Introduction – Psychology in India, Volume 3

Introduction

Girishwar Misra

This volume deals with the broad domain of disciplinary developments in the areas of clinical psychology and health psychology. While doing so, we have included the efforts to address the concerns of two special groups—the differently abled and the aged. There are two chapters that focus on intervention. One is on therapeutic practices to help people suffering from mental disorders and problems at the individual level and the other is concerned with interventions at the level of the community. All these areas are increasingly becoming very important.

In contemporary research and professional practice, the twin areas of disease and health are separately emphasized. This indicates that it is not sufficient enough to attend to the issues pertaining to illness or disease alone. Instead, we must look at the issues of prevention and maintenance of health in the general population, too. Health, being dynamic, is a process-oriented phenomenon that requires continuous monitoring and effort on the part of individuals. Its awareness has become more salient, as we notice that today's major health challenges, such as CAD and diabetes, are significantly linked with people's lifestyles. The value of the context of life world also becomes more pertinent when we notice that understanding and practices related to health are embedded in the matrix of socio-cultural meanings, beliefs, and customs. As a result, health behaviours are organized differently in the diverse cultural and subcultural settings.

The relationship of health with ecology and environment too is very critical. In concrete terms, health lies at the intersection of body and environment. In the Indian thought, smooth and productive functioning of a person (jiva) is conceptualized in terms of harmony between person and environment. Ayurveda, the Indian science of medicine, recognizes that the properties of persons and the objects in the environment are common and therefore, one must strive at synchronization of the two. It holds health to be a state of equilibrium and disease to be a state of disequilibrium. The healthy lifestyle (swasthya vritta), as elaborated by Charaka in his treatise, includes the following of a daily routine (dincharya), a seasonal routine (ritucharya), an ethical lifestyle (sadvritta), proper nutrition and diet (ahara), living in a sound environment, and good public sanitation. Consequently, health is a matter of joint functioning of the body, mind and spirit. This kind of holistic view is gaining increasingly greater support across the globe.

As a developing country going through socio-economic transformation, India is currently facing a variety of health-related challenges at different levels of the socio-economic hierarchy. The rise of consumerism, significance of material success, influence of the media, economic liberalism, the information and communication revolution, and globalization are also nurturing a new kind of ideology and belief system that are, in turn, creating new challenges and problems. Market forces have come into direct conflict with policies related to health. The infrastructure for health care in the public sector is declining at a fast rate, and private players are coming in to provide health facilities at a higher cost, which is unaffordable for a vast majority of the society. As a country, India is inhabited by diverse groups and communities that are at different levels of development. Dealing with their health needs is a gigantic task requiring resources, planning and political will.

Following an inclusive approach, the country has committed itself towards ensuring the health and well-being of the people in general and particularly of those who are on the margins of society. In this connection, the disabled and the elderly require special attention. The equality of opportunity and considerations for human rights demand urgent attention to them. The need for better health care for the people requires an understanding of the notions of health and well-being, problems encountered by the people who suffer from diseases, and the efforts made to ameliorate the suffering of the sick. So, pathology, or deviation, as well as the positive state of health are valuable. There is acute shortage of trained mental health professionals. Against this backdrop, the chapters of this volume make efforts to critically evaluate the work done by psychologists pertinent to these areas.

Chapter 1 is on ‘Clinical Psychology’ by Prabal K. Chattopadhyay. He presents a comprehensive account of the diverse developments in this field, with a focus on the application of the concepts of clinical psychology in daily life and analysis of the professional concerns of clinical psychologists. The analysis of psychological disorders gives the details of epidemiology and demographic patterns. The classification of mental disorders and the present status of such classification in the Indian cultural context have been provided. In particular, the status of research on the disorders of childhood, adolescence, adulthood, old age, substance abuse disorders, organic brain dysfunctions, psychosomatic/psycho-physiological disorders, and sexual dysfunctions and deviances has been analysed.

The chapter also offers an appraisal of the research pertaining to family assets and liabilities in the context of mental disorders. Chattopadhyay observes that the stresses and conflicts experienced by women, with special emphasis on conflicts originating from home role attitude and employment role attitude, have a significant impact on children's mental health. Patterns of psychological disorders in relation to psychotherapeutic intervention strategies adopted, and their limitations in relation to the cultural context, have been documented. Issues pertaining to crisis intervention, and measures adopted for rehabilitative interventions for patients with cancer, people suffering from conduct disorders, and attempted suicides, are discussed.

Chattopadhyay also provides an account of psycho-social rehabilitation and its present status in the Indian set-up, with special emphasis on family therapy. He offers a critical appraisal of the status of community mental health, which covers attitudes towards mental illness and the status of psychiatric and psychosocial rehabilitation in the community. While dealing with these issues, an account of measures adopted for rural development in India, including population control, are also delineated.

Psychodiagnostics constitutes an important aspect of the practice of clinical psychology. The chapter discusses the situation related to tests/tools to suit the cultural context including neuropsychological and psychophysiological methods; comparisons of direct and indirect tools employed for assessment and research. In this context, Chattopadhyay raises some important methodological issues pertaining to procedural errors in test standardization, in employing indices for assessing behaviour pathology, and in the application of clinical methods for assessment and evaluation. The analysis shows that there is need for more care and sustained effort towards improving the measures and procedures used in research and practice in the field of clinical psychology. Finally, the chapter examines the issues of professional development. In doing so, the situation of programmes run for training clinical psychologists in India is critically evaluated. The author shares his reflections for future research and training.

Chapter 2 is on ‘The Psychology of Disabled People’ by Anita Ghai. It reviews research done in the area of disability. The attempt here is to locate and evaluate research efforts that focus on different dimensions of disability. The review examines various issues, such as prevalence of disability, issues of definitions, terminology and measurement. Further, the attempt is to highlight the assumptions and models of disability, as well as, comprehending the connotations attached to disability in Indian society. Attitudes towards disability, dispositional characteristics, gender issues, and impact on the family are some of the other issues that have been discussed.

Ghai observes that disability issues are yet to achieve prominence in psychological research. Mainstream psychology has tended to relegate disability to a peripheral area of concern. The existing research could not incorporate the paradigm shift evident in the disability discourse. Instead, there is a perpetuation of a ‘two-group’ approach (disabled-normal), without ever interrogating the assumptions underlying the concept of normality. The conceptual framework guiding these efforts is largely medical, which makes disability an essentialist and reductionist category. It is one kind of problem to be impaired and another kind of problem to be in a culture where the impairment is used to produce disability. For research to impact practice, a more holistic approach of inquiry is needed. Finally, the chapter makes some suggestions for future research so that the quality of lives marked with disability can be improved.

Chapter 3, on ‘Geropsychology in India’ by P. V. Ramamurti and D. Jamuna, discusses developments in geropsychology. Gerontology, which is the study of ageing and old age, is a multidisciplinary subject of growing global significance. Its major subfields are biogerontology, geriatrics (medical aspects), and the study of the behavioural and social aspects of ageing. Geropsychology is the study of behavioural change across the life span. This field sets its sights on the welfare of the elderly.

The chapter starts with a brief account of the historical development of the study of ageing and surveys the significant trends in the development of geropsychology in India, the foundations of which can be traced to the 1950s. In the last six decades, considerable work has been done on ageing, of which psychological, socio-familial and welfare aspects constitute the bulk.

Ramamurti and Jamuna note that, as one progresses in life, the accumulation of earlier experiences has its effect on one's present as well as future behaviour. The best way of ensuring a good later life is to ‘catch them young’, and ensure that people adopt such early lifestyles that would promote longevity that is disability free, happy and lively. By modulating genetic expression and the psychophysical environment, the severity of the contributory factors to the process of ageing can be mitigated, and the whole process of ageing can be substantially arrested.

Indian research in geropsychology, over the years, has covered many facets of individual and social behaviour. Significant studies deal with public perceptions (attitudes) towards ageing and the aged; personal and social adjustment; adjustment to retirement and leisure; cognitive aspects of ageing, including perception and memory; personality characteristics; social supports and networks; health behaviour and perception of disability; mental health; frustration, stress and anxiety, psychosocial issues in elder care at home and in institutions; elder abuse, neglect and ageism; and intergenerational relationships. Most of the aged are women and are based in rural areas. Hence, gender and rural–urban issues are of significance. Ageing is found to be associated with greater spirituality. Many exhibit anxiety for their personal future and the end of life.

Ramamurti and Jamuna observe that ageing has been perceived as being associated with illness and reduced physical and psychological fitness. We need to design behavioural interventions, and make old age happier and productive. Studies on the ingredients of successful and active ageing do provide certain cues for such programmes. The chapter discusses studies of psychosocial characteristics of long-lived individuals and psychological correlates of good quality of life in the older years.

The chapter hints at the strengths and lacunae of the research effort in geropsychology in India. The grey areas that need to be attended are also highlighted. In view of greater health awareness, health practices, better control of disease and disability, and repair of diseased organs, a major segment of aged people would be physically and psychologically able. We need to evolve effective programmes for the productive utilization of this increased human resource. However, we need to pay attention to the special contexts of ageing in India. Longevity and quality of life in the aged can be viewed as a dynamic weighted regression on a host of factors (internal and external) that impinge on the person as he/she passes through the life span.

With a large segment of the population being poor and residing in rural localities, the medical model of care services (as prevalent in western countries) may not be feasible. Instead, a modified social model of care services would be more appropriate. The psychological component in such cases would be good interpersonal altruistic behaviour by the care providers and care recipients.

Chapter 4 is on ‘Health Psychology: Progress and Challenges’ by Sagar Sharma and Girishwar Misra. They have made an effort to integrate and analyse the progress of research in health psychology in the past one decade, and to identify the emerging challenges. They argue that ‘health’ needs to be understood in the ecological context of people, which is critical to the construction and experience of health and illness. This becomes more pertinent in view of the current realization that health is not simply the absence of illness. It is closer to the Indian view that treats health holistically as a state of delight or a feeling of spiritual, physical and mental well-being. Yet, the lived meaning of health is quite diverse, depending on the social world of people and their perceptions. This makes understanding the socio-cultural construction of causation of illness and well-being relevant. Recent research has drawn attention to the role of indigenous beliefs, like karma and metaphysical beliefs, in promoting well-being.

Sharma and Misra concentrate on three questions. The first question is, ‘who becomes sick and why?’ Research has demonstrated that the level of health and illness are jointly determined by social structural environment (e.g., socio-economic status [SES], family structure, residential density, age and gender), as well as psychological factors (e.g., stress, dispositions, coping, and social support). It has been found that livelihood stress, sexual conflicts and familial conflicts are the major fallout of lower SES and lead to poor quality of life. Chronic crowding has been found to be associated with difficulties in adjustment in school, poor academic achievement, elevated blood pressure, learned helplessness and impaired parent–child relationship.

Studies show that the behaviour of adolescents jeopardizes their health. The health-damaging lifestyles are located in the social-structural and psychological contexts. In case of geriatric health and well-being, research has focused either on social-structural or psychosocial variables in terms of life stress, vulnerability, anxiety, depression etc. The possible linkage of social structural and psychological variables with health and ageing remains largely unexamined. Gender-related variations in health and well-being have also been noted. While women often show less subjective well-being than males, the social and economic empowerment of women is found to be positively associated with subjective well-being. However, research on marital status and well-being has provided diverse results.

Stress is the cause of most psychophysiological disorders, and people who are exposed to life-event stress are at a greater risk of psychological distress and poor physical health. Chronic stressors in everyday life situations (e.g., academic settings, poverty, family, parenting, social life) also influence health and well-being. Research has shown that certain dispositions also make people prone to illness. Tamasic dispositions are found to generate occupational stress with strong psychological, psychosomatic and behavioural consequences. Adults who follow anasakti are, on the other hand, less distressed and exhibit fewer symptoms of ill health. Various researchers have tackled trait anger and trait anxiety and its effects, and have found that it leads to cardiovascular diseases, hypertension and peptic ulcers.

Another psychosocial contributor to health and illness is social support. Research has shown that emotional support has a stress-buffering effect, and connectedness (e.g., network size) is likely to have direct effects on health and well-being. Stress, dysfunctional family background and low SES are some of the precursors to substance abuse. Psychological distress, sensation seeking, dependence, loneliness, depression, anxiety, and alienation are often found in higher degree among substance abusers. Health behaviour is also influenced by health-related cognitions. Widespread lack of basic knowledge in the area of fertility, maternity, STDs and sexuality have led to marital distress, life-threatening diseases, and unsafe sexual practices. The rapid spread of AIDS worldwide is a direct fallout of lack of awareness and inadequate knowledge.

The second question addressed in the review is, ‘among the sick who recovers and why?’ Research related to issues of coping with chronic illness and events of mass destruction has been reviewed in this context. Children suffering from chronic illness, like epilepsy, have lower psychological well-being and greater incidence of problems, like depression, lower number of behaviour problems, conflict, low satisfaction and low self-esteem and happiness. Research has also been done on patients with diabetes, AIDS and cancer. Diabetic patients’ major concerns are related to future complications, interference in work and social life, whereas the diagnosis of AIDS leads to depression, adjustment disorder and cyclothymia. Cancer precipitated a number of psychological distresses, including socio-emotional problems, sexual problems, perceived rejection, depressive episodes, obsessiveness with illness and other related symptoms.

Healing and psychological recovery result from several factors, some of them being: a faith-bond between patient and health professional, acceptance of suffering, future orientation, optimism, perceived control, and relationship with the family. Areas that need greater focus in term of research are culture-sensitive intervention and health of caregivers, who generally tend to be the women of the household.

Research has shown that people who suffer due to catastrophic disasters of mass destruction face psychological trauma that involves a state of shock, heightened anger, anxiety, depression, helplessness, obsessional paranoid symptoms, post-traumatic stress disorder (PTSD), and other psychiatric disorders. There are subcultural differences in coping with the trauma. Residents of urban areas, being more materialistic, reported greater degree of trauma than the villagers, who believed that discharging their duties would lead to peace and harmony. Men had higher suffering and lower recovery than women. Research has demonstrated that social-structural changes in a post-disaster phase altered the nature and intensity of suffering and impeded the healing process.

The third question addressed in the review is, ‘how can illness be prevented and health promoted?’ Illness prevention and health promotion initiatives include: (i) individual-based interventions, and (ii) community-based interventions—programmes aimed at the prevention of illness and promotion of health. It has been noted that such programmes must be based on the understanding of traditions, belief systems, patterns of family and community interactions and indigenous resources. Culturally sensitive therapeutic techniques are being used. It has been noted that healing in itself is a spiritual experience involving an inner sense of well-being, balance, harmony and peace. Service, or volunteering, is also therapeutic, as selfless service to others is seen to be a way to transcend egoistic desires promoted by today's consumer-bound culture.

Sharma and Misra note that interventions targeted at, and through the community, not only comprise extensive health awareness programmes but also involve the community as an active partner in providing psychological care. Greater awareness regarding contagious diseases, like HIV/AIDS, tuberculosis and hepatitis, needs to be created along with the removal of sexual myths, taboos and misconceptions. Television serves as an excellent medium to reach the public with health messages, as do other channels of communication like folk theatre and songs. Interpersonal psychosocial care is a community-based intervention that is most often used for disaster management. It alleviates suffering, prevents pathological developments, and facilitates recovery and long-term rehabilitation of survivors.

The authors observe that research in health psychology needs to address issues of individual lifestyles, gender differences, social and community factors, living and working conditions, general socio-economic, cultural and environmental conditions and, finally, the interaction among these factors, when attempting to understand health and illness. Health psychologists should also address psychosocial and psychosomatic problems of women, specific life-cycle challenges and possible life-threatening chronic conditions. The paucity of research on religion/spirituality and health is striking and hence a comprehensive research effort needs to be made in that direction. Another neglected area is coping with events of mass destruction, and this needs to be addressed in a socio-culturally sensitive manner. Studies of health-beliefs and practices show that they mediate treatment-related decisions among patients and health-related consequences. Beliefs, including supernatural factors, still prevail in the minds of masses. There are reports of various disorders pertaining to such beliefs.

The review also takes into account factors that contribute to health and illness, including the social-structural and psychosocial environments, and the dispositions and the factors that comprise health-related behaviours or lifestyles. Social-structural factors include socio-economic status, family structure, residential density, age, and gender. In this regard, the status of women's health requires further study. Psychosocial factors include stress, psychosocial resources, dispositions, coping and social support. Behavioural contributors to health and illness include social-structural and psychosocial aspects of health behaviour, and health awareness. Available studies are largely correlational and cross-sectional, and an important area covered in the review is the study of coping with chronic illness and events of mass destruction, which indicate the complexity of the processes.

Finally, there are studies on illness prevention and health promotion. The authors raise issues pertaining to health, communication and psychosocial care and look at the macro-level issues related to the psychosocial and coping aspects of medical illness and care. The review reveals that there are multiple factors that contribute to health and illness. A shift is noticed in favour of marginalized groups and the sick.

Chapter 5 of this volume is by Kiran Rao on ‘Psychological Interventions: From Theory to Practice’. Using the metaphor of a journey, Rao takes us to visit places of interest in the field of psychotherapy research. The chapter is divided into four major sections. The first section, called ‘Heritage Sites’, reviews work carried out with indigenous approaches such as yoga, meditation and Indian psychotherapy. The review shows that there has been a distinct improvement in the research design, and several studies have empirically tested the merit of yogic practice. It has been reported that the effects of yogic practice are sustained over long periods, and there are incubation effects, particularly if it is made a part of the individual's lifestyle. Although the effectiveness of the system of yoga is documented in case of reducing anxiety and depression and enhancing well-being, an indigenous psychotherapeutic paradigm based on yoga is yet to emerge. Rao also notes that greater attention needs to be paid to the selection of the sample, especially in the clinical setting, such as diagnosis, duration of illness and concurrent treatment effects. She also observes that while the Ramayana, Mahabharata and the Bhagavat Gita contain innumerable stories that can be suitable vehicles to convey important themes in the therapeutic process, this mythological heritage remains unutilized because young trainee therapists are not aware of this knowledge base.

Rao observes that 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. A truly indigenous framework for psychotherapy in India will have to reflect the diversity of a pluralistic, multicultural society.

The second section is ‘Familiar Places’, and includes well-established behavioural interventions in a variety of conditions. Research in the area of behavioural interventions has moved from case reports to small group studies, and randomized case-control designs. 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 (e.g., anxiety disorder, obsessive compulsive disorder and sexual dysfunction). The use of behavioural interventions in chronic medical conditions such as diabetes is an area that needs to be examined in detail.

Work carried out using cognitive behaviour therapy (CBT) forms the third section. This is the most popular of the therapeutic approaches. Its effectiveness has been fairly well-established in a variety of conditions, especially mood and anxiety disorders. New developments in the application of CBT include its use in children and in patients with psychotic symptoms. Within the CBT model itself, the focus is on behavioural rather than cognitive techniques, and the former appear to be more effective. Rao observes that culture-specific content in dysfunctional assumptions or negative automatic thoughts is an area that merits further attention.

The fourth section is the ‘Road Less Travelled’. It includes all other psychological interventions from psychoanalysis and supportive psychotherapy to family and community-based interventions. Rao notes that 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. Individual psychotherapy has been mainly supportive and psycho-educational. A positive step in this context is the development of family-based approaches to therapy.

Studies also indicate a shift from mainly symptom control with medical management, to improving the functional ability and quality of life using psychosocial interventions. An integrated approach, including indigenous relaxation techniques together with cognitive strategies, holds promise. Yoga and meditation have been consistently found to play an important role in promoting physical, mental and spiritual well-being. Despite this, they are treated as adjuncts to other treatments or used as a last resort. There is sufficient evidence that meditation can induce physiological relaxation, limit negative thought patterns by enhancing self-observation and management as well as lead to deep transformation of personality. Indigenous practices of vipassana meditation and shavasana have been found to be quite effective.

Rao draws attention to wide variation in the settings in which psychological interventions have been carried out as well as in the type and level of professional training of 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. Therefore, increasing opportunities and avenues for training are the need of the hour. The paucity of trained professionals has led to a large number of programmes for training ‘lay’ counsellors.

The last section of the chapter is ‘The Journey Ahead: Back to the Future’. In this section, Rao raises some important concerns that deserve the attention of researchers, therapists and agencies involved in providing health services. She argues a case for yoga and meditation as treatment modalities in their own right, rather than ancillary ones used merely for symptomatic treatment. She also identifies some priority areas in which research is warranted. These include: longitudinal studies of the impact of lifestyle interventions for the prevention of illness and promotion of well-being, and studies addressing the process analysis of therapy and help seeking, as well as the readiness to accept such therapy. These are culturally relevant themes, and we have very little systematic knowledge of them. Rao also points to the need to extend therapeutic interventions for marginalized people. The paucity of trained mental health practitioners in a vast country like India and the lack of any regulatory body for its monitoring are matters of grave concern, and demand urgent attention both from professional bodies and the government. It is hoped that budgetary provisions for the health sector would be enhanced. This push could have important impacts on people's quality of life.

In the last chapter entitled ‘Psychosocial Interventions for Community Development’, Ajit K. Dalal has endeavoured to examine issues related to major societal interventions. Community development has been a major concern for the government, bureaucrats, activists and social scientists for the last 50 years. For rapid socio-economic development of the country, it is considered imperative that local communities are actively involved in the developmental process. Earlier research has shown that people's aspirations and expectations play an important role in the success of community development programmes. It was also realized that psychosocial interventions have to be integral components in all community development programmes. Dalal examines some of the substantive issues regarding conceptualization, contextual factors and methodology of community-focused psychological interventions for development. He presents an overview of the contribution of Indian psychologists, and their major concerns that form the body of knowledge in this domain. Community development programmes are examined in a historical perspective to identify the role of psychological factors in mobilizing local communities.

Dalal presents a review of research conducted by Indian psychologists to examine the concept of voluntarism in the Indian cultural context. He discusses some major governmental and non-governmental programmes to illustrate the role of psychological factors, both as interventions and as outcomes. It is observed that the success of developmental programmes often depends not only on the availability of monetary and material resources, but also on human factors, that is, the commitment, involvement and integrity of programme initiators. People like Anna Saheb, Pandurang Shastri, Sudarshan and Rajendra Singh have emerged as the heroes of success stories. Another critical factor is the compatibility of a programme with local beliefs, practices and aspirations. Programmes that have transparency and openness are joined by a larger number of people than those controlled by a handful of people at the apex level.

Dalal critically examines the psychological factors that impede and facilitate community development in the light of available research. He notes that some of the major barriers include: an oppressive village environment, a culture of dependence, a lack of trust, the disempowerment of local communities and the undermining of native knowledge. However, some possibilities of improvising psychological interventions at both macro and micro levels do exist. Dalal argues that a holistic view of development should take into consideration the network of relationships that define the well-being of an individual in the Indian context. Large-scale psychological interventions are taking place in the field, which need to be properly documented and examined. Dalal contends that psychologists need to engage themselves more actively in interdisciplinary action research to overcome methodological and practical challenges of intervening at the community-level. In this respect, it is important to build an active interface among academic institutions, NGOs and communities.