Psychological Interventions: From Theory to Practice
THE JOURNEY BEGINS: AN INTRODUCTION
The metaphor of a journey is used to convey to the reader the research carried out in the area of psychological interventions. The Indian Council of Social Science Research surveys are milestones that mark the distance covered in this journey and indicate the dilemmas at the crossroads and the direction for onward travel. It is interesting to note that the first survey had a couple of paragraphs devoted to psychotherapy and the reviewer (Krishnan, 1972) was disappointed at the paucity of research in this area. At the time of the second survey, significant progress had been made and this was reflected in the fact that counselling and therapy formed a separate chapter. The reviewer (Murthy, 1981) observed the increasing popularity of behaviour therapy, as seen by the large number of case reports. Counselling was mainly carried out in community and organizational settings. Application of yoga and meditation to ameliorate distress and enhance well-being received considerable attention. The third survey saw the road divide: Yoga-based techniques and counselling were dealt with in a chapter on ‘mental health’ and psychotherapeutic interventions were included in a chapter on ‘mental illness and treatment’ (Pandey, 1988). In the former, Sathyavathi (1988) highlighted the role of counselling in primary prevention and that of yoga and meditation in restoring health. In the latter, while some empirical research had been conducted in behaviour therapy, published work in psychotherapy was mainly theoretical or anecdotal and experiential. The reviewer (Verma, 1988) was critical of the published work and exhorted the need for well-designed research in the area. The last survey saw the paths merge and psychological therapies were included in a single chapter titled ‘mental health, illness and therapy’ (Pandey, 2001). The reviewer (Kapur, 2001) commented that, while behaviour therapy had retained its popularity, psychotherapy research had a ‘long way to go in India’ (p. 453).
Considerable progress has been made in the last decade, and it is significant that the editor of the present survey perceived the need to acknowledge this by devoting a separate chapter to psychological interventions. While most textbooks of psychotherapy refer to the theoretical basis of psychotherapeutic work, this review highlights the issues related to its practice. The chapter is divided into four major sections. The first three, deal with the indigenous approaches (yoga and meditation), learning-based approaches in behaviour therapy, and cognitive behaviour therapy (CBT), respectively. The last section subsumes all the other approaches: individual and group psychotherapy, family-, and community-based interventions. Each section includes a brief comment on the research in that area. The chapter concludes with a few suggestions for the journey ahead.
HERITAGE SITES: INDIGENOUS APPROACHES
The use of yoga, meditation, and spirituality in psychotherapy continue to receive considerable attention and their role in enhancing physical/psychological and well-being has been repeatedly stressed (Balodhi, 2002; Nathawat, 1996; Rangaswami, 1996; Vigne, 1997). In this section, empirical evaluations of yogic techniques and meditation practices for managing stress, anxiety, depression, and physical problems as well as promoting well-being are discussed. Research related to the concepts or practice of Indian psychotherapy is also presented.
Yoga, as a science of the mind, provides techniques for promoting mental peace and tranquillity (Bhusan, 1996–1997). Roy (2000) elaborates on the usefulness of karma yoga, yoga nidra and raja yoga for controlling the mind. Krishna Rao (2000) discusses the possible use of yogasanas in psychotherapy and highlights their role in the treatment of anxiety, depression, and somatoform disorders. In practicing asanas, the emphasis is on coordinating breathing with movement and paying attention to both the sensation generated by the movement as well as the stillness. As a result, body awareness increases and the individual becomes sensitive to inner processes. Since emotions are often reflected in the body, asanas provide a means to deal with emotional blocks and muscle tensions. In addition, long-term practitioners of yoga are able to exercise voluntary control over their autonomic processes, which helps them in coping with psychological stress (Krishna Rao, 1995).
Khumar et al. (1993) found shavasana to be effective in alleviating depression in a sample of 50 female university students. More importantly, continuation of this yogic exercise for a longer period led to a significant positive change in the students. Other researchers have corroborated these findings. Yogic practices were effective in relieving anxiety and depressive symptoms associated with the menstrual cycle in working women (Sridevi & Krishna Rao, 1996). A three-week yogic training course led to highly significant improvement in the mental health of both men and women (Aminabhavi, 1996). University students who had been practicing yoga for 8 months were found to have lower neuroticism scores as well as lower levels of anxiety and depression (Triveni & Aminabhavi, 1999). Nathawat et al. (1999) reported that two weeks of training in yoga was effective in reducing depression in patients with psychosomatic and neurotic disorders. A more comprehensive intervention in the form of a yogic lifestyle, which included practicing of asanas, pranayama, and meditation, as well as simple, sattvic diet for 15 days was found to be effective in reducing anxiety and depression in persons suffering from gastrointestinal disorder, anxiety, and depression (Mishra & Sinha, 2001).
Raina et al. (2001) tried yoga therapy in alcohol dependence syndrome. They observed that the positive effects were enhanced at 24 weeks compared to 8 weeks. However, it was effective in preventing relapse only in mild to moderate cases of alcohol dependence. In three different studies (Verma, 1996–1997) demonstrated that the practice of yoga was as effective in reducing psychological disturbances as drug therapy. In addition, continued practice over a period, led to a positive sense of well-being not observed in drug therapy.
Janakiramaiah and his research group (Janakiramaiah et al., 1998) carried out a series of studies to establish the therapeutic efficacy of Sudarshan Kriya Yoga (SKY) in affective disorders. The authors found that daily practice of SKY for about half an hour brought about significant improvement in 25 of 37 (68 per cent) patients with dysthymic disorder accompanied by demonstrable physiological and psychological effects. They, however, acknowledged the limitation of not having included a placebo control group.
In a more rigorously designed and executed study, Janakiramaiah et al. (2000) compared the therapeutic efficacy of SKY with two antidepressant treatments (modified electro convulsive therapy, ECT, and imipramine, IMN) in 45 inpatients with melancholia. Remission rates at the end of the trial were 93, 73, and 67 per cent in the ECT, IMN, and SKY groups, respectively, indicating that medical treatments are more effective when depression is severe. In a companion study, Rohini, et al. (2000) used a randomized control trial (RCT) to compare partial SKY treatment (ujjai + bhastrika + yoga nidra) with full SKY treatment (ujjai + bhastrika + cyclic breathing + yoga nidra) in 30 patients with major depressive disorder. Although there were more treatment responders in the full SKY group, this difference was not statistically significant. The authors recommend further studies to define the role of the various components in the intervention.
Yoga can be an effective tool for stress management in business personnel (Roy, 2000). Vempati and Telles (2000) examined the effect of a two-day, yoga-based stress management programme, consisting of yoga practices and stress education, on psychophysiological responses of mid-level managers with varying levels of occupational stress. Occupational stress and autonomic responses using a four-channel polygraph were assessed both at the beginning and at the end of the two-day workshop. The results showed that for persons with high occupational stress scores at the baseline assessment had reduced sympathetic activity after the intervention. However, no significant changes were observed in the case of individuals whose occupational stress index was below the median. In a subsequent study in 35 male volunteers, Vempati and Telles (2002) examined changes in sympathetic activity after two sessions of yoga-based guided relaxation and supine rest. Results indicated a significant decrease in oxygen consumption and increase in breath volume after guided relaxation. Further, comparable reductions in heart rate and skin conductance during both types of relaxation were noticed. During guided relaxation, the power of the low frequency (LF) component of the heart rate variability spectrum reduced, whereas the power of the high frequency (HF) component increased, indicating reduced sympathetic activity. The researchers concluded that yoga-based techniques are more effective when baseline sympathetic activity is high.
Several studies have reported the beneficial effects of meditation practice. Vasudevan et al. (1994) used a single-group design, in which 7 Ss with tension headache were exposed to 30 sessions of yogic meditation. Although reductions in the frontalis muscle tension and skin conductance were not statistically significant, significant reduction in pain perception was observed. In a controlled study, Deepak et al. (1994) examined the efficacy of meditation in drug-resistant epilepsy. All patients were given antiepileptic drugs, and their serum drug levels were monitored regularly. Patients in the experimental group who practiced meditation for 20 min/day for 1 year showed a significant reduction in seizure frequency and duration (observed on electroencephalogram, EEG) during the observation period of 1 year. The study needs to be replicated, as it offers some promise in a treatment resistant condition with a high degree of disability and burden.
Participants at a vipassana camp, both Indians and foreigners, were assessed on measures of anxiety and codependence before and after the camp (Purohit & Chowdhry, 1999). The authors noted that vipassana decreased anxiety and co-dependence in both the groups. Nathawat and Kumar (1999) compared three methods of meditation (vipassana, transcendental meditation, and yoga) with Jacobson's Progressive Muscular Relaxation (JPMR) in a sample of 50 women and found all the four to be equally effective in reducing negative affect and increasing positive affect and life satisfaction.
In an e-mail survey of people's awareness about yoga and its therapeutic value, Pandey and Subbakrishna (2000) report that north Indians believed that physical postures (asanas) and breathing exercises to be the important component of yoga and more useful in physical illness, while south Indians perceived meditation to be the important component and more effective in psychological illness. These findings indicate that client expectations need to be taken into consideration in choosing a particular technique.
Yoga exercises and meditation have been found useful in children. Jhansi and Krishna Rao (1996) investigated the role of transcendental meditation (TM) in improving the attention regulation capacity of 19 TM practising and 20 non-practising children (matched for age and class). Analysis of the data revealed greater attention regulation capacity among TM practitioners compared to their counterparts due to the regular cognitive exercises involved in meditation practice. Adjustment to school and teachers improved in children aged 12 to 15 years, after practice of vipassana meditation for three days (Purohit & Sudha, 1999).
Shamasundar (1993) highlighted the thematic richness and variety of Indian mythological material for psychotherapeutic work. He suggested that themes from Indian mythology might be used to (a) stimulate association and insight, (b) explain etiology and develop alternate modes of coping in a patient or a key family member, and (c) stimulate the therapist to experiment with a new therapeutic strategy. The Mahabharata and the Ramayana are two great and popular epics and an integral part of the Indian ethos. They are both treatises that deal with human interaction as well as man's relation to God. Jacob and Gopalakrishna (2003) have suggested ways in which the Ramayana can be used in therapy and even draw parallels with cognitive therapy. The Bhagavad Gita exemplifies a prototypical psychotherapeutic situation in the Indian culture. Equanimity, as a mental state, is seen as being essential for success (Gupta, 1997). However, Rangaswami (1996) stated that there are several indigenous therapeutic procedures that may consist of paradigms based on, among others, the guru–chela relationship, the Bhagavad Gita, the Vedas and ahimsa as a method of self-control. He concludes that the Indian system of psychotherapy is based on sound social philosophy and theory and has specific therapeutic techniques to promote the individual's well-being from a holistic perspective. Sharma et al. (1995) elaborated on the interface between religion and psychotherapy. Religious psychotherapy can be used in its own right or to augment any form of psychotherapy. However, on the part of the therapist, it would require greater sensitivity to understand the patient's religious values and use them in psychotherapy. There is a bi-directional relationship between culture and psychotherapy that accounts for the variations in psychotherapy seen across different cultures.
Although the relevance of the system of yoga to psychotherapy is well accepted, an indigenous psychotherapeutic paradigm based on yoga is yet to emerge (Krishna Rao, 2000). This may be because there are very few psychotherapists in India who are trained in both the Western and Indian systems to explore this in depth. Theoretical articles espousing the benefits of yoga and meditation continue to be published. There is a distinct improvement in the research design, and several studies have empirically tested the merit of yogic practice using physiological as well as psychological measures of outcome. The practice of yoga and meditation is not only effective in reducing anxiety and depression, but also enhances well-being. What is important is that benefits of yogic practice are sustained over long periods, and show incubation effects. The practices will yield maximum benefit if they become part of the individual's lifestyle.
Greater attention needs to be paid to selection of the sample, especially in the clinical setting, such as diagnosis, duration of illness, and concurrent treatment effects. In clinical practice, one has seen patients with psychosis worsen or relapse when they have undergone practice in meditation, suggesting that these techniques are contraindicated in certain conditions. It is also not recommended for patients who have schizotypal traits or dissociative disorders (Gore, 2002). However, the literature is silent on any adverse consequences of such practice. Negative side effects of meditation practice have been reported in the West (Craven, 1989). It is not known whether Indian clients, because of their greater cultural acceptance of these practices, do not experience these side effects or that adverse events are infrequently reported.
The use of metaphors in psychotherapy is recognized across cultures (Muran & DiGiuseppe, 1990). The Ramayana, Mahabharata, and Bhagvata contain innumerable stories so intrinsic to Indian culture and lend themselves as suitable vehicles to convey important themes in the therapeutic process. The main reason for mythological heritage remaining unutilized is that young trainee-therapists are not aware of this knowledge base as it does not form part of the training curriculum.
FAMILIAR PLACES: BEHAVIOUR THERAPY
Behaviour therapy continues to be the most popular intervention in clinical settings. This section deals with interventions based on learning principles and includes studies ranging from single case reports to rigorously carried out controlled trials. Several practitioners have highlighted its use in various clinical disorders (Kumaraiah & Prasadarao, 1996; Sengar & Srivastava, 2000; Veeraraghavan, 1998). Most of the studies have been multimodal in their approach. However, to gain some understanding of the efficacy of specific techniques, the studies are dealt with in two sections: those focusing primarily on relaxation based methods including biofeedback, and those in the more traditional behaviour therapy mode using behavioural counselling and relaxation, together with operant- and classical-conditioning-based techniques such as systematic desensitization, exposure and response prevention, and skills training. Studies in which cognitive restructuring forms part of the behavioural programme are included here, while those in which the main focus is on cognitive distortions are dealt with in the next section. Research dealing with similar conditions have been arranged together to get a better understanding of the treatment efficacy.
Relaxation-Based Interventions Including Biofeedback
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is a common clinical condition. Persons with this condition may present more often to a general hospital, since the physical symptoms are fairly disabling. Simple psychological interventions can be effective without the adverse side effects of medication.
The Broota technique of relaxation was more effective than JPMR in reducing test anxiety in 30 high-test anxious students (Broota & Sanghvi, 1994). However, Sultana (1999) found JPMR to be efficacious in treating 20 male students diagnosed as having anxiety, insomnia, and adjustment problems. Along with symptom removal, significant reduction in galvanic skin response and lifestyle changes were noted at three months follow up and these treatment gains were maintained at 2 years.
Vanathy et al. (1998) found that EEG theta neurofeedback training (NFT) was as effective as EEG alpha NFT neurofeedback training in clients with GAD. Both brought about significant reduction in self-reported and observer-rated anxiety measures, and a significant improvement in the quality of life measure. However, the effects of alpha and theta NFT were not seen on the EEG spectral analysis carried out at pre- and post-treatment phases in all subjects.
The therapeutic efficacy of biofeedback therapy (BFB) and pharmacotherapy in 50 GAD patients was compared by Sarkar et al. (1999). Patients were randomly assigned to the two treatment modes. The therapeutic effects were measured using objective scores on the Hamilton Anxiety Rating scale and projective responses on the Somatic Inkblot Series in pre- and post-treatment conditions. The study demonstrated the equal importance of both therapies in reducing GAD symptoms.
Studies have evaluated the efficacy of different relaxation techniques, biofeedback, and meditation in some of the common physical disorders such as hypertension, coronary heart disease, and peptic ulcer. Dixit et al. (1994) reported that vipassana meditation was significantly better than BFB in regulating blood pressure, as indicated by the electrophysiological parameters. Broota et al. (1995) compared the efficacy of three different relaxation techniques, namely, Broota Relaxation Technique, JPMR, and shavasana in reducing symptoms of hypertension. Eight sessions in eight consecutive days were conducted. Results indicated that while all the three relaxation therapies reduced symptoms of hypertension, shavasana was the most effective, followed by Broota Relaxation Technique and JPMR.
Guided somato-psychic relaxation was useful in reducing anxiety, depression and blood pressure in seven female patients with mild essential hypertension (Joy & Sreedhar, 1998). The three control subjects reported a mild increase in all the three variables. In a subsequent study, using a randomized control design, Anjana and Sreedhar (2000) observed that five sessions of guided somato-psychic relaxation were effective in reducing blood pressure, pulse rate, maladjustment and alienation, and improving quality of sleep and purpose of life, in a sample of 20 elderly males (65 to 75 years).
Mandke et al. (1996) used a single-case design with pre- and post-intervention assessments to assess the effectiveness of BFB-induced relaxation and behavioural counselling in reducing physical symptoms, anxiety, and pain in five patients with coronary heart disease who had undergone bypass surgery (30 to 60 years). They found that BFB was more effective. Progressive muscular relaxation and health education had a positive effect on the physiological (lipid values) and psychological adjustment of post-myocardial infarction patients (Krishnaveni & Devi, 1998).
In a controlled study, Agarwal et al. (2000) assessed the beneficial role of electromyograph (EMG) biofeedback therapy in 140 patients with diagnoses such as anxiety neurosis, essential hypertension, coronary heart disease, and diabetes mellitus in the age group of 55 to 65 years. The experimental group (N = 72), who received EMG biofeedback therapy for 3 months, showed significant improvement in various electrophysiological and psychological parameters as opposed to the control group.
Mukhopadhyay and Turner (1997) point out that psychological stress leads to a state of chronic over-arousal and contributes to the development of essential hypertension. Biofeedback lowers arousal thus reducing blood pressure. They attributed treatment failure in BFB to the lack of standardized treatment methodology and inadequate attention being paid to the individual patient's psychophysiological response to stress and suggested steps for enhancing the success rate of BFB treatment.
Behavioural interventions have been used extensively in children with behavioural and conduct problems and psychosomatic conditions, as well as, in a variety of conditions in adults. A detailed behaviour analysis is a prerequisite for the success of a therapeutic programme.
Behavioural Intervention in Children
1. Behavioural and conduct problems: Several case studies present the use of differential reinforcement and other techniques such as activity scheduling, time out (TO), and behavioural counselling (Agarwala & Bhandari, 1994; Ghose & Chattopadhyay, 1993; Jena, 1998; Karthikeyan, 1993; Kaushik & Singh, 1993; and Nanda, 1999).
Sethia and Sinha (1993) outline classroom- and home-based interventions together with self-control procedures for modifying behavioural excesses and deficits in hyperactive children. Modelling techniques were used by Vidyasagar and Mishra (1993) to reduce aggression in ten delinquent males (12 to 24 years). Karpe et al. (1994) examined the effect of stress inoculation training (SIT) on anger outbursts in four boys (13 to 16 years). Following 10 sessions of JPMR and 15 sessions of SIT and relaxation, subjects showed a significant improvement from pre- to post-intervention assessment. Using a case-control group design, Kannapan and Kaliappan (1993) examined the efficacy of behaviour therapy techniques in reducing the level of aggression of 105 delinquent boys (13 to 18 years). The two therapies (relaxation therapy and systematic desensitization) were equally effective, and boys in both the intervention groups were less aggressive than those in the control group.
Kannapan et al. (1993) investigated the effect of seven different behaviour modification packages on daily hassles, stress, and well-being in 240 deviant higher secondary school boys (14 to 16 years) who were randomly assigned to 7 experimental and 1 control groups. At the end of 1 year, subjects in all the experimental groups reported significant reduction in hassles and stress, and improvement in well-being. A combination of all the techniques yielded higher positive changes than individual procedures.
Behaviour modification techniques were successful in dealing with a variety of behavioural problems such as passing urine at inappropriate places, hyperactivity, aggressive behaviour, and inattentiveness in 30 children aged 6 to 12 years (Rao, 1998). Follow-up studies of 18 children (60 per cent) of the original sample revealed significant improvement in 10 children. Devi (2002) reported that both differential reinforcement to other behaviour (DRO) and time out (TO) were equally effective in the management of disruptive behaviours among 15 primary school children. Arun and Kaur (2002) discuss the treatment of four cases of impulse control disorder in children ranging in age from 3 to 12 years, using an intervention package comprising relaxation therapy, distraction, differential reinforcement, and self-control strategies. Treatment gains were maintained on follow up at 2 years.
Rangaswami (1995) used multimodal behaviour therapy to treat school refusal in six adolescents. Techniques such as relaxation training, assertiveness skills, and counselling of parents and teachers were effective with the adolescents returning to school by the end of 3 weeks. Reinforcement techniques were used to increase social interaction and participation of 50 socially isolated school children in the age group of 8 to 10 years (Tiwary, 1999).
2. Psychosomatic disorders: Rastogi et al. (1993) treated five children aged 8 to 14 years presenting with abdominal pain. Self-control and extinction techniques were effective and there was no recurrence of symptoms at six months follow up. Banerjee et al. (1993) found self-hypnosis to be more effective than IMN in treating enuresis in children. However, there was a significant interaction between age and hypnosis with self-hypnosis being less effective in younger children (5 to 7 years) compared to IMN treatment. The treatment response was not related to the hypnotic responsitivity of the patient in either group. Mishra (2000) studied the relative efficacy of pharmacotherapy and behaviour modification (parental counselling, toilet training, and contingency contracts) in the treatment of enuresis in 20 children. After 3 months’ intervention, pre-post-intervention comparisons revealed significantly higher efficacy of behaviour modification technique in comparison to pharmacotherapy.
Agarwala and Kumari (2000) used a multiple baseline design to treat children with onychophagia (nail biting). Nail biting was associated with anxiety and tension and responded well to the combined application of progressive relaxation and self-monitoring techniques.
Behavioural Intervention in Adults
1. Obsessive compulsive disorder: The effectiveness of behavioural intervention in the treatment of obsessive compulsive disorder (OCD) has been highlighted through several case studies (Maheshwari, 2000; Rangaswami, 1994; Rangaswami & Palaniappan, 1995; Varma & Kumaraiah, 1995; Yogananda & Prasadarao, 2001). Techniques of exposure and response prevention and modelling of appropriate behaviour have been used. Although treatment has been time intensive, taking up to 50 sessions, gains have been maintained on three to six months follow up. Kuruvilla and Rajagopalan (1994) observed that in order for behaviour therapy to be effective, patients should receive at least four hours of therapy per week.
Reviewing the application of self-monitoring techniques in the modification of obsessive-compulsive behaviour, Basavarajappa and Mishra (1993) explain the theoretical basis and present behavioural formulations of conditions where such procedures are effective. The outcome of such intervention in three males and two females is discussed in the light of various learning theory paradigms. The results are quite encouraging as improvement was maintained on long-term follow up ranging from 2 to 20 years.
Rangaswami (1997a) examined the effectiveness of different therapeutic techniques in 12 patients with OCD who were sub-typed as checkers, cleaners, and doubters. Overall, about two-thirds showed complete recovery using exposure and response prevention, modelling, thought stop, and relaxation. However, there was a significant interaction between type of symptom and technique.
Methodologically rigorous research in this challenging condition was carried out by Sahoo et al. (1999). They assessed the strength of conditionability trait in predicting the therapeutic outcome of behaviour therapy in 28 OCD patients. Cognitive flooding, spouse/parent assisted modelling, and progressive relaxation were the procedures adopted. The therapeutic outcome was assessed in terms of a criterion of a minimum 60 per cent reduction in symptoms. The conditionability trait was measured by acquisition and extinction trials involving a buzzer as the stimulant and galvanic skin response as the response. Results indicated an inverse correlation between conditionability trait and therapeutic outcome validating the hypothesis that conditionability was a sound prognostic predictor of behaviour therapeutic outcome in OCD. A high degree of conditionability indicated a lower probability of therapeutic success. In addition, therapeutic outcome was more effective in patients with mild/moderate OCD traits as compared to patients manifesting severe OCD (Sahoo et al. 2001).
Datta and Broota (2000) compared the efficacy of behaviour therapy and yoga therapy in fifteen patients diagnosed as OCD. Patients were assigned to either of the three treatment conditions: (a) behavioural therapy (Jacobson's progressive relaxation technique); (b) yoga therapy (for thought stopping); and (c) a combination of behaviour therapy and yoga therapy. A combination of behaviour therapy and yoga therapy was found to be most effective than any one therapy administered alone.
2. Psychosomatic disorders: Efficacy of behavioural intervention in the management of peptic ulcer was reported by Thankachan and Mishra (1996). Five males (20 to 40 years) diagnosed with duodenal ulcer on gastrointestinal endoscopy, underwent 45 sessions of JPMR and behavioural counselling in the areas of health education, assertiveness, improving communication skills, and restructuring cognitions. Though only three patients showed significant change in the post-therapy endoscopic evaluation, all five cases recorded an improvement in clinical parameters as indicated by symptom scores and pain scores. Therapeutic gains were maintained at two years follow up.
Latha (1998) examined the efficacy of self-monitoring in changing dietary habits in 18 subjects over a period of one-and-half years. The nutritional counselling programme was administered in four phases to all the subjects. In the first phase, baseline data on the dietary habits of the subjects were collected. The second phase focused on lectures and literature on Indian food and their properties. The last two phases included individualized counselling and follow-up. The self-monitored group was able to maintain a lower level of calorie intake even during the follow-up phases.
Matam et al. (2000) examined the efficacy of behavioural intervention in the management of treatment compliance in young type I diabetics. The intervention comprised 15 individual sessions consisting of behavioural counselling for family and significant others, diabetes education, relaxation, contingency management, and cognitive restructuring. In addition to psychological outcome measures, glycosylated haemoglobin test (HbA1) was done at pre- and post-treatment. The authors concluded that behavioural intervention is an effective adjunct to routine medical care especially improving treatment compliance and metabolic control. The researchers have described in detail the psychosocial aspects to be kept in mind when dealing with young patients with diabetes mellitus (Matam et al., 2001). Agarwal et al. (2002) have also reported on the use of behavioural intervention in diabetes.
Several others have commented on the use of behavioural techniques in specific conditions such as anorexia nervosa (Avasthi et al., 1997), tension headache (Devi & Kaliappan, 1997), cancer (Khokhar & Khokhar, 2001) and chronic pain (Malhotra et al., 1999).
3. Sexual problems and dysfunction: Kothari (1996) discusses the various therapeutic approaches to sexual dysfunction including drug treatment, hypnosis, behaviour therapy, psychoanalysis, couple therapy, and group therapy. He concluded that sex therapies attempt to improve sexual functioning as well as resolve the intrapsychic conflicts that underlie sexual problems.
Erectile dysfunction and premature ejaculation are frequently reported sexual problems that respond to behavioural packages (Avasthi et al., 1994; Shrivastava et al., 1993).
Manjula et al. (2003) report on individually tailored interventions in 38 single males with sexual dysfunction. In addition to sex education, JPMR, fantasy training, masturbation training, activity scheduling, and cognitive restructuring were some of the main techniques used. The authors highlight the cultural aspects seen in these clinical presentations and difficulties encountered in applying psychological therapies in the Indian context. Practical issues of working with patients with dhat syndrome in India have also been outlined (Raj et al., 1998).
Arulmani (1998) illustrates the management of homosexuality using Guthrie's contiguous conditioning model. It is important to note here that homosexuality is no longer considered a ‘disorder’ and its ‘treatment’ will, therefore, involve several ethical safeguards. Basu (2000) discusses the effectiveness of various treatment options in the treatment of gender dysphoria. As there are several legal and social issues associated with sex reassignment surgery (SRS), mental health professionals have an important role to play in its management.
4. Substance abuse and dependence: Prasadarao and Mishra (1994) reviewed behavioural models for alcohol dependence and developed a multidimensional therapeutic programme based on the predisposing factors (such as personality), acquisitional factors (such as psychological cues), and maintaining factors (such as alcohol-related expectancies). The role and efficacy of various psychological interventions in the treatment of substance abuse and relapse prevention have been highlighted (Kumar & Malhotra, 2000; Manickam et al., 1994; Rangaswami, 1997b).
Rajendran (1993) explored the recovery rate in 55 male alcoholics who underwent various combinations of behavioural treatment (relaxation training, aversion therapy, thought-stopping, covert sensitization, and assertiveness training). The participants were assigned to four groups (physical, psychological, social, and combined) depending upon the areas of weakness as indexed through the multidimensional scale for drinking. Results indicated that the physical group reported the highest rate of abstinence (67 per cent) and the lowest rate of relapse (20 per cent).
Ramesh and Kumaraiah (1997) explored the efficacy of about 30 sessions of social skills training (SST) and behavioural counselling in the treatment of a group of 20 alcohol-dependent individuals. A single group design with pre-, mid-, and post-assessment was adopted. Motivation for change, assertiveness, and alcohol-related disabilities were measured. Follow-up after 16 months revealed complete abstinence from alcoholism. They concluded that both SST and behavioural counselling are effective methods in the treatment of alcoholism, especially when a significant other is involved.
The role of psychological factors in the treatment of alcohol dependence in 300 male patients was examined by Saini and Khan (1997). Treatment comprised a broad-spectrum package including chemotherapy, behaviour therapy, individual, group, and family counselling. Patients were discharged from the hospital after detoxification and were on regular follow-up for one year. Treatment outcome was evaluated in terms of recovered versus relapsed. Results indicated that personal belief and stress were the most significant predictors of treatment outcome.
Kamath and Murthy (1998) examined the usefulness of four sessions of group therapy in a comprehensive treatment programme for 30 inpatients with a diagnosis of alcohol dependence. Sessions were held weekly and focused on education about factors contributing to harmful use of alcohol, coping skills including drink refusal and the role of disulfiram. Majority (86 per cent) of the group perceived the intervention as beneficial. With the exception of a few case studies in modifying smoking behaviour (Kumari et al., 1993, 1996), the focus in the area of substance abuse has been largely on alcohol dependence. Several authors have suggested that intervention strategies for substance abuse should be multimodal and holistic. A broad-based, eclectic approach including pharmacotherapy, behavioural, and psychotherapeutic approaches would be essential. Techniques such as self-control, stress management, social support, motivational training, covert sensitization, behavioural contracting, and cognitive therapy need to be individually tailored (Malhotra et al., 1996; Rangaswami, 1997b).
Research in the area of behavioural interventions has moved from case reports to small group studies, and randomized, case-control designs. Standardized tools are increasingly being used for pre- and post-assessment. Longer follow-up periods, ranging from three months to two years, to examine maintenance of treatment gains is another positive development. Behavioural intervention is the treatment of choice in children with conduct problems, mental retardation, and when multiple difficulties are present. In adults, it is most effective in disorders where conditioning plays an important role in the psychopathology such as anxiety disorder, OCD, and sexual dysfunction.
Erectile dysfunction and premature ejaculation are the frequently reported sexual problems. Gender differences in seeking help for sexual dysfunction are evident. All the studies have been carried out with men, indicating that women's sexual difficulties are still largely not addressed. The other interesting aspect is the use of individual-based behavioural techniques for the single male seeking help for sexual dysfunction, as opposed to the predominantly couple-based approach advocated by Masters and Johnson in the West. Several myths and misconceptions regarding normal sexual functioning are present and a number of people seek help from quacks. Sex education in schools and the treatment of sexual dysfunction are areas that merit greater professional attention.
Although the studies cited in this review have reported good outcome in the treatment of substance dependence, these findings need to be interpreted with some caution. Individuals with substance dependence are known to respond poorly to learning-based approaches and prone to relapse over a period of a year. Longer follow-up periods are required before drawing any conclusion. It would also be of interest to note whether there are culture specific factors, such as presence of spouse or family member that may contribute to a better treatment response. The use of behavioural interventions in chronic medical conditions such as diabetes is an area that needs to be examined in detail.
For the reduction of arousal, the relaxation-based techniques appear to be more cost effective than the use of BFB. It is important to note that the indigenous methods such as vipassana meditation and shavasana were more effective than JPMR. The role of client expectations and acceptance of treatment approaches needs to be examined further. Biofeedback, being cost intensive, may be more suitable in hospital settings for specific conditions or treatment refractory cases. Traditionally, learning-based approaches are time intensive. Studies have used interventions ranging from 5 to 45 sessions. Given the time and personnel constraints in the Indian context, the efficacy of briefer treatments needs to be established.
FAVOURITE DESTINATION: COGNITIVE BEHAVIOUR THERAPY
Consistent with trends in the West, CBT is increasingly becoming the most popular form of intervention. In India, the efficacy of CBT in a wide variety of clinical conditions as well as settings is reflected in several articles (Akoijam & Prasadarao, 2002; Gupta & Gupta, 1998; Kuruvilla, 2000; Mishra, 1993, 1998; Prasadarao, 2000; Rangaswami & Kaliappan, 1995). This section will deal with the use of CBT in adults suffering from depression, anxiety, psychosis, and general medical conditions and its use in children.
Cognitive Behaviour Therapy in Adults
In a sample of 22 clients with anxiety neurosis, Abraham and Kumaraiah (1993) evaluated the additive effect of SIT and EMG feedback-assisted relaxation on psychological as well as physiological measures. The introduction of SIT in the treatment protocol led to significant psychological changes and greater self-control in the clients. These changes were stable and maintained over a period of time (Abraham & Kumaraiah, 1994a). In addition, clients who reported fewer initial symptoms were significantly more responsive to the therapeutic programme (Abraham & Kumaraiah, 1994b).
Biswas et al. (1995) examined the effectiveness of CBT compared to BFB and pharmacotherapy in treating 16 patients with GAD. Results indicated that although all the three treatment procedures were almost equally effective in reducing severity of GAD, CBT was selectively more effective in reducing cognitive distortions and improving self-control measures. Maximum improvement (69 per cent) was noted on an objective measure of anxiety (Hamilton Anxiety Rating Scale), followed by the physiological measure of skin conductance (44 per cent) and the least improvement was on the subjective report (28 per cent) on Spielberger's Trait Anxiety Inventory (STAI) (Biswas & Chattopadhyay, 2000). The authors acknowledge that subjective rating of improvement may have been higher had they used the state version of the STAI. In a subsequent study, the researchers investigated the clinical characteristics of 30 male patients with GAD (25 to 40 years) and their relationship to the outcomes of cognitive and BFB therapies (Biswas & Chattopadhyay, 2001). Patients with a shorter duration of illness and greater internal locus of control benefited more from cognitive therapy. Singh and Banerjee (2002) report the successful treatment of panic attacks with 16 sessions of a combination of hypnosis and rational emotive therapy.
Sharma et al. (1996) reported that 25 sessions of SIT were effective in reducing anxiety in four test anxious female students (13 to 18 years). Singh and Broota (1995) found that high-anxious students had poor study habits and improved their academic performance following study skill counselling. This finding was corroborated by Sanghvi (1995). Sud and colleagues in a series of studies demonstrated that attention skills training and cognitive modelling were effective in reducing test anxiety and worry and improving performance (Sud, 1994; Sud & Prabha, 1995, 1996). These gains were maintained even under stress conditions (Sud & Sharma, 1995). The researchers observed that the relaxation training did not have any significant effect (Sud & Prabha, 1996), probably because the learning and transfer of relaxation as a general coping skill takes a longer time. Attention skill training was effective in reducing the worry component, but not the emotionality component (Sud & Prabha, 2000). Interestingly, the performance of the low-anxious group also improved after the intervention. The findings highlight the need to introduce specific study skills training programmes in schools.
Nalini et al. (1996) examined the efficacy of Beck's CBT in reducing depression and negative thoughts in 25 neurotic depressives. Therapy resulted in a reduction in depressive features as well as negative thoughts from the pre- to the post-assessment period. Evaluating the comparative efficacy of CBT and drug therapy in the treatment of 330 individuals with mild depression, Dixit et al. (2000) reported that, while both treatments were effective in the short run, more patients relapsed once their medication was stopped, indicating that CBT was effective in maintaining treatment gains. Singh and Kaushik (2000) compared the effectiveness of relaxation, cognitive therapy, and meditation technique in modifying the coping skills of three middle-aged women at risk for depression. Results showed that, though relaxation and cognitive therapy reduced the problems to some extent, meditation was the most effective.
Deliberate Self Harm
Raj and Kumaraiah (2000) present the case of a 20-year-old male patient with a history of repeated suicide attempts following perceived failure in his academic and personal life. The patient improved with 10 sessions of CBT and problem solving skills training spread over three months. Follow-up assessment revealed maintenance of improvement. The efficacy of a more comprehensive cognitive behavioural package including cognitive and behavioural methods, problem solving skills training, and behaviour counselling for significant others in the family was examined in a case control group design (Raj et al., 2001). A sample of 20 deliberate self-harm (DSH) patients received 10 sessions of CBT and 20 patients in the control group were administered routine medical treatment. Post assessment at the end of 3 months indicated that on all variables, except impulsivity, CBT was more effective than routine medical care in the management of DSH, indicating that a combination of both treatment approaches will work best.
The use of CBT for drug resistant psychotic symptoms is a more recent application. Jena (1999) describes the use of 15 sessions of galvanic skin response (GSR) BFB, reciprocal inhibition and cognitive restructuring in a 44-year-old male with auditory hallucinations and stereotyped shoulder jerks. Raj et al. (1999) highlight the use of 12 sessions of CBT in the management of drug resistant auditory hallucinations. In both case reports improvement was sustained at 1-month follow up. Shriharsh et al. (2003) examined the effect of CBT on adjustment and psychopathology in patients with schizophrenia and schizoaffective disorder. They found that post treatment gains after CBT were not sustained at nine months follow up, although patients were still better than pre-treatment levels.
Mehrotra and Pai (2001) describe the process of cognitive behavioural intervention in a case of acute and transient psychotic disorder and state that the patient had gained insight about her unusual experiences. However, it is not clear whether the improvement was part of the remission of psychoses in response to pharmacotherapy.
General Medical Conditions
Veeraraghavan (1998) highlighted the increasing relevance of cognitive behavioural techniques, such as self-monitoring, control and regulation, skills training, and cognitive therapy, in the field of medicine. Behavioural assessment is a prerequisite for interventions in the field of behavioural medicine (Prasadarao & Kumaraiah, 1997).
Several case studies have brought out the process issues involved in carrying out CBT in medical conditions such as dermatitis artefacta (Midha, 1998) and chronic low back pain (Prachi et al. 1999).
Cognitive-behavioural intervention was effective in reducing anxiety and depression in HIV-infected patients (Prachi et al., 1998a, 1998b). The therapeutic package included Jacobson's progressive muscular relaxation, relaxation using GSR BFB, psychoeducation, cognitive restructuring, activity scheduling, and behavioural counselling.
Cognitive behavioural intervention was successful in modifying Type A behaviour pattern and decreasing anxiety (George et al., 1998) and reducing hostility in coronary heart disease (Prasadarao et al., 2000).
The impact of brief (1 week) cognitive therapy on mild depression associated with gynecological problems in women was examined by Dixit et al. (2001). Four groups comprising women with a diagnosis of chronic pelvic pain, infertility, menopause, and delivery problems and having mild depression were included. Post therapy there was significant improvement. CBT, which included Rational Emotive Therapy, JPMR and behavioural strategies, was administered over a period of three months for women with menopausal symptoms (Mathur & Jani, 2002). The package was found to be effective in reducing tension and frustration, sexual problems, tiredness, weakness, and feelings of uneasiness and loneliness.
Efficacy of cognitive therapy in 14 patients diagnosed with irritable bowel syndrome was examined by Pathak and Srivastava (2002). Patients received an average of 28 sessions spread over a period of 12 weeks and therapy included techniques such as reassurance, logical challenging, exposure, and self-coping measures. Treatment gains were maintained at two-year follow-up.
Pai et al. (2003a) discuss the feasibility of using brief CBT intervention in non-terminally ill, hospitalized cancer patients undergoing radiotherapy. Highlighting the process issues, they observed that, while help-seeking for distress was low, relaxation techniques and distraction coping were better accepted than the cognitive methods (Pai et al., 2003b).
Cognitive Behaviour Therapy in Children and Adolescents
Modelling and cognitive restructuring techniques were effectively combined to increase altruistic behaviour in children and adolescents (Agarwala & Jain, 1993). Using a comparative group design, Mukhopadhyay and Chakrabarti (1996) demonstrated that cognitive modification was more effective than token economy in children with learning problems and conduct disorders, both in terms of improvement in behaviour and less relapse. Rangaswami (1997c) reported a case of a 16-year-old girl presenting with trichotillomania. CBT comprising applied relaxation, response prevention, and self-control strategies was found to be effective. Parents were counselled and involved as co-therapists. Treatment gains were maintained at 6 months follow up. Rangaswami (1998) formulated a developmentally-based cognitive model of OCD in children and adolescents.
The late 1980s and 1990s were characterized by the cognitive revolution. This is reflected in the increasing number of articles on CBT. The CBT is one of the most researched forms of psychotherapy. Its effectiveness has been fairly well-established in a variety of conditions, especially in mood and anxiety disorders. New developments in the application of CBT include its use in children and in patients with psychotic symptoms. The studies reviewed in this section reflect these trends. Efficacy of CBT is well established in the West and has been replicated in Indian studies. CBT has been used with success in common mental disorders, psychosis and medical conditions, and with children and adolescents. With the exception of the studies using SIT and rational emotive therapy, an eclectic approach has been followed. Moreover, within the CBT model itself, the focus is on the behavioural techniques rather than on the cognitive, and the former appear to be more effective. Is this because the client is more comfortable with behavioural methods as against the cognitive? However, it is well known that behavioural techniques, especially relaxation practices, over a period reduce the arousal symptoms that, in turn, reduce the anticipatory negative cognitions. While some case studies have merely focused on the outcome, a few have provided good insights into the process of therapy. Clinically and culturally relevant issues such as clients’ compliance with home work assignments and diary keeping and the use of CBT with illiterate or low literate clients need to be highlighted. Culture-specific content in dysfunctional assumptions or negative automatic thoughts is also an area that merits further attention.
Behavioural medicine is interdisciplinary in nature and acknowledges that pharmacotherapy and psychological intervention work in a complimentary fashion. It not only focuses on reducing the symptoms of stress, anxiety, and depression, but also aims at teaching adaptive behaviour that can help maintain a healthy lifestyle. While behavioural medicine is well accepted in the Western setting, in India, the role of a psychologist in a general hospital is still in its infancy. Only when there is a dialogue between physician and psychologist will the process of consultation liaison be established.
THE ROAD LESS TRAVELLED: OTHER APPROACHES
This section includes several psychotherapeutic approaches that are extremely important and clinically relevant, but have not received the kind of attention given to behaviour therapy and CBT. Some of this neglect is because of inadequate training in these approaches. It is hoped that the future reviews will see work in these approaches grow.
Kumar and Ram (2001) discuss the recent trends and status of psychotherapy in general, and specific therapeutic methods in particular, and observe that Western psychotherapeutic techniques are being modified to suit the Indian culture. They conclude that insufficient training facilities impede the progress of psychotherapy in India. Sinha (2001) points out that psychotherapeutic work is not adequately documented in India and highlights some of the difficulties of conducting research in this area.
Psychotherapy and Counselling in Children and Adolescents
Malhotra and Das (1996) present the challenges faced in the management of childhood psychiatric disorders and state that more research is needed to develop a rational basis for the use of various pharmacological and psychotherapeutic techniques. Counselling was found to be more effective than moral reasoning as an intervention to increase social competence in girls studying in classes 5 to 7. Social competence was measured in terms of school performance, hard work, appropriate behaviour, learning, and happiness (Reddy, 1994). An 8-week intervention consisting of play therapy and parental counselling was effective in reducing aggressive conduct and improving overall adjustment and family environment in children aged 8 to 12 years (Dogra & Veeraraghavan, 1994). In a much younger age group of pre-schoolers (3- to 6-year-olds), Kumari and Chhikara (1997) demonstrated that psychological intervention was effective in enhancing their cognitive development and functioning.
Psychological management of children with emotional and conduct disorders using behavioural techniques, play and group therapy has been outlined by Kapur (1995, 1997). The therapeutic issues involved in using play therapy in children and supportive psychotherapy in adolescent boys and girls was brought out in a special issue of the NIMHANS Journal (Kapur, 1999). Another positive development has been the publishing of the proceedings of a national seminar on psychological therapies with children and adolescents held in October 2001 at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore (Kapur & Bhola, 2001).
Psychotherapy and Counselling in Adults
Sengupta et al. (1993) describe the use of psychotherapy in a person with dissociative amnesia following a traumatic incident. Several case reports of psychotherapy in depression have appeared (Bharathi & Nagaraja Rao, 2001; Lavakare, 1997; Narayanan, 1998). Sharma and Rao (2002) describe an eclectic approach, using supportive, cognitive behavioural and cognitive retraining tasks spread over a year, in a 20-year-old girl with tuberous sclerosis. The case illustrates the need for a multidisciplinary approach and the complex psychosocial issues involved in dealing with neuro-psychiatric conditions.
Transactional analysis (TA) was found to increase the emotional maturity of 60 students enrolled in a pre-university course (Sringar & Rao, 1994a). It was then used with 60 patients (18 to 30 years) with antisocial personality disorder (APD). Subjects were divided into experimental and control groups, with the former being exposed to TA for four weeks. Results revealed the positive impact of TA on the emotional maturity of patients with APD (Sringar & Rao, 1994b).
Ilangovan and Rangaraj (2001) examined the relationship between group counselling programmes in test anxiety and scholastic achievement in a sample of male and female, first-year diploma students. Marks obtained on the revision test and in a public examination by the subjects were collected. Correlation analyses revealed a significant and negative correlation between test anxiety and scholastic achievement. Bhola and Kapur (2002) reported that 95 per cent of a sample of adolescent girls demonstrated clinically significant change in outcome measures after school-based supportive psychotherapy. The authors conclude that there is a need to go beyond mere statistical significance in examining change in outcome measures. Veeraraghavan and Singh (2002) highlight the variety of interventions available for the treatment of anxiety disorders.
Shukla and Singh (2000) found supportive psychotherapy combined with drug treatment to be superior to drug treatment alone in 40 male patients (20 to 30 years) with the dhat syndrome. At one-month follow-up, patients who were given supportive psychotherapy along with drug treatment showed significant decrease in depressive scores in comparison to the drug treatment group.
Andrew et al. (2000) developed a standardized technique of counselling for common mental disorders (CMDs) in general health care settings that consisted of three components—education, breathing exercise, and problem solving. In a pilot investigation of the model, two trained counsellors treated 41 general health care attenders with CMD (16 to 70 years). Findings revealed that just over half the subjects attended at least two sessions, and for this group, the difference in GHQ-5 scores between the first and the last session was significant showing improvement. Using a RCT, the researchers (Patel et al., 2003) compared the efficacy and cost-effectiveness of this counselling module with antidepressant for the treatment of common mental disorders in general health-care settings and found that the psychological intervention was not more effective than placebo. The authors concluded that when chronic, adverse life circumstances are present, community-based social interventions might be more in keeping with patients’ expectations.
Sinha (1994) discusses intervention strategies both at the micro and macro levels to alleviate the suffering of the elderly and to improve the environment in which they can utilize their residual competence to the maximum. Dosajh (1999) suggests psychosynthesis as a means of prevention and treatment of old age problems like senile dementia, Alzheimer's, and Huntington's.
Most of the published work relating to psychoanalysis has been theoretical in nature. Banerjee (1994), compared yoga with psychoanalysis in terms of unconscious–conscious, polarity of instincts such as life and death, ignorance and egoism, pleasure and pain, concentration and relaxation, independence and individuality. Though there are similarities in the therapeutic aspects of both disciplines, the spiritual objectives aimed at in the higher stages of yoga, have no parallel in psychoanalysis. The yogic view of psychodynamics is based on the concept of asakti–anasakti, that is, attachment and detachment. Bhusan (1996–1997) states that this model is more comprehensive than the psychoanalytic model of id, ego, and superego.
Mehta (1997) discusses the establishment of psychoanalysis in India, its virtual extinction, and the increasing usage of psychoanalysis by Indians in the US. The focus is on the problem of treating Indians in America and the way it is closely linked to the historical aspects of psychoanalysis in India. The problem of first generation immigrants in the United States of America is the healing of split-self representations, whereas the problem of second-generation immigrants is an attempt to integrate the two cultures in their identity. Roland (1995) analysed four clinical case studies of patients from India and Japan to highlight the importance of taking into consideration value issues in psychoanalysis (rooted in Western perspectives) with Asian patients. He indicates that norms of dependency and interdependency, deference to superiors, separation-individuation, autonomy, self-assertiveness, and verbal articulateness are unique to a culture and affect the pattern of functioning of people. Dube (1999) highlights the practice of psychoanalytic group psychotherapy.
Adopting a feminist perspective, Davar (1999) argues that the Indian assimilation of psychoanalysis is underlined by patriarchal and upper caste Hindu interests. Neki (2000) stated that psychotherapeutic and psychoanalytic concepts appear to be limited when employed in non-Western cultures. In the Eastern cultures, ‘conscious’ and the ‘unconscious’ appear as simultaneous modes of functioning of the mind rather than two separate compartments. However, Kakar (2003) commenting on psychoanalysis and Eastern spiritual healing traditions, observed that the Eastern healing discourse goes considerably beyond most traditional psychoanalytic formulations on the nature and communication of empathy in the analytical situation. Further examination of this process, he states may lead to the inclusion of meditative practice in psychoanalytic training.
Marital and Family Therapy
The family plays a crucial role in determining the mental health of its individual members. The family may contribute to pathology, but is also the main care provider. A national symposium organized at NIMHANS, Bangalore, in 1994 deliberated on the changes taking place in the marital and family unit. The proceeding of this symposium was published in 2003 (Bhatti et al., 2003). Chandrasekhar and Tripathi (2001) highlighted the role of the family in the prevention and management of mental health problems. Most of the psychological intervention with families has revolved around family psychoeducation. Parents of children who are mentally or emotionally challenged and family caregivers of persons with mental illness have been the focus. Natarajan and Thomas (2002) identified the need for family therapy from the narratives of parents that they studied. The important issue of family violence has been highlighted by Veeraraghavan (1995). She makes a case for comprehensive clinical and community-based programmes using behavioural techniques for the treatment and prevention of violence. Shah (2002) sensitively broaches the complex issues relating to therapy in couples with abuse and violence. She shares her concerns as a therapist and trainer and, using a case, provides some guidelines as to how to proceed in therapy with such couples.
Parents of Children with Difficulties
Home-based family care in mental retardation (MR) has gained worldwide recognition and attention. In India, it is important to work with families to ensure optimum care and successful family adaptation (Girimaji, 1993). Approaches to such family interventions include parent education and training, parent counselling, family adaptation, and interactive/transactional models. Basu and Deb (1996) report on the effectiveness of a home-based intervention programme for parents of children with attention-deficit hyperactivity disorder (ADHD). Parents were trained to carry out attention enhancing tasks and self-control strategies with the children. The study highlighted that when parents are motivated and there is a congenial family atmosphere, this intervention can be successful. Russell et al. (1999) examined the efficacy of interactive group psychoeducation on measures of parental attitude toward intellectual disability. A group of 57 parents of intellectually disabled children in India was randomized to 10 weeks of experimental and control therapy. The authors concluded that interactive group psychoeducation was effective in changing the attitudes of parents of intellectually disabled children. Group work is a viable option to be developed in situations where resources are limited. Malhotra et al. (2002) describe in detail a treatment package, consisting of psychoeducation, supportive and behavioural techniques for parents of autistic children delivered in three to six sessions. They emphasize the need to provide a great deal of support to parents while using them as co-therapists.
Family Caregivers of Persons with Chronic Illness
Shankar and Menon (1993) conceptualized and implemented an eight-module intervention for families of persons with serious mental illness attending a community-based, non-residential rehabilitation centre. Impaired communication, negative emotional patterns, abnormal family environment, and depression in caregivers were present in a sample of 30 families with non-remitting forms of schizophrenia (Chandra et al., 1994). Using a pre-post research design, Sharma and Veeraraghavan (1995) found that 12 to 15 sessions of behavioural family therapy (BFT), comprising psychoeducation, communication skills, and problem solving skills, resulted in improved social skills and better home environment in 20 patients with schizophrenia.
Brief intervention, comprising mental health education, was effective in reducing the distress experienced by family members of the chronic mentally ill (Prema & Kodandaram, 1998a) and in developing a more positive attitude and communication with their patients (Prema & Kodandaram, 1998b). Psychoeducation for carers of patients with schizophrenia and schizoaffective disorder resulted in more positive attitudes among carers (Shriharsh et al., 2003).
Family psychoeducation was successful in treating psychogenic pain (Dosajh & Dosajh, 1999) and Urs et al. (2002) reported that 12 to 16 sessions of psychotherapy and structured psychoeducational intervention was effective in enhancing the perceived social support from family and friends in cancer patients. Matam et al. (2003) outline the role of the family, particularly parents, in the overall management of diabetes mellitus. Parents play a crucial role in the care and treatment adherence of young diabetics, especially in terms of hospital visits, frequency of blood tests, and patterns of diet and exercise. Using the case of a 19-year-old girl, the authors illustrate the importance of working with families of young diabetics in India.
Nath and Craig (1999) highlight that, in comparison to the West, Indian families may have very different world views and ideas of ‘self’, leading to a different family organization. The presence of complex, extended family systems makes systemic therapy a viable form of treatment in India. However, therapists in India often share many of the values of their counterparts in the West. Hence, the authors caution that family therapists in India must resolve their own personal and professional problems and work in culturally appropriate ways. Interestingly, as a corollary to this view, Karuppaswamy and Natrajan (2005) share their experiences of being family therapists of Indian origin in a Western context. They highlight the importance of recognizing the therapist's world view and cultural assumptions in order to work effectively with clients.
The introduction of the Persons with Disability Act of 1995 has been a major step forward for the welfare of persons with disability in India. Psychosocial issues impacting on the quality of life of people with chronic illness and their right to live a life with dignity has been recognized. This has resulted in the need for treatment to go beyond medical management alone.
Sen (1995) discusses the role of counselling in reducing the handicapped individual's specific disabilities and the need to eradicate societal stigma towards the disabled. The emphasis is on improving the life standards of the disabled through their full participation, equal status, social integration and solidarity. Reviewing studies done in India (Jha, 1998) concluded that behaviour modification techniques play an important role in the rehabilitation of mentally retarded individuals.
Gopinath and Rao (1994) provide an overview of the psychosocial issues involved in the rehabilitation of the chronic mentally ill and highlight the techniques that can be used. Interventions aimed at enhancing the functional competence of the disabled as well as those aimed at modifying the person's socio-cultural and physical environment to compensate for continuing disability are outlined by Menon (1996).
Rao (1995) urges the clinician to recognize depressive symptoms in people with schizophrenia and outlines the strategies, especially the need for long-term supportive therapy, to address this important issue. A therapeutic package comprising drug therapy, psychotherapy, and yoga was tried out in 10 patients with schizophrenia (Dosajh, 1995). Broota (1998) illustrates the use of a comprehensive treatment plan including medication, life style management techniques, relaxation training, individual, and family therapy in an adult male with schizophrenia. The highlight of this report is the long-term follow-up over a 15-year period. A comprehensive psychosocial intervention programme for relapse prevention in schizophrenia was tried out by Rangaswami (2000) on six male patients with schizophrenia who were on maintenance neuroleptic medication. The intervention included psychoeducation, social skills training, stress management, and vocational rehabilitation carried out thrice weekly for 3 months. Patients receiving the intervention had significantly greater reduction in both symptoms and disability, better quality of life and no relapse in the 6-month follow-up period as compared to matched patients who were on medication alone.
The impact of a psychosocial intervention on the behaviour of 132 chronic schizophrenic adult inpatients (21 to 50 years), divided into groups of 10 to 12 members each was examined. The psychosocial intervention consisted of performance contingent verbal feedback and biweekly group activities like telling stories, discussing current events, playing games, and listening to audiotapes. A matched control group was not exposed to the intervention. Findings revealed a statistically significant decrease in behavioural deficits, particularly in the areas of verbal fluency and motor speed in the experimental groups (Sovani & Thatte, 1994, 1998). It is important to note that these patients were living in the mental hospital in a fairly under-stimulating environment.
Several community-based organizations in the non-governmental sector are running therapeutic services for the care of the chronic mentally ill. While many are based on the principal of therapeutic community, they use behavioural techniques to reduce problem behaviours, group work, and activities to enhance social skills and family interventions to engage the family in the therapeutic process (Kalyanasundaram & Verghese, 2000; Patel & Thara, 2003).
Rao (2002) highlights the need to understand individual factors contributing to stress, recognize stress related symptoms, and then adopt methods of coping and mastering stress. Stress management intervention at the workplace is an important primary prevention strategy. Personal, social, and work-related problems can adversely affect productivity, efficiency, and health of the employee. Training of managers and providing the services of a professional counsellor at the workplace are some of the measures (Bhatia & Bhatia, 1999; Khattri, 1997). Counselling in organizational settings focuses on the worker's emotional and personal problems on the one hand, and organizational problems on the other, and fosters mutual trust and confidence between the employer and employees. Counselling can be particularly useful in increasing self-esteem, morale, and job satisfaction as well as in reducing anxiety, tension, and conflicts both on and off the job resulting in increased productivity of the organization.
Sharma (2000) conceptualized a model to understand the interface between stress in the family and at work, and formulated an integrated three-module intervention programme. In Module 1, individuals are trained to change their lifestyles to minimize stress related situations, whereas steps to reduce stress in the work setting are taken at the organization level. Module 2 focuses on intervening on the behalf of employees and their families in various work and non-work settings. Awareness of each other's work, responsibilities, hazards, and consequences of failure or success is enhanced along with training in stress management techniques. Module 3 focuses on specific family problems.
Cognitive behavioural techniques at the workplace have also been tried out. A single session of Rational Emotive Therapy (RET) was carried out on 13 bank managers (Helode, 2002). Pre- and post-assessment revealed a significant reduction in occupational stress. Singh and Srivastava (2002) carried out eight sessions of cognitive intervention over 3 months in a group of 40 employees experiencing moderate to high level of stress. When compared to the control group (n = 30), the individuals who had received the intervention, reported improved job satisfaction and performance and better physical and mental health.
Bhattacharya et al. (1994) examined the application of transactional analysis principles for seeking the collaboration of local villagers in managing the forest regions of India. The case study reveals that if development practitioners, planners, and field workers take cognizance of the life position of their target groups, and if they change their ego states to suit each situation, there is a greater likelihood of the programme being successful.
Pande et al. (2000a, 2000b) discuss the objectives and outcome of the short-term plan of mental health care in the earthquake affected Marathwada region. Immediate intervention in the first month after the disaster was carried out for nearly 2,500 hospitalized survivors who were identified as the top priority group. A multidisciplinary treatment team from the Maharashtra Institute of Mental Health (MIMH), Pune, provided psychological interventions through orienting the survivors to field reality, early detection of psychopathology, grief counselling, etc. Outreach counselling services from the second to sixth month after the disaster were provided to the psychologically ‘at risk’ population. Training programmes for mental health professionals were organized to impart necessary skills, appropriate sensitization programmes were launched for peripheral health workers and NGO workers. The short-term intervention found immediate acceptance. Good rapport was developed with the community, and active follow-up mechanisms helped to fulfil the other objectives. This study is one of the few comprehensively planned and executed community-based psychosocial interventions and an excellent example of disaster management at the site of the crisis.
Training of Counsellors and Therapists
One of the most detailed accounts of training lay counsellors is provided by Kapur (1997). Given the paucity of trained mental health professionals and child psychologists, she describes the challenges of using teachers as counsellors to implement a school mental health programme.
Pant et al. (1998) observed that entry level characteristics of trainees in a counsellor training programme influenced the effectiveness of training. They proposed that, in addition to academic knowledge, the candidates be selected on the basis of certain personality characteristics. Training programmes for lay counsellors’ improved knowledge, competence, and confidence of the trainees in different dimensions of counselling (Manickam, 1998). However, there were no significant changes in the personality dimensions of the trainees as a result of the training. Shamasundar (1999, 2001) highlighted the importance of empathy and praxis as therapist qualities to be focused on in training.
The Family Psychiatry Centre at the NIMHANS, Bangalore, has been conducting a structured training programme in family therapy for over a decade. Shah et al. (2000) present findings from a preliminary evaluation of this programme indicating that at the end of one month of training, the participants reported an improvement in many of the basic family therapy skills, as well as enhanced conceptual skills.
Tharyan (2000) discusses the need for psychotherapy training for psychiatric residents and highlights the role of supervision. Expert time was maximized and time constraints overcome by trying out group supervision. The author concluded that group supervision was useful in providing a background for general issues in psychotherapy, but that trainees preferred individual supervision for discussing management difficulties of individual patients. Verma and Kaur (2000) point out that psychotherapists face several ethical dilemmas in the course of therapy, especially since there is no single right way or treatment of choice. This would call for some degree of introspection on the part of the therapist at every stage of therapy from intake to termination. They highlight that this is an important area that has received very little attention.
In 1994, a symposium on training was organized at NIMHANS, Bangalore. The symposium focused on various aspects of training from pedagogy in training to supervision. It is heartening to note that the publication of the proceedings went in for a second edition in 2001, possibly reflecting the increasing interest in the area (Kapur et al., 2001).
Individual psychotherapy has been mainly supportive and psychoeducational and, together with the cognitive behavioural approaches, seems to have all but replaced psychoanalysis and the dynamically oriented therapies. This could largely be due to the fact that the latter therapies require formal training and supervision. It could also, however, reflect the need and expectations of clients. Socio-economic status, including education, influence client's explanatory models of distress as well as expectations in therapy. When family and support systems are intact, individuals use these networks to obtain emotional support and expect informational and instrumental support from professional and social agencies (Rao et al., 2001). However, with shrinking social networks, there is a greater demand for emotional support from professional care providers (Pillay & Rao, 2002).
A positive step in this regard is the development of family-based approaches to therapy. Since family members are the main sources of support and care, it is important to strengthen this resource. The last decade has seen a greater emphasis on the comprehensive management of severe mental disorders. There has been a shift from mainly symptom control with medical management to improving the functional ability and quality of life using psychosocial interventions. The initiatives in this area are encouraging.
Community interventions can be of two types: Those aimed at primary prevention and those directed at early intervention. Stress management programmes are an example of the former. With an increasing number of disorders being termed as ‘stress related’, there is a need to develop and disseminate intervention modules aimed at prevention of illness and promotion of health. An integrated approach, including indigenous relaxation techniques together with cognitive strategies, holds promise. The efforts of the team at Maharashtra Institute of Mental Health (MIMH), Pune, in the aftermath of the Latur earthquake, are indeed laudable and illustrate the benefits of early intervention. The study demonstrated that it is possible to introduce psychosocial intervention as part of a disaster management programme and reduce the impact of the trauma. These experiences led to early recognition of psychological trauma and interventions being mobilized on a large scale when the Gujarat earthquake took place.
With regard to training, the documentation of the pedagogy of a few of the psychotherapy training programmes in the country as well as the efforts made to structure and evaluate therapy training are a good beginning. Nevertheless, a lot more needs to be done in this very important area.
THE JOURNEY AHEAD: BACK TO THE FUTURE
In the last decade, research in psychological interventions has come a long way. Given the constraints of time and resources that most clinicians and researchers experience, the publication output has been impressive. However, there are miles to go…!
Yoga and meditation have been consistently found to play an important role in promoting the physical, mental, and spiritual well-being of clients seeking help. Despite this, yogic practices and meditation have not been routinely used in the clinical setting. They have been treated as adjuncts to other treatments or used as a last resort for treatment refractory cases. There is sufficient evidence to warrant their inclusion in service delivery. Meditation, especially, has tremendous potential in the psychotherapeutic situation. It can induce physiological relaxation, limit negative thought patterns by enhancing self-observation and management as well as lead to deep transformation of personality. It is therefore, compatible with modern psychological interventions and shares common ground with both the insight oriented as well as the behavioural approaches. However, full justice is not being done if it is used as a form of symptomatic treatment. It needs to be conceptually integrated into the psychotherapeutic regimen. Moreover, the practice of certain asanas or breathing techniques should not be done in isolation, but ideally, form a part of a holistic approach to lifestyle management. Incorporating yogic practices and meditation in the life skills training modules in schools and colleges and in stress management programmes at work settings, may pay dividends in the form of prevention of illness and promotion of health. More longitudinal studies are required to confirm this.
Contrary to Western literature advocating JPMR as the most effective technique for reducing arousal, studies done in India have found the indigenous practices of vipassana meditation and shavasana to be more effective. Since these techniques are culturally more appropriate, client expectations may play a significant role in enhancing treatment efficacy. Andrade (2002) has cautioned that this could also result in a strong placebo effect that would need to be controlled for in intervention research.
The vast number of parables from the ancient Indian texts act as metaphors in psychotherapy. When used by the client they represent the language of the unconscious; when used by the therapist, they generate new patterns of awareness for the client. Knowledge of these stories was traditionally part of the socialization process in India. Increasing urbanization and westernization has resulted in an alienation from this heritage. This could result in the therapist not being sensitive to the client's worldview. It also indicates that greater attention needs to be paid to introduce this knowledge base in the educational system in general, and in psychotherapy training in particular. Introduction of these modules in the training will also help in the development of an integrated approach to psychotherapy. In the past, many researchers have questioned the relevance and applicability of Western models of therapy. At the same time, others have drawn parallels between psychoanalysis and yoga, CBT and the Bhagvad Gita, indicating that while the larger framework may actually be quite similar, cultural differences may be reflected in the content. The impact of socio-cultural factors on attitudes to help-seeking and level of acceptance of psychological intervention require more focused attention.
Psychotherapy research designs in this review have ranged from the venerable case study method to the ‘gold standard’ of RCTs with the emphasis being on outcome. Several researchers have stated that while the RCT is one of the strongest ways in which to establish efficacy of a treatment in a controlled situation, it may not be the most appropriate design to demonstrate effectiveness of therapies in the real world (Essock et al., 2003). Stiles and Shapiro (1989) opined that the use of the drug metaphor is inappropriate as it implies that process and outcome are distinct phenomena in psychotherapy. There is increasing recognition that process-outcome research may help us address the outcome paradox in psychotherapy, that all techniques are equally effective (Llewelyn & Hardy, 2001). Process research examines what actually happens in therapy. It looks more closely at client and therapist characteristics and the interactions between therapist and client both in and across sessions. The article by Pai et al. (2003b) illustrates these issues.
Western studies have observed that as many clients report positive changes when a therapist ‘listens’ to what they have to say, controlling for the ‘Hawthorne effect’ in psychotherapy research is important. Therefore, control groups need to be active, ‘attention-placebo’ groups rather than ‘no intervention’ groups. However, in the Indian context, the study by Patel et al. (2003) suggests that one cannot assume that an opportunity to discuss one's problems will, in itself, be therapeutic. None of the studies reviewed have referred to the therapeutic relationship or addressed process issues such as dependency, transference, and difficulties in termination. Another area in which the research is silent is that of poor/non-responders to therapy as well as dropouts from therapy. It would be equally important to know what aspects of therapy clients perceive as not helpful and what kinds of clients do not benefit from psychological intervention. Longitudinal studies that attempt to contact clients lost to follow up would also throw light on this area. Overall, client and therapist characteristics and the therapeutic relationship merit serious attention in future research. This needs to be done keeping a gender sensitive perspective.
Research in psychotherapy is time, personnel, and cost intensive, especially if one looks at the rigour with which process-outcome studies are being carried out in the West. Both quantitative and qualitative research designs and their data analyses have got very sophisticated. Studies have even attempted to examine how the brain responds to psychotherapy (Gabbard, 2000). The use of audio- and videotapes, the preparation of transcripts and rating of sessions by independent raters all seem a luxury in our country. Despite these constraints, the focus of therapy, in terms of the problems that clients present with, need to be examined. It is possible that interpersonal conflicts are in the forefront, overshadowing the intrapsychic difficulties that may be present. One has often observed in clinical practice, that it is only when clients have addressed the immediate systemic concerns using supportive and cognitive-behavioural strategies that they are able to shift to a more personal, dynamically oriented framework. Margison et al. (2000) argue in favour of gathering good quality data from routine practice. They suggest the use of the practice research network (PRN). The PRN model involves a number of clinicians who agree to collaborate for the purpose of research. This results in generating large data sets that would otherwise not be feasible. At the same time, such research would reflect the challenges of the practice of psychotherapy. This model is particularly suited for countries such as India, where human and economic resources need to be pooled. To achieve this, it would be important to build capacities in carrying out therapeutic research and for reporting the findings. This will also enable more clinicians to publish their work. There is a wide variation in the settings in which the psychological interventions have been carried out as well as in the type and level of professional training of the therapists. In the absence of a regulatory body monitoring professional training, the onus is on each individual therapist to ensure that he/she is qualified to deal with a particular client's problems and carry out the intervention. A beginner therapist needs adequate supervision to feel comfortable in the therapeutic situation. Therefore, increasing opportunities and avenues for training is the need of the hour.
The paucity of trained professionals, has led to a large number of programmes for training ‘lay’ counsellors. These groups of care providers form an important first line of care especially for community-based intervention. However, they are trained in brief supportive interventions. If they carry clients for long periods, they may actually delay or hamper the process of the client seeking appropriate help. A data base of clients seeking help including their socio-demographic characteristics, the presenting problems and their expectations from therapy will help to develop and test different intervention modules for various levels of professional training. It is equally important to develop appropriate therapeutic interventions to address the emotional needs of persons who are vulnerable, such as the poor, illiterate, and the elderly, who are currently not adequately represented in the existing system.
Finally, is there an uniquely Indian model of psychotherapy? The question still eludes an answer. The evidence suggests that Western models and approaches are effective. However, the manner in which they are contextualized and delivered for the individual client are uniquely Indian. The practice of psychological interventions is largely eclectic. Many purists of psychotherapy may argue that eclecticism is an excuse for not having a sound rationale for adhering to certain concepts, embedded in a particular framework. However, judicious eclecticism reflects the ability of the therapist to be flexible and sensitive to the client's needs. Most therapists in India would probably argue against the use of essentially reductionistic, manual based therapeutic approaches followed so widely in the West. A truly indigenous framework for psychotherapy in India will need to reflect the diversity of a pluralistic, multi-cultural society.
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