rigidity, deficits in problem-solving skills, hostility, impulsivity, and psychiatric disorders are the factors related to DSH (Raj et al., 2000). If we look at suicide as an impulsive act or response to a crisis, then we might lose sight of the predisposing factors and aim at solving the index of crisis.
Most of the intervention studies have failed to a great extent in preventing suicide. This may be due to lack of holistic understanding of DSH itself. Therefore, holistic studies that fulfil the individual's needs without compromising the scientific rigour, are required. However, it is worthwhile to find the factors influencing the patient's decision to comply with prescribed treatment; an area of research that will also help identify characteristics of patients having risk for suicide. Nowadays help lines are helping, but lack of adequate knowledge of the personnel (because they are mostly staffed with non-professionals) might not be helpful to save a person from his extreme need to die. Clinical assessments by mental health professionals, periodically, remain the most effective deterrent to suicide. Nevertheless, educating the parents/relatives about the signs and symptoms of depression, sensitizing them about the warning signals such patients give, would definitely reduce the rate of suicides.
Conduct disorders (impulsive and excessive aggressiveness) in children and adolescents present one of the major therapeutic challenges to mental health professionals. They manifest symptoms like, excessive fighting, bullying, destructiveness, cruelties, repeated lying, persistent disobedience, severe defiant provocative behaviour. Until a few years ago, much gloom hung over the possibility of intervening in such problems with immediate action. Recent research findings indicate that individuals can frequently be induced to alter their feelings, attitudes, and behaviour as a result of social influence from others. Psychological intervention, namely, play therapy, parental counselling (Dogra & Veeraraghavan, 1994), and behavioural intervention, namely modelling (Vidyasagar & Mishra, 1993) are found effective. Follow-up reveals a satisfactory outcome. But a larger sample would help in generalizing the findings of this study.
Rehabilitative interventions for cancer patients generally fall into three categories—pharmacological, behavioural, and psychotherapeutic.
Pharmacological management of cancer patients typically centres on issues like nausea, vomiting, anorexia, and such other difficulties induced by chemotherapy. Emotional disorders, like anxiety, depression, and pain, are usually treated with drugs.
For pain control, appetite control, and other side-effects associated with chemotherapy and radiation therapy, behavioural and behavioural-cognitive approaches have been successful. BFB appears to have the minimum effect on coping with chemotherapy, but relaxation and guided imagery are found to be helpful to control chemotherapy side-effects.
In contrast to pharmacological and behavioural interventions which are directed primarily toward reducing physical discomfort, psychotherapeutic interventions including individual therapy, group therapy, family therapy, and cancer support groups attempt to meet the psychological and informational needs of cancer patients.
Individual psychotherapy in such typical cases follows a crisis-intervention format rather than intensive psychotherapy model. Common issues here are: fears of recurrence of pain, of death, of loss of organs and interference with valued activities. Family therapy provides an opportunity for better communication among family members to provide the patients social support. In group therapy, educational and informational supports are very valuable in promoting psychological adjustment to patients with cancer.
PSYCHOSOCIAL REHABILITATION (PSR)
Psychosocial rehabilitation is a recent concept which has replaced the term psychiatric rehabilitation; the latter refers predominantly to drug prescription and drug compliance, whereas the former refers to the affected person, his family and community as well. In this respect efforts have been made to study some priority areas like coping mechanisms of care givers and family burden of disease (Chadda, 2003; Singh, 2002). Another need of the community is to develop packages for the family and caregivers attending to the needs of persons suffering from severe mental illnesses including dementia, especially Alzheimer's disease.
The rehabilitation unit of the NIMHANS, Bangalore, has been expanding (Kalyansundaram & Verghese, 2000) comprehensive rehabilitation services through teamwork, to the mentally handicapped and psychiatrically ill persons. Each team, as a unit, offers services (occupational therapy, day care programmes, rehabilitation wards, half-way homes, vocational rehabilitation services, family education services, etc.) to patients and their family members. Family ward is a unique system at NIMHANS where the patient and a key member of the family stay together in the hospital premises. It is an open ward. The members of the ward (each unit) are free to move and live their daily life activities under supervision of a therapist. This system helps in relapse prevention and thus brings long-lasting treatment outcomes. Gupta (1999) and her associates have demonstrated that in patients with epilepsy and head injury, cognitive rehabilitation/neuro-rehabilitation programmes, which comprised attentional and memory training, supportive therapy, and deep breathing relaxation exercise, along with home-based intervention strategies, was effective to enhance psychosocial well-being of the patients.
The basic premise of family therapy is that the problem shown by the patient is a sign that something is wrong with the entire family; the family system is not operating properly. In such cases, patients show improvement through individual therapy, but relapse when they return home. The difficulty may lie in poor communication among family members or in an alliance between some family members that excludes others. The therapist may visit the family to observe conflicts and problems of communication in a natural setting and advise them accordingly. Sometimes, video tape recordings are played back to make family members aware of how they interact. The best way to treat them is to set up a family unit in the hospital premises itself (Verghese et al., 1994). Family therapy overlaps with marital therapy but has a somewhat different origin. A child's temper tantrums or a teenager's eating problems may be treated better in a family setting. Family therapy improves communication patterns, the role functioning of individuals, for example, an alcoholic with other family members and thereby helps to reduce discrepancies in interpersonal perception facilitating the emergence of more harmonious relationships. Incongruence in perception is a measure of each member's relative isolation, and its assessment is a necessary prerequisite to effective family intervention. An important application of family therapy, for example is teaching families of people, with schizophrenia patients to communicate more positively. Training programmes that enhance family members’ skills in expressing negative emotions and interacting in a positive way can reduce relapse rates for patients with schizophrenia, and many other problems.
Rehabilitation activities in developing countries, particularly in India, rarely view their modus operandi systematically. Nor are there attempts to assess the outcome of such measures with a systematic follow-up programme. Such follow-up programmes should include both training and research concerning mental health problems. In this context, some Indian researchers are of the opinion that psychiatric rehabilitation in India has been an end in itself rather than being means to an end (Ranganathan et al., 1996). In India, multifarious social problems, like unemployment, poverty, illiteracy, stigma, and professional pessimism pose great challenges to rehabilitation workers. The need to be aware of available community resources (e.g., immediate availability of treatment facilities) and limitations (e.g., believing spirituality, witchcraft, etc.), and readiness to deliver health services even in the remote corners of the rural areas (WHO, 1989) have been emphasized by Indian researchers long ago (Reddy et al., 1986). Barring sporadic attempts, no systematic effort has been made in India to make use of community resources in the field of mental health. In some mental hospitals and of late some school- and college students have been involved in providing entertainments or related recreational activities. Even these meagre activities are rarely documented (Ranganathan et al., 1991; Ranganathan & Parthasarathi, 1982).
Ranganathan et al. (1996) who have clearly depicted the nature of agencies came forward to offer help for resource utilization in community services. Of the 236 community agencies 30.5 per cent of business and commercial organizations (did not extend their services) and more than 50 per cent of government agencies did not provide necessary help. Welfare agencies (for disabled students and non-student volunteers) extended their help without any reservation. The reasons for such resistance to offer help were fear, anxieties, false beliefs, and the stigma related to mental patients even after their recovery from such illness (Ranganathan et al., 1996). This shows the necessity to sensitize our people to the patient's needs and problems. In a primary care setting in Goa, the prevalence of common mental disorders (CMD) (equivalent to neuroses) was reported to be 46 per cent which was strongly associated with females, economic problems, and disability. Mostly use of multiple drugs, injectable vitamins, and benzotiazepines are the methods of treatment as Indian patients, in general, expect such methods of treatment instead of counselling/psychotherapy (Patel, 1996, 2000). To expand psychological treatment, Andrew et al. (2000) developed and standardized technique of counselling. Unfortunately, nearly half of the patients attended only one session, which shows that these people need to be made aware of the benefits of such treatments prior to its application.
There are mainly three models of therapeutic intervention: the clinical model, the community model, and the social action model. The social action model is perhaps impractical in our country, at the moment. Methods of community intervention have taken four forms: crisis intervention: consultation, mental health education, and utilization of para-professionals, particularly for the socially disadvantaged group.
Successful implementation of rehabilitation programmes in the community requires primarily three measures—involvement of community agencies, utilization of community support, and adequate training for mental health professionals. For adequate training, multifarious issues related to the patients’ needs and problems require to be focused.
Concerted efforts of mental health professionals, planners, especially policy makers along with teachers, voluntary workers, socio-religious and political leaders, police personnel, and guardians are needed in implementing a successful programme. That is, a team spirit is indispensable in psychosocial rehabilitation. This would definitely pave the way for improving the QOL of people disturbed due to mental health problems.
COMMUNITY MENTAL HEALTH
The National Mental Health Programme of India (Government of India, 1982) has emphasized the need for community participation in the development of mental health services in the country. This can be done through collaboration with sectors like education, social welfare, etc. The main aim of the programme is to impart knowledge to public so that they do not bracket any emotional problem with mental illness. Secondly, to educate the public that mental illness must not be interpreted as ominous. Thirdly, to raise the awareness of the general population about identifying and utilizing the resources available for scientific treatment of mental illness through mental health professionals. This can be achieved only by a change of attitude of the public and through interaction of the community with mental health professionals.
ATTITUDE TOWARDS MENTAL ILLNESS
Most of the Western studies reveal that females harbour less negative attitudes towards mental illness than males (e.g., Bhugra, 1989). Indian studies showed contradictory results where males were found to be more favourably as well as unfavourably oriented towards it. Basu and Raguram (1996) in a study on 140 teachers (mean age 39.30 years, SD 10.34 years) working in government-aided and private schools of Bangalore found that female teachers and elderly teachers had similar negative attitudes towards mental illness. These results are useful in formulating orientation programmes.
India is mostly populated with rural people and agriculture is their main vocation. Owing to unavoidable consequences of modernization, westernization, urbanization, and industrialization, the traditional lifestyle of the villagers is changing and thereby the gap between cities and villages in most areas has decreased. Still, village populations lack resources and they live in impoverished conditions. These problems have drawn the attention of professionals (Patel et al., 1998), particularly of clinical psychologists. Attempts have been made to bring about some change in the value system and attitudes of people living in villages. The Government of India launched a variety of programmes to focus on bringing about all-round development of the villages. These programmes were unsuccessful mainly because of their failure to change the mental make-up of rural masses. The failure of our planning efforts in inducing improvement and change in their behaviour is not necessarily a matter of economic opportunities and lack of resources alone, but of the significant changes in the behavioural style and strategies required of the villagers. They strongly resist innovation and progress (Tiwari et al., 2002).
Since values govern human behaviour, changes of attitude are possible through changes of value systems. Nearly two decades ago, Chakraborty (1991) suggested that the salient values of the Indian socio-cultural ethos are: respect for the individual, cooperation and trust, work is worship, ethical and moral boundaries, self-discipline and restraint, their need to give, and their spirit of renunciation and detachment. Recent empirical studies have identified some of the values which reflect the core concerns and preferences of Indians (Sinha & Sinha, 1994). These are: hierarchical perspectives, the power to play, preferences for personalized relations, social networking through self-other dichotomy, and collectivistic orientation. Studies have examined the value patterns of farmers in relation to commercialization of farms. In general, they indicate socio-cultural differences in value preferences among Indians.
On 150 villagers (18 to 76 years) drawn from three developed and three underdeveloped villages of Deoria district of eastern Uttar Pradesh, where a five-point rating scale was administered. It was found that (Tiwari et al., 2002) certain instrumental (helpful, self-controlled, honest, logical and ambitious) values as well as terminal (salvation, freedom, and longevity) values were positively related to the level of development of the villagers demonstrating a link between various instrumental and terminal values in rural development. This study also reveals that villagers belonging to different age levels show different levels of instrumental and terminal values, for example, villagers belonging to relatively younger age groups were more responsible and were desirous for higher levels of social recognition. Because of their basic values they can be involved in planning and implementing various developmental programmes. In recent decades, high priority has been assigned to the development of rural areas. This has been considered part of a larger process of social development. Thus, the process of planned institutional change can be need-based to better fit human needs and aspirations on the one hand to social policies and programmes on the other. Apart from government agencies, some voluntary organizations should also be involved in the planning and implementation of these programmes.
TESTS/TOOLS STANDARDIZED TO SUIT OUR SOCIO-CULTURAL NEEDS
It has been emphasized by Indian scholars that to meet the needs of Indian socio-cultural traditions, it is necessary to have indigenous tests for psychological assessments (Malhotra et al., 1999; Masroorjahan et al., 2002; Mishra et al., 2000; Venkatesan, 2002a, 2002b).
The tests/tools developed during the period under review may be broadly categorized as follows: those related to (i) primary mental functions; (ii) higher cortical functions; (iii) personality factors including locus of control (LOC), ego functions, and overall coping of adult subjects; (iv) assessment of behavioural problems of children; (v) attitude measuring scales; and (vi) assessment of psychopathology.
The Binet-Simon intelligence scale (1964), reappraised by Venkatesan (2002b) on a sample of 759 children (419 boys; mean age 93.4 months, SD 3.2), shows that certain test items merit displacement by upward/downwards reallocations to suit our population. Khire's (1993) effort to develop an intelligence test following Guilford's model of intellect is another significant development. The Advanced Progressive Matrices was standardized on university students (n = 250). The present norms are found to apply to career guidance and selection of students (Bhogle & Prakash, 1994).
Beck's Depression Inventory was adapted into Bengali and its clinical validity and statistical validity obtained (Basu et al., 1995). Bengali adaptation was done on Eysenck's Personality Questionnaire (Basu & Basu, 1996) in the northeastern part of India. The English form of the Ego Function Assessment (Modified) scale of Bellak (1989) was translated into Bengali and has been adapted and standardized on the Bengali population (university students) both normal (n = 100) (Basu et al., 1996; Basu & Banerjee, 1998) and clinical groups (Basu, 1993; Basu & Basu, 1996; Basu et al., 1997; Basu et al., 2000), with schizophrenia and depression and patients with somatization disorders; the differences obtained imply the impact of cultural influence on ego functions development.
Shenoy and Kapur (1995) examined sensitivity of the behavioural problem scale of the Child Behaviour Checklist in Indian children (n = 39) of 5 to 11 years. Most of the items and the cut-off scores of Schenbsche and Edelbrock's are found unsuitable for use with Indian children. The sample size was small and came down further when divided into various diagnostic categories. The scale cannot, therefore, be applied to children in general. Gessells Drawing Test of intelligence was extended and revalidated on 842 children (mean age 9.3.12 months, SD 40.50 months) with communication disorders in Mysore. Test-retest reliability and concurrent validity were reported (Venkatesan, 2002a).
A children's behaviour rating scale has been developed (Arifunnisa & Thimmappa, 2001) based on 350 children and 100 teachers from various schools in Bangalore, on a three-point rating format; various types of reliability and validity were established. It covers five areas of problem behaviour, namely, aggression, anti-social behaviour, personality problems, hyperactivity, and day dreaming. This is a handy tool for identifying children's behaviour problems in school situations that require psychological assistance. Such devices are helpful for screening and survey purposes. These inventories, however, are not in themselves sufficient for epidemiological or clinical work.
Attitude scales for measuring attitude towards eating (anorexia) (Avasthi et al., 1997; Chadda et al., 1987; Nehru et al., 2001) and medication (allopathic treatment) (Varma et al., 1994) have been developed. A scale for assessing attitude towards alcoholism (Chakravarthy & Kaliappan, 1995) has been validated based on the Likert method of summated rating. This has a reliability correlation of 0.87; criterion and construct validities have been established. This can measure attitude changes in both clinical and normal populations. The developmental psychopathology checklist developed by Kapur et al. (1994) has satisfactory reliability and validity as a clinical tool of assessment. It has therapeutic and classificatory implications, too.
Relapse (substance abuse) precipitant inventory has been adapted in Hindi (Mattoo & Malhotra, 2000). The Bengali version of the General Health Questionnaire (Basu & Dasgupta, 1996) and the Defense Mechanism Inventory are available (Sanyal et al., 1993). Singh et al. (2000) adapted a quality of life questionnaire to assess both the disease process and the child's overall functioning. This particular study was on children with asthma. The Toronto Alexithymia Scale (20 items) has been standardized in Hindi (Pandey & Mandal, 1996; Pandey et al., 1996).
Indian relatives of mental patients bear the burnt of illness, especially in the absence of adequate mental health facilities (Murthy et al., 1997); thus, it is necessary to assess the coping patterns of caregivers in our cultural context.
Coping strategies of caregivers of schizophrenia (Chandrasekaran et al., 2002), neurotic disorders (Gupta et al., 1991), and bipolar disorders (Chakrabarti & Gill, 2002), have been assessed employing unmodified coping scales of Western origin. However, to suit our population the self-report coping checklist of Scafuza and Kuipers (1999) was translated into Hindi for clinical use. It is a short test with satisfactory psychometric properties (Nehru et al., 2002).
Translating and adapting previously validated instruments may be a quick way, but it is not a substitute for developing psychological tests de novo (Nehru et al., 2002). Phrases or idiomatic expressions, recognized, and understood only in some specific cultural groups, should be avoided while constructing scales for other cultures (Suhail, 2000).
Sahoo (1995) has developed the Test Indigenization Survey Instrument (TISI) to assess the level of indigenization of tests used in India. He considered sets of parameters—content and context. The format includes concept, language, items, and format. Each of these components is operationalized. The author has asserted that the use of TISI would provide feedback on existing tests and help in future development of indigenous tests.
Tests standardized are to be applied keeping in view the limitations noted in those studies. The sample size was mostly not representative and was restricted to certain situations only, namely, chronic patients, or hospital patients, or only on males, irrespective of education, marital status, SES, etc. Furthermore, assessments were cross-sectional and non-blind. The results also suggested that certain items need further refinement. For wider applicability, these results, therefore, have to be replicated on larger samples across age, sex, and settings, and with more independent raters.
Neuropsychological (NPL) Methods
Studies on NPL perspectives have been reported in both psychiatric and neurological patients. Laterality has been associated with schizophrenic pathology (Biswas et al., 1996; Mandal & Singh, 1993; Shukla et al., 1993; Tiwari & Mandal, 1998). Perceptual impairment in depressives (Asthana et al., 1998) in their interpersonal difficulties, and somatoperceptual impairment (Pandey et al., 2000) and tactual recognition of cognitive stimuli (Mandal et al., 1999; Pandey et al., 1999) in focal brain damaged (BD) patients, and transfer and interference of motor skills in mental retardation (Mohan et al., 2001) have been reported. Cultural specificity was observed in hemifacial asymmetry (Mandal et al., 2001). A detailed review on NPL methods in cognitive assessment of cerebral laterality is available (Chattopadhyay, 1998).
Applying Wiscon's Card-sorting Test, Mukhopadhyay and Das (2003) found that patients with OCD (n = 10) and paranoid schizophrenia (n = 10), despite adequate attention and concentration, showed poorer problem solving skills compared to matched (24 to 55 years) normals (n = 10). The age range of the subjects was quite wide and it is not known whether obtained findings were contaminated by the subjects who were over 50 years.
The Bender Visuo-Motor Gestalt Test (BVMGT) was administered to determine lobe functions in BD patients with frontal lobe (n = 8), temporal lobe (n = 5), parietal lobe (n = 6), and patients with schizophrenia (n = 10), without schizophrenia (n = 10), and patients with OCD (n = 10). BVMGT characteristics represent dysfunctionality of each of the three lobes and denote predominant temporal lobe dysfunction in OCD and frontotemporal-parietal-dysfunctions in schizophrenia (Mukhopadhyay et al., 1999). These findings require replication on larger number of subjects.
Studies on electrophysiological methods are less frequently reported. Averaged evoked potentials (AEP) were measured applying both visual and auditory stimuli to study hemisphere involvement in head trauma patients (Mohanty et al., 1993a, 1993b). The research also has focused on readiness potential and inter-hemispheric EEG coherence as biological markers among alcoholics (Michael et al., 1993). Studies on AEPs require sophisticated electronic gazettes and adequate laboratory facilities; non-availability of these might be the reasons for relatively fewer numbers of reported studies in India on AEPs.
NPL test findings have been utilized in psychosocial intervention programmes in connection with siblings of autistic children (mean age = 14.4 years) (Tarafdar et al., 2004). This study was on ten subjects only, and hence requires replication on larger samples. Luria-Nebraska (LND) Neuropsychological Battery was applied on 100 patients (16 to 50 years) with epilepsy (mean age 24.40, SD 7.97 years) and compared with 30 normal (mean age 25.86, SD 8.10 years) controls. Of the patients, 25 had generalized seizure and 75 had partial seizure with secondary generalization. Findings revealed that a few items in LND neuropsychological test need modification for use in the Indian context (Masroorjahan et al., 2002). The authors advised that caution be used during item interpretation to prevent false positive results in patients groups as well as in normals. Likewise, Gupta (1999) suggested that NPL test findings be used as an ancillary investigation which required blending with the clinical and other investigations. Further studies should focus on developing the Luria-Nebraska NPL profile of normal Indian adults and modifying the items of this test to improve its applicability on the Indian population.
Special training facilities need to be provided for application of psychophysiological and NPL methods, preferably with an interdisciplinary research orientation for quick and accurate identification of etiological factors.
Comparison of Direct Tools and Indirect Tools Employed in Our Research
Though there is tremendous development in the publishing of a variety of psychological tests to suit the needs of contemporary Indian society, the concepts, however, have been frequently borrowed from Western psychological literature. The self-report measures often use examples from Indian social settings, and in this way the content is contextualized to some extent. By this, the problem of cultural bias is partly overcome, but conceptual mapping remains problematic so far as understanding the presence of the phenomenon in culture and its distribution are concerned (Srivastava & Misra, 1996; Srivastava et al., 1996).
To evaluate psychological status completely on the basis of self-rating indices would be subject to falsification for various reasons because the use of questionnaires/inventories rests mainly upon what Wilder has called the ‘Inventory Promise’. That is, the underlying assumptions are that the subjects are always motivated to describe their feelings exactly. In practice, however, we see that subjects, especially patients, show lack of motivation to read the items carefully, understand clearly and to fill in the forms properly.
A subjective psychological test can be misused in the absence of a monitoring system and a lack of knowledge of the principles and problems of psychological assessment at large. At the same time, it is impossible to develop a test that can measure the same construct for groups with diverse cultural backgrounds (Misra et al., 1999). One possible way to obviate this difficulty is to use some objective measures, namely, psychophysiological, neuropsychological (NPL) etc., where the experimenter is not dependent at all on the subjects verbatim, or where the subjects can manipulate their answers in any way. Puhan and his associates have constructed a number of tests involving a projective-inventory approach (Puhan, 1995) to assess aggression, dependence proneness, social responsibility, etc. They have demonstrated a low correlation of these measures with social desirability when compared to the correlation between self-report measures and social desirability. But, in projective tests also inter-rater reliability has to be assessed, which again demands more expertise.
In a study, Suhail (2000) reported that a sizeable proportion of Asian respondents complained of difficulty in understanding the concept behind each item of a questionnaire test. This could be the reason for the inconsistencies obtained in the reported findings, for example, anxiety, revealed through questionnaire methods as opposed to those obtained through psychophysiological measures mostly show contradictions (Chakraborty et al., 2001; Mukhopadhyay & Chattopadhyay, 2000; Sanyal et al., 1998). Furthermore, adequate knowledge about subjects’ autonomic vis-à-vis biological stability and central capacity for arousal modulation required in life-adjustment, can best be understood through indirect measures like GSR, electromyogram (EMG) and electroencephalogram (EEG) (Mukhopadhyay et al., 1996). Electrophysiological measures were reported to be better indicators of biological stability, for example, CNS arousal, than subjective reports (Mohanty et al., 1993a, 1993b). To assess treatment outcome we need parallel tests, which are not mostly available. But the use of objective measures can help to obviate such problems related to repeated measures (subjective). Likewise, training outcomes can be measured in unbiased ways through objective tests. In a pre- and post-design on 274 (230 males) athletes, Khan and Mohan (1992) assessed the effects of aerobic training on psychological attributes of athletes at the Institute of Sports Training, Patiala. Results revealed that sports training in general had positive effects on psychological attributes (competition anxiety, achievement need, LOC, etc.) of the athletes, an issue that requires central attention of clinical psychologists and other concerned personnel to raise the Indian athletes’ performance to glorious levels in world competition. Questionnaires applying single measure assessment fail to reveal many of the negative qualities of subjects that need to be rectified through training for the performance expected from them. Recent research in sports psychology has urged employing psychophysiological measures for obtaining desirable training outcomes in soccer performers in India (Chattopadhyay et al., 1994; Saha et al., 2001).
Psychological tests are developed mostly by academic psychologists but their validity is determined largely by practising clinical psychologists; a balance between scientific vigour and clinical utility is often difficult to achieve (Thapa, 2000). However, NPL methods have helped to overcome some of such problems to a certain extent (Chattopadhyay, 1998). NPL tests may be described as objective-subjective, whereas psychophysiological measures may best be designated as objective-objective. It is possible to have standardized laboratory methodology, like the International 10–20 System in EEG recording, throughout the country to avoid subjectivity totally. However, brain scans and MRI would be better indicators compared to traditional EEG measures to study lobe functions and different symptomatologies.
Studies should be undertaken to ascertain the psychometric properties of tests employed independent of test constructors. Such an exercise would enhance the credibility of test scores so that our predictions are found to be dependable. The assessment of intelligence, for example, in India requires altogether a different orientation to make an authentic appraisal of intellectual functions (Srivastava et al., 1996). Systematic training, like that of apprenticeship in learning, is necessary for diagnosticians to shift focus from absolute dependency on questionnaire measures to indirect objective measures. This would make for better reliability of obtained findings through quick and easy elimination of the errors, which contaminate data, particularly with psychiatric patients. Such a shift, however, is not to mean that in general the reliability of standardized questionnaires is in question.
SOME METHODOLOGICAL ISSUES
Technically, any psychological test is supposed to be an objective and standardized measure of a sample of behaviour. It is therefore, necessary that such instruments should not be biased in favour of or against any group or community. However, being empirical in nature and relying on the distribution of scores in specific samples, such tests/psychological instruments are intrinsically susceptible to a number of sources of cultural bias, which is more so in India because of its multicultural scenario. Diverse ecological cultural settings—owing to linguistic, geographic and religious variations—place complex demands on researchers. Therefore, blindly borrowing from Western tests would have dangerous consequences in pursuing either selection or diagnosis in our country. Likewise, care is to be taken that adaptations do not turn out to be merely imperfect translations of some Western tests. Many well-standardized and often used psychological tests are differently perceived by the subjects belonging to different age groups, sex, and culture. Puhan (1982) in this context suggested that conventional reliability and validity assessment should be substituted by psychometric invariance assessment that simultaneously evaluates both consistency and meaning of these tools in more relevant terms. He has also cautioned researchers to fulfil the prerequisite of including many marker variables in the factor analysis of the test under consideration.
Psychological tests in India are made available by various publishers of psychological documents and books. There have been very few efforts at quality control. Most of these tests are issued by the publishers without certification by experts or psychological institutions (Misra et al., 1999) unlike in the West, where even a qualified person has to be certified for purchasing psychological tests and to be entitled to use these tests. This could be the reason why most test manuals are inadequate in providing us complete information on psychometric properties of these tests.
The National Library of Educational and Psychological tests (NLEPT, 1996) of the National Council of Educational Research and Training (NCERT) has provided critical reviews by psychologists of published psychological tests. A compendium of these reviews has been published by the NCERT (NLEPT, 1996), where they indicate tests that are of very poor quality, in the sense that they do not conform to the requirements of psychological testing (Misra et al., 1999). In most cases, the validity of the psychometric properties of published tests has not been established. With regard to reliability, researchers frequently report the internal consistency and in a few cases mention test-retest reliability. The approach to measurement is quite uniform across the type of psychological concepts assessed, for example, attitudes, interests, adjustment, parent–child interaction, etc., are treated in the same manner. Information about many important details of a test, such as, time requirement, standardization sample, reliability, and validity, etc., are either simply not available or reported inadequately by the test deviser. The range of tests published, however, covers a vast area, which in terms of theme corresponds well to the range covered in Western literature (Misra et al., 1997).
It seems essential that research be undertaken to ascertain the psychometric properties of tests used independent of the test deviser (Srivastava et al., 1996) to enhance credibility of tests scores, and also to make the users predictions firm. A detailed account of such standardization lacuna has been given by Srivastava et al. (1996).
Indices of Behaviour Pathology
Behaviour disorders have been reported in 10 per cent to 40 per cent of the cases attending child guidance clinics in the country, depending upon geographical areas and several other factors. The diagnostic sub-classification of psychiatric disorders, particularly in children, causes several practical difficulties and is the reason for conflicting rates of such behavioural problems that are obtained in different clinical reports. Different studies employ different diagnostic criteria, which makes generalization quite difficult on account of such methodological issues and non-representative nature of samples. The present status of psychiatric classification, with regard to Indian culture, has been described earlier in this chapter.
Several caveats should be borne in mind when comparing the estimates of disorders across studies. These include variations in sample characteristics, sources of information, method of elimination, and case definition. Some studies have limitations in terms of sample size, sampling techniques, socio-demographic representations, lack of concern of cultural diversity of the community at large, and lack of multi-informant data. Most studies have used a single-stage screening design (particularly studies on adolescents). Most studies on adolescents are school-based samples only with fewer general populations or clinic-based studies. In studies on adolescents, there have been few systematic efforts to understand the needs and concerns of adolescent girls; this lacuna is found in Indian epidemiological research.
Some studies relied on self-reports and did not use any diagnostics-structured interview schedule to identify comorbidity in psychiatric diagnoses.
Studies in the field of behaviour toxicology may suffer from certain problems in research and execution (Gupta, 1998). Insensitive/inappropriate measures of outcome might have been employed in the search for effects at low dose. For example, studies analysing the effects of low-level exposure to lead have used blood lead (Chattopadhyay et al., 1993) levels in categorizing the subjects. As blood is a short-term storage system for lead, this can result in misclassification/wrong categorization of subjects and thus induce bias in the interpretation of the result. Usually, a small number of subjects have been sampled which might be the reason for obtaining non-significant effects, even though the group actually would differ.
Neuropsychologists engaged in exploring the relationship between cortical structures and higher mental functions use two methods—experimental and clinical. Though neuropsychologists believe that the experimental method is more powerful in understanding normal brain functions, recently available technologies are perhaps, inadequate to draw definite conclusions. Faced with such a problem, neuropsychologists are found more inclined to use clinical methods for examining performance deficits in brain-damaged patients rather than performance accuracy in intact brain subjects. However, clinical methods should be used with caution (Sergent, 1988).
The emotional valence hypothesis also needs to be the revisited because the role of the left hemisphere in positive emotion processing is vague (Mandal & Asthana, 1999). Some researchers proposed a left hemisphere advantage for positive emotions while others proposed a bilateral advantage for such emotion processing. Further research is needed to solve this dilemma.
Little attempt has been made to resolve the inconsistencies found in somatoperceptual studies (Pandey, 2000) by substantiating findings with clinical populations. Such studies may help clarify ambiguities that have arisen in experimental studies with intact subjects. The possible reasons for such paucity in clinical studies may be that the dependent measure of performance in the experimental approach is not analogous to the dependent measure of impairment in a clinical approach (Mandal et al., 1996). Also, problems arise due to methodological differences in the analysis of data, for example, in the dichhaptic and haptic methods (Pandey et al., 2000). Likewise, variations in the reported findings may be related to sample characteristics, severity, and prognosis of the pathology, onset of the disorder, course of psychopathology, and task-oriented characteristics response format (nominal or ordinal). Control of such sources of variations, experimentally or statistically, does not seem feasible in a single study because such an attempt may create other methodological problems.
Limitations noted with regard to statistical treatment of the data of the research reports, under review, have been mentioned while narrating each study, and need not be repeated here.
Coming to the subjectivity–objectivity dichotomy, it is found that a subjective psychological test can be misused due to the absence of a monitoring system, and thus our predictions are not mostly dependable. Wide variations are noted in the reports of psychometry on the same subjects, done at different institutions/clinics, by different clinicians, which definitely leave a negative impression in the mind of the public about the usefulness of psychometric tests. Secondly, psychological tests are mostly developed by academic psychologists, but their validity is determined by clinical psychologists; thus a balance between scientific vigour and clinical utility is difficult to achieve. Therefore, a shift in focus of the researchers, from absolute dependency on subjective tests to that of objective measures is very essential. In psychophysiological research, the concept of LIV (law of initial value) needs to be revisited. LIV states that greater the excitation (at the prestimulus level), the weaker will be the additional excitation with stimulation. Paradoxically, it denotes that the subjects with low prestimulus excitation exhibit greater reactivity followed by rapid habituation of response. Thus, the rate of decrement of skin-conductance response amplitude overtime to reach the criterion of habituation, is considered as a single criterion following LIV. But, researchers of late, both in the country (Mukhopadhyay & Chattopadhyay, 1995) and abroad (Bernstein, 1973), have observed that the relationship between the rate of decrement of response habituation and the initial level of arousal, as a general psychophysiological law, is still debatable. LIV is not equally applicable to individuals having varying degrees of basal anxiety. Rigorous research, applying different psychophysiological measures, namely, skin-conductance, EMG, EEG, and averaged evoked response is necessary to overcome such confusion on LIV. It is praiseworthy that Indian researchers have shown a convergence with that of the Western researchers on this controversial and critical issue in psychophysiological research.
Be it psychological or psychophysiological measures, apprenticeship in learning/working is essential to obtain better reliability of to our research findings.
In sum, substantive diversity in the reported research findings refer to the (i) content areas (starting from prenatal characteristics of mothers to that of after-death bereavements), (ii) variety of age groups (childhood to old age), (iii) population characteristics (including destitutes, divorced, prisoners, psychiatric patients, neurological patients, STDs, terminal diseases, addictions and persons with psychosomatic disorders, gifted children/special children; individuals with unsatisfactory parent–child interaction etc.), (iv) diverse settings (labs, clinics, hospitals, schools, industry persons residing in their own house as well as in homes for the old, etc.) and absence of structural settings (runaway children, homeless families), (v) diverse disciplines (criminology, neurology, neuro-surgery, paediatrics, health psychology, public health), (vi) diversity in selection of groups (case control design, cross-sectional, and longitudinal), (vii) diversity in topics (starting from etiology to that of treatment/management), (viii) diversity in methods of data collection and evaluation.
Of course, diversification in research is necessary to meet the varied conditions in which clinical psychologists work and the challenges they face in drawing valid and scientific inferences from studies. Ideal methodological practices are not necessarily always available. Results obtained are thus mostly tentative; statistical inferences drawn are based on arbitrary decisions. The precise point of findings called statistically significant is purely a matter of convention (Singh, 2002) rather than a statistically justifiable criterion.
In spite of these limitations, clinical psychologists are to put their efforts to maximize reliable and valid information from research and enrich our knowledge.
TRAINING PROGRAMMES IN CLINICAL PSYCHOLOGY IN INDIA
The training programmes in clinical psychology at present in India have generated discontent (Thapa, 2000). There appears to be wide discrepancy between what is emphasized in training and what clinical psychologists eventually find themselves doing (Thapa, 2000). The present training is neither pervasive nor adequate, as it is mainly mental hospital-based and trains clinical psychologists to function as a part of multidisciplinary team. Such trainees are ill-equipped to work in different settings, such as, general hospitals in particular and in the community at large (Prabhu, 1983, 1994, 1997). However, this issue has been focused in the curriculum development programmes undertaken by the UGC to train up clinicians in a community need-based framework. Need for such stronger mechanism for monitoring, evaluating and officially accrediting clinical training programme has been emphasized long ago (Verma & Puri, 1996).
Till 1996 there were only 600 trained/qualified clinical psychologists in India (Verma & Puri, 1996), mainly from NIMHANS, Bangalore (n = 377) and C.I.P., Ranchi (n = 217), of which only a half of whom were professional members of IACP (Verma & Puri, 1996). In the last five to six years, training in the field of clinical psychology commenced at a few more centres including government psychiatric hospitals (RINPAS, Ranchi), private medical colleges (Kasturba Medical College, Manipal, and Ramachandra Medical College, Chennai), universities (Patna, Agra, Bhopal, Meerut, Varanasi, Allahabad, Calcutta, etc.), private psychiatric institutions and private universities (e.g., Amity) under different nomenclatures like MA Clinical Psychology, M.Phil. Clinical Psychology, Diploma in Clinical Psychology, Advanced Diploma in Applied Clinical Psychology, PG Diploma in Psychotherapy, Guidance and Counselling. Thus, the total number of qualified clinical psychologists has risen compared to 1996; however, the ratio of such professionals is inadequate, particularly considering the population of India. Such a gap in the demand-supply ratio of qualified clinical psychologists is due to lack of training facilities.
At this transition phase of the profession and considering the requirements of service needs, clinical psychologists are no more confined to mental hospital settings (Gupta, 2001). NIMHANS-NHRC (1999) observed that a half of the Government Psychiatric Hospitals of the Country have one or two posts of clinical psychologists but only a half of these vacancies are filled up. Another 20 per cent of government psychiatric hospitals had no posts of clinical psychologists.
At present, there are nearly 3,500 psychiatrists as against 600 clinical psychologists (IACP members: 450) in the country (Gupta, 2001). This indicates that professional training has not been sufficiently promoted in the country. Thus, the professional status of the discipline of clinical psychology as a distinct branch of mental health is yet to be recognized by central and state governments. Prabhu (2001) identified this gap as avoidance of facing professional problems.
Another neglected aspect of training in India relates to training in psychotherapy, that should provide along with academic content (broad range theoretical model), opportunity for acquisition of generic skills (e.g., being emphatic and effective in communication) for which trainees require exposure to diverse therapeutic procedures. Also, the selection procedure for the trainees needs to be fine-tuned to select those who have the required personal attributes and attitudes (Thapa, 2000) which are fundamental to the practice of clinical psychology.
To function effectively in the expanding horizons, clinical psychologists must be provided legal security (Rao & Mehrotra, 1998; Thapa, 2000). It is worth noting that vide the Gazette Notification (of 29 September, 1995) of the Government of India, the Medical Council of India initially recognized a course namely Diploma in Medical Psychology and in the initial years this diploma was awarded to senior clinical psychologists who served the country in different capacities. There have been subsequent changes in the course content and also its nomenclature (e.g., diploma in medical and social psychology; M.Phil. in clinical psychology) as per the need of the time and resources available. But a significant lack of concern is noted, which of course is alarming, in seeking recognition from Medical Council of India after these changes. Recently the Rehabilitation Council of India recognized clinical psychologists as Rehabilitation Professionals. Such a shift in recognition has caused some degree of dissatisfaction among the clinical psychologists of the country, who feel that they are not only confined to rehabilitation activities but are also actively involved in psychodiagnostics and psychotherapeutic activities. Clinical psychologists must not be clubbed with other lesser trained professionals, like audiologists, speech therapists, short-term training certificate holders in counselling (without any basic knowledge of psychology) and untrained/semitrained psychologists (Prasad, 1997), under the rubric of Rehabilitation Professionals (Verma & Puri, 1996). This needs to be amicably resolved by setting up a state council. Another feasible solution is to explore the possibility of registration of clinical psychologists by establishing a mental health authority in each state with a controlling agency at the National level.
There is also a need for some kind of adequate control through a ‘code of conduct’ in the quality of services provided by the clinical psychologists by their adherence to ethical issues in practice (Verma & Kaur, 1998). An upsurge in professional training has led to the problem of definition, that is, ‘who is a clinical psychologist?’ (Prabhu, 2001). This is highly necessary for the professional development and adequate level of quality control in services delivered by clinical psychologists in the country. Thapa (2000) recently delineated the criteria of a good professional advocated by Sanford (1951). Training should emphasize the importance of team spirit required in psychiatry.
Another aspect of training is to deal with continuing education and development (e.g., renewing licences as done in the United States) for maintaining professional standards, quality control, and for avoiding professional burn out (Prabhu, 1996).
Apart from organizational support, with the spectrum of the challenges in our trajectory, how far we are trained as clinicians and clinical psychologists is matter for introspection; what more we can do to prove our worth as professionals, is to be projected into time, surely not singly or partly alone but together (Mishra, 1995); it should be both intra- and inter-professional in framework.
What is indigenous in clinical psychology is the clinical attitude that is necessary not only to learn but also to do something about it (Wyatt, 1988). Since the large proportion of trainees in psychiatry, in India, are themselves from different sub-cultural backgrounds, the openness and respect with which the supervisor and teachers approach the area of culture may facilitate an attitude that would invite exploration of cultural and sub-cultural differences as part of mature, integrated, psychotherapeutic technique and practice. Efforts to explore the types of training programmes, particularly for assessment and therapy, which are effective to produce positive outcomes with ethnic groups remain an area for considerable future search in our country.
REFLECTIONS FOR FUTURE RESEARCH
These have been detailed at the end of each of the sub-sections depicted in the main text of this chapter.
The promotion of adult education, like that of integrated child development services, developing positive attitude towards mental illness, is required for the identification and fostering of creativity in children as appropriate strategies for effective human resource development in our country.
High priority has to be given to the development of rural areas and considered as a part of a larger process of social development; the latter refers to the process of planned institutional changes which can be need-based to fit well between human needs and aspirations on the one hand and social policies and programmes on the other. Apart from government agencies, NGOs should also be involved in planning and implementation of various rural development programmes, for which they should be provided adequate training in the area of mental health problems by clinical psychologists.
An informative cross-cultural and sub-cultural phenomenon that merits attention in the concluding section is that in the Indian way of life there are certain characteristics that need to be used as pointers to take up systematic research in future, if these disorders are to be prevented in our society.
Understanding culture-bound symptomatology provides a large arena where both unique- and familiar behaviour pathologies can be examined for the light they shed on etiology and treatment.
The Present Status of Research in Clinical Psychology: Critical Review and Reflections for Future Research
The present era may best be described as the age of stress and strain. Not only psychiatric patients, even normals of the present day society are constantly exposed to certain stress-inducing situations, particularly in keeping pace with the rat race in all spheres of life, be it academic, familial, occupational, political, or personal. Subjective well-being, therefore, has been the main focus of attention during recent years. Subjective well-being is a matter of personal perception, this has to be evaluated in the backdrop of cultural issues and variables. Accordingly, assessment and intervention strategies of disordered behaviour that are employed must be culturally sensitive. But, relatively little attention has been paid to such cultural variables in the research reported during the tenure of the present survey. The issue of subjective well-being poses certain challenges to clinical psychology with particular emphasis on the preventive and promotive aspects of mental health.
To keep pace with the demands of society in this millennium, a change in perspective is called for, from clinical psychology and not only from clinical psychologists. Such a change has to be in all aspects of the field, and has to start from the training imparted to the professionals for the services they will render to the community at large. Health psychology, school psychology, gerentology, forensic psychology, industrial psychology, crisis intervention, and rehabilitation are some of the frontier areas of clinical psychologists that require immediate attention in future. Thus, the future for clinical psychologists has grown enormously over the years. But, to provide excellent services what is needed is change of attitude of clinical psychologists. They must move up from a technician-like role to that of a decision-making professional. Many clinical psychologists unfortunately are found to be over-dependent on psychiatrists, as though they are unsure of making decisions on their own; they feel inferior, presumably, because prescribing drug treatment is beyond the jurisdiction of clinical psychologists. However, in clinical settings, the specific functions they render are psycho-diagnosis and psychotherapy where they work independently as they are the sole authority in this area. The prevailing treatment strategy calls for intervention through psychotherapy/counselling, where his psychiatrist colleague has a partial role to play, at least in the present-day system, where a psychiatrist cannot possess only a basic degree of MSc in psychology along with an MBBS. Needless to add that the acquisition of such basic degrees make these two professionals independent in their respective areas of treatment, though they work together in psychiatry as a team for the benefit of the patients. Non-cooperation between these two professionals, if any, may cause great hindrance to the client/patient in receiving complete treatment. These two professionals must cease their ego clashes, recognize and acknowledge each other's speciality and jurisdiction, render services to psychiatric patients, and to the larger community for its greater benefit. Mutual understanding and cooperation between these two professionals are prerequisites. Without these, there cannot even be useful discussions between them on the cases they treat and to render complete and satisfactory services to the psychiatric patients they serve. Likewise, cooperation and understanding with psychiatric social workers are also equally essential to sustain the team spirit in the treatment of psychiatric pathology.
Information about childhood mental disorders in India is scarce. Inadequate intake of vitamins, proteins and calories by children, particularly those from rural areas, is an important cause for such children being the slowest developers in all most all aspects of development. The promotion of adult education, like that of integrated child development services, is required to maintain general health-welfare of such children on the one hand, and to identify their creative aspects that usually remain undiscovered on the other. Such programmes will definitely be conducive to implementing appropriate strategy for effective human resoures development (HRD) in our country.
In line with the National Policy on Education (1986) in HRD, schools should undertake enrichment programmes for raising QOL, particularly for girls and women in the rural areas of India. However, a persistent gap has remained between the demand for such programmes and their supply.
Compared to the research studies done on the etiology of different mental disorders, there have been relatively larger numbers of studies on the problems of adolescents and young adults, but they have largely ignored the importance of cross-cultural variations at the onset of adolescence. However, many Indian researchers have focused upon gender discrimination and similar other stigma that makes adolescence an underserved population. There appears to have a sizeable mismatch between the need for and availability of required services in this regard.
Community-based programmes for awareness, particularly for school mental health, are urgently needed. Rigorous research is also necessary into the methods suitable to unveil the hidden emotional problems of adolescents, in particular, and of individuals with emotional problems, in general.
In the research on adult psychiatric patients, a significant shift in research interest towards sub-cultural and cross-cultural comparison is noted. Culture-specific psychiatric syndromes, for example, dhat syndrome, content of hallucination, delusions etc., have been investigated by our researchers. But relatively fewer numbers of studies on such phenomena have been reported in recent research. Research is needed for satisfactory treatment outcomes.
An appreciable number of studies have employed neuropsychological methods of measurement instead of applying traditional subjective measures, again, a shift from intra-individual to inter-individual approach in the management and intervention of patients are evident from a screening of the reported studies. Such a shift no doubt, is highly encouraging in that they are keeping pace with the modern development of assessment and treatment. Thus, for example, family therapy is the method of choice in the treatment of children's tantrums, or teenagers problems related to eating, or to develop adequate communication among the members of a family with schizophrenia, Because the basic premise of family therapy is not what is wrong with the individual, but what is wrong with the system. Therefore, the establishment of family therapy units, like that at NIMHANS, Bangalore, is required in every mental hospital for quicker recovery of patients as well as to reduce relapse rates.
Ethnic background and rural/urban dichotomy have been associated with symptomatology where even the nature and content of hallucinations and delusions have been the subject of research in different diagnostic categories of patients. Attitudinal differences among different cultures in relation to mental illness have been investigated. But cross-cultural comparisons of symptoms have mostly been made by comparing results with findings reported from other countries; such comparisons thus lack empirical evidences because of methodological contradictions. These studies however, depict how cultural values and expectations can affect the way distress is perceived and expressed.
Considerable emphasis has been bestowed on the study of psychosocial stress for understanding the etiology of different psychosomatic disorders. Several researchers in the last decade or so have inquired into aggression, anxiety, coping style, locus of control, and the overall personality type associated with different types of psychosomatic disorders namely, CHD, pain syndrome, irritable bowel syndrome, ulcer, diabetes mellitus, hypertension, endocrinological disorders, and sexual dysfunctions. Stress and terminal diseases, namely, cancer have drawn the attention of researchers. Individual coping strategy with heightened physiological (anxiety and depression) and endocrinological (prolactin and cortisol) arousal are found important etiological factors for cancer.
Brief psychotherapy is helpful as intervention strategy along with pharmacotherapy for cancer patients.
While patients with functional psychiatric disorders represent one extreme of the continuum of psychiatric disorders, patients with organic psychosis represent the other extreme of it. Research interest shown in recent years to examine whether disturbances in cognitive functioning, like memory, result from cortical pathology or from an interaction between cortical and sub-cortical pathology in normal subjects, as well as in patients with brain dysfunction. Somatoperceptual impairment in focal-brain damaged patients has been investigated applying NPL methods. Hemispheric superiority and its association with stimulus type or content have been investigated. Thus, a multivariate approach has been employed in studying organic brain disorders. But, findings based on NPL methods have not been consistent. However, cultural superiority was observed with respect to hemifacial asymmetry and valence of emotional expression. But, impact of environmental pollutants in causing deleterious effects in organisms has been dealt with less significantly. India's climate conditions are likely to enhance the toxic effects of various substances and early detection of such adverse effects through NPL tests is essential for the successful prevention of tragedies like that in Bhopal.
Research reports are also available on population control, unwed mothers, HIV infection—which are quite appropriate to the demands of the society. With regard to amelioration of these problems, there is a shift from traditional re-educative psychotherapy to behaviour therapy which of course, is a much-needed shift in our research. The results of brief therapy are encouraging. Interestingly, family environment, parental upbringing process, and parents’ personality are found to be by and large responsible for causing many such problems—an issue that is very important in our culture both for understanding etiology and implementation of therapeutic intervention strategies.
Another emerging issue with Indian researchers is addiction and substance abuse disorders particularly in adolescents. Though biochemical and pharmacological aspects of addiction have been reported, the understanding of psychological substrata remain embryonic. Frustration-aggression patterns of personality alone do not reflect the root cause of choice of a particular substance that leads to eventual dependence on it. Furthermore, most of the reported studies have been cross-sectional in nature. Client-matched and gender-matched intervention strategies must be sought for future research and longitudinal studies with long-term follow-up.
Not only psychiatric patients, but also individuals with old age problems have also been the subjects of attention for Indian researchers and policy makers, so much so that the UGC, ICSSR and ICMR have made ageing a priority area of research. Academic journals and critical reviews on ageing are available in India. Geographical variations and rural-urban settings are found to be responsible for differing impacts upon the lives of the elderly. Social support, particularly family support, is a major source of life satisfaction in the India's elderly. But gender discrimination has been noted in research findings—which is unfortunate—in providing overall resources to mitigate problems of the elderly in our country; for example, men have larger family networks available than women. However, with the changing demographic scenario, more attention be focused on factors that increase the vulnerability of women as they age. Interestingly, it has been depicted by our researchers that in spite of our life being influenced by modern developments and the changed culture of the West, our traditional Indian lifestyle is taken into account while programming coping strategies for our old age population.
The impact of gender discrimination, recent shifts in family patterns, women's employment, women's education on mental health of our individuals have been revealed through recent research. Many studies depicting the relationship between divorce rates and psychopathology are available in context to our culture, where pathological personality disorders and transient clinical syndromes are reported to be more prominent in divorced couples than happily married couples. But, research findings on gender difference in marital happiness have been inconsistent across culture. Not only in marital interaction, in occupational adjustment also has impact of one's family upbringing been found to be significant in our research.
There is a need for long-term prospective studies on the adaptation processes of individuals and families in life crisis. Future research should focus on identification of the characteristics of growth-promising families, of family climate, and examine how families function in a broader ecological context.
In the application of psychotherapeutic intervention techniques, a host of such methods have been applied and the overall Indian scenario in this perspective presents a mixed picture. Mixed in the sense that although a good number of techniques under the rubric of behaviour therapy (BT) and/or cognitive behaviour therapy (CBT) have been applied to our population, at the same time discontentment has been felt by clinicians on the application of Westernized concepts of psychotherapy to solve psychopathology which is predominantly bound to our culture.
Secondly, even with regard to the application of BT and CBT, outcome reports have been largely controversial with the exception of a few, where consistency in the findings have been reported. Such inconsistency, again, may be attributed to a host of factors originating from methodological issues, namely, lack of standardization of techniques from one laboratory to the other, fewer numbers of subjects investigated and quite often only single case studies reported, and an admixture of pharmacotherapy with psychotherapy Of course, for clinical purposes, such a combination may be necessary without any follow-up, etc. The latter issue however, indicates our problems in reporting a research finding that might be clinically significant (e.g., therapeutic outcome in a very large atypical case like trichotolomania, torticolis), but turns out to be statistically insignificant. It shows that the age-long unresolved issue regarding application of statistics in behavioural sciences remains controversial, particularly in context of clinical research. Significance of case studies has to be given proper weightage.
Thirdly, the subject matter of research (particularly the characteristics of the patients) and the treatment methods described, both varied tremendously depending upon the theoretical orientation of the authors. Some of the reported findings require replications on larger numbers of subjects/patients and with longer period of follow-up. A few such serious methodological issues have emerged. Rigorous research is necessary to overcome such methodological limitations.
Use of NPL methods of measurement, unlike the application of traditional subjective measures, has shown an increase in rate, but quality control in construction of test material is essential.
Psychophysiological research has been, relatively, less reported in the period covered in this survey, though some significant studies have been conducted in Indian laboratories during early 1990s. Lack of infrastructural facilities may be one of the reasons for lack of initiative on the part of the Indian researchers to continue such research. Application of psychophysiological methods has to be encouraged, particularly to overcome contradictions and confusions in the reported literature owing to application of subjective measures. Mention may be made here that Indian researchers validated objective methods in revealing hidden emotional problems as opposed to those of subjective methods, which no doubt is a significant advancement in Indian research.
Ethnic background has been associated with symptomatology and combined efforts, namely psychoeducation, vocational rehabilitation; and maintenance pharmacotherapy has been given to reduce relapse and to improve social adjustment and quality of life of Indian patients. However, in most of these studies the number of subjects investigated was too small and without the long term follow-up to warrant generalization of these findings. Such combined efforts for the treatment of psychiatric patients are worth mention and it is expected that broad spectrum projects will be taken up for future research.
A few guidelines regarding minimization of diversity in our research findings, as well as, to standardize our culture bound therapeutic techniques have been focused in Indian research. For example, it has been emphasized that treatment outcome predictors be established which can contribute to identifying factors important for intervention. To name a few, for example, premorbid personality traits are reported to be sound predictors for response to treatment with BT. Likewise, ego functions have been claimed by some Indian researchers as reliable predictors for determining therapy outcome in psychiatric patients when they are on traditional psychotherapeutic intervention strategies.
Psychotherapeutic intervention techniques, including family therapy/group therapy, have been employed by our clinicians to a wide variety of subjects suffering not only from psychiatric disorders but also on those who have some physical ailments, namely, gastrointestinal and upper respiratory complaints, muscle-twitching, numbness, pain in the abdomen, etc. Objective measures be employed for the assessment of both the intensity of the problems, as well as for the treatment outcome; obviously assessment of the intensity of the problems a priori to treatment is essential, to establish a reference point for post-treatment comparison of treatment outcome, if any. It has been customary, so to say, to use a brief questionnaire, for rating scale and obtaining an idea about the patients/clients at the pre- and post-treatment phases which is quite often misleading due to obvious reasons (detailed in the text).
Systematic training facilities are still lacking in Indian institutions for clinical psychologists to shift focus from absolute dependency on subjective measures to that of objective measures to obtain more reliable information. Keeping this in mind, IACP has to emphasize this matter so that the curriculum is framed accordingly at the institutions offering training courses for the clinical psychologists. Also, psychology has to be included in school curriculum from early secondary (Class VI) level.
The Government of India in its National Mental Health Programme (1982) emphasized the need for community participation in the development of mental health services in the community. Though some efforts have been made, the overall outcome has not been very promising probably because of the lack of infrastructural facilities including specialized manpower.
A variety of community-based resources have been developed to serve the psychological needs of different groups. One such resource is the half-way house, where patients who have been hospitalized can live while making the transition back to independent living in the community. Residential centres are available for people who are recovering from problems of addiction and for delinquents or runaway youth or for battered wives. Troubled teenagers may be in need of discussing their sexual problems (rape, etc.) with others in a group, under the supervision of a trained counsellor, who plays an important role to provide remedial education, joint counselling and help family persons with personal problems.
This is to provide immediate help for individuals and families undergoing intense stress. During periods of acute emotional turmoil people mostly feel overwhelmed and incapable of dealing with the situation. They may not be able to wait for a therapy appointment, or they may not know where to turn. One form of crisis intervention may be provided (of course in the Indian situation one has to bear in mind financial affordability) by 24-hour walk-in services, in a community mental health centre, where a person can receive immediate attention. The role of clinical psychologists here would be to clarify the problem, provide reassurance, suggest a plan of action, and mobilize the support of other agencies or family members (may be at this juncture clinical psychologists can get the help of psychiatric social workers for home visits, etc.). Such intervention is usually short-term (five to six sessions), to provide at hand support to the client Such short-term intervention often makes hospitalization unnecessary.
Media, Hotlines, and Helplines
Dissemination of information relating to mental health and availability of helpline information is essential. Telephone hotline services are also a kind of crisis intervention. These centres are usually staffed by volunteers, under the direction of mental health professionals. Some focus specifically on suicide prevention, and some others on persons with different types of distress. But volunteers must be trained professionally.
Instead of psychiatric rehabilitation (mainly based on treatment with drugs), the current concept is psychosocial rehabilitation that takes into account the affected person and his/her family members along with other community resources. This method is very helpful in teaching communication and emotional interaction among family members, because communication gaps in some form or the other happens to be the primary factors of emotional maladjustment in a majority of the psychiatric cases. This method of intervention has its application in India, though the number of institutions offering such treatment resources are insufficient compared to the needs of society.
Clinical psychologists have significantly contributed to the management and rehabilitation of challenged groups of different nature and capacity. For example, for persons with mental retardation many intervention programmes and community-oriented service models formulated by the clinical psychologists in India have been well recognized (Mathur et al., 1986, 1989; Peshwaria, 2000). Subsequently, composite rehabilitation centres were established by the Ministry of Social Justice and Empowerment, Government of India (Pant & Bagrodia, 2003), and clinical psychologists are working as professors and assistant professors in such institutions. Because of their significant contributions, clinical psychologists have been well-recognized by the Government of India as key Rehabilitation Professionals.
Training Programmes in Clinical Psychology in India
The present training programmes in clinical psychology in India have generated discontentment, as they are mostly confined to hospital settings (Prabhu 2001). Prabhu in this context urged upon the fact that the clinical psychology training programme in India should move out of hospital settings, if not medical settings. However, recent training programmes have formulated curricula that incorporate more and more rural development and community mental health programmes. The present training programme is mainly hospital-based, and trains clinical psychologists to function as part of multidisciplinary team, but not as independent professionals in the larger community setting. The need for a stronger mechanism for monitoring, evaluating and accrediting the clinical training programme has been emphasized by IACP long ago.
Gap in Demand–Supply Ratio of Trained Clinical Psychologists
In the transition phase of the profession, clinical psychologists are no more confined to mental hospital settings. As per the requirements of the service needs, there is a large gap in demand-supply ratio of clinical psychologists due to lack of training facilities. About half of the government psychiatric hospitals in the country have one or two posts of clinical psychologists (NIMHANS-NHRC, 1999), but only half of these posts are filled up. Another 20 per cent of the government psychiatric hospitals do not have posts of clinical psychologists. At present, there are nearly 3,500 psychiatrists as against 600 clinical psychologists (Indian Association of Clinical Psychologists, 450 members) in the country. Thus, the professional status of the discipline of clinical psychology, as a distinct branch of mental health, is yet to be recognized by the central and state governments.
In the last five to six years, training in the field of clinical psychology commenced at a few more centres, apart from NIMHANS, Bangalore, and CIP, Ranchi, but such an upsurge in professional training has led to confusion about who a clinical psychologist is. Clinical psychologists must not be clubbed with other lesser trained professionals, like, audiologists, speech therapists, short-term training/certificate holders, untrained/semi-trained psychologists. This is very essential for the professional development and adequate level of quality control in services delivered by clinical psychologists in the country. Clinical psychologists are not only confined to rehabilitation activities, they are more actively involved in psycho-diagnostics and psychotherapeutic activities. Clarification of such confusion is essential for quality control in services.
Another feasible solution is to explore the possibility of registration/licensing of clinical psychologists through available council in each state, with a controlling agency at the national level. Of course, prohibition is required for some kind of control through a ‘code of conduct’ related to ethical issues in the services provided by clinical psychologists.