Assignment

Unit 1

Submitted to

Dr. Abdul Salam

Head, Department of clinical psychology

Imhans

Submitted by

Deena K Varghese

1st year M.Phil clinical psychology trainee

Imhans

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 Defining Clinical Psychology

A fundamental characteristic of clinical psychology is its deep roots into clinical practice, unlike
other fields of psychology. The major advances in psychological assessment and treatment that have
been introduced by clinical psychologists in the past decades have found their inspiration from their
activities in the front-lines delivery of clinical services (Guidi & Fava, 2014). In an attempt to define
and describe clinical psychology, J. H. Resnick (1991) proposed the following definition and
description of clinical psychology:

“The field of clinical psychology involves research, teaching, and services relevant to the
applications of principles, methods, and procedures for understanding, predicting, and
alleviating intellectual, emotional, biological, psychological, social and behavioral
maladjustment, disability and discomfort, applied to a wide range of client populations” (p. 7).

According to Resnick, the skill areas central to the field of clinical psychology include assessment and
diagnosis, intervention or treatment, consultation, research, and the application of ethical and
professional principles. Similar themes can be identified in the definition of clinical psychology given
by Division 12, the society of clinical psychology of the American psychological association.

The definition is as follows.

"The field of clinical psychology integrates science, theory and practice to understand, predict,
and alleviate maladjustment, disability and discomfort as well as to promote human adaptation,
adjustment, and personal development. Clinical psychology focuses on the intellectual,
emotional, biological, psychological, social, and behavioral aspects human functioning across
the life span, in varying cultures and at all socioeconomic levels"( society of clinical
psychology, 2002).

Activities of clinical psychologists

Norcross et al. (2004) surveyed 694 clinical psychologists in 2003. In this survey of 694
randomly selected clinical psychologists from the APA Division 12 (Clinical Psychology) roster,
roughly 34% were women. Only 7% of clinicians were members of racial minorities. As for primary
theoretical orientation, 29% of the sample described themselves as eclectic/integrative, 28% as
cognitive, 15% as psychodynamic, and 10% as behavioral. Only 12% of the clinical psychologists
sampled, expressed any dissatisfaction with their choice of clinical psychology as a career. The
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percentage of clinicians adhering to a psychodynamic orientation has declined over the years, whereas
the corresponding percentage for a cognitive orientation has increased dramatically. The popularity of
the eclectic orientation has been strong for some time (Norcross et al., 2004).

Norcross et al (2004) found that psychotherapy is of one sort of the most frequently engaged in
activity by psychologists. Clinical psychology is the leading force underlying psychotherapy research
and practice. Other area is diagnosis and assessment. All practicing clinicians engage in assessment of
one form or another aims to better understand the individual so that a more informed decision can be
made or the most desirable course of action selected. Clinical psychologists who have full or part-time
academic appointments obviously devote a considerable amount of time to teaching. Clinical
Supervision activity is really another form of teaching. However, it typically involves more one-to-one
teaching, small group approaches, and other less formal, non classroom varieties of instruction. Whether
in university, internship, or general clinical settings, clinical psychologists often spend significant
portions of their time supervising students, interns, and others. It also involves seeing clients and then
discussing their cases with a more experienced supervisor. Clinical psychology has grown out of an
academic research tradition. By virtue of their training in research, their extensive experience with
people in distress, and their knowledge of both therapy and assessment, clinical psychologists have the
ability to consume and to produce new knowledge. The weight and potential growth of clinical
psychology lie in its capacity to maintain a strong clinical focus in research and to progress in emerging
lines of research that have been developed. In consultation and in teaching, the goal is to increase the
effectiveness of those to whom one’s efforts are directed by imparting to them some degree of expertise.
Nearly every clinical psychologist spends time on administrative tasks. For example, client records must
be maintained, those infernal effort reports must be filled out each month, and research projects must be
cleared by committees set up to safeguard the rights of human subjects. Clinical psychologists who
work for agencies or institutions will likely serve on several committees such as personnel, research,
patient rights etc.

History of the field of clinical psychology

History of clinical psychology in ancient time

The awareness of mental illness, as distinct from physical illness, can be dated back as far back
as 2100 BC, to the ancient Babylonians. Ancient cultures such as those in south and central Americas as
well as the ancient Hebrews contributed to the treatment of mental illness. Earlier, mental illness was
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viewed from a religious perspective and the treatment included prayer, wearing of amulets and various
religious rituals were performed.The historical roots of medicine and philosophy can be found from the
writings of ancient Greek philosophers. He proposed that psychopathology arise from the imbalance of
bodily humors. The bodily humors includes blood, black bile, yellow bile and phlegm. An excess of
black bile is considered to be a source of melancholy. He also described mental conditions into types.
Some of them are phrenitis, mania, hysteria and paranoia. Phrenitis was a condition in which the person
had high fever and irrelevant talk, but the symptoms vanished when the fever had subsided. Mania was
use to describe the condition in which a person was acutely agitated in the absence of fever. Patients
with hysteria were mainly women and presented with vague bodily complaints. Paranoia was
characterized by bizarre thinking in the absence of fever.

Greek Thinkers Socrates (470-347 BC) emphasized on the healing powers of speaking and self-
expression. Plato believed that soul had three levels such as logistikon, the thumos and the alogistikon.
He proposed that logistikon resided in the brain and was responsible for logic and reason. Thumos was
considered as a part of chest and responsible for aspirations and courageous and the alogistikon resided
in the stomach and was responsible for instincts and appetite. Aristotle also believed in the healing
power of words spoken by patients with mental disorders.

According to the yellow emperor’s book of internal medicine, which was published in second
century BC, mental illness resulted from the imbalance of the powers of yin and yang in Chinese. We
still use some of the traditional Chinese medical treatments such as acupuncture. Evidences indicate that
ancient Chinese people used tests of mental abilities as part of their recruitment of civil servants for
over 1000 years prior to the development of psychological tests in Europe and the United states. But,
during that period medieval Europe witnessed a decline in the growth of philosophy and science and
religious thought dominated that period. They viewed mental illness as a result of demonic possession
or other supernatural powers and religious ritual were used for treatment. “Malleus Malificarum” (The
witches Hammer), a publication of that time, was used a manual for the identification, torture and trial
of witches. This book was endorsed by the pope and went through nineteen editions over a 300 year
period. The renaissance period saw the reemergence of a scientific and more humanistic approach to
people with mental disorder in Europe. Paracelus, a physician during that period rejected the spiritual
causes of mental illness, introduced a biological approach to mental illness. He practiced a form of
medicine which we might call today as homeopathy. Another important figure during that period was
Weyer. Like Paracelus, he argued that human behavior could be understood as a function of biological
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processes. He developed a sophisticated descriptive classification system that included toxic psychoses,
senile psychosis, hysteria, delusions, paranoia, depression and epilepsy. In 1583, he published “De
Praestigiis Daemonum” (The slight of hand of demons) which disputed the Malleus Malificarum.

Clinical psychology in eighteenth and nineteenth century

By the 18th century, mental illness was accepted as falling under the purview of medical
profession, as part of psychiatry. But the lives of patients remained horrific and they were chained and
housed in asylums. The patients were ridiculed and mistreated by their guardians. The treatment
methods included adjusting bodily fluids including purges, blood- letting by leeches or other means and
vomits. Benjamin Rush, one of the early pioneers of psychiatry, frequently used such method. Majority
of the psychiatrist during that period believed that mental illnesses were caused by an inflammation of
the brain due to an excess of blood in that area. Starvation was used as another technique because the
patients’ bodies would not able to produce excess blood, phlegm, or excrement due to deprived calories.
But depression was thought as a result of lack of blood to the brain.

A new treatment philosophy, moral treatment movement was introduced during the last 19th
century resulted in significant reforms in the mental health field. This movement was initiated, nearly
simultaneously by Phillipe Pinel in France and William Tuke (1732-1822) in England. ‘A treatise on
insanity’ written by Pinel described the moral treatment of mentally ill. Á description of the retreat in
1813’ written by Samuel Tuke was instrumental in spreading moral treatment to the United States. The
first institution established in the United States during the reforming period was Friends asylum in
Pennsylvania. The McLean asylum, the Blooomingdale asylum and the Harford retreat centre were
established in 1824. Dorothea Dix was one of the eminent personalities, who campaigned tirelessly for
government support as well as public support for institutions to treat the mentally ill. But the moral
treatment was short lived and the reasons include the influx of chronic and severely disturbed as well as
poorly educated immigrant patients, the enormous size of the institutions and the professionals in the
field.

Developments in the field of psychological testing

Sir Francis Galton was interested in the scientific approach to the measurement of individual
differences. Galton was strongly influenced by theory of evolution proposed by Charles Darwin and
believed in the concept of hereditary. He was an advocate of eugenics, which claims that a better race of
humans could be created only if more intelligent and successful people were encouraged to mate. On
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1869, he wrote the book ‘Hereditary Genius’. He assumed that all knowledge is acquired through the
senses and reasoned that intellectually gifted people would have more sensitive systems compared to
limited people. So his tasks included tests of color sensitivity, hearing acuity, ability to discriminate
between varying weights, and reaction times. Galton established a laboratory at the South Kensington
museum in 1885 and measured various characteristics of over 9000 people.

Galton was inspired by James Mckeen Cattel, whose doctorate dissertation focused on
individual differences in reaction times which was carried out in the laboratory of Wilhelm Wundt in
Germany. He was the first person to coin the term ‘mental test’ in the article published in 1890. He
described some of the important principles of psychological testing. He emphasized on the importance
of the adoption of a standard battery of tests that would be administered in exactly the same fashion by
different researchers. According to Cattel, the strength of hand squeeze, the time it takes to move one’s
arm a set distance, the ability to discriminate between two weights, reaction time to sound and naming
colors and accuracy of bisecting the middle of a 50cm line, judgment of 10 seconds time and the
number or letters remembered after one presentation make up a standard battery.

Emergence of scientific psychiatry

Emil Kraeplin published his first edition of his text book on psychiatry in 1883, in which he
gave a detailed description dementia praecox, characterized by hallucinations, delusions and
progressive deterioration in intellectual functioning. Dementia praecox is now known as schizophrenia.
The book had eight editions and in the latter editions he described the subtypes of dementia praecox
including paranoid, hebephrenic and catatonic. He differentiated dementia praecox from manic
depressive illness, based on its origin of endogenous causes or exogenous causes. Kraeplin believed that
dementia praecox was due to inherent, constitutional factors and the latter was due to external
conditions. He viewed endogenous diseases as incurable but proposed that patients with exogenous
disorders had a more favorable prognosis. Hysteria was one of the major disorder during that period
took the attention of many psychiatrist. Hysteria is referred to as a condition in which patients presented
with vague or unusual medical complaints, for which no physical cause was identified. The symptoms
included anxiety, fatigue, memory loss, anesthesia and paralyses and patient population consisted of
females. Most European physicians dismissed the patients with hysteria because they believed that the
symptoms were raised to get the attention of others. Jean Martin Charcot, a French neurologist proposed
that a hypnotic state could only be induced in patients with hysteria. By conducting objective

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neurological examinations of people under hypnosis, Charcot demonstrated that the symptoms could not
be produced by conscious deception. One of Charcot’s pupils, Piere Janet the hysterical symptoms as a
result of significant emotional shock experienced by the patients prior to the onset of hysterical
symptoms. The patients reported no conscious memories of these traumas when not under hypnosis. But
he opposed the idea of Charcot that hypnosis could only be induced in patients with hysteria. The
writings of Hippolyte Bernheim and Joseph Breuer also contributed to the field of psychology during
this period. Sigmund Freud, a contemporary of Janet, who also studied briefly with Charcot proposed
that unconscious conflicts led to the development of hysteria. His psychoanalytic treatment, and the
varied psychodynamic therapies were dominated during the most of 20th century. Furthermore, his ideas
about unconscious influenced the development of psychological testing, especially projective
techniques.

The first psychological laboratory was established by Wilhelm Wundt in 1879 in the University
of Leipzig. During this period, William James also established a psychological laboratory at Harvard
University in the United States. G. Stanley Hall established the second U.S laboratory in 1883 and
James McKeen Cattell opened the third in 1888. In 1896, Witmer established the world’s first
psychological clinic. The clinic worked primarily with children who were having difficulties in school.
In a meeting of the American psychological association in 1896, Witmer conveyed his vision of the
psychological clinic as a place where public service, research, and instruction of students could be
carried out the same time. He established the field’s first journal, the psychological clinic, and was its
first editor. It is considered to be the forerunner of the journal of consulting psychology. He also
established the first training program in clinical psychology and provided a framework for what clinical
training should look like.

Alfred Binet’s scale was the forerunner of modern tests of intelligence. In 1904, the minister of
public instruction in Paris appointed a commission to study how to best serve the needs of impaired
children in the educational system. They wanted to identify the children who could not benefit from
instruction in the regular classroom. Alfred Binet, along with Theodore Simon developed an
intelligence scale, known as Binet Simon scale, composed of 30 items arranged in order of difficulty.
They selected items for the scale by systematically testing them with normal children. The newer
edition which was released in 1908 included more items and they were grouped by age levels from 3 to
13. Binet and Simon introduced mental age as the score for their scale. They also developed a
classification system for children based upon their performance on the scale. It includes an idiot (mental
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age of 2 years or lower), an imbecile (3 to 7 years), and moron (mental age above 7 years). A third
version of the scale was published in 1911 that extended the scale from age 3 to adult. Binet introduced
the idea of norm referenced test of intelligence, which reflected the idea that the best way for
psychologists to study individual differences was first to understand the norm first. And another benefit
was his tests measured complex intellectual processes such as judgment, problem solving, abstract
reasoning and memory.

Childhood: World War II through World War II

By 1916, the First World War was in full swing and by 1917 the United States declared war on
Germany. When the US entered WWI, APA president Robert Yerkes formed a committee to work with
the army to develop methods of classifying recruits according to their abilities, which led to the
development of Army alpha and army beta test. The Alpha test was a verbal scale for the use with
English speaking recruits and Beta test was a non verbal test of intelligence to assess men whose
primary language was not English. The period between the two world wars saw a huge amount of work
in the area of intellectual testing. By 1920s, Otis classification test (1923), the institute of educational
research intelligence scale (1925), Miller analogies test (1926) was developed. Lewis Terman revised
the Binet test and published the Stanford Binet scale in 1916. The Good enough draw a man test (1926)
measured a child’s intelligence by scoring a drawing the child produced in response to the instructions
“draw a man”. A major revision of the Stanford Binet scale was published by Lewis Terman and Maud
Merrill in 1937. The test included age levels ranging from 2 years to a “superior adult III category”. The
test had two equivalent forms, L and M, to minimize practice effects. Wechsler Bellvue scale was
published in 1939. He was dissatisfied with the available methods of measuring intelligence in adults
because they tended to be upward extensions of measures originally designed for children. The
inclusion of verbal and non verbal items was innovative.

Psychologists were also devoting their attention to developing tests for measuring personality
and diagnosing mental disorders. In 1917, Robert Woodworth created first test for detecting mental
disturbances known as psychoneurotic inventory. In 1921, Herman Rorschach published
psychodiagnostik, which included ten inkblot cards. The diagnosis was based upon the responses to a
set of ten inkblots. Thematic Apperception Test was developed by Henry Murray at the Harvard
psychological clinic and published it in 1938. The MMPI, originally published in 1943, was an

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empirically derived test designed for the purpose of making differential diagnoses among psychiatric
disorders.

In the 1920s and 1930s, psychoanalysis had its most direct impact upon the developing field of
clinical psychology through its influence upon psychological testing. Although, Neither Rorschach or
Murray was Freudians, the influence of psychoanalytic thinking can be seen in how others interpreted
their tests. During this period, Pavlov was busy with his experiments on classical conditioning. John B
Watson published an article entitled “psychology as a behaviorist views it” in 1913 and it was a bold
statement in which Watson sought to redefine psychology into a science of behavior. He emphasized
upon the importance of environment and learning in shaping human behavior. His demonstration of fear
conditioning in Little Albert paved the way for conditioning models of anxiety disorders. In a sequel to
Watson and Raynor’s (1920), Mary Cover Jones, used conditioning principles to eliminate an irrational
fear in young child named Peter.

In terms of professional developments during this time, James McKeen Cattell founded the
psychological corporation, which blossomed as a developer and marketer of psychological tests. It was
difficult for APA to manage the outgrowing number of nontraditional psychologists because it
emphasized on the promotion of science of psychology. The qualification for membership reflected the
organization’s scientific emphasis. In the 1921, membership in APA required a Ph. D in Psychology and
published post-doctoral research. By 1926, APA created an associate member status while full
membership still required publications; one could be an associate member without ever having
published a paper. There were efforts by clinical psychologists to form their own professional
organizations in the early years of the discipline. In 1917, a group of 49 psychologists formed the
American association of clinical psychologists (AACP) and was incorporated into APA becoming the
section of Clinical psychology. In 1937, the American association of applied psychology (AAAP) was
formed. The clinical psychologists in APA were frustrated. They had disbanded the clinical section of
APA in 1937 and many sought an organizational home in AAAP. In the 1920’s psychiatry fought
against clinical psychologists functioning as diagnosticians, but it became as an accepted service during
1930s. By the late 1930s many clinical psychologists started to conduct psychotherapy on a limited
basis and it was not greeted positively by their colleagues in psychiatry. A joint committee of APA and
AAAP developed a constitution and the publication requirement for membership was dropped during
1942 and I 1944, the constitution was accepted and AAAP voted itself out of existence and transferred
its membership to APA. Early in WWII, psychologist tended to be used for selection and classification
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of military personnel. But as the war progressed and the causalities mounted, more and more
psychologists were called upon to provide clinical services.

Adolescence: Post WWII and the development of an identity

Since there was an increasing need of clinical psychologists after the WWII, APA appointed a
committee to develop a model for training clinical psychologists, which was chaired by David Shakow.
And the report is known as Shakow report and it recommended that clinical psychologists be rained at
the doctoral level. The course duration envisioned was four years in which the first two years were spent
for training in science of psychology, research methods and statistics as well as diagnostic and
therapeutic methods at the university. The third year was devoted to internship and full term clinical
work. The fourth year focused on dissertational research. By 1948, APA started to accredit doctoral
training programs in clinical psychology and had specified that they were to be site visited every five
years b two or more psychologist who would evaluate the training program. In 1949, the National
institute of mental health funded a conference on graduate training in Boulder, Colorado, which was
represented by APA. They agreed with recommendations described in the Shakow report. They
proposed the scientist practitioner model in which participants were asked to develop the skills to apply
psychological knowledge but also to contribute to that knowledge base. The recommendations are the
following:

1. Clinical psychologists were to be trained at University psychology departments

2. They were to trained as scientists first and clinicians second
3. They should be required to complete a one year internship of full time clinical work.
4. They should be trained in diagnosis, research and therapy
5. They should be required to complete original research making a contribution to the field and
culminating in the Ph. D.

The scientist practitioner model of training was recognized as a unique experiment by the
Boulder conference participants. Clinical psychology is the integration of science and practice. The
scientist-practitioner model is one of the eminent approaches used in the training of clinical psychology
over the past fifty years. The basic assumption of scientist-practitioner model is that science and
practice must continually inform each other. Integration of science and practice defines the model.
"Scientist- practitioner psychologists embody a research orientation in their practice and practice
relevance in their research". Graduate training programs that adhere to the scientist-practitioner model
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prepare students in three broad areas-research, assessment, and intervention. Students are trained to
conduct psychological research but also to apply knowledge drawn from psychological research in their
practice. The scientist-practitioner model of training is often referred to as the boulder model, named for
Boulder, Colorado, the city where a committee of psychologists met in 1949 and formally adopted this
model of training for clinical psychology.

The conference was followed by an incredible growth for training in clinical psychology. Grant
money was available from the USPHS graduate training programs and hundreds of funded internships at
VA facilities were created. In 1947, there were twenty two universities offering doctoral training in
clinical psychology. Since there was a high need for psychologists, there was an abundant support for
training of clinical psychologists and for clinical research.

Adulthood; Milestones and growing pains

The major changes were happened in the field of training, psychotherapy, psychological testing
and professional practice.

Training

The first conference in which an alternative to the Boulder model was formally proposed was
held in Miami Beach in 1958. They encouraged the exploration of alternative training methods,
including masters-level training and professional training that would culminate in a Doctorate of
Psychology (Psy. D). In the 1960s there was growing discontent with scientist-practitioner training
among a vocal group of clinical psychologists. While University faculty tended to support the Boulder
model, students and practitioners were more critical. They complained that too much time and effort
was spent developing research skills instead of clinical training. Students were frustrated with the length
of Ph D training programs. In 1968, the University of Illinois initiated a Psy. D. program that
deemphasized research and gave more importance to clinical training. The first professional school, the
California school of professional psychology was founded in 1969. In the Vail conference which
happened in the 1974, endorsed the Psy.D as a legitimate alternative to traditional PhD program and
scholar-practitioner model to the scientist-practitioner model. They also proposed that masters’ level
training should qualify individuals to use the title psychologist, which was rejected by APA. The vail
model deemphasizes the need for research experience in training and emphasizes training in the delivery
of psychological services. The Vail model training program prepares its graduates for career in clinical
practice.
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 The next conference happened in Salt Lake City. Utah, in 1987. They acknowledged the
legitimacy of the Psy. D as well as emphasized the importance of training in research for every clinical
psychologist. Most controversial recommendation of this conference was all professional schools
should be affiliated with a regionally accredited university which was rejected APA. The other model
of training is Clinical scientist training. Students in a clinical scientist program are taught to apply
scientific standards to evaluate clinical methods and apply only those methods for which there is
significant scientific support. The clinical scientist model of training, as the name implies, strongly
emphasizes scientific research. The goal of clinical scientist training programs is to produce
psychologists who will further add our applied knowledge through research.

Psychotherapy

During this time, controversial modifications to traditional psychoanalytic approach were

happening. This included patient sitting in a chair rather than lie on a couch and the les frequency of
sessions. Carl Roger, the proponent of Client centered therapy, believed that all human beings have the
capacity to grow and move toward self-actualization. In client centered therapy, the therapist creates
circumstances that allow the client to shed conditions of worth and release his or her capacity for
personal growth. He was being one of the first to test his ideas through empirical investigation and made
recordings of his sessions. Behavior therapists involved the application of principles of classical and
operant conditioning to clinical disorders. Joseph Wolpe developed a psychotherapy technique
systematic desensitization based upon the principle of reciprocal inhibition. B. F Skinner demonstrated
that the behavior of laboratory animal could be modified by consequences of specific responses and the
principles of operant conditioning was used I different techniques such as token economy, child
behavior management strategies. Behavior therapy expanded during 1960s and 1970s. The researchers
also looked into the cognitive aspects of a person’s experiences. The pioneers in the field o cognitive
behavior therapy are Albert Elis and Aaron Beck.

Psychological testing

During 1960s, there was strong backlash against psychological testing. A 1965 special issue of
American psychologist was devoted to criticisms of psychological testing and papers in its defense.
Many questioned the poor reliability and validity of the psychological test. Behavior therapists
advocated for direct observation of behaviors of interest and functional analysis. Humanists such as
Rogers did not see the need for constructs such as psychiatric diagnoses, the unconscious mind, or
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stable personality traits. Jensen (1959), Eysenck (1958) and a review written by TAT, Zubin, Eron and
Shumer (1965) criticized the reliability of projective tests. Intellectual testing has also been virulently
attacked. The major criticisms were that it did not represent minority groups in their standardization
samples. These criticisms helped to improve the standards for normative data and tried to be inclusive in
item content as well. And there had been proliferation of specific tests designed to measure specific
attributes. And there had periodical revisions in tests. In 1970s John exner undertook to develop a
uniform system for administering, scoring and interpreting the Rorschach that could be used reliably. A
major revision of the MMPI was finally published in 1989.

Professional Practice

Changes were happening in the professional practice also. A licensing law restricts the
performance of certain functions to individuals who are recognized members of that profession. A
certification law, on the other hand, controls only the use of the title. The first certification law for
psychologists went into effect in Connecticut in 1945. The law required that those who wishing to use
the title psychologist have a Ph. D and one year professional experience. Although they received strong
opposition from medical community, gradually the certification laws were passed in Kentucky,
Minnesota, Newyork, Maine, Washington etc. In the 1970s, psychologists won important legal suits
against insurance companies. In these cases, the courts held that patients should have the freedom to
choose among professionals who provided the services. Therefore, other mental health professionals, in
addition to psychiatrists, should be eligible for third-party payment for their services. The growing
number of divisions within APA attests to the increasing specializations of the field. Division 12 was
formed to give clinical psychologists a professional home within APA.

Ethics in Clinical Psychology

The American Psychological Association's (APA's) Ethical Principles of Psychologists and
Code of Conduct (hereinafter referred to as the Ethics Code) consists of an Introduction, a Preamble,
five General Principles (A – E), and specific Ethical Standards. The Preamble and General Principles
are aspirational goals to guide psychologists toward the highest ideals of psychology. Although the
Preamble and General Principles are not themselves enforceable rules, they should be considered by
psychologists in arriving at an ethical course of action. The Ethical Standards set forth enforceable rules
for conduct as psychologists.

General Principles
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Principle A: Beneficence and Non maleficence

Psychologists strive to benefit those with whom they work and take care to do no harm.

Principle B: Fidelity and Responsibility

Psychologists establish relationships of trust with those with whom they work. They are aware of their
professional and scientific responsibilities to society and to the specific communities in which they
work.

Principle C: Integrity Psychologists seek to promote accuracy, honesty, and truthfulness in the
science, teaching, and practice of psychology.

Principle D: Justice Psychologists recognize that fairness and justice entitle all persons to access to and
benefit from the contributions of psychology and to equal quality in the processes, procedures, and
services being conducted by psychologists.

Principle E: Respect for People's Rights and Dignity Psychologists respect the dignity and worth of
all people, and the rights of individuals to privacy, confidentiality, and self-determination.

Ethical standards

If psychologists learn of misuse or misrepresentation of their work, they take reasonable steps to
correct or minimize the misuse or misrepresentation. If psychologists' ethical responsibilities conflict
with law, regulations, or other governing legal authority, or demands of an organization with which
psychologists are affiliated or for whom they are working conflict with this Ethics Code, psychologists
make known their commitment to the Ethics Code and take steps to resolve the conflict. When
psychologists believe that there may have been an ethical violation by another psychologist, they
attempt to resolve the issue by bringing it to the attention of that individual, if an informal resolution
appears appropriate and the intervention does not violate any confidentiality rights that may be
involved. Informal Resolution of Ethical Violations is not resolved properly in that fashion,
psychologists take further action appropriate to the situation. Such action might include referral to state
or national committees on professional ethics, to state licensing boards, or to the appropriate
institutional authorities. This standard does not apply when an intervention would violate confidentiality
rights or when psychologists have been retained to review the work of another psychologist whose
professional conduct is in question. Psychologists should cooperate in ethics investigations,

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proceedings, and resulting requirements of the APA or any affiliated state psychological association to
which they belong. Psychologists do not file or encourage the filing of ethics complaints that are made
with reckless disregard for or willful ignorance of facts that would disprove the allegation.

Competence:

First, clinicians must always represent their training accurately. Clinicians have an obligation to
“actively” present themselves correctly with regard to training and all other aspects of competence. This
also means that clinicians should not attempt treatment or assessment procedures for which they lack
specific training or supervised experience. When there is any doubt about specific competencies, it is
wise to seek out supervision from more experienced clinicians. Clinicians should be sensitive to
treatment or assessment issues that could be influenced by a patient’s gender, ethnic or racial
background, age, sexual orientation, religion, disability, or socioeconomic status. Finally, to the extent
that clinicians have personal problems or sensitive spots in their own personality that could affect
performance, they must guard against these problems’ adversely influencing their encounters with
patients.

Privacy and Confidentiality Clinicians have a clear ethical duty to respect and protect the
confidentiality of client information. Clinicians should be clear and open about matters of
confidentiality and the conditions under which it could be breached. The famous Tarasoff case which
happened in 1976 gives us an idea about the importance of breaching confidentiality in certain
situations. The events leading up to this case began when a client at a university counseling center told
his therapist that he planned to kill his girlfriend. The therapist informed the campus police of the
client’s intentions. The police promptly took the client into custody, but because the girlfriend was away
on vacation, they decided to release him. Subsequently, the client did indeed kill his girlfriend. Later,
the woman’s parents sued the therapist, the police, and the university, arguing that these three parties
were negligent in not informing them of the threat. The California Supreme Court eventually ruled in
favor of the parents, holding that the therapist was legally remiss in not informing all appropriate
persons so that violence could have been avoided. Such a decision surely raises issues that would tax the
judgment of nearly every clinician

Human Relations

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 Sexual activities with clients, employing a client, selling a product to a client, or even becoming
friends with a client after the termination of therapy are all behaviors that can easily lead to exploitation
of and harm to the client.

Research and Publication

When institutional approval is required, psychologists provide accurate information about their
research proposals and obtain approval prior to conducting the research. They conduct the research in
accordance with the approved research protocol. When obtaining informed consent as required in
Standard 3.10, Informed Consent, psychologists inform participants about (1) the purpose of the
research, expected duration, and procedures; (2) their right to decline to participate and to withdraw
from the research once participation has begun; (3) the foreseeable consequences of declining or
withdrawing; (4) reasonably foreseeable factors that may be expected to influence their willingness to
participate such as potential risks, discomfort, or adverse effects; (5) any prospective research benefits;
(6) limits of confidentiality; (7) incentives for participation; and (8) whom to contact for questions about
the research and research participants’ rights. They provide opportunity for the prospective participants
to ask questions and receive answers. Psychologists obtain informed consent from research participants
prior to recording their voices or images for data collection unless (1) the research consists solely of
naturalistic observations in public places, and it is not anticipated that the recording will be used in a
manner that could cause personal identification or harm, or (2) the research design includes deception,
and consent for the use of the recording is obtained during debriefing. Psychologists do not conduct a
study involving deception unless they have determined that the use of deceptive techniques is justified
by the study’s significant prospective scientific, educational, or applied value and that effective non-
deceptive alternative procedures are not feasible. Psychologists explain any deception that is an integral
feature of the design and conduct of an experiment to participants as early as is feasible, preferably at
the conclusion of their participation, but no later than at the conclusion of the data collection, and permit
participants to withdraw their data. Psychologists do not fabricate data while reporting research. If
psychologists discover significant errors in their published data, they take reasonable steps to correct
such errors in a correction, retraction, erratum, or other appropriate publication means.

Ethical dilemmas are inevitable during psychotherapeutic interactions, and these complexities
and challenges may be magnified during the training phase. The study aimed to explore trainee clinical
psychologists’ perspectives on the ethical dilemmas faced in the practice of therapy. The objectives

16
were threefold: (i) to explore the types of ethical dilemmas encountered by trainee clinical
psychologists, (ii) to explore the experience of ethical dilemmas in the practice of therapy among trainee
clinical psychologists, and (iii) to explore clinical psychology trainees’ perceptions regarding the
resolution of these dilemmas. The experience of ethical dilemmas in the arena of therapy and the
methods of resolving these dilemmas were examined among 35 clinical psychologists in training,
through an anonymous and confidential online survey. The trainees’ responses to four open-ended
questions on any one ethical dilemma encountered during therapy were analyzed, using thematic
content analysis. The results highlighted that the salient ethical dilemmas related to confidentiality and
boundary issues. The trainees also raised ethical questions regarding therapist competence, the
beneficence and non-maleficence of therapeutic actions, and client autonomy. Fifty-seven per cent of
the trainees reported that the dilemmas were resolved adequately, the prominent methods of resolution
being supervision or consultation and guidance from professional ethical guidelines. The trainees felt
that the professional codes had certain limitations as far as the effective resolution of ethical dilemmas
was concerned. The findings indicate the need to strengthen training and supervision methodologies and
professional ethics codes for psychotherapists and counselors in India (Bhola, Sinha, Sonkar &
Raguram, 2015).

Current trends in clinical psychology

Clinical psychologists in the seventies found a role as experts in psychological testing
(particularly the IQ, or MMPI and the Rorschach in doubtful diagnostic case) at a time when there was
very little emphasis on psychiatric diagnosis. In those years, however, a clinical psychologist, Jean
Endicott, and a psychiatrist, Robert Spitzer, developed the Research Diagnostic Criteria that paved the
ground for the advent of DSM-III and subsequent refinements. This renewed emphasis on symptomatic
assessment apparently decreased the role of clinical psychologists, because of the shared ground with
psychiatry. It seemed that not much could be added to the practical implications of a DSM diagnosis.
The validity and reliability of MMPI and projective testing faded, and neuropsychologists took over
cognitive assessment (Overholser, 2014) . However, in due course, the substantial limitations and
clinical inadequacies of this approach emerged . Exclusive reliance on diagnostic criteria has
impoverished the clinical process and does not reflect the complex thinking that underlies decisions in
psychiatric practice2. Paul Emmelkamp and other clinical psychologists have introduced the concept of
macro-analysis (a relationship between co-occurring syndromes and problems is established on the basis
of where treatment should commence in the first place). It is supplemented by micro-analysis, a detailed
17
analysis of specific symptoms, which can be accomplished by the use of questionnaires and rating
scales. This approach supplants the obsolete notion of psychometric battery to be administered to
everyone, which is still fashionable, for instance, in neuropsychology (Fava & Tomba, 2012).

The research methods of experimental psychology and experimental clinical medicine began to
be applied to the development and assessment of psychological treatments. Now, psychological
treatments are beginning to undergo a new shift, driven by the widespread availability of digital
technology. Taking stock of the current tech revolution occurring in clinical psychology, Fairburn and
Patel (2017) provided a much-needed narrative review of the digital interventions to date (i.e., mobile
apps, internet-based interventions, computerized cognitive training), those in the pipeline, and their
likely impact on clinical practice and the global dissemination of psychological treatments.

Chronic diseases and conditions typically require long-term monitoring and treatment protocols
both in traditional settings and in out-patient frameworks. The economic burden of chronic conditions is
a key challenge and new and mobile technologies could offer good solutions. mHealth could be
considered an evolution of eHealth and could be defined as the practice of medicine and public health
supported by mobile communication devices. mHealth approach could overcome limitations linked with
the traditional, restricted, and highly expensive in-patient treatment of much chronic pathology. Possible
applications include stepped mHealth approach, where patients can be monitored and treated in their
everyday contexts. Unfortunately, many barriers for the spread of mHealth are still present. Due the
significant impact of psychosocial factors on disease evolution, psychotherapies have to be included
into the chronic disease protocols. Existing psychological theories of health behavior change have to be
adapted to the new technological contexts and requirements. In conclusion, clinical psychology and
medicine have to face the “chronic care management” challenge in both traditional and mHealth
settings.

Internet-delivered cognitive behavior therapy (ICBT) has been tested in many research trials, but
to a lesser extent directly compared to face-to-face delivered cognitive behavior therapy (CBT). Riper et
al (2014) conducted a systematic review and meta-analysis of trials in which guided ICBT was directly
compared to face-to-face CBT. Studies on psychiatric and somatic conditions were included. Systematic
searches resulted in 13 studies (total N=1053). There were three studies on social anxiety disorder, three
on panic disorder, two on depressive symptoms, two on body dissatisfaction, one on tinnitus, one on
male sexual dysfunction, and one on spider phobia. Face-to-face CBT was either in the individual

18
format (n=6) or in the group format (n=7). Results showed a pooled effect size (Hedges' g) at post-
treatment of −0.01 (95% CI: −0.13 to 0.12), indicating that guided ICBT and face-to-face treatment
produce equivalent overall effects. Study quality did not affect outcomes. While the overall results
indicate equivalence, there are still few studies for each psychiatric and somatic condition and many
conditions for which guided ICBT has not been compared to face-to-face treatment. Thus, more
research is needed to establish equivalence of the two treatment formats (Riper et al, 2014).

Despite encouraging evidence regarding the effectiveness of internet-based intervention for a

broad range of mental disorders (e.g., Andrews et al., 2010; Riper et al., 2014), both the quality and the
effectiveness of most digital interventions remain unclear. For instance, the vast majority of mental-
health mobile apps and therapist-free computerized training are neither theory driven nor evidence-
based (Donker et al., 2013; Anthes, 2016). Some of these apps may even be harmful (e.g., Gajecki et al.,
2014; Anthes, 2016). Although supporting evidence is building ( Birney et al., 2016), much of the
research has been limited to pilot studies, often conducted by the apps’ own developers rather than by
independent researchers, and randomized clinical trials tend to be statistically underpowered and
unreplicated (Anthes, 2016; Torous et al., 2017).

Reference

Andrews, G., Cuijpers, P., Craske, M.G., McEvoy P & Titov, N. (2010). Computer Therapy for
the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health
Care: A Meta-Analysis. PLoS ONE 5(10).Retrieed from
https://doi.org/10.1371/journal.pone.0013196

Anthes, E. (2016). Mental health: There's an app for that. Nature, 7, doi: 10.1038/532020a.
Bhola, P., Sinha, A., Sonkar, S & Raguram, A. (2015). Ethical dilemmas experienced by clinical
psychology trainee therapists. Indian Journal of Medical Ethics, 12(4), 206-12.

19
Birney, A. J., Gunn, B. A., Russell, J. K., & Ary,D. V. (2016). MoodHacker Mobile Web App
With Email for Adults to Self-Manage Mild-to-Moderate Depression: Randomized
Controlled Trial. JMIR Mhealth Uhealth, 4(1).

Bellack, A. S & Herson, M. (1998). Comprehensive Clinical Psychology (2nd Volume). Pergamon
publisher.

Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, MR & Christensen H. (2013).
Smartphones for smarter delivery of mental health programs: a systematic review.
Journal of Medical internet Research., 5(11).

Fava, G. A., Rafanelli, C & Tomba E. (2012). The clinical process in psychiatry: a clinimetric
approach. Journal of Clinical Psychiatry , 73.

Fairburn, C. G. & Patel. V. (2017). The impact of digital technology on psychological treatments
and their dissemination. Behavior research and therapy, 88. Retrieved from
doi: 10.1016/j.brat.2016.08.012

Gajecki et al. (2014). Effects of Baseline Problematic Alcohol and Drug Use on Internet-Based
Cognitive Behavioral Therapy Outcomes for Depression, Panic Disorder and Social
Anxiety Disorder. Retrieved from https://doi.org/10.1371/journal.pone.0104615

Norcross, John & Wampold, Bruce. (2011). Evidence-Based Therapy Relationships: Research
Conclusions and Clinical Practices. Psychotherapy (Chicago, Ill.). 48. 98-102.
10.1037/a0022161.

Society of clinical psychology. (2002). The Clinical Psychologist. Retrieved from

https://www.div12.org/wp-content/uploads/2014/01/2009.62.1.pdf

Riper , H., Andersson, G., Cuijpers, P., Carlbring, P. & Hedman, E. (2014). Guided Internet- based
vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a
systematic review and meta-analysis. World Psychiatry, 13(3), 288–295.

Overholser, J. C. (2014). Protesting the decline while predicting the demise of clinical
psychology: can we avoid a total collapse? Journal of Contemporary Psychotherapy,
44.

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Thorpe, G. L. & Hecker, J. E. (2005). Introduction to Clinical psychology, Science, Practise, and
ethics. Pearson Education (Singapore) Pte. Ltd.

Torous et al. (2017). The efficacy of Smartphone‐based mental health interventions for
depressive symptoms: a meta‐analysis of randomized controlled trials. World Psychiatry,
16(3). doi: 10.1002/wps.20472.

Trull, T. J. (2005). Clinical Psychology (7th ed). US, Vicid Knight Publisher.

21
 MENTAL HEALTH AND ILLNESS

Mental health is the ability to “cope with and adjust to the recurrent stresses of living in an acceptable
way” (Anderson K N, Anderson LE & Glanze, 2002). Mentally health people are self aware, self-
directed and self-responsible for their action and are able to cope well. It is influenced by three factors
1)inherited factors 2)childhood nurturing 3)life circumstances. The risk of ineffective coping behaviours
increases when problems exist in anyone of these areas. If behaviours interfere with daily activities,
impair judgement or alter reality, the individual is said to be mentally ill. Mental illness is a disturbance
in one’s ability to cope effectively.

In the study titled ‘Mental Illness and Mental Health: The Two Continua Model Across the
Lifespan’ by Westerhof and Keyes (2009) focuses on mental illness as well as three core components
of positive mental health: feelings of happiness and satisfaction with life (emotional well-being),
positive individual functioning in terms of self-realization (psychological well-being), and positive
societal functioning in terms of being of social value (social well-being). The two continua model holds
that mental illness and mental health are related but distinct dimensions. It was found that older adults
scored lower on psychopathological symptoms and were less likely to be mentally ill than younger
adults. ie, older adults experienced more emotional, similar social and slightly lower psychological
well-being. Study concluded that today’s older adults have fewer mental illness problems, but they are
not in a better positive mental health than today’s younger adults. These findings support the validity of
this study.

Early societies believed that everything is nature was alive with spirits. Illness was thought to be caused
by the worth of evil sprits. People with mental illness were possessed by the demons or forces of evil.
Treatments focused on removing evil sprits, magical therapies includes frightening masks and noises,
incantations, vile odors, spells etc used. Physical therapies includes trephining-cutting holes in the skull
to encourage the evil sprits to leave- massage, bleeding, induced vomiting etc.

Greeks introduced the idea that mental illness could be rationally explained through observation.
Hippocrates was the first to base treatment on the belief that nature has a strong healing force. He
proposed the humoral theory of disease. According to this theory mental illness as a result of an
imbalance of humors- the air, the fire, the water and the earth. Each basic element had a related humor
or part in the body. An imbalance in the humors resulted to illness.

22
According to Plato the life is a dynamic balance maintained by the soul- “irrational soul” in the heart
and “rational soul” in the head. If the rational soul was unable to control theundirected parts of the
irrational soul, mental illness resulted.As like Greece, Romens also believed that demons caused illness.
But the romans shows little interest in learning about the body or mind. They treat the patients with
pleasant physical therapies such as warm baths, manage, music and peaceful surroundings.

In China, the mental illness was rarely diagnosed because they believed that it lose their status in the
society. The illiterate interpret the mental illness as the entering of supernatural power and exorcism
was the common treatment. In India , according to Sigerist’s (1945) account many persons receive
medical care for physical and mental illness from indigenous practioners; mainly followed by the
principle of Ayurveda.

Middle ages

From 500CE-1100 CE, church developed into a powerful institution. Early Christians believed that the
mental illness was either the punishment for sins, possession or the result of witch craft. To cure the
mental illness the priest performs demonic exorcisms- religious ceremonies in which patients were
physically punished to drive away the evil possessing sprits.

The first English institution for mentally ill people was initially founded in 1247 by Sheriff of London.
By 1330, Bethlehem Royal hospital had developed into a lunatic asylum that eventually became
infamous for it’s brutal treatments. By 1500’s psychotic behaviours were being accurately observed and
recorded, but the reformation movement returned many insane people to the streets as church santures
closed.

Since the renaissance, the power of church slowly declined as an intense in material gain and worldly
affairs developed. Also the view about mental illness also changed and recognised without bias. By mid
1500’s behaviours were accurately recorded for melancholia, mania and psychopathic personalities.
Mental problems were then thought to be caused by some sort of brain disorders- except in case of
sexual fantasies, which were considered to be God’s punishment or possession by the devil. But the
actual treatment of mentally troubled people remained inhumane.

Until 18th century the inhumane treatment continued and during the later part of 18th century psychiatry
developed as a separate branch of medicine. In 1792, Philippe Penal liberated patients from their

23
chains and accepted them as human beings in need of medical assistants, nursing care and social
services.

Dr. Benjamin Rush was the important figure in 19th century he advocated clean conditions, good air,
lighting, food and kindness. As a result of his efforts mentally troubled patients were no longer caged in
basements of general hospitals. Dorothea Dix was another prominent figure of moral treatment. Dix
fought for the rights of mentally ill people. Dix’s efforts helped for the construction of 30 mental
hospitals throughout U. S and the care of mentally ill were greatly improved.

Emil Kraeplin developed the taxonomy of mental disorders in 1896. He proposed the disease model of
abnormality, was subjected to analysis and considered normality to be relative to physical, geographical
and cultural aspect of define group. Later the classification system of mental health disorders was
developed on the basis of WHO’s ICD (ICD: WHO 1992), this is in it’s eleventh version. The first
international classification edition, known as the International List of Causes of Death, was adopted by
the International Statistical Institute in 1893. ICD helps for the identification of health trends and
statistics globally, and the international standard for reporting diseases and health conditions. It is the
diagnostic classification standard for all clinical and research purposes.The chapter ‘F’ classifies
psychiatric disorders as metal behavioural disorders, code them on as alphanumeric system from F00 to
F99. The versions of ICD-10 are

a) Clinical Description of Diagnostic Guidelines (CDDG)

b) Diagnostic criteria for research (DCR)
c) Multi axial classification version
d) Primary care version

In the study titled ‘ From ICD 10 to ICD 11’ by Rydelius (2012) summarized the changes in ICD
11. In ICD-11 there will not be a separate section on disorders in childhood and adolescence and
disorders of psychological development. ICD-11 will be arranged on a “life-time-axis” basis. The
disorders with childhood onset and mental retardation (to be called Intellectual Developmental
Disorders) be included in a neurodevelopmental cluster together with schizophrenia and primary
psychotic disorders, while childhood presentations of other disorder will be included in other
clusters. ICD-11 will specifically address both cultural and developmental aspects of disorders and
focus also upon a manual for primary care.

24
The APA devised it’s own classification system known as Diagnostic & Statistical Manual (DSM),
which having much in common with ICD, differences in a no of details. The benefits of these
classification systems are, any individual presenting with a set of problems will receive the same
diagnosis across the world and receive same treatment. DSM was first published in 1952 and now in it’s
fifth revision. The DSM-IV-TR is multi axial and the five axes are:

a) Clinical Psychiatric Diagnosis

b) Personality disorders and Mental retardation
c) General medical conditions
d) Psychosocial and Environmental problems
e) Global assessment of functioning: current and in past one year

The DSM-5has revised diagnoses and broaden diagnostic definitions while narrowing definitions in
other cases. A significant change in the fifth edition is the deletion of the subtypes of schizophrenia and
autistic spectrum disorder. ASD is classified on the basis of intensity (mild, moderate and severe).
Severity is based on social communication impairments and restricted, repetitive patterns of behaviour,
with three levels: 1 (requiring support), 2 (requiring substantial support) and 3 (requiring very
substantial support). It is notable the DSM-5 is identified with Arabic rather than Roman numerals. The
DSM-5 eliminated the axis system, instead listing categories of disorders along with a number of
different related disorders.

In 20th century a book written by Clifford Beers about his experience as amental patient set the Mental
hygiene movement into motion. The movement mainly focused on removing stigma attached to mental
illness. The first and second world war pointed out need for comprehensive mental health care. In 1946,
National Mental Health Act provided funding in research, training of mental health professionals and
mental health facilities. This also contributed significant knowledge about PTSD.

The aetiology of mental health problems depends on various risk factors, these do not act
independently, but combine in some way to influence the risk an individual has for developing a
disorder.The aetiological models of mental illness are:
Biological Model
Biochemical explanations of mental health problems focus on the biological processes
underlying mood and behaviour. Both are regulated by brain systems, whose actions
are mediated by neurotransmitters. These systems allow us to perceive information,

25
integrate that information with past memories and other salient factors, and then
respond emotionally and behaviourally. Disruption of these systems as a result of
inappropriate neurotransmitter actions results in inappropriate perception, mood and
behaviour. Biochemical models are often considered to be in opposition to psychological
explanations: mental health problems are seen as either psychological in nature or to
have a biological cause.
The psychosocial perspectives understand humans not just as biological organisms but also as
people with motives, desires and perceptions. The major ones are
• Psychodynamic
• Behavioural
• Cognitive
• Humanistic
• Existential
Psychodynamic Perspective
Sigmund Freud founded this school, which emphasized the role of unconscious motives and
thoughts and their dynamic interrelationship in both normal and abnormal behaviour. A key concept is
the unconscious, which has hurtful memories, forbidden desires and other experiences that have been
repressed. This will emerges in fantasies, dreams, slips of tongue etc. When such part of unconscious
material is brought to awareness and integrated into the conscious part may lead to irrational and
maladaptive behaviour.
Freud’s psychoanalytic theory can be seen as the first systematic approach showing how human
psychological process can result in mental disorders. This perspective replaced brain pathology with
intrapsychic conflict and exaggerated ego defences as the suspected cause of at least some mental
disorders.
Behavioural Perspective
This emerges in early 20th century as a reaction against psychoanalysis. Behaviour therapy
rejected the notion of psychic processes influencing mood and behaviour and the unscientific nature of
psychoanalysis. According to this, the study of directly observable behaviour and of the stimuli and
reinforcing conditions that control it could serve as a basis for understanding human behaviour, normal
and abnormal. This approach was first introduced by Watson through his book Behaviourism in 1924.
The roots of this perspectives are In Pavlov’s study of classical conditioning and Thorndike’s study of

26
instrumental conditioning- later named as operant conditioning by Skinner. The central theme of this
approach is Learning- the modification of behaviour as a consequence of experience. Behaviourists
focused on the effects of environmental conditions on the acquisition, modification, and possible
elimination of various types of response patterns, both adaptive and maladaptive.
Cognitive- behavioural Perspective
The most widely practised therapy is a derivative of behaviour therapy, known as cognitive or cognitive
behavioural therapy (Beck 1977). It considers our thought processes, or cognitions, as the prime
determinant of behaviour and mood. It makes no assumptions of past trauma or future aspirations and is
not based on a model of personality as are psychoanalysis and humanistic therapies. Instead, it focuses
on how the thoughts we have at any one time influence mood and behaviour. It assumes that the
cognitions that result in mental health problems are somehow ‘faulty’ and dysfunctional. Therapy
focuses on changing them to more functional and less inappropriate ones through a number of
educational and therapeutic strategies. It also retains a strong behavioural focus: distorted cognitions,
for example, may be challenged by behavioural experiments designed to illustrate errors of thinking.
Humanistic Perspective
This approach mainly views human nature as basically ‘good’. It emphasizes present conscious
processes and places strong emphasis on people’s inherent capacity for responsible self direction. The
concept of self as a unifying theme, humanistic psychologists emphasize the importance of
individuality. Carl Rogers was the most prominent figure in this. Roger developed the systematic
formulation of the self concept. Humanistic psychologists emphasize that values and the process of
choice are key in guiding our behaviour and achieving meaningful and fulfilling lives. According to this
view psychopathology is essentially the blocking or distortion of personal growth and the natural
tendency towards physical and mental health.
Existential Perspective
This resembles the humanistic view in its emphasis on the uniqueness of each individual, the quest for
values and meaning, and the existence of freedom for self direction and self fulfilment. Existential
tinkers are especially concerned with the inner experiences of an individual in his or her attempts to
understand and deal with the deepest human problems. The basic themes are existence and essence,
meaning and value and existential anxiety and encounter with nothingness. According to this approach
the psychopathology is the product of a failure to deal constructively with existential despair and
frustration.

27
 With the introduction of psychotherapeutic drug treatment people with illness were
deinstitutionalised. This led to the idea of community mental health care, ie mentally ill people could
live within their communities or work with their therapist on an output basis. But the change in political
climate left the project uncompleted and countless mentally ill people without treatment.

The study titled ‘What is the impact of mental health-related stigma on help-seeking? A systematic
review of quantitative and qualitative studies' by Clement, Schauman, Graham, Maggioni in 2005 states
that Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most
commonly reported stigma barrier. A detailed conceptual model was derived that describes the
processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic
minorities, youth, men and those in military and health professions were disproportionately deterred by
stigma.

In U. S National Alliance for Mental Illness (NAMI) was founded in 1979 to represent and advocate
for victims struggling with mental health issues. It also help to educate about mental illness and health
issues, also help to eliminate stigma attached to these disorder such as anxiety and depression. In 2001
WHO created Mental Health Global Action Programme (MHGAP) to enhance the mental health of
people. In 2006, The NAMI conducted first comprehensive survey and grading of state adult mental
health care system. The grade is D. Recommendation focused on increased funding, availability of care,
access to care and greater involvement of consumers and their families.

In 1982, the government of India launched National Mental Health Programme (NMHP) to improve
the status of mental health in India. In 1996, the ministery of health and family welfare , Government of
India formulated the District mental Health Programme. This venture bring mental health care to the
disadvantaged sections and rural areas of society. Also NGO’s play an important role in treatment of
mental illness.

In the study of ‘Mental Health Issues and Challenges in India: A Review’ (2013) by Reddy, Venkata &
Gupta, Arti & Lohiya, Ayush & Kharya, Pradip. (2013) focused on the burden of mental disorders and
the various issues and challenges at community level. The result shows that burden of mental disorders
seen by the world is only a little. Based on the reviews through electronic data, various studies had
shown that the prevalence of mental disorders were high in females, elderly, disaster survivors,
industrial workers, children, adolescent and those having chronic medical conditions.

28
 The current mental health awareness in India is poor, but there are many organisations and
individuals working to transform it and there are effective measures and treatments. But the extreme
shortage of mental health workers and institutions, the stigma and the lack of awareness related to
mental illness and the economic burden etc are the main reasons that effect the mental health of Indian
population negatively. So open discussion with public (not just with experts in the field), educating
about the signs and symptoms of mental illness, encourage to seek support, primary health care etc help
to create a more inclusive environment for people with mental illness.

REFERENCES

1. Ahuja, N.,(2011). A Short Textbook of Psychiatry (7th ed). New Delhi. Jaypee

Brothers Medical Publishers (P) Ltd.

2. Bellack, A. S., & Hersen, M. (1998). Comprehensive Clinical Psychology: Foundations.

Pergamon: The University of Virginia.
3. Bennet, P.,(2005). Abnormal and Clinical Psychology: An Introductory Textbook

(2nd ed.). Newyork: McGraw-Hill Education.

4. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M. (2007). Abnormal Psychology
(13th ed.). New Delhi. Pearson Education
5. Clement, S., Schauman, O., Graham, T., &Maggioni, F. (2005). What is the impact of
mental- health related stigma on help seeking? A systematic review of quantit
ative and qualitative studies. Psychological Medicine, 45(1). Retrived from
https://doi.org/10.1017/S0033291714000129

6. Reddy, B., Venkata., Gupta., Arti., & Lohiya., et.al (2013). Mental Health Issues and Challenges
in India: A Review. International Journal of Scientific and Research Publications, 3.

Retrived from https://www.researchgate.net/publication/267453837_Mental_Health_

Issues_and_Challenges_in_India_A_Review.

7. Rydelius, P. (2012). From ICD 10 to ICD 11. Neuropsychiatrie de l'Enfance et de l'adolescence,

60. Retrived from http://www.em-consulte.com/en/article/737397.

8. Valfre, M. M. (2013). Foundations of Mental Health Care (5th ed). USA. Mosby.
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 9. World Health Organization. (2003). Investing In Mental Health. Retrived from

https://www.who.int/mental_health/media/investing_mnh.pdf.

10. Westerof, G.J., & Keyes, C. L. M.,(2009). Mental illness and mental health: The
Two continua model across the life span. Journal of Adult Development, 17(2).

Retrived fromhttps://link.springer.com/article/10.1093/jurban/78.3.458.

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Unit iii
Epidemiology
The branch of medicine which deals with the incidence, distribution, and possible control of diseases
and other factors relating to health.
Epidemiological studies in Indian Context
Psychiatric epidemiology lags behind than other branches of epidemiology due to
Difficulties encountered in conceptualizing
Difficulty in diagnosing
Difficulty in defining a case
Difficulty in sampling
Difficulty in selecting an instrument
Lack of resources
Stigma

Journey started six decades back

First psychiatric epidemiological study in India 1961, Agra by Dr. K.C Dube
Development of PSE
Development of Indian psychiatric survey schedule (IPSS)
Initial epidemiological studies in India
Prevalence of psychiatric disorders
9.5 to 370 per 1000 population
Limitation: Wide variation in the prevalence rates
Landmark International Epidemiological studies
Epidemiological catchment area program
National comorbidity survey

Pitfalls in Indian studies

Indian epidemiological studies were largely inadequate to tap
31
 Non psychotic disorders like panic disorders, social phobia, obsessive compulsive disorder,
sexual dysfunction, substance use.
Epidemiological studies in substance use disorder was done by
National Household Survey (NHS)
Drug Abuse Monitoring System (DAMS)
Rapid Assessment Survey(RAS)
Focused Thematic Studies(FTS)
The studies was on
Drug abuse and women in India
Burden on women through abusing family members
Drug abuse in rural population
Drug consumption in border areas
Drug abuse in prisons
Pilot Study of International Pilot Study of Schizophrenia (IPSS) by WHO concludes that
Outcome of schizophrenia is better in developing countries than in developed countries
Study by Determinants of Outcome of Severe Mental Disorders (DOSMeED) by WHO concludes that
Indian population less time spent in psychotic episode and less impairment of social functioning.

Study conducted by ICMR confirmed the above 2 findings.

A study titled “Psychiatric epidemiology in India” by Suresh Bada Math, and C. R. Chandrashekar &
Dinesh Bhugra reports the following:
Epidemiological studies report prevalence rates for psychiatric disorders from 9.5 to 370/1000
populations in India. Most of the epidemiological studies done in India neglected anxiety disorders,
substance dependence disorders, co-morbidity and dual diagnosis. The prevalence of mental disorders
reported in epidemiological surveys can be considered lower estimates rather than accurate reflections
of the true prevalence in the population. Researchers have focused on broad non-specific, non-
modifiable risk factors, such as age, gender and social class. Future research focused on the general
population, longitudinal (prospective), multi-centre, co-mMental healthorbid studies, assessment of
disability, functioning, family burden and quality of life studies involving a clinical service providing
approach, is required.
Socio-cultural correlates of mental illness
Landmarks in Social Psychiatry

32
 • Karen Horney(1937)- personality as it interacts with other people
• Erik Erikson(1950)- influence of society on development
• H. Stack Sullivan( 1953)- integration of sociological and psychodynamic concepts and the role
of early interpersonal interactions in the development of the self
• August Hollingshed and Frederick Readlich (1958)- influence of social class on psychiatric
conditions
• Alexander H Leighton (1959) – relationship between social disintegration & mental illness
• Burrow was an early pioneer of the social causes of mental disorder and suggested "Sociatry" as
the name for this new discipline.

• Over the years many sociologists have contributed theories and research which has enlightened
psychiatry
• The relationship between social factors and mental illness (Hollingshead and Readlich in
Chicago in the 1930s): a high concentration of individuals diagnosed with schizophrenia in
deprived areas of the city –replicated subsequently numerous times throughout the world,
• Still controversy exists as to the extent of drift of vulnerable individuals to these areas or of a
higher incidence of the disorder in the socially disadvantaged;
• Midtown Manhattan Study conducted in the 1950s by Cornell University hinted at widespread
psychopathology among the general population of New York City (Srole, Sanger,
Michael, Opler, and Rennie, 1962
• Social psychiatry was instrumental in the development of therapeutic communities. Under the
influence of Maxwell Jones
• The aim of therapeutic communities was a more democratic, user-led form of therapeutic
environment, avoiding the authoritarian and demeaning practices of many psychiatric
establishments of the time
• Social psychiatry has been important in developing the concept of major "life events" as
precipitants of mental ill health

SES is the position of an individual on a socio-economic scale that measures factors like education,
income, type of occupation, place of residence, and in some populations, ethnicity and religion.
Important determinant of health, nutritional status, morbidity and mortality
SES influences accessibility, affordability, acceptability and actual utilization of various available
health facilities.
There have been several attempts to develop different scales to measure the socioeconomic status.
• Socially constructed differences between women and men in roles and responsibilities, status
and power (Gender bias), interact with biological differences between the sexes to contribute to
differences in the nature of mental health problems suffered, health seeking behaviour of those
affected and responses of the health sector and society as a whole
• Striking gender differences are found in the patterns of mental illness

DESCRIPTION OF CULTURE BOUND SYNDROME

33
 The designation ‘culture-bound reactive syndromes’ refers to psychopathological entities that i)
are not seen in the West, ii) are not mere variants of well- recognized psychiatric disorders iii) have
geographically defined prevalence, and iv) are largely determined, at least in their symptomatology, by
beliefs and assumptions prevalent in the native culture. Following are four such syndromes

1. Dhat syndrome
This is a disorder affecting young and sexually inexperienced men. The majority of these so
afflicted live in rural areas and belong to families with extremely conservative attitudes towards sex.
The symptomatology includes various manifestations of anxiety and multiple hypochondriacal
complaints. The patient attributes his distress to an excessive loss of semen via night emissions. The
patient remains tense and preoccupied, cannot sleep well, and loses weight. It can be understood only in
its cultural context. In India, attitudes towards semen and its loss constitute an organized, deep-seated
belief system that can be traced back to the scriptures of the land. Semen is considered to be the elixir of
life, in both a physical and mystical sense.

2. Possession Syndrome
Symptoms of spirit possession occur in association with schizophrenic and manic states, as well
as independently. In the former instance, the symptoms of possession, that is referred to as Possession
Syndrome. The condition occurs almost exclusively among women, and generally in the lower levels of
literacy and socioeconomic class. Such behaviour focuses the attention of the family on the individual;
valuable time is gained; and the resulting structural realignment of forces within the family often
improves the precipitating conditions.

3. Bhang Psychosis
European psychiatrists working in India when the country was still under British rule were
impressed with the frequency of psychotic reactions associated with chronic Bhang abuse. Ewens(1904)
felt that 20% of all psychiatric disorders in India were due to cannabis intoxication. Dhunjibhoy (1930),
an Indian psychiatrist provided the first detailed description of what he called ‘ Indian Hemp Insanity’, a
paranoid psychosis difficult to distinguish from schizophrenia. From all these descriptions, it is hard to
determine whether Bhang Psychosis was an entity in itself or simply a schizophrenic reaction unmasked
in a susceptible individual by the use of cannabis. Two recent reports again assert the independent
existence of such a disorder on the grounds that the paranoid-visual hallucinatory clinical picture occurs
only in chronic Bhang users and remits when the intoxicant is discontinued.

4. Keemam Dependence
Keemam is an indigenous product of India. It is a black substance of semi-solid consistency,
generally taken along with betel leaves and lime. The three substances are chewed and their paste is
kept in the mouth and sucked. Vahia and Sheth (1970) have observed that while while keemam gives a
feeling of high, it also produces psychic dependence and its discontinuation may be associated with
mild withdrawal symptoms. These investigators subjected Keemam to pharmacological analysis and
found, contrary to the general belief that Keemam is a type of tobacco, that it contains in addition to
nicotine a substance pharmacologically like morphine as well as other unidentifiable indigenous
intoxicants. They propose that Keemam dependence is a pharmacologically attenuated and culturally
sanctioned form of drug dependence.

HOW CULTURAL AND SOCIAL FACTORS INFLUENCE HELP SEEKING BEHAVIOUR

34
 Takeuchi, Uehara, and Maramba (1999) state that “cultural factors are critical to understand
access to mental health services, the proper screening and diagnoses that lead to treatment, and the
actual effectiveness of treatment, but many of the relevant policy decisions will be based on the
assumptions made about services and models for service delivery.” They continue by reiterating the
importance of documentation and research of cultural factors for changes in policy and services.
Unfortunately, few studies have specifically tested whether cultural factors actually are linked to help
seeking. Mental health utilization rates of Asian Americans have been reported to be lower than those of
Whites (Chin, 1998).
Chin found various factors that have affected help seeking resulting in the underutilization of services
by Asian Americans. These include:
1. A holistic emphasis concerning the inseparability of the mind and body (i.e.,
somatization of emotional distress and emphasis on medication)
2. A view of the therapist as an authority
3. An unfamiliarity and unacceptability of psychotherapy, especially for immigrants
and refugees who seek solutions through lay and spiritual leaders.
4. Shame and stigma associated with mental illness.
However, utilization according to Sue and Morishima (1982) is a poor indicator of the degree of
mental distress. They suggest that some other factors may also contribute to this underutilization of
services. These include “use and availability of alternative resources (e.g., general practitioners and
medical clinics, counselling over psychiatric services, herbalist, and or family) cost considerations,
location and knowledge of facilities, hours of operation, belief systems about mental health, and
responsiveness of services,” (Chin, 1998). Language barriers may also contribute to the underutilization
of mental health services by Asian Americans (Leong, 1986), not only in the form of language itself but
also the communication of illness.
• The family appears to be an important factor in shaping fundamental values and beliefs, and
influencing attitudes to help-seeking (Nobles & Sciarra, 2000). The decision to seek help for
psychological problems is determined and predominately made by males in the immediate
family, or elders in the extended family.
• Religious leaders and institutions have retained durable and strong affiliations in their
community and assume an influential role in the welfare and mental-health care of their people.
The possible cause of underutilization of services may be a dependence on religious institutions
for providing support, and religious leaders for spiritual guidance, in times of psychological
discomfort.
It is likely that cultural beliefs, shame, stigma, fear of being misunderstood, traditional family
structures, traditional support systems, and lack of trust of external providers may all influence mental-
health-care utilization. It would be highly desirable to support religious leaders with educational
programmes on mental-health issues enabling them to enhance the scope, knowledge, and methods of
supporting those with mental-health problems. This would empower religious leaders to effectively
advise and refer to the most appropriate mental-health services. Reassuring and educating families will
likely facilitate the support they provide and treatment adherence. Community awareness of the
availability of mental-health services needs to be more widely promoted to allow ethnic minorities
greater access to services.

Mental Health

35
Mental health includes our emotional, psychological, and social well-being. It affects how we think,
feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental
health is important at every stage of life, from childhood and adolescence through adulthood.

According to Medilexicon's medical dictionary, mental health is:

"Emotional, behavioral, and social maturity or normality; the absence of a mental or behavioral
disorder; a state of psychological well-being in which one has achieved a satisfactory integration of
one's instinctual drives acceptable to both oneself and one's social milieu; an appropriate balance of
love, work, and leisure pursuits."

Psychological well being

Psychological Wellbeing has two important facets.

The first of these refers to the extent to which people experience positive emotions and feelings of
happiness. Sometimes this aspect of psychological wellbeing is referred to as subjective wellbeing
(Diener, 2000).

Yoga
Yoga, which is derived from the Sanskrit word Yuj, refers to union, communion and identification of the
individual soul with the Universal Soul
Yoga is considered to be the art of healthy living-physically, mentally, ethically and spiritually
The regular practice of yoga is believed to lead to a calm disposition and an integrated personality
Empirical studies over the last few decades have consistently demonstrated the effectiveness of
meditation and yoga in diverse populations with various disorders
In a review of clinical applications of yoga for the pediatric population, Birdee, et al (2009) found 34
controlled studies published between 1979 and 2008. In these studies, yoga had been assessed for
effectiveness in investigations of physical fitness, cardio-respiratory effects, motor skills/strength,
mental health and psychological disorders, behavior and development, irritable bowel syndrome and
birth outcomes following prenatal yoga. Yoga led to significant improvement in all the parameters
Puymbroeck, et al (2007) reported that an 8 week course of yoga consisting of pranayama and different
types of asanas led to improved physical health and coping among informal caregivers
More recently, Tekur, et al (2010) successfully used a two week program involving asanas for back
pain, pranayama, relaxation techniques, meditation, lectures on yogic lifestyle, devotional sessions and
stress management through yogic counseling for 160 patients with chronic lower back pain (CLPB) in
the age range of 18 to 60 years
Meditation
36
Meditation is described as a self-directed practice for relaxing the body and calming the mind.
According to literature and scientific studies, the practice of meditation enhances feelings of wellness
and reduces stress
Most meditation techniques are part of Eastern religious practices followed in countries like India and
China. The components of meditation may include specific postures, the use of a mantra, breathing
exercises, focusing of attention and an accompanying belief system
Marlatt and Kristeller (1998) noted that spiritual interventions, especially meditation-based
interventions such as Transcendental Meditation and Vipassana Meditation are associated with reduced
alcohol and substance use. Meditation is used to develop mindfulness at physical, psychological and
spiritual levels. These approaches increase self-awareness, lead to insight, reduce impulsiveness and
increase tolerance of common stressors. This in turn reduces the need to use psychoactive substances
that an individual may be using to cope with problems of existence. Meditation replaces the use of
substances that artificially alter states of consciousness and mimic authentic spiritual experiences
temporarily
Among adolescents, Transcendental Meditation (TM) has been applied to reduce absenteeism, rule
infractions, stress and negative school behavior in a sample of 45 African American adolescents in the
age range of 15 to 18 years
The intervention involved daily meditation for a duration of 15 minutes over a period of four months
(Barnes, et al, 2003)
It aids in creating sacred moments in life Goldstein (2007)
Yunesian, et al (2008) evaluated the effect of a 12 week TM course on the mental health of 85 adults in
the age range of 20 to 55 years. Results revealed that there was a significant reduction in anxiety and
somatization after completion of treatment
Manocha, et al (2008) used guided meditation over a two week period to reduce stress and improve
well-being among 299 general practitioners in Australia. They opined that meditation could be an
effective mental health promotion and prevention strategy
Studies carried out in the Indian setting have revealed that mindfulness based cognitive behavior
therapy is effective in the treatment of anxiety and depression in the adult population. The approach
reduced anxiety, worry and dysfunctional cognitions by 30% to 40% in a sample of six patients with
anxiety disorders. The patients received 23 sessions of MBCT spread over a period of 6 to 8 weeks
(Mao, et al, 2003)
In another study, Ramnarayan, et al (2005) found that MBCT was efficacious in not only reducing
distress, subjective depressive symptoms and dysfunctional cognitions, but also in improving the quality
of life in a sample of four cases
Majgi, et al (2004) compared the efficacy of Mindfulness Based Stress Reduction (MBSR) with
Mindfulness Meditation (MM) in reducing stress in Border Security Force personnel. The sample
consisted of 30 subjects who were randomly assigned to the two treatment groups, with 15 in each

37
group. Both the treatments consisted of ten sessions and results indicated that both approaches were
equally efficacious in reducing perceived stress and improving psychological well-being.
Suman and Sharma (2008) used a semi-structured interview schedule to examine religious and spiritual
beliefs of alcohol and drug dependent patients. The sample consisted of 35 patients in the age range of
20 to 46 years. Results revealed that 29 patients (83%) reported that they had used religious approaches
in the past to achieve abstinence once they realized that the use of substances had become a problem.
These approaches included prayers, meditation, religious vows and pilgrimages. They reported
benefiting from such approaches and were able to abstain for periods ranging from 3 weeks to 6 months
Sharma and Suman (2008) examined the role of spirituality in smoking cessation in a sample of 35 adult
smokers in the age range of 25 to 50 years. They found that 15% of the patients had contemplated using
techniques such as prayers, meditation or undergoing the ‘Art of Living’ course
Sukhwal and Suman (2009) in a study of 236 college students in the age range of 18 to 21 years, found
that spirituality and religiosity were correlated with less favorable attitudes toward alcohol and less
positive expectancies from alcohol use

Quality of Life
The standard of health, comfort, and happiness experienced by an individual or group.
On the whole, social scientists have failed to provide consistent and concise definitions of quality of
life. The task is indeed problematic, for definitions of life quality are largely a matter of personal or
group preferences; different people value different things. (George and Bearon 1980: 1)
Introduction The phrase ‘quality of life’ is now widely used, both in academic writing and everyday life.
It is one of those taken-for-granted terms, of which we think we know the meaning. Although there will
be some common understanding of what is meant by ‘quality of life’, we may use the term differently in
our private and professional lives. We might anticipate considerable variation in its meaning for people
of different age groups and cultural backgrounds as well as significant gender differences. Quality of
life is one of a number of social science concepts, which are regularly used in everyday life and have
become part of the cultural and political vocabulary. Perhaps the classic example is that of class. Within
most sociological theories of social stratification, class refers to the power relations between social
groups, particularly in terms of economic power (Giddens and Birdsall 2001). Yet in everyday life it is
used in a number of ways, most commonly to describe different social groups in terms of lifestyle and
culture. Consequently it is also used pej A similar fate has befallen the concept ‘quality of life’. Like
‘class’, ‘quality of life’ has been a part of social science theory for a number of years but in the last forty
years it has slowly entered into the cultural and political vocabulary. In social science users of the
concept belong to a broad church. Thus uses of the concept encompass the built, physical, economic and
social environments, as well as the meaning of life to the individual and the subjective experience of life
quality. The purpose of this book is to examine the concept of ‘quality of life’ as used by social science
researchers in studying ageing and the experience of later life from a critical gerontological perspective.
We will provide a critical approach to the conceptualization and measurement of quality of life in social
gerontology and health and social care research. We are not providing a sourcebook of methods or

38
measures of quality of life since a number of these exist already (for example Bowling (1995a) and Carr
et al. (2003)). But we will re-examine what we mean by quality of life in a postmodern world, by
exploring the impact of continuous personal and societal changes on the lives of older people. In so
doing we will draw on a wide range of studies which have reported on the experiences of older people
and which in various ways present their quality of life. The emergence of the concept of quality of life
Before attempting to understand what we mean by ‘quality of life’, we consider the emergence of the
concept in the social science and gerontological literature. Two traditions have dominated the way
quality of life has been conceptualized and measured within the social sciences: social indicators
research and quality of life outcomes in health and social policy research. Both traditions are supported
by a substantial social science research industry sustained by the continuing need of policy makers and
politicians to evaluate ‘quality of life’. The policy focus on quality of life in the European Union’s
research agenda and the work of the Foresight panels (Foresight Ageing Population Panel 2000)
illustrates the continuing importance of the concept of quality of life to European public policy.
Consequently both traditions have focused on issues of measurement rather than developing the
necessary theory to underpin the concept and its operationalization in public policy. Social indicators
research developed in response to the growing dissatisfaction among policy makers with economic
indicators such as Gross National Product (GNP) per capita as measures of societal importance and also
to a rising awareness that despite economic prosperity and growth in standards of living in the post-
World War II era, groups of the population continued to be dissatisfied with their social well-being
(Carley 1981). The emergence of quality of life research in health and social care reflects the shift in
medical preoccupation from the management of acute to chronic disease and the focus on morbidity
rather than mortality as an outcome of medical intervention. The recognition of the importance of
quality as well as quantity of life is captured by the World Health Organization’s definition of health as
‘a state of complete physical, mental and social wellbeing’. Although both 2 Quality of life and older
people these traditions were responding to different political, economic and social stimuli their parallel
development has been important for the understanding of the quality of life of older people. The term
quality of life is a relatively recent term in the academic literature. It did not appear in the International
Encyclopaedia of Social Sciences until 1968 and in Index Medicus until the mid-1970s. Life quality,
however, was an implicit part of gerontological research in both Europe and North America for some
time before. The British tradition emerged in the 1950s as part of the studies undertaken by the Institute
of Community Studies (Townsend 1957, 1963; Young and Willmott 1957; Marris 1958; Townsend and
Wedderburn 1965). This early work described the low level of material resources experienced by older
people living in the East End of London during the postwar years and the poverty of the environment in
which many older people lived. The tradition not only focused on the deprivation of urban postwar
Britain but investigated the nature of urban communities, particularly the role that social networks and
levels of social support played in determining a person’s quality of life (Townsend 1957). Retirement,
bereavement, loneliness and isolation were highlighted as important influences on older people’s lives
(Tunstall 1966; Townsend and Tunstall 1968). Much of this early work provided the framework for the
development of the political economy perspective and the powerful theory of structured dependency
(Townsend 1981) (see Chapter 5). The tradition has persisted to the present day through the writings of
Chris Phillipson (Phillipson 1982, 1998; Laczko and Phillipson 1991) and Alan Walker (1980, 1981,
2000), among others, to provide a coherent understanding of later life and implicitly the quality of that
life. The American social gerontological tradition, which also emerged during the postwar period,
focused more specifically on the subjective experience of later life. A core concept was life satisfaction,
39
developed as part of disengagement theory (Cumming and Henry 1961) in the 1950s. A product of the
dominant functionalist social science of the 1960s was the preoccupation with the measurement of life
satisfaction (Neugarten et al. 1961) and subsequently ‘quality of life’ in American gerontological
research, particularly clinical gerontology. This focus on the measurement of quality of life in older
people reflects the dominant activity at the time which still dominates today: the measurement of the
quality of life in health and illness. Within North America this has led to a highly productive industry
for quality of life researchers and one which is now a global phenomenon. And, because of the
preoccupation with health and ageing, it dominates our thinking about quality of life within social
gerontology. It would be unfair to characterize the development of the concept in North America as
without its critics. In a classic paper Jay Gubrium and Robert Lynott (1983) posed three key questions:
1 What is the image of life and satisfaction presented to subjects in the items of the five most commonly
used scales and indices? 2 How might the image enter into the process of measurement? 3 How does the
image compare with experiences of life and its satisfactions among older people revealed by studies of
daily living? What is quality of life? 3 These remain important questions and ones to which we return in
Chapter 6. Defining quality of life It is not our intention to be typically ethnocentric in our approach to
the topic of this book. In reviewing quality of life research it is evident that different studies have used
widely different definitions and methods of assessing quality of life. These have been rooted in the
cultures and takenfor-granted assumptions of policy makers and researchers. We do, however, need to
provide some kind of framework in which to locate our discussion. From a critical social gerontology
perspective two key principles have emerged. First, factors and criteria, which define a good quality of
life for older people, are likely to apply equally to people from other age groups. Second, the experience
of being an older person in contemporary society is determined as much by economic and social factors
as by biological or individual characteristics. Thus, for example, in the context of chronic illness,
quality of life is an individual experience which for older people will be influenced by their own general
expectations and perceptions of older age and of living with ill health or disability. Expert definitions So
what is quality of life? A useful starting point is Farquhar’s (1994) classification of quality of life
definitions. She distinguishes initially between expert definitions and lay definitions. Three major types
of expert definitions are identified: global, component and focused definitions. Global definitions are
rather general. For example Abrams (1973) defines the expression of quality of life as the degree of
satisfaction or dissatisfaction felt by people with various aspects of their lives. Or, put more simply,
quality of life is the provision of the ‘necessary conditions for happiness and satisfaction’ (McCall
1975). Component definitions emphasize the multidimensional nature of the concept and separate
different dimensions of quality of life. George and Bearon (1980) identified four dimensions, two of
which are ‘objective’ (general health and functional status; socio-economic status) and two of which are
‘subjective’ (life satisfaction, self-esteem). In contrast, Hughes (1990) highlights eight dimensions, or
what she describes as ‘constituent elements’, as part of a conceptual model of quality of life (personal
autonomy, expressed satisfaction, physical and mental well-being, socio-economic status, quality of the
environment, purposeful activity, social integration and cultural factors). A modified version of this
approach has been presented in relation to the quality of life of people with dementia (Bond 1999) and
has been further adapted and is presented in Table 1.1 (p.6). The third type of expert definitions,
focused definitions, centre on just one or two of these dimensions and tend to reflect the political or
professional agendas of different disciplines. For example, within health services research, quality of
life often focuses on health and functional status measures (Bowling 1996) and within health
economics, on utility assessment (Torrance 1986). 4 Quality of life and older people Lay definitions In
40
recent years there has been a resurgence in the view that lay rather than expert definitions are more
appropriate. A good example here is the way that the disability movement has redefined the meaning of
disability from the perspective of people who are differently abled. Despite a long tradition in British
social gerontology of listening to the voice of older people, there are few studies that have attempted to
seek the perspective of older people about their quality of life. Claims are often made that the
perspective of the other is being used, for example in the field of health status measurement (Fitzpatrick
et al. 1998), but most approaches base this assertion on the fact that older people are providing the data.
In this context study respondents will be simply acting ‘as a passive vessel of answers’ (Holstein and
Gubrium 1995: 7). A particular issue here is the way that study respondents will structure their
responses as either public or private views (Corner 1999). We explore further some of these theoretical
and methodological challenges in Chapters 5 and 6. Population surveys of older people rarely focus on
the lay definition of quality of life. They use the standard social epidemiological framework
encompassing expert definitions and concepts (see for example Townsend 1957; Hunt 1978b; Bury and
Holme 1990; Bowling and Windsor 2001; Phillipson et al. 2001). Yet on those occasions where older
people have been asked to describe their quality of life, ‘older people can and do talk about their quality
of life’ (Farquhar 1994: 152). Older people talk about quality of life in different contexts but the
important components (most frequently mentioned) of a good quality of life are: family (children),
social contacts, health, mobility/ability, material circumstances, activities, happiness, youthfulness and
living environment (Farquhar 1994, 1995). Older people’s assessments of their quality of life appear to
be based on their expectations (Fisher 1992), which in turn are grounded in their life experiences and
life biographies. In reporting their experiences older people made comparisons with the experience of
their peers as well as within their own lives. ‘They set their lives in context: the context of time’
(Farquhar 1994: 153). In our experience the context of place and time, and the context in which older
people are telling their life stories will influence the kinds and detail of experiences which are reported.
Thus the perceived status of the listener, for example whether he/she is a health professional or social
science university researcher, will have an important bearing on the kinds of stories and the details of
life stories reported. A conceptual model Accepting that there are a number of caveats, existing research
suggests that expert definitions, which use component definitions, are broadly in line with the reports of
older people themselves. We can therefore think of no better starting point than to reflect on Beverley
Hughes’s account of the concept (Hughes 1990). Quality of life is a multidimensional concept, which
has no clear or fixed boundaries. We have briefly seen that there is little agreement about what
constitutes specific ‘domains’ of quality of life. Also it is clear that What is quality of life? 5 there are
different perspectives on how to assess a ‘high’ or ‘low’ quality of life or who determines the relevance
of constituent elements to different individuals. Key domains Many of the key domains of quality of life
identified in social gerontological research reflect the demand for policy research and particularly the
evaluation of the physical and social environments in which people live. It is therefore important to
distinguish quality of life from quality of care (Bond and Bond 1987). To some extent the original list of
domains generated by Hughes (1990) and her subsequent conceptual model of quality of life has been
influenced by that agenda. Successful ageing (Baltes and Baltes 1990a) has not, until relatively recently,
contributed enormously to our understanding of the concept. Table 1.1 (adapted from Hughes 1990)
lists the key domains that reflect a research agenda, which includes positive as well as negative aspects
of ageing. Subjective satisfaction The most important domain of quality of life, if there is one, must be
the overall satisfaction an individual has with life. This was a central part of the research done in the US
over the last forty years (Neugarten et al. 1961; Palmore and Luikart 1972; Larson 1978; Campbell
41
1981; Chipperfield and Havens 2001) and has also been important in Britain (Hall 1976). The methods
used to assess subjective satisfaction, however, have come under close scrutiny over the years and there
remains considerable debate about what is being measured (Gubrium and Lynott 1983). Table 1.1
Domains relevant to the quality of life of older people . Subjective satisfaction: global quality of life as
assessed by individual older person. . Physical environmental factors: standard of housing or
institutional living arrangements, control over physical environment, access to facilities such as shops,
public transport and leisure providers. . Social environmental factors: family and social networks and
support, levels of recreational activity and contact with statutory and voluntary organizations. . Socio-
economic factors: income and wealth, nutrition and overall standard of living. . Cultural factors: age,
gender, ethnic, religious and class background. . Health status factors: physical well-being, functional
ability and mental health. . Personality factors: psychological well-being, morale, life satisfaction and
happiness. . Personal autonomy factors: ability to make choices, exercise control and negotiate own
environment. 6 Quality of life and older people Physical environmental factors The standard of the
physical environment has been a significant factor in quality of life research. Housing quality has been
judged by occupancy levels, the presence or absence of basic amenities such as indoor WC and hot
running water, the presence of central heating in some or all rooms, as well as the general condition and
state of disrepair of the building (Bond 1993b). It is noticeable how indicators of the physical
environment have changed over the last fifty years, reflecting the relative improvement of housing stock
since the 1950s. Similarly, the physical environment of institutional facilities such as nursing or
residential homes have been judged by the proportion of single or multiple occupancy rooms, the nature
of communal rooms, access for people with disabilities and again the physical condition of the building
(Bond 1993b). The physical proximity of both housing and institutional facilities in relation to other
community facilities such as shops and recreational facilities has always been seen as significant. But
increasingly control over the physical environment has become an important standard of the quality of
physical environments (Wagner 1988), reflecting once again the relative values of policy makers and
society over time. Social environmental factors Family and social support networks have remained
fundamental aspects of the social environment from the early community studies to the current day
(Wenger 1996). This reflects not only the importance of the family and social networks in our social
structure but also the policy maker’s preoccupation with community care (DHSS 1983a). Apart from
the family and social networks, levels of recreational activity and social participation (including paid
and unpaid work) and the availability of formal and informal services have been widely accepted as
important indicators of the quality of the social environment (Willcocks et al. 1987; Allen et al. 1992;
Allen and Perkins 1995). Socio-economic factors Given the hegemony of the globalized consumer
culture and the response of individuals to that culture, income and wealth are seen as the key factors
influencing quality of life. In absolute terms the list of the basic essentials of everyday life is increasing.
Adequate cover, nutrition and warmth are taken for granted. Inequalities in the overall standard of living
continue to dominate academic and political debate. Relative poverty (Townsend 1970) and relative
deprivation (Runciman 1966) remain important factors in a person’s quality of life. Cultural factors In
the social sciences we tend to recognize the presence of cultural differences resulting from the social
status attributed to an individual’s age, gender, class What is quality of life? 7 position, ethnic
background or religious preference. When conceptualizing quality of life these factors are frequently
treated as homogeneous but the reality is that there is often as much individual difference within social
or cultural groups as there is between different social or cultural groups. Health status factors Later life
is often characterized as one of sickness and infirmity. It is also, almost by definition, about the only
42
certainty in life: death. It is therefore not surprising that health status continues to be treated by
gerontologists as a very important factor in quality of life. Physical well-being, functional ability and
mental health (Gurland and Katz 1992; Mroczek and Kolarz 1998) have all been shown to be associated
with quality of life. Personality factors An individual’s personality and psychological make-up are often
associated directly with mental health but also function indirectly to influence quality of life. Studies
have investigated quality of life in terms of psychological wellbeing, morale, life satisfaction and
happiness (George 1979). But perhaps the most important personality factor to quality of life is a
person’s sense of self and personal identity (Taylor 1989). Personal autonomy factors Linked to
personality factors but dependent also on the social and physical environments are personal autonomy
factors such as the ability to make one’s own choices, the ability to exercise control and the ability to
control or negotiate one’s own physical or social environment (Allen et al. 1992). Quality of life as a
relative concept Apart from the ontological debate about the constituent elements of quality of life we
have already hinted at two other key issues, namely how we define levels of quality in life and from
whose perspective. The two are interlinked. Our dominant persuasion is to ‘take the perspective of the
other’ and hence older people’s perspectives on quality of life should, in our view, have precedence
over experts. But from a societal perspective the views of experts in terms of, for example, resource
allocation, will remain important. Therefore, although throughout this book we take the perspective of
older people themselves, it is important to recognize that other perspectives cannot be ignored in the
study of quality of life. Determining the quality in life remains particularly problematic. We would
probably all agree that a high quality of life is better than a low one. Yet it would be ethnocentric and
inappropriate to make a judgement about the quality of life of other cultures, for example, Amazon
Indians whose huntergatherer existence and low life expectancy is not something usually coveted by the
majority of Europeans. (Of course, the concept of quality of life is very 8 Quality of life and older
people much a modernist concept and may not be one that exercises the thoughts of many people in
traditional societies.) A simple solution to the definition of high and low quality would be to take only
the perspective of individuals. How we each decide on what we mean by high or low quality of life
would be an individual judgement. We can see that group consensus may evolve but within similar
social groups there would always be individual preferences. If we reduced our understanding of quality
to the sum of individual subjective experiences there would be little point in investigating quality of life.
Equally quality cannot be reduced to objective and absolute assumptions determined by experts. From a
societal perspective we should also recognize that consensus is not achievable. (Of course it will still be
of interest to investigate how individual older people and experts arrive at their particular definition of
quality. A good research question from a constructionist perspective would be about how ‘quality’ and
‘quality of life’ are socially constructed.) Our preferred method of resolving the tensions between
individual and societal perspectives on the one hand and objective and subjective definitions on the
other hand is to define quality of life, like poverty and relative deprivation, as a relative concept. Such a
concept must be grounded in theoretical constructions of ageing, something we return to in Chapter 5.
Equally from a societal perspective it must be a concept that is measurable and have meaning for
individuals within different social groups. We explore issues of measurement in Chapter 6. But what do
we mean, then, when we describe quality of life as a relative concept? It is not simply one of individuals
having different expectations of life, although this would be an element of it. Equally it would be
inappropriate to regard quality of life simply as an aspect of relative deprivation resultant on the
maldistribution of economic and social resources. But as a starting point we would argue that the quality
of life of individuals is relative to the historical, economic and social context in which they are situated
43
and will be influenced by individual life experience. We would therefore not expect older people to
define their quality of life in the same terms as younger generations. Likewise we would not expect
older people with disabilities to use the same criteria when assessing their quality of life as those older
people without disabilities. We would expect people of different cultures to view quality of life in
different ways. By using ‘quality of life’ in relative terms we are free in the following chapters to
examine the concept from a number of perspectives and to ground the concept within a number of
specific theoretical contexts. This book comprises a further six chapters. In Chapter 2 we focus on how
older people describe their own quality of life, situating their accounts within the context in which they
are constructed. We draw on both explicit and implicit accounts. Chapter 3 summarizes some of the
experiences of growing older in contemporary multicultural society. The chapter highlights aspects of
the built environment and the living arrangements of older people. Data on standards of living, family
and social networks and health and well-being are presented. What is the meaning of quality of life to
older people and how is it presented by the arts and the media? Chapter 4 highlights the enormous What
is quality of life? 9 variability in the experiences of older people and focuses on the meaning that quality
of life has to older people. It also contrasts the different ways that the arts and the media have explicitly
represented quality of life in older people. How much do existing social gerontological theories reflect
the concerns and interests of older people? Chapter 5 evaluates some of the key theories that could be
used to explain the quality of later life. The chapter explores institutionalized ageism and structured
dependency theory, and social participation and theories of productive ageing. It also examines the
importance of self-esteem and other social psychological constructs that mediate the everyday
experience of the social world. How should quality of life be assessed in gerontological research?
Chapter 6 reviews the key issues in the measurement of quality of life drawing on the large literature
and experience from the health field. It will compare different methods used routinely in research and
discuss the importance of gaining the perspective of the older person. In our final chapter we bring
together key issues from the previous six chapters and present an alternative approach to quality of life
and older people. We will describe a framework for understanding quality of life that suggests the
meaning that individuals give to their quality of life is probably determined by their life context: by the
political, economic and cultural influences of the society in which they live; by individual lived
experience across the life course; by their current expectations, attitudes and values and by the context
in which the individuals reflectively provide this account. We argue for the need to rethink the way we
use the concept ‘quality of life’ in gerontological research, policy and practice and suggest how the
concept might be used more effectively.

SELF- CONCEPT

Amala Shanker

44
The self system is both an array of self-relevant knowledge, the tool we use to make sense of our
experiences, and the processes that construct, defend and maintain this knowledge (Epstein, 1973;
Higgins, 1996; Markus, 1977).

The self-concept functions as a repository of autobiographical memories, as an organizer of experience,

and as an emotional buffer and motivational resource (Markus & Wurf, 1987). Self-concept
predominantly entails the awareness of the individual, in terms of “What I am” and “what I can do”.
This perceived sense of self in turn influences both the person’s perception of the world and his
behavior.

Self-concept is our perception or image of our abilities and our uniqueness. At first one's self-concept is
very general and changeable, as we grow older, these self-perceptions become much more organized,
detailed, and specific (Pastorino & Doyle-Portillo, 2013).

Self-concept is defined as the sum of an individual's beliefs and knowledge about his/her personal
attributes and qualities. It is classed as a cognitive schema that organizes abstract and concrete views
about the self, and controls the processing of self-relevant information (Markus, 1977; Kihlstrom and
Cantor, 1983). Self-esteem is the evaluative and affective dimension of the self-concept, and is
considered as equivalent to self-regard, self-estimation and self-worth (Harter, 1999). It refers to a
person's global appraisal of his/her positive or negative value, based on the scores a person gives oneself
in different roles and domains of life (Rogers, 1981; Markus and Nurius, 1986). Positive self-esteem is
not only seen as a basic feature of mental health, but also as a protective factor that contributes to better
health and positive social behaviour through its role as a buffer against the impact of negative
influences. It is seen to actively promote healthy functioning as reflected in life aspects such as
achievements, success, satisfaction, and the ability to cope with diseases like cancer and heart disease.
Conversely, an unstable self-concept and poor self-esteem can play a critical role in the development of
an array of mental disorders and social problems, such as depression, anorexia nervosa, bulimia,
anxiety, violence, substance abuse and high-risk behaviours. These conditions not only result in a high
degree of personal suffering, but also impose a considerable burden on society. Thus, self-esteem is
considered an influential factor both in physical and mental health, and therefore should be an important
focus in health promotion; in particular, mental health promotion.

Empirical studies over the last 15 years indicate that self-esteem is an important psychological
factor contributing to health and quality of life (Evans, 1997). Several studies have shown that
45
subjective well-being significantly correlates with high self-esteem, and that self-esteem shares
significant variance in both mental well-being and happiness (Zimmerman, 2000). Self-esteem has been
found to be the most dominant and powerful predictor of happiness (Furnham and Cheng, 2000).
Positive self-esteem, internal standards and aspirations actively seem to contribute to well-being
(Garmezy, 1984; Glick and Zigler, 1992). According to Tudor (1996), self-concept, identity and self-
esteem are among the key elements of mental health. Research on optimism confirms that a somewhat
exaggerated sense of self-worth facilitates mastery, leading to better mental health (Seligman, 1995).
Evidence suggests that positive self-evaluations, exaggerated perception of control or mastery and
unrealistic optimism are all characteristic of normal human thought, and that certain delusions may
contribute to mental health and well-being (Taylor and Brown, 1988). Self-esteem could thus be said to
serve as a defence mechanism that promotes well-being by protecting internal balance.

Self-esteem plays a significant role in the development of a variety of mental disorders. According to
the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), negative or unstable self-
perceptions are a key component in the diagnostic criteria of major depressive disorders, manic and
hypomanic episodes, dysthymic disorders, dissociative disorders, anorexia nervosa, bulimia nervosa,
and in personality disorders, such as borderline, narcissistic and avoidant behaviour. The clinical
literature suggests that low self-esteem is related to depressed moods (Patterson and Capaldi, 1992),
depressive disorders (Rice et al., 1998; Dori and Overholser, 1999), hopelessness, suicidal tendencies
and attempted suicide (Overholser et al., 1995). Correlational studies have consistently shown a
significant negative relationship between self-esteem and depression (Beck et al., 1990; Patton,
1991). Research results indicate that self-esteem is inversely correlated with anxiety and other signs of
psychological and physical distress (Beck et al., 2001). Ginsburg et al. (Ginsburg et al., 1998) observed
a low level of self-esteem in highly socially anxious children.

Self perception and self regulation

Self perception is an individual’s ability to respond differentially to his own behavior and its controlling
variables is a product of social interaction (Mead, 1934; Rely, 1949; Skinner, 1957)

Bem's (1972) self-perception theory proposes that individuals determine what they are feeling and
thinking by making inferences based on observing their own overt behaviour. Bem suggests that we
learn about ourselves and others in essentially by observing behaviour and making dispositional
inferences about them. Self-perception theory can be subsumed under the more general attribution
46
theory, which deals with how individuals make causal inferences about their own and others' behaviour.
Attribution theory in general is more appropriate to the consideration of self-concept as a causal factor
in social interaction than to questions of self-concept development.

Self Regulation- Self regulation is the universal capacity that develops along with other cognitive and
socio-emotional capacities. Self regulation is the self-in-action, successful self regulation feels good;
failed self regulation feels bad. Self regulation entails the channeling of energy, effort and motivation
toward a goal, the strategies relevant to goal attainment and the goal itself. Self regulation is the
coordination of neural, cognitive, affective and behavioral processes to moderate reactivity, excitability,
and arousal (Rothbart & Rueda,2005). Self regulation requires both behavioral inhibition and behavioral
activation (Avila,2001). Self regulatory capacity can be described as a motivational resource that can be
turned on to pursue one’s goals. Self regulation is basic to human happiness, self worth and social
regard (Bandura, 2001).

Attribution Theory

An attribution is the process of assigning causes to things that happen. Causal attributions help us
explain one’s own behaviors and make it possible to predict what we or others are likely to do in future.
Attribution theory is rooted in the work of Kurt Lewin, Julian Rotter, John Atkinson, Fritz Heider,
Harold Kelley, and Bernard Weiner. Heider (1958) argued that people try to identify the dispositional
properties that underlie observed behaviour and do so by attributing behavior either to external
(situational) causes or internal (dispositional) causes. Attribution theorists have been interested in
whether different forms of psychopathology are associated with distinctive and dysfunctional
attributional styles. Attributional style is a characteristic way in which an individual tends to assign
causes to bad or good events. For example, depressed people tend to attribute bad events to internal,
stable and global causes (“I failed the test because I’m stupid as opposed to “I failed the test because the
test was difficult”). Non-depressed people tend to have what is called a self-serving bias in which they
are more likely to make internal, stable, and global attributions for positive rather than negative events
(Mezulis et al., 2004). Attributions become important parts of our view of the world and can have
significant effects on our emotional well-being (Abramson et al., 1978; Buchanan & Seligman, 1995;
Mineka et al., 2003).

Learned Helplessness

47
Martin Seligman (1974, 1975) first proposed that the laboratory phenomenon known as learned
helplessness might provide a useful model of depression. In the late 1960s, Seligman and his colleagues
(Maier et al., 1969; Overmier & Seligman, 1967) studied laboratory dogs when they were exposed to
uncontrollable shocks. The theory states that when animals or humans have no control over aversive
events (such as shock), they may learn that they are helpless, which makes them unmotivated to try to
respond in the future. Instead, they exhibit passivity and even depressive symptoms. They are also slow
to learn that any response they do make is effective, which may parallel the negative cognitive set in
human depression. These observations led to the learned helplessness model of depression (Seligman,
1974, 1975). Hiroto and Seligman (1975) went on to propose that learned helplessness may underlie
some types of depression. That is, people undergoing stressful life events over which they have little or
no control may develop a syndrome like the helplessness syndrome seen in animals.

The Reformulated Helplessness Theory

Abramson et al. (1978) proposed that when people are exposed to uncontrollable negative events, they
ask themselves why, and the kind of attributions that people make, are, in turn, central to whether they
become depressed. The theory proposes three critical dimensions on which attributions are made, 1)
internal/external, 2)global/specific, and 3)stable/unstable. They proposed that a depressogenic or
pessimistic attribution for a negative event is an internal, stable and global one. People who have a
relatively stable and consistent pessimistic attributional style have a vulnerability or diathesis for
depression when faced with uncontrollable negative life events.

Stress Diathesis Model

The word diathesis stems from the Greek idea of predisposition, which is related to the humeral theory
of temperament and disease (Zuckerman, 1999). Diatheses is a predisposition toward developing a
disorder. It can derive from biological, psychosocial and/or socio-cultural causal factors. Many mental

48
disorders are believed to develop as the result of some kind of stressor operating on a person who has a
diathesis or vulnerability for that disorder.
Stress is the response of an individual to the demands that he/she perceives as taxing or exceeding
his/her personal resources (Folkman & Moskovitz, 2004; Lazarus, 1993). Selye (1963) defined stress as
events that represent a strain on the person’s adaptive capability that cause an interruption in the
person’s routine or habitual functioning. It usually occurs when an individual experiences chronic or
episodic events that are undesirable. The presence of a diathesis or vulnerability is often inferred only
after stressful circumstances have led to maladaptive behaviour. Further, in some cases, factors
contributing to the development of a diathesis are highly potent stressors on their own. For example, a
child who experiences the death of a parent may acquire a diathesis or vulnerability for becoming
depressed later in life. Several researchers have given ways in which stress and a diathesis combines to
lead to the development of a disorder (Ingram & Luxton, 2004; Monroe & Simon, 1991). In the
additive model, diathesis and stress sum together and when one is at a higher level the other can be
low, and vice versa. This implies that a person with no diathesis can also develop a disorder when the
stress is really severe. In the interactive model, some amount of diathesis must be present before stress
in order for a disorder to develop. Thus, according to the interactive model, someone with no diathesis
will never develop the disorder, no matter how much stress he/she experiences. Whereas, someone with
the diathesis will show increasing likelihood of developing the disorder with increasing levels of stress.
The ipsative model posits an inverse relationship between components such that the greater the
presence of one component the less of the other component is needed to bring about the disorder. Thus,
for example, minimal stress is needed for depression to occur in individuals with a strongly
depressogenic schema (Ingram and Luxton, 2005).
In a study done by Hilsman, Ruth, Garber and Judy (1995) the cognitive diathesis–stress model
of depression was tested in a sample of 439 children in grades 5 and 6. Students who reported a negative
explanatory/attributional style or and cognitions highlighting lack of academic control and competence
expressed more distress after receiving unacceptable grades than did students without such cognitions.
Studies done by Gazzele and Ladd (2003), highlighted that in children, individual vulnerability (anxious
solitude) and interpersonal adversity (peer exclusion) predict most elevated depressive symptom over
time.

Protective Factors

49
Since late 1980’s, attention has been focused on the concept of protective factors, which are influences
that modify a person’s response to environmental stressors, making it less likely that the person will
experience the adverse consequences of the stressors (Cicchetti & Garmezy, 1993; Masten 2001; Rutter,
1985). One important protective factor in childhood is being part of a family environment in which at
least one parent is warm and supportive, allowing the development of good attachment relationship
between the child and parent (Masten & Coatsworth, 1998). Some protective factors are just qualities
or attributes of a person such as an easy going temperament, high self-esteem, high intelligence, and
school achievement (Masten, 2001; Rutter, 1987)

Resilience
The root for the English word “resilience” is the word “resile,” which means “to bounce or spring back”
from re- “back” + salire- “to jump, leap”; Agnes (2005).
Resilience has been defined in a variety of ways, including the ability to bounce back or recover from
stress, to adapt to stressful circumstances, to not become ill despite significant adversity, and to function
above the norm in spite of stress or adversity (Carver, 1998; Tusaie & Dyer, 2004). The term resilience
has been used to describe three distinct phenomena, good outcomes despite high-risk, sustained
competence under threat and recovery from trauma (Masten, Best, & Garmzey, 1990).
Resilience is tied to the ability to learn to live with ongoing fear and uncertainty, namely, the ability to
show positive adaptation in spite of significant life adversities and the ability to adapt to difficult and
challenging life experiences.
Protective factors may differ across gender, race and cultures. For instance, girls tend to become
resilient by building strong, caring relationships, while boys are more likely to build resilience by
learning how to use active problem-solving (Bernard, 1995).

Social Support
Cobb (Cobb, 1976) defined social support as the individual belief that one is cared for and loved,
esteemed and valued, and belongs to a network of communication and mutual obligations.
Social support is received from helps the individual mobilize his psychological resources and master his
psychological, emotional burdens; they share his tasks; and they supply him with extra money,
50
materials, tools, skills, and cognitive guiding for improving his handling of the situations ( Caplan,
1974).
Social support is a moderator of life stress. Primary social support consists of the emotional and
material support available to a person in the primary group, namely the immediate family. Emotional
social support is a vital need especially for the mentally ill and this may be provided by family, relations
or friends or peers. Supportive interactions, close effectual ties and the presence of a confidant along
with socially supportive network is important for alteration, modification and works as protective
factors in crisis situations.

References

Abramson, L.Y., Metalsky, G.I. and Alloy, L.B. (1989) Hopelessness depression: a theory based
subtype of depression. Psychological Review, 96, 358–372.
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Beck, A., Steer, R.A., Epstein, N. and Brown, G. (1990) Beck Self Concept Test. Psychological
Assessment , 2, 191–197.

Evans, D.R. (1997) Health promotion, wellness programs, quality of life and the marketing of
psychology. Canadian Psychology, 38, 1–12.
Harter, S. (1999) The Construction of the Self. A Developmental Perspective. Guilford Press, New York.

Furnham, A. and Cheng, H. (2000) Lay theories of happiness. Journal of Happiness Studies
,1, 227–246.

Garmezy, N. (1984) The study of stress and competence in children: a building block for developmental
psychopathology. Child Development, 55, 97–111.

Glick, M. and Zigler, E. (1992) Premorbid competence and the courses and outcomes of psychiatric
disorders. In Rolf, J., Masten, A.S., Cicchetti, D., Nuechterlein, K.H. and Weintraub, S.
(eds), Risk and Protective Factors in the Development of Psychopathology. Cambridge
University Press, Cambridge, pp. 497–513.

Hammen, C. and Goodman-Brown, T. (1990) Self schemes and vulnerability in specific life stress in
children at risk for depression. Cognitive Theory and Research, 14, 215–227.

Heider, F. The psychology of interpersonal relations. New York: Wiley, 1958.

Kihlstrom, J.F. and Cantor, N. (1983) Mental representations of the self. In Berkowitz, L.
(ed.), Advances in Experimental Social Psychology. Academic Press, San Diego, CA, vol. 17,
pp. 1–47.

Markus, H. (1977) Self schemata and processing information about the self. Journal of Personality and
Social Psychology, 35, 63–78.

Markus, H. and Nurius, P. (1986) Possible selves. American Psychologist, 41, 954–969.
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Overholser, J.C., Adams, D.M., Lehnert, K.L. and Brinkman, D.C. (1995) Self esteem deficits and
suicidal tendencies among adolescents. Journal of American Academy Child and Adolescent
Psychiatry, 34, 919–928.

Patterson, G.R. and Capaldi, D.M. (1992) Mediational model for boys depressed mood. In Rolf, J.,
Masten, A.S., Cicchetti, D., Nuechterlein, K.H. and Weintraub, S. (eds), Risk and Protective
Factors in Development of Psychopathology. Cambridge University Press, Cambridge, pp. 141–
163.

Rice, K.G., Ashby, J.S. and Slaney, R.B. (1998) Self-esteem as a mediator between perfectionism and
depression: A structural equations analysis. Journal of Counseling Psychology, 45, 304–314.

Rogers, T.B. (1981) A model of the self as an aspect of the human information processing system. In
Canton, N. and Kihlstrom, J.F. (eds), Personality, Cognition and Social Interaction. Erlbaum,
Hillsdale, NJ, pp. 193–214.

Seligman, M.E.P. (1995) What You Can Change and What You Can't. Knopf, New York.

Taylor, S. and Brown, J. (1988) Illusions and well-being: a social psychological perspective on mental
health. Psychological Bulletin, 103, 193–210.

Zimmerman, S.L. (2000) Self-esteem, personal control, optimism, extraversion and the subjective well-
being of mid-western university faculty. Dissertation Abstracts International B: Sciences and
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FAMILY INFLUENCES AND PSYCHOPATHOLOGY

What is a dysfunctional family?

A dysfunctional family is a family, in which conflict, misbehavior and even abuse on the
part of individual members of the family occur continually, leading other members to
accommodate such actions. Children sometimes grow up in such families with the
understanding that such an arrangement is normal. Dysfunctional families are most
often a result of the alcoholism, substance abuse, or other addictions of parents,
parents' untreated mental illnesses/defects or personality disorders, or the parents
emulating their own dysfunctional parents and dysfunctional family experiences.
Violence and verbal abuse are typical outcomes. Dysfunctional family members have
common symptoms and behavior patterns as a result of their common experiences
within the family structure. This tends to reinforce the dysfunctional behavior, either
through enabling or perpetuation.

Types of dysfunctional families

(a) The Inadequate Family – This type of the family is characterized by inability to cope
with the ordinary problems of the daily living. It lacks the resources, physical and
54
psychological for meeting demands. Incompetence of such families can’t give its
children the feeling of safety and security or adequately guide them in the development
of essential competencies.
s The Disturbed Family or Home: Disturbed family may have certain characteristics like
(1) the presence of parents who are fighting to maintain their own equilibrium and who
are unable to give the child the needed love and guidance (2) Exposure of the child to
emotional and faulty parental models and (3) almost inevitably, the inclusion of the
child in the emotional conflicts of the parents. Disturbed homes have been associated
with high incidence of psychological disturbances among children.
(c) The Antisocial Family: Here the family espouses values not accepted by the wider
community. The parents are overtly or covertly engaged in behavior that violates the
standards and interests of the society at large. They provide undesirable models to the
child. Children in such families may be encouraged in dishonesty, deceit and other
undesirable behavior patterns and imitate the behavior and attitudes of their parents.
Their social interactions are shallow and manipulative.
(d) The Disrupted Family- Disrupted families are incomplete, whether as a result of death,
divorce, separation or some other condition. A number of studies have shown traumatic

55
effects of divorce on a child. Feelings of insecurity and rejection may be aggravated by conflicting
loyalties. Delinquency and other maladaptive behaviors are much higher among children and
adolescents coming from disrupted homes.

(e) The Discordant Family: Here one or both the parents are not getting satisfaction and
may express feelings of frustration and disillusionment in hostile ways such as nagging,
belting and doing things purposely to annoy the other person. Serious discordant
relationships are likely to be frustrating, hurtful and generally pathogenic in their effects
on both the adult and the children.
Faulty Parenting in Dysfunctional Families:

a) Deficient Parents:
Deficient parenting is characterized by having marked inadequacies in parents to provide
children emotional and material care. These parents would likely to hurt their children more by
omission than by commission. Frequently, chronic mental illness or a disabling physical illness
contributes to parental inadequacy. Children tend to take on adult responsibilities from a young age
in these families. Parental emotional needs tend to take precedence, and children are often asked to
be their parents' caretakers. Children are robbed of their own childhood, and they learn to ignore
their own needs and feelings. Because these children are simply unable to play an adult role and
take care of their parents, they often feel inadequate and guilty. These feelings continue into
adulthood.

b) Controlling Parents:
Unlike the deficient parents, controlling parents fail to allow their children to assume
responsibilities appropriate for their age. These parents generally show excessive dominating
attitude to children and making decisions for their children well beyond the age at which
this is necessary. Controlling parents are often driven by a fear of becoming unnecessary to their
children. This fear leaves them feeling betrayed and abandoned when their children become
independent. On the other hand, these children frequently feel resentful, inadequate, and
powerless. Transitions into adult roles are quite difficult, as these adults frequently have
difficulties making decisions independent from their parents. When they act independently these
adults feel very guilty, as if growing up were a serious act of disloyalty.

c) Alcoholic Parents:
Alcoholic families tend to be chaotic and unpredictable. Rules those are applicable to
one day may not be applicable in other days. Promises are neither kept nor
remembered. Expectations vary from one day to the next. Parents may be strict at times
and indifferent at others. In addition, emotional expression is frequently forbidden and
discussion about the alcohol use or related family problems is usually nonexistent.
Family members are
56
usually expected to keep problems a secret, thus preventing anyone from seeking help. All of these
factors leave children feeling insecure, frustrated, and angry. Children often feel there must be
something wrong with them which make their parents behave this way. Mistrust of others,
difficulty with emotional expression, and difficulties with intimate relationships carry over into
adulthood. Children of alcoholics are at much higher risk for developing alcoholism than are
children of non-alcoholics.

d) Abusive Parents:
Abuse can be verbal, physical, or sexual.
Verbal abuse - such as frequent criticism, being critical to children’s behavior, frequently putting
down children in front of others, comparing with other children regarding their academic,
scholastic, behavioral, even physical appearances and showing less positive reinforcements - can
have enduring effects, particularly when it comes from those entrusted with the child's care.

Definitions of physical abuse vary widely. physical abuse can be defined as "the infliction
of physical injuries such as bruises, burns, welts, cuts, bone or skull fractures; these
are caused by kicking, punching, biting, beating, knifing, strapping, paddling, etc."
Physically abusive parents can create an environment of terror for the child, particularly
since violence is often random and unpredictable. Abused children often feel anger.
Children of abusive parents have tremendous difficulties developing feelings of trust
and safety even in their adult lives.
Sexual abuse is the most blatant example of an adult abusing a child purely for that
adult's own gratification. Sexual abuse can be any physical contact between an adult
and child where that contact must be kept secret. Demonstrations of affection -- such
as hugging, kissing, or stroking a child's hair -- that can be done openly are quite
acceptable and even beneficial. Sexual abuse happens to both boys and girls. It is
perpetrated by both men and women. It cuts across lines of race, socioeconomic level,
education level, and religious affiliation.
Family theories in pathological development
a) Double bind (Bateson, Haley and Weakland)- It emphasizes on giving the child incomplete
messages (e.g. strictly avoiding a physical embrace, while saying why don’t you show me
more affection?). This theory hypothesized that repeated exposure to such as dilemma
generates or aggravates the schizophrenic state.

(b) Schism and skew (Ruth Lide and Weakland)- They systematically studied the
characteristics of schizophrenic families using a psychoanalytic oriented psychodynamic
perspective. Their main emphasis was on the triadic and dyadic relationship in the
families. In one type of family, there is a prominent power struggle between the parents
and one parent gets overly close to a child of the oppositive sex. In other types of
57
family, skewed

58
relationship with one parent involves a power struggle between the parents and the resulting
dominance of one parent.

(c) Pseudo-mutuality and pseudo-hostility- (Lyman Wynne and Margaret Singer) - They
described families in which emotional expression is suppressed by the consistent use of
pseudo mutual or pseudo hostile verbal communications. This suppression results in the
development of verbal communication that is unique to that family and not necessarily
comprehensible to anyone outside the family. Problems arise when the child leaves
home and has to relate to other people.
(d) Family interaction pattern – Environmental studies on the etiology of schizophrenia
have stated that pattern of communication relating to family systems are thought to
contribute to a member becoming schizophrenic. It has been seen that schizophrenic
families communicate with less clarity and accuracy than do normal families
Early Deprivation or Trauma
Children who do not have the resources that are typically supplied by parents or parental
surrogates may be left with deep and sometimes irreversible psychological scars. The needed
resources range from food and shelter to love and attention. Deprivation of such resources can
occur in several forms. The most severe manifestations of deprivation are usually seen among
abandoned or orphaned children, who may be either institutionalized or placed in a succession
of unwholesome and inadequate foster homes. However, it can also occur in intact families where,
for one reason or another, parents are unable (for instance, because of mental disorder) or unwilling
to provide close and frequent human attention and nurturing. We can interpret the consequences of
parental deprivation from several psychological viewpoints. Such deprivation might result in
fixation at the oral stage of psychosexual development (Freud); it might interfere with the
development of basic trust (Erikson); it might retard the attainment of needed skills because of a
lack of available reinforcements (Skinner); or it might result in the child’s acquiring dysfunctional
schemas and self-schemas in which relationships are represented as unstable, untrustworthy, and
without affection (Beck).
Researches shows that childhood trauma is associated with high vulnerability to psychotic
disorder , And positive psychotic symptoms in vulnerable individual individuals may be arising as
a consequence of the level and frequency of exposure to abuse rather than neglect (Manuela et al ,
2011)Also , women who reported sexual trauma in childhood were more likely to exhibit
psychopathology than those who were never sexually abused. Being sexually victimized and
raped in adulthood was associated with a particular risk for substance dependence (Kevin et al
,2005)

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Institutionalization

In some cases children are raised in an institution where, compared with an ordinary
home, there is likely to be less warmth and physical contact; less intellectual, emotional,
and social stimulation; and a lack of encouragement and help in positive learning.
Current estimates are that worldwide up to 8 million children live in orphanages. Many
children institutionalized in infancy and early childhood show severe emotional,
behavioral, and learning problems and are at risk for disturbed attachment
relationships and psychopathology. At least some of these problems may be the result of
delayed maturation in brain electrical activity . Institutionalization later in childhood of
a child who has already had good attachment experiences was not found to be so
damaging . However, even some of the children institutionalized at an early age show
resilience and do well in adolescence and adulthood.
At least in one study the physiological changes extended to brain development, with
children with severe institutional deprivation showing reduced overall brain volume,
although the volumes of their amygdala, which is involved in emotion regulation were
enhanced (Mehta et al., 2009).
Attachment difficulties , emotional reactivity , psychiatric symptomatology were
seems to be more evident in institutionalized children , who are institutionalized at an
early age (Bos et al , 2011) Researches also shows that institutionalization have a
negative impact in all aspects of child`s development like – physical , behavioral , social
and emotional (Maclean, 2003)
Child maltreatment

Neglect and Abuse in the Home

Most infants subjected to parental deprivation are not separated from their parents but, rather,
suffer from maltreatment at home.. Parents can neglect a child in various ways—by physical
neglect, denial of love and affection, lack of interest in the child’s activities and achievements, or
failure to spend time with the child or to supervise his or her activities. Cases of parental abuse
involve cruel treatment in the form of emotional, physical, or sexual abuse. Parental neglect and
abuse may be partial or complete, passive or active, or subtly or overtly cruel.
Outright parental abuse (physical or sexual or both) of children has been associated with many
negative effects on their emotional, intellectual, and physical development, although some studies
have suggested that, at least among infants, gross neglect may be worse than having an abusive
relationship. Abused children often have a tendency to be overly aggressive (both verbally and
physically), even to the extent of bullying. Some even respond with anger and aggression to
friendly overtures from peers . Researchers have also

60
 found that maltreated children often have difficulties in linguistic development and
significant problems in behavioral, semotional, and social functioning, including
conduct disorder, depression and anxiety, and impaired relationships with peers, who
tend to avoid or reject them. Such adverse consequences are perhaps not surprising
given the multitude of very long-lasting negative neurobiological effects that
maltreatment has on the developing nervous system .
Child maltreatment includes the following 4 kinds

1. Neglect ( Lack of supervision)

2. Physical abuse(Causing death, injury or visible marks such as bruises)
3. Sexual abuse (Penetrative genital or oral contact / Non-penetrative genital or
genital-oral contact/ Non-contact sexual exposure and exploitation)
4. Emotional abuse(Emotional unavailability/ Hostility
and rejection/Developmentally inappropriate interactions/ Exposure to domestic
violence/Using the child for the fulfilment of the adult’s needs/ Failing to
promote the child’s socialization)
Child maltreatment exerts its influence indirectly, through the following:

• An altered bodily and neurological response to stress. For instance, children who have
been maltreated have higher baseline levels of cortisol than do children who have not
been maltreated. Such alteration of the stress response in those who have been
maltreated continues into adulthood (Tarullo & Gunnar, 2006; Watts- English et al.,
2006).
• Behaviors that are learned as a consequence of the maltreatment. For instance,
maltreatment may result in a type of learned helplessness, so the children are more
likely to be victimized as adults (Renner & Slack, 2006).
• Biases in discriminating and responding to facial expressions. For instance, children
who have been physically abused are more likely to perceive photographs of faces as
conveying anger than are children who have not been physically abused (Pollak et al.,
2000).
• Difficulties in attachment. Children who have been maltreated are less likely to develop
a secure type of attachment than are children who have not been maltreated (Baer &
Martinez, 2006).
• Increased social isolation. For instance, children who have been physically abused
report feeling more socially isolated than children who have not been physically abused
(Elliot et al., 2005).

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 Researches shows that neglected boys seems to have lower verbal IQ and more impared
relatedness than abused or boys with no history of neglect or abuse. Abused girls also seems to have
an increase in conduct disorder (Rogeness et al , 1986)

Impact of maltreatment on
brain development
Subcortical structures:
hippocampus and amygdala
Animal research has shown that the hippocampus functions are impaired when animals are exposed
to chronic stress. Studies of adults with post-traumatic stress disorder (PTSD) who have histories of
childhood maltreatment, an early form of stress, consistently report that these individuals have
smaller hippocampal volumes Overall, there is relatively consistent evidence for reduced white
matter and reduced grey matter volume in the cerebellum of maltreated children. Functional
brain imaging research suggests that experience of maltreatment is associated with increased
amygdala and anterior cingulate cortex response in affective and cognitive control paradigms,
respectively..

Attachment

The Growth of Primary Attachments

Many years ago, Rudolph Schaffer and Peggy Emerson (1964) studied the development of
emotional attachments by following a group of Scottish infants from early infancy to 18 months of
age. He identified 4 phases of attachment
1. The Asocial Phase (birth to about 6 weeks). The very young infant is somewhat
“asocial” in that many kinds of social or nonsocial stimuli produce a favorable reaction,
and few produce any kind of protest.
2. The Phase of Indiscriminate Attachments (about 6 weeks to 6 or 7 months). Now
infants clearly enjoy human company but tend to be somewhat indiscriminate: they
smile more at people than at other lifelike objects such as talking puppets and are likely
to fuss whenever any adult puts them down.

3. The Specific Attachment Phase (about 7 to 9

months).
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 Between 7 and 9 months of age, infants begin to protest only when separated from one particular
individual, usually the mother. Now able to crawl, infants often try to follow along behind their
mothers to stay close and greet mothers warmly when they return. They also become somewhat
wary of strangers
4.The Phase of Multiple Attachments (about 9 to 18 months). Within weeks after
forming their initial attachments, about half the infants in Schaffer and Emerson’s study
were becoming attached to other people such as fathers, siblings, grandparents, or
perhaps even a regular babysitter. By 18 months of age, very few infants were attached
to only one person, and some were attached to five or more.

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Early Theories
of Attachment
Psychoanalytic
Theory
“I Love You Because You Feed Me” According to Freud, young infants are “oral” creatures
who derive satisfaction from sucking and mouthing objects and should be attracted to any person
who provides oral pleasure. Because it was usually mothers who fed them, it seemed logical to
Freud that the mother would be-come the baby’s primary object of security and affection,
particularly if she was relaxed and generous in her feeding practices.

Learning Theory
I Love You Because You Reward Me. For quite different reasons, some learning theorists also
assumed that infants become attached to persons who feed them and gratify their needs. Feeding
was thought to be particularly important for two reasons . First, it elicits positive responses from a
contented infant that increase a caregiver’s affection for the baby. Second, feeding is an occasion
when mothers provide an infant with many comforts—food, warmth, tender touches, soft,
reassuring vocalizations, changes in scenery, and even a dry diaper (if necessary)— all in one
sitting. Over time, then, an infant would come to associate his or her mother with pleasant or
pleasurable sensations, so that the mother herself becomes a valuable commodity. Once the
mother (or any other caregiver) has attained this status as a secondary reinforcer, the infant is
attached, and he or she will now do whatever is necessary (smile, cry, coo, babble, or follow) in
order to attract the caregiver’s attention or to remain near this valuable and rewarding individuals.
In 1959, Harry Harlow and Robert Zimmerman reported the results of a study designed to
compare the importance of feeding versus tactile stimulation for the development of attachments
in infant monkeys. The monkeys were separated from their mothers on the first day of life and
reared for the next 165 days by two surrogate mothers.each surrogate mother had a face and well-
proportioned body constructed of wire. However, the body of one surrogate (the “cloth mother”)
was wrapped in foam rubber and covered with terry cloth. Half the infants were always fed by this
warm, comfortable cloth mother, the remaining half were always fed by the rather uncomfortable
“wire mother.” The research question was: Would these infants become attached to the “mother”
who fed them, or would they instead prefer the soft, cuddly “cloth mother”? Even if their food had
come from the “wire mother,” infants spent time with “her” only while feeding and ran directly to
the “cloth mother” whenever they were upset or afraid. So all infants became attached to the cloth
mother, thereby implying that contact comfort is a more powerful contributor to attachment in

64
monkeys than feeding or the reduction of hunger. Studies have also shown that feeding is not any
more important to human infants than to baby monkeys.

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Cognitive-Developmental Theory
To Love You, I Must Know You Will Always Be There. Cognitive-developmental theory
reminds us of the holistic character of development by suggesting that the ability to form
attachments depends, in part, on the infant’s level of cognitive development. Before an attachment
can occur, the infant must be able to discriminate familiar companions from strangers. He or she
must also recognize that familiar companions have a “permanence” about them (object
permanence), for it would be difficult to form a stable relationship with a person who ceases to
exist whenever he or she passes from view (Schaffer, 1971). So perhaps it is no accident that
attachments first emerge at age 7 to 9 months— precisely the time when infants are entering
Piaget’s fourth sensorimotor substage, the point at which they first begin to search for and find
objects that they’ve seen someone hide from them A major assumption of the ethological
approach is that all species, including human beings, are born with a number of innate behavioral
tendencies that have in some way contributed to the survival of the species over the course of
evolution. John Bowlby (1969, 1980), who was originally a psychoanalyst, came to believe that
many of these built-in behaviors are specifically designed to promote attachments between infants
and their caregivers. Even the attachment relationship itself is said to have adaptive significance,
serving to protect the young from predators and other natural calamities and to ensure that his or
her needs are met. Ethologists argue that the long-range purpose of the primary attachment is to
permit members of each successive generation to live long enough to reproduce, thereby enabling
the species to survive.

Attachment theory by Mary ainsworth

Mary Ainswirth proposed that is usually possible to characterize an infant`s attachment to the
caregiver in one of four ways:
Secure Attachment. The securely attached infant actively explores while alone with the mother
and may be visibly upset by separations. The infant often greets the mother warmly when she
returns and, if highly distressed, often seeks physical contact with her, which helps to alleviate
that distress. The child is outgoing with strangers while the mother is present.
Resistant Attachment. These infants try to stay close to their mother but explore very little while
she is present. They become very distressed as the mother departs. But when she returns, the
infants are ambivalent: They remain near her, although they seem angry at her for having left them
and are likely to resist physical contact initiated by the mother. Resistant infants are quite wary of
strangers, even when their mothers are present.
Avoidant Attachment.. They often show little distress when separated from the mother and will
generally turn away from and may continue to ignore their mothers, even when their mothers try
to gain their attention. Avoidant infants are often rather sociable with strangers but may
sometimes avoid or ignore them in much the same way that they avoid or ignore their mothers.

66
Disorganized/Disoriented Attachment. It appears to be a curious combination of the resistant
and the avoidant patterns that reflects confusion about whether to approach or avoid the caregiver.
When reunited with their mothers, these infants may act dazed and freeze, or they may move
closer but then abruptly move away as the mother draws near, or they may show both patterns in
different reunion episodes.
Separation
Bowlby (1960, 1973) first summarized the traumatic effects, for children from 2 to 5 years old, of
being separated from their parents during prolonged periods of hospitalization. First, there are the
short-term or acute effects of the separation, which can include significant despair during the
separation as well as detachment from the parents upon reunion; Bowlby considered this to be a
normal response to prolonged separation, even in infants with a secure attachment. However, he
also found evidence that children who undergo a number of such separations may develop an
insecure attachment. In addition, there can be longer term effects of early separation from one or
both parents. For example, such separations can cause an increased vulnerability to stressors in
adulthood, making it more likely that the person will become depressed or show other psychiatric
symptoms (Canetti et al., 2000; Carlson et al., 2003). As with other early traumatic experiences,
the long-term effects of separation depend heavily on whether support and reassurance are given a
child by parents or other significant people, which is most likely if the child has a secure
relationship with at least one parent .

Inadequate Parenting Styles

Even in the absence of severe deprivation, neglect, or trauma, many kinds of deviations in
parenting can have profound effects on a child’s subsequent ability to cope with life’s challenges
and thus can create a child’s vulnerability to various forms of psychopathology. Therefore,
although their explanations vary considerably, the psychological viewpoints on causes of
psychopathology all focus on the behavioral tendencies a child acquires in the course of early
social interaction with others—chiefly parents or parental surrogates (e.g., Parke, 2004; Sroufe et
al., 2000). A parent–child relationship is always bidirectional: As in any continuing relationship,
the behavior of each person affects the behavior of the other.. For example, parents who have
babies with difficult temperaments (who are very prone to negative moods) find it difficult and
stressful to deal with their babies (e.g., Putnam et al., 2002; Rutter, 2006). For a second example,
in an early study, Rutter and Quinton (1984) found that parents tended to react with irritability,
hostility, and criticism to children who were high in negative mood and low on adaptability (
Crouter & Booth, 2003).

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Parenting Styles:
Researchers have been interested in how parenting styles— including their disciplinary styles—
affect children’s behavior over the course of development. A parenting style reflects an attitude
and values that are expressed toward a child across a wide range of settings (L. R. Williams et al.,
2009). Four types of parenting styles have been identified that seem to be related to different
developmental outcomes for the children: (1) authoritative, (2) authoritarian, (3)
permissive/indulgent, and (4) neglectful/uninvolved. These styles vary in the degree of parental
warmth (amount of support, encouragement, and affection versus shame, rejection, and hostility)
and in the degree of parental control (extent of discipline and monitoring versus leaving the
children largely unsupervised) Parental control includes both behavioral control (rewards and
punishments) and psychological control (e.g., expression of approval versus disapproval, or guilt
induction).

1) Authoritative Parenting - Authoritative

(both demanding and responsive): parents
are assertive, but not intrusive or
restrictive. Disciplinary methods are
supportive rather than punitive. Children
are expected to be assertive as well as
socially responsible, self-regulated as well
as cooperative
The authoritative style is one in which the parents are both very warm and very careful to set clear
standards and limits on certain kinds of behaviors while allowing considerable freedom within
these limits. They tend to be attentive and sensitive to their needs while still enforcing their limits.
This style of parenting is associated with the most positive early social development; the children
tend to be energetic and friendly and to show development of general competencies for dealing
with others and with their environments (Baumrind, 1993). They also usually have secure
attachment relationships (Karavasilis et al., 2003) and show high levels of overall well-being, as
well as good school performance when followed into late adolescence (Berk, 2003; Slicker &
Thornberry, 2002). Not surprisingly they also are less likely to exhibit either emotional disorders
(e.g., anxiety and depression) or behavioural problem such as conduct problems and delinquency
(L. R. Williams et al., 2009). Recent work has also shown that authoritative parenting is often
effective in promoting resilience in children living in highly stressful contexts induced by war,
conflict, and displacement (Salem-Pickartz & Donnelly, 2007).

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 2) Authoritarian Parenting - Authoritarian
(demanding but not responsive): parents
are obedience- and status-oriented, and
expect orders to be obeyed without
explanation.
Parents with an authoritarian style are high on control but low on warmth. They often appear quite
cold and demanding, favoring punitive methods if their children disobey. Their children tend to be
conflicted, irritable, and moody (Baumrind, 1975, 1993; Berk, 2003; Siegler et al., 2003). When
followed into adolescence, these children tend to be lower

69
in social and academic competence than children of authoritative parents, with boys doing
particularly poorly in social and cognitive skills. Boys with authoritarian fathers— especially
those high on hostility—are also at heightened risk of engaging in substance abuse and other
delinquent activity (Bronte-Tinkew et al., 2006; Hoeve et al., 2009). If such authoritarian parents
also use overly severe discipline in the form of physical punishment—as opposed to the
withdrawal of approval and privileges—the result tends to be increased aggressive behavior on the
part of the child (Berk, 2003; Emery & Kitzmann, 1995)

3) Permissive/Indulgent Parenting
Indulgent (responsive but not demanding): parents are non-traditional and lenient,
allow considerable self-regulation, and avoid confrontation.
Parents with a permissive/ indulgent style are high on warmth but low on discipline and control.
This lenient style of parenting is associated with impulsive and aggressive behavior in childhood
and adolescence (Baumrind, 1967; Hetherington & Parke, 1993; Siegler et al., 2003). Overly
indulged children are characteristically spoiled, selfish, impatient, inconsiderate, and demanding.
In adolescence, they tend to do less well academically and to show more antisocial behaviors
(e.g., Steinberg et al., 2006). Confusion and difficulties in adjustment may occur when “reality”
forces them to reassess their assumptions about themselves and the world.

3) Neglectful/Uninvolved Parenting
Uninvolved (both unresponsive and undemanding): most parenting of this type falls
within the normal range, but in extreme cases it might encompass both rejecting–
neglecting and neglectful parenting.
parents who are low both on warmth and on control exhibit the neglectful/ uninvolved style. They
tend to be disengaged and not supportive of their children. This style of parental uninvolvement is
associated with disruptions in attachment during early childhood (Egeland & Sroufe, 1981;
Karavasilis et al., 2003) and with moodiness, low self-esteem, and conduct problems later in
childhood (Baumrind, 1991; Hetherington & Parke, 1993). These children of uninvolved parents
also have problems with peer relations and with academic performance (Hetherington & Parke,
1993).

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 Outcomes of inadequate parenting styles

Parent And Family Characteristics

Some parent and family characteristics also show systematic links with children’s risk of
emotional and behavioural problems. Parents’ own mental health is among the most important of
these. In part, these associations may reflect heritable influences; in part, they seem likely to follow
from the effects of parents’ mental health problems on marital relationships and parenting.
Depressed mothers, for example, are known to be less sensitive and responsive to their infants, and
attend less, and respond more negatively, to older children . Alcohol and drug abuse and major
mental disorders in parents may impair parenting in more wide-ranging ways; when parents are
antisocial, effects may also be mediated through the endorsement of antisocial attitudes and social
learning. Childhood conduct problems are more common among the children of very young
mothers , often reflecting associated educational and social disadvantages and lack of social
supports. The specific contributions of fathers’ parenting, father absence and relationships with
non- resident parents are attracting increasing attention in research . Large family size may be
associated with increased risk for delinquency, but has few links with other aspects of children’s
adjustment. Only children are not typically at any increased psychiatric risk, and share with other
first-borns some small advantages in cognitive development. Birth order also appears to have few
implications for behavioural adjustment, although youngest children show some increased rates of
school refusal.

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 Marital Discord and Divorce
When parents separate, most children show some short-term behavioural or emotional difficulties;
in general, these disturbances are not severe. School progress and motivation may also be
affected, and longer-term influences have been detected on young people’s own patterns of
relationship formation and stability later in life . Research suggests that these responses are not
simply ‘oneoff’ effects of parental separation; many children experience parental discord before
their parents separate, and divorce itself is often followed by a cascade of other changes.
Problematic relationships between parents may continue, and parents themselves are likely to be
distressed. In addition, many families face marked declines in economic circumstances, and for
some children parental separation will be followed by house moves, school changes, and other
disruptions to their social networks. Later outcomes for children may be impacted by each and
any element of this complex network of change.
Disturbed parent–child patterns such as parental rejection are rarely found in severe form unless
the total familial context is also abnormal. Thus disturbed family structure is an overarching risk
factor that increases an individual’s vulnerability to particular stressors.
Marital Discord Whatever the reasons for marital discord, when it is long-standing it is likely to
be frustrating, hurtful, and generally damaging in its effects on both adults and their children . But
even less severe cases of marital discord also have negative effects on many children. For
example, one study showed that children of parents with high levels of overt conflict showed a
greater disposition to behave aggressively toward both their peers and their parents than children
from less conflictual marriages (Cummings et al., 2004). Another study found that college
students who reported high levels of marital conflict in their parents also showed elevated conflict
in their own romantic relationships, which in turn was linked to poorer quality of their own
romantic relationships (Cui & Fincham, 2010). Interestingly, one study found that children could
be buffered against many of the damaging effects of marital conflict if one or both parents had the
following characteristics: warmth, proneness to giving praise and approval, and ability to inhibit
rejecting behavior toward their children (Katz & Gottman, 1997).

Effects of Divorce on Parents

Unhappy marriages are difficult, but ending a marital relationship can also be enormously
stressful for the adults, both mentally and physically. The negative effects are often temporary,
with most people being able to adapt constructively within 2 to 3 years, but some adults never
fully recover (Amato, 2000; Hetherington, 2003a). Divorced and separated persons are
overrepresented among psychiatric patients, although the direction of the causal relationship is not
always clear. In their original comprehensive reviews of the effects of divorce on adults, Amato
and Keith (1991a) concluded that it is a major

72
source of psychopathology as well as of physical illness, death, suicide, and homicide. It should
also be recognized, however, that divorce actually benefits some individuals (Amato, 2000,
2010)—with some evidence that women are more likely to benefit than men (Hetherington, 2003a).
There is also some evidence that individuals who were in high- distress marriages before divorce
are more likely to show an increase in happiness than are individuals who were in low-distress
marriages before divorce (Amato & Hohmann- Marriott, 2007). In addition, favorable adjustment
after divorce is positively associated with higher income, dating someone steadily, remarriage,
having had relatively favorable attitudes toward divorce before it happened, and being the partner
who initiated the divorce (Amato, 2000).

Effects of Divorce on Children

Divorce can have traumatic effects on children, too. Feelings of insecurity and rejection may be
aggravated by conflicting loyalties and, sometimes, by the spoilng the children may receive while
staying with one of the parents. Not surprisingly, some children do develop serious maladaptive
responses. Temperamentally difficult children are likely to have a more difficult time adjusting
than are temperamentally easy children (Hetherington et al., 1989). Somewhat ironically, difficult
children may be the ones whose parents are more likely to divorce, perhaps because having
difficult children is likely to exacerbate marital problems . Delinquency and a wide range of other
psychological problems such as anxiety and depression are much more frequent among children
and adolescents from divorced families than among those from intact families, although it is likely
that a contributing factor here is prior or continuing parental strife (Chase- Lansdale et al., 1995;
Strohschein, 2005). Research findings also show that, on average, such children had shown these
problems to some degree even before their parents divorced (Amato, 2010; Strohschein, 2005). In
addition, a number of studies have demonstrated that the adverse effects of divorce on adaptive
functioning may persist into adulthood. On average, compared to young adults from families
without divorce, young adults from divorced families have somewhat lower educational
attainment, lower incomes, lower life satisfaction, and an increased probability of being on
welfare and having children out of wedlock (Chase- Lansdale et al., 1995; Hetherington et al.,
1998). Children from divorced families are also more likely to have their own marriages end in
divorce. At one time it was thought that the detrimental effects of divorce might be minimized if a
successful remarriage provided an adequate environment for childrearing. Unfortunately,
however, studies revealed that children living with a stepparent were often no better off than
children living with a single parent, although this was more true for girls than for boys. Other
studies have shown that children—especially very young children—living with a stepparent are at
increased risk for physical abuse (injury and even death) by the stepparent relative to children
living with two biological parents (Daly & Wilson, 1988, 1996).ss

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Family interaction style and relapse
If family members exhibit hostility, voice unnecessary criticism, or are emotionally overinvolved,
then the family environment is characterized by high expressed emotion. British researchers found
that among people with schizophrenia, those whose families showed high expressed emotion were
more likely to have the disorder recur; the same association between high expressed emotion and
relapse has been found in other studies in the United States and China (Butzlaff & Hooley, 1998;
Yang et al., 2004). This may be because high expressed emotion is associated with family
members’ belief that the patient has the ability to control his or her symptomatic behaviors, which
sometimes leads the family members to push the patient to change (Miura et al., 2004).
Unfortunately, these exhortations may well backfire—instead of encouraging the patient to
change, they may produce the sort of stress that makes the disorder worse! When family members
are educated about the patient’s disorder and taught more productive ways of communicating with
the patient, relapse rates generally decline (Miklowitz, 2004).

COMMUNICATION IN DIFFERENT FAMILY TYPES

Consensual Families
Families high in both conversation and conformity orientation are labeled consensual. Their
communication is characterized by a tension between pressure to agree and to preserve the
existing hierarchy within the family on the one hand, and an interest in open communication and
in exploring new ideas on the other hand. That is, parents in these families are very interested in
their children and what the children have to say, but at the same time also believe that they, as the
parents, should make decisions for the family and for the children. They resolve this tension by
listening to their children and by spending time and energy in explaining their decisions, as well
as their values and beliefs, to their children in the hope that their children will understand the
reasoning behind the parents' decisions and adopt the parents' belief system. Children in these
families usually learn to value family conversations and tend to adopt their parents' values and
beliefs.

Pluralistic Families
Families high in conversation orientation and low in conformity orientation are labeled pluralistic.
Communication in pluralistic families is characterized by open, unconstrained discussions that
involve all family members and a wide range of topics. Parents in these families do not feel the
need to be in control of their children by making decisions for them, nor do they feel the need to
agree with their children's decisions. That is, parents are willing to accept their children's opinions
and allow them to participate in family decision making. Because of their emphasis on the free
exchange of ideas and the absence of overt pressure to conform or to obey, these families are low
in conflict avoidance and openly address their conflicts with one another, engage in positive
conflict-resolution strategies, and usually are

74
able to resolve their conflicts. Children of these families learn to value family conversations and
learn to be independent and autonomous at the same time, which fosters their communication
competence and their confidence in their ability to make their own decisions.

Protective Families
Families low on conversation orientation and high on conformity orientation are labeled
protective. Communication in protective families is characterized by an emphasis on obedience to
parental authority and by little concern for conceptual matters or for open communication within
the family. Parents in these families believe that they should be making the decisions for their
family and their children, and they see little value in explaining their reasoning to their children.
Conflict in protective families is perceived negatively because of the great emphasis placed on.
Family members are expected not to have conflicts with one another and to behave according to
the interests and norms of the family. Because communication skills are not valued and not
practiced much, these families often lack the necessary skills to engage productively in conflict
resolution should it come to open disagreements.

Laissez-Faire Families
Families low in both conversation orientation and conformity orientation are labeled laissez1aire.
Their communication is characterized by few and often lifeless interactions between family
members that involve only a limited number of topics. Parents in laissez- faire families believe
that all family members should make their own decisions, but unlike parents in pluralistic families,
they have little interest in their children's decisions and therefore do not talk to them about their
decisions. Frequently, members of laissez-faire families are emotionally divorced from their
families. Laissez-faire families value neither conformity nor communication very much. As a
result, they do not experience their families as constraining their individual interests, and incidents
of colliding interests and thus conflicts are rare. In addition, these families do not engage much in
conversation with one another and therefore tend to avoid conflict. Children of these families
learn that there is little value in family conversation and that they have to make their own
decisions. Because they do not receive much support from their parents, however, they come to
question their decision making ability

Expressed emotion
Expressed emotion (EE) refers to care giver's attitude towards a person with a mental disorder as
reflected by comments about the patient made to an interviewer. It is a significant characteristic of
the family milieu that has been found to predict symptom relapse in a wide range of mental
disorders. The empirical data show that EE is one of the major psychosocial stressor and it has
direct association with recurrence of illness.

75
The construct of EE comprises of the following factors/behavioral patterns: Criticism, hostility,
and emotional overinvolvement (EOI). Like many other environmental stressors, EE behaviors
are not pathological or unique to families of mental disorders, but they can cause relapse of
psychiatric symptoms among people with a vulnerability to stress. It has been sufficiently
established that high EE attitudes are reflected in actual interactions within the families of mental
illness. Findings states that communication patterns in families with high EE relatives are usually
characterized by more intense and negative verbal exchanges, oppositional or conflictual in
nature.

Hence, EE refers to the quality of family

interactions, explicitly the existence of
hostility, criticism, and EOI.
ORIGINS OF EXPRESSED EMOTION
To understand the origins of the concept “Expressed Emotion,” one has to go back to the 1950s
for the seminal works by George Brown.. To understand the basis for the symptom relapse, a
study was initiated by George Brown and his colleagues with 229 men discharged from psychiatric
hospitals, 156 of them with a diagnosis of schizophrenia.
From the study, it was observed that the strongest link with relapse and readmission was the type
of home to which patients were discharged. Surprisingly, the patients who discharged from
hospital to stay with their parents or wives were more likely to get relapse and needed readmission
than those who lived in lodgings or with their siblings. It was also found that patients staying with
their mothers had reduced risk of relapse and readmission if patients and/or their mother went out
to work. It suggested the probable adverse influence of prolonged contact of patients with their
family members in influencing the degree of disability and level of functioning.

THE COMPONENTS OF EXPRESSED

EMOTION
George Brown explained five components of EE. which includes critical comments,
hostility, EOI, positive remarks, and warmth. The quantification of critical comments
and hostility is greatly reliant on the way in which the respondent uses their tone of
voice to convey their feelings (anger, rejection, irritability, ignorance, blaming,
negligence, etc), while the judgment of overinvolvement also takes into account on the
basis of reported behavior such as caregivers blaming themselves, sacrificing things,
being overprotective of patients, excessively being concerned for patients, neglecting
personal needs of self (i.e., caregiver's), and similar others
Critical comments

76
These are basically counted during the interview. Careful observations of direct communications
among patients and caregivers prove that critical caregivers get involved in angry exchanges with
the patient whom they seem unable to prevent or to step away from. These potentially lead to
physical violence, and it is the nature of some families with high EE. Patients who are unable to
get up in the morning, who fail to wash regularly, or who do not participate in household tasks are
criticized for being lazy and selfish; Examples: Family caregiver may express in an increased
tone, tempo, and volume that patient frustrates them, deliberately causes problems for them, family
members feel burden

77
of patient, living with him is harder, commenting that patient is ignoring or not following their
advices.

Hostility
It is rated as being absent or present during the interview and it is a consequence of unmanageable
anger and irritation followed by critical comments and leads to rejection of the patient. Hostility is
expressed by general criticisms or attitudes that are rejecting of the patient.
Examples: Caregivers state that patient causing problems for them, wishing to live away from the
patient, shouting at the patient, easily getting angry and getting irritation, patient can control
himself, he is acting.

Emotional overinvolvement
EOI manifests itself by over-emotionality, excessive self-sacrifice, over-identification, and extreme
overprotective behavior with the patient. Unfortunately, this has the effect of discouraging the
person's skills and self-reliance, so that in the long run, overprotectiveness hampers the person's
recovery. It also leads to dependence of the patient on their caregiver. The patient then becomes
worried about the outlook of having to cope without the continuous support of their caregiver and
becomes dependent. This EOI is most commonly shown by parents, especially mothers, and
occasionally by fathers, but rarely by other relatives.
Examples: Caregivers blame themselves for everything, feeling like everything is their fault;
showing pity, not allowing the patient to carry out his day-to-day activities, neglecting self, giving
less important personal needs rather than patient needs.

Warmth
It is assessed based on kindness, concern, and empathy expressed by the caregiver while talking
about the patient. It depends greatly on vocal qualities with smiling being a common
accompaniment, which often conveys an empathic attitude by the relative. Warmth is a significant
characteristic of the low EE family.
Examples: Caregivers state that patient tries to get along with everyone, he makes a lot of sense,
he is easy to get along with, and it is good to have him around, patient's behaviour is appropriate
since it is not his/her pre-morbid self.

Positive regard
Positive regard comprises of statements that express appreciation or support for patient's behavior
and verbal/nonverbal reinforcement by the caregiver.
Examples: Family states that they feel very close to the patient, they appreciate patient's little
efforts or initiation in his day-to-day functioning, they state that they can cope with the patient and
enjoy being with him/her.

MEASURES OF EXPRESSED EMOTION

78
 Camberwell family interview

The EE status of the family members can be assessed with the Camberwell Family Interview
(CFI) after the patient had been admitted to in-patient care. It is a well-known gold-standard
measure of EE. The CFI is conducted with the patient's close relatives

79
(family caregiver) without the patient being present. During the interview, relative's speech is
recorded and later used for coding. This semi-structured interview consist of questions which
address the onset of the patient's illness and the symptoms that were noticeable to the relative in
the months earlier to the patient's worsening of illness or admission to the hospital. Also, the
interview focuses on the level of stress in the household, irritability among the family members,
participation of the patient in routine household tasks, and the daily routines of the patient and
various family members or overall family functioning. The duration of the interview is between 1 to
2 hours. The CFI gives ratings on five scales those are Criticism, Hostility, EOI, Warmth, and
Positive Remarks.

Five-minute speech sample

The five-minute speech sample (FMSS) is similar to the CFI in that family members talk about
their patient and their relationship for five uninterrupted minutes and the speech is recorded and
later coded for the overall level of EE, criticism, and EOI. The FMSS, however, requires less time
to administer (5 minutes) and score (20 minutes) compared with the Camberwell Family
Interview. One or more critical comments, negative comments about their relationship, or a
critical statement at the start of the interview are all indicative of high criticism on FMSS

Level of expressed emotion scale

This is a 60-item, self-report scale that measures the emotional environment in the patient's most
important relationships. It has 60 items that form the four subscales, namely Intrusiveness,
Emotional Response, Attitude toward Illness, and Tolerance and Expectations. Items are rated in a
true–false format, and the scale produces a score for the level of EE overall as well as a score for
each of the four response patterns

Perceived criticism
This measure of EE is most simple of all measures. This scale recognizes that the most important
element of EE is criticism. It consists of only one question, namely “How critical do you consider
your relative to be of you?” It is administered as a 10-point Likert-type scale and anchored with
the values “not at all critical” and “very critical indeed.” This scale takes very less time (1 minute)
to administer it. Interviewer can ask patients to rate how critical they think their relatives are of
them using this scale. In addition, interviewer can also ask patients how critical they think they are
towards their relative using the same scale.

Family emotional involvement and criticism

scale
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It is a 14-item scale which assesses two dimensions of EE: EOI and perceived criticism (PC) in
the family. It is important to address the EOI and criticism when working with families with
member who has severe and persistent mental illness. Higher criticism and overinvolvement
scores are associated with more mental healthcare visits to hospitals for

81
biomedical and psychosocial services due to higher rates of relapses. This scale proposes that EE
is an important variable in assessing and treating both biopsychological distresses. On 14-item
scale, the PC subscale should clearly indicate negative attitudes and EOI scale clearly reveal high
levels of emotional involvement The 14 items are organized such that PC is assessed by even-
numbered items and EOI is measured by odd-numbered items. A 5-point Likert-type scale
includes response options of almost never, once in a while, some, often, almost always. On this
scale, high scores indicate greater levels of PC and EOI.

Family attitude scale

It is a useful 30-item, self-report measure of EE which emphasizes on the criticism and hostility.
Respondents report how often each statement is true. It is alike to the Level of EE scale in that
either close relatives or patients of schizophrenia may complete the scale. Some examples of
items include “I wish he were not here,” “He appreciates what I do for him,” “I lose my temper
with him,” “He is a real burden,” “He ignores my advice,” and “I feel very close to him,” “He is
hard to get close to.”

CAREGIVER FACTORS ASSOCIATED WITH

EXPRESSED EMOTION

Caregivers personality factors and expressed emotion

Although precise reason for high or low EE attitudes in caregivers is not yet completely
unraveled, it has been suggested that EE might partially reflect caregiver's personality traits.
Researches indicates that care givers with high EE reported reduced satisfaction of their
individual activities, reduced optimism about their future, and reduced self-efficacy compared
with low EE caregivers. Moreover, caregivers of high EE were less empathic, rigid, and impatient
than low EE caregivers. A critical comment of caregiver is dependent less on the degree of the
patient's symptoms than on the caregiver's own personality factors. If a caregiver is easily adjusted
to the difficult circumstances and has patience generally, he or she is likely to be a non-critical
caregiver. If a caregiver is usually tense or irritable during stressful situations, this stress can result
in feelings of anger. All these factors reveal that personality characteristics are significantly related
to caregiver's high or low EE.

Caregiver's attributions about the causes of the patient's illness or their illness behaviors are also
been linked with EE. A particular group of attributions related with EE is controllability
attributions. EE research reveals an association between caregiver's critical comments and
controllability attributions such that high-criticism caregivers are more likely to believe that
patients can have control over the manifestation of their symptoms than low-criticism
parents.And, . If the caregivers believe that they have contributed to the patient's problems in some
way, then they might consequently behave in an emotionally over-involved way by expressing
82
their feelings of guilt through overstressed emotional responses or protectiveness toward the
patient. These guilty attributions of caregivers may

83
be unnecessary (i.e., relatives may well have had nothing to do with the onset or course of illness),
but these may be harmful to caregiver's as well as patient's psychological state.

MODELS OF EXPRESSED EMOTION

Locus of control model

Studies show that locus of control and EE has significant associations, especially with internal
locus of control. Individuals with a high internal locus of control view themselves as accountable
for the consequences of their actions and believe that they have control over reinforcements. Those
with a high internal locus of control are more likely to believe that their efforts will be successful
and they are more active in seeking information and knowledge regarding their circumstances.
Those with a high external locus of control believe that powerful others, fate, or chance primarily
determine events. It is said to be the people with high external control who have no hold over the
situation and they are reported to be inactive, have decreased self-esteem, and not trusting of
others. High EE caregivers, particularly those who are high in criticality, have been shown to have
a more internally based locus of control than do low EE caregivers and to be more self-blaming
also found that highly critical caregivers are more likely than low-critical caregivers to have an
internal locus of control.

Stress-diathesis model (stress vulnerability

model)
Stress-diathesis model combines both biological and ecological factors to explain the
manifestation of mental disorders and it is one of the most significant models to understand the
development of psychopathology. In this model, the degree of vulnerability to a given psychiatric
episode is determined by each person's tolerance to traumatic or stressful life events. As EE
appears to accurately determine relapse among patients, the research suggested that family
environment may be a major contributing factor to critical stress levels among persons with
schizophrenia. Stress-diathesis approach facilitates the view that both patients and caregivers are
involved in a system of mutual influence in which each contributes to the stress that acts on the
intrinsic vulnerabilities of the other; this perspective emphasizes upon interactions between
vulnerability and stress variables.

Considerable research data on EE with regard to illness relapse shows EE as a form of

psychosocial stress. In the previous decades, the EE construct has led to the development of
family-based psychosocial therapies for schizophrenia that seek to decrease patients’ relapse rates
by changing structural aspects of the family environment. These efforts have been satisfying and
have yielded in substantial clinical benefit for many patients and their family caregivers.

84
EMOTIONS AND THE DEVELOPMENT
OF PSYCHOPATHOLOGY IN INFANCY
AND
EARLY CHILDHOOD
In this early stage of development, the primary context in which emotional development takes
place is the relationship between the child and the primary caregiver on which its life
depends. Within this relationship, emotion patterns and affective-cognitive structures begin to
self-organize, the brain’s emotion centers develop and are shaped by the affective displays of the
caregiver and caregiving experiences, and the ability to regulate the expressive components of
emotion experience emerges. These evolutionarily and genetically determined qualities in the
infant exert significant influence on the caregiver and result in reciprocal cycles of emotion
patterns for both participants in the relationship .
Child maltreatment is perhaps the most damaging circumstance in caregiver-child relationships
and has the potential to derail normal development of intersystem connections between the
cognitive and emotions systems, perception of emotions in the self and others, and neurobiological
mechanisms that regulate emotion experience and expression (Cicchetti & Lynch, 1995).
However, maltreatment often co-occurs with several other factors that can also hamper emotional
development, including maternal psychopathology, poverty, intrauterine drug exposure, and an
environment that may expose the child to violence and multiple caregiver change .

The Developmental
Functions of Emotions
in Externalizing
Behavior Problems
The emotional expressions that infants observe in adults provide the infants with their
earliest source of information about the way emotional exchanges occur in the
environment. Therefore, it is not surprising that beginning in early toddlerhood, children
exposed to frequent angry maternal responses and inter adult conflict are more likely
to engage in noncompliant behavior. By the end of the preschool years, angry and
aggressive behaviors become less common, and those children who exhibit consistent
negative emotionality are more likely to continue to display aggressive behavior . Not
surprisingly, children who are not accepted by their peers tend to have difficulty
managing their anger and, as a result, are more likely to make retaliatory responses
. In adolescence, conflicting emotions and emotion patterns become more prominent, and
adolescents with a more poorly developed sense of self and understanding of the complexity of
85
personal relationships exhibit less positive emotion and more anger .It is likely that consistent
anger-driven peer difficulties, deficient empathy, and maladaptive patterns of self-conscious
emotions emerging in childhood would contribute to a shallower personal and interpersonal
understanding during adolescence. As a result, children with these difficulties are most likely to
persist with retaliatory, aggressive behaviors and begin to exhibit the delinquent behavior
associated with CD emerging in childhood, continuing in adolescence, and possibly culminating
with APD and more severe criminal behavior in adulthood.

86
 Maladaptive Peer Relationships
Important peer relationships usually begin in the preschool years. Children at this stage are hardly
masters of the fine points of human relationships or diplomacy. The child’s own immediate
satisfaction tends to be the primary goal of any interaction, and there is only an uncertain
recognition that cooperation and collaboration may bring even greater benefits. A substantial
minority of children seem somehow ill equipped for the rigors and competition of the school
years, often because of temperamental factors in the child or dysfunctional family situations. A
significant number of them withdraw from their peers and become loners. A significant number of
others (especially males) adopt physically intimidating and aggressive lifestyles, often becoming
schoolyard or neighborhood bullies. Being either a loner or a bully does not bode well for good
mental health outcomes. This is in part because both often lead to peer exclusion and peer abuse.
Chronic peer exclusion is particularly likely to lead to decreased classroom participation and
declining school performance, whereas peer abuse is particularly likely to lead to actual avoidance
of school
.Several studies have found bullies to show high levels of both proactive aggression (where they
initiate the aggressive behavior) and reactive aggression (where they overreact when confronted).
Although some bullies probably behave this way because of deficits in social skills, others (often
the ringleader in a group of bullies) have a more sophisticated understanding of social behavior,
which enables them to manipulate and organize their peers (often driven by status goals) so that
they can avoid being caught while making others suffer.
The experience of intimacy with a friend has its beginning in this period of intense social
involvement. If all goes well, a child emerges into adolescence with a considerable repertoire of
social knowledge and skills that add up to social competence. Such resources can be strong
protective factors against parental rejection, frustration, demoralization, despair, and mental
disorder

The Peer Relationships of Children with

Psychiatric Disorders
Though peer problems clearly play a role in the diagnosis of psychiatric disorders, the peer
relationships of children with specific psychiatric disorders have received substantially less interest
compared to normal and distressed, but subclinical, populations of children. Therefore, relatively
little is known about the type and quality of peer interactions and the impact of those interactions
on the emergence and maintenance of psychiatric/psychological disorders.

Attention Deficit/Hyperactivity Disorder

The diagnosis for Attention Deficit /Hyperactivity Disorder (ADHD) does not include
problematic peer relationships as an essential symptom; however, some researchers have argued
that interpersonal difficulties should serve as a defining characteristic in ADHD. Almost half of
ADHD children have significant peer relationship problems (Guevremont & Dumas, 1994).
Children with ADHD display large social skills deficits, often seen as

87
intrusive, loud, annoying, and generally aversive by their peers. In addition, there is evidence that
the social reasoning of ADHD children may be more negative. Overall, ADHD children have
been found to be more likely to experience disturbed peer relationships and rejection by peers
(Landau & Moore, 1991).
A further complicating factor is the high degree of comorbidity of ADHD with other psychiatric
diagnoses, particularly the other Disruptive Behavior Disorders (i.e., Conduct Disorder and
Oppositional and Defiant Disorder) and Learning Disorders (LD). This comorbidity may
additionally contribute to peer disturbances

Conduct Disorder
As with ADHD, children with Conduct Disorder (CD) tend to have very problematic peer
relationships and to be highly disliked or rejected by their peers. However, unlike ADHD, the
primary peer difficulty in CD tends to be aggression. Rather than being simply intrusive,
irritating, and overbearing to peers, CD children tend to bully and otherwise aggress toward peers,
to intimidate and victimize peers, and to violate the rights of peers (e.g., steal, lie, or destroy
property). It is hypothesized that CD children experience early maladaptive patterns of
reinforcement for aggressive behavior as well as exposure to hostile role models, resulting in a
hostile, self-defensive view of the world; so that, in the end, aggression becomes the response of
choice to deal with interpersonal situations). Aggression can be a very effective tool for achieving
goals and for controlling the behavior of others, but it also increases the likelihood that others will
reciprocate the aggression. This pattern develops into a self-perpetuating negative cycle between
the child and the social context whereby both the child’s aggressive behavior and his or her self-
defensive view of the world are continually reinforced and maintained (Coie & Dodge, 1998). In
longitudinal studies, peer rejection in early and middle childhood predicts conduct problems in
late childhood and adolescence and there is some evidence that peer rejection mayplay a causal
role in the development of CD (Patterson, Capaldi, & Bank, 1991). When aggressive children are
rejected from the broader peer group, they tend to associate with other aggressive and rejected
peers . Involvement in a deviant peer group exposes them further to deviant models and restricts
their opportunities to interact with nondeviant peers. Furthermore, deviant peers may reinforce
delinquent acts through their positive responses to deviant behavior .Involvement in deviant peer
groups has been found to be predictive of adolescent substance use, disruptive behavior, and
delinquency .

Anxiety Disorders
Anxiety disorders are among the most common psychological disorders of childhood and
adolescence. Although several anxiety disorders are associated with impaired peer relationships,
developmental models of social anxiety, in particular, have implicated limited social interaction
and poor peer relationships (Rubin & Burgess, 2001). For example, young children with certain
temperamental vulnerabilities, such as behavioral inhibition, experience psychological and
physiological discomfort in social situations, which may place them at risk for the development of
social anxiety. Withdrawal from social interaction during early childhood limits important
socialization opportunities, and thereby may impede the development of social skills. Social skill
deficits may then elicit

88
negative peer reactions, which, in turn, perpetuate further social withdrawal and increase social
anxiety. This cycle may be sustained and strengthened if anxiety decreases as a result of social
avoidance because such negative reinforcement increases the likelihood of subsequent avoidance
and withdrawal. However, the friendships of these children are relatively lacking in fun, intimacy,
helpfulness and guidance, and validation and caring. Other studies indicate that social anxiety is
associated with peer rejection .

Depression
Although deficiencies in social relationships are not required for the diagnosis of depression,
current conceptualizations of the etiology and maintenance of depressive symptoms emphasize
the role of social skills and dysfunctional interpersonal behavior. Children lacking in social
support are believed to be at an increased risk for depression (Windle, 199.Peer relationships have
been found to protect adolescents against depressive symptoms more than parental relationships .
Depressed children tend to perceive their own status more negatively than their peers do, view
themselves as less accepted by their peers and report a lower friendship quality with their best
friends .A number of other factors provide further explanation for depressed children/adolescents’
problematic peer relationships, including depressed children’s difficulty handling conflict with
peers, more emotional dysregulation during stressful peer interactions, and depressed youths’
tendency to seek excessive reassurance from peers .However, depressed children with high-
quality friendships may also be at risk. Recent research indicates that close friends who spent
excessive amounts of time ruminating over problems (called co-rumination) are at risk for greater
internalizing symptoms like depression

Poor Childhood Peer

Relationships and Later
Adult Adjustment
Indeed, the premise that children with relationship problems are at risk for later life difficulties is
one of the most widely shared professional and popular beliefs about development and
psychopathology and has played an important role in motivating research on children’s adjustment
with peers. In general, available data do provide compelling evidence of a link between
problematic peer experiences in childhood and children’s risk for subsequent mental health
difficulties. This conclusion rests in part on numerous studies that document differences in the peer
relationship histories of disordered versus non disordered adults. Research indicates, for example,
that peer relationship problems, especially peer rejection, are associated with increased rates of
internalizing symptoms, such as anxiety and depressive symptoms. Links have also been found
between early peer relationship difficulties and various forms of externalizing difficulties,
including involvement in juvenile and adult criminal behavior. Rejected children were perceived
by their peers as less likable and more aggressive than popular children. Rejected children were
also perceived by their teachers as having more conduct problems, aggression, motor excesses, and
attention problems than their popular counterparts. Moreover, rejected children reported a more
external locus of control and higher levels of conduct disturbance and substance abuse, performed
less well academically, failed more grades, and were more likely to drop out of school and to
commit delinquent offenses than the popular children. Clearly, rejected children were at risk when
compared with popular children. Furthermore,
89
rejected children differed from average children on most of these same measures, including failed
grades, dropping out of school, and commission of delinquent offenses

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91
 SOCIAL INFLUENCES AND PSYCHOPATHOLOGY

Submitted to, Submitted by,

Dr. Jaseem K Prijitha S
Assistant Professoer 1st year Mphil CP trainee
Dept. of Clinical psychology IMHANS
IMHANS

Man is by the nature a social animal; an individual who is unsocial naturally and not accidently is
either beneath our notice or more than human. Society is something in nature that precedes the
individual. Anyone who either cannot lead the common life or is so self-sufficient as not to need to,
and therefore does not partake of society, is either a beast or a god.
Aristotle
Politics, c. 328 B.C.
92
Social explanations of mental disorders.
• Sociological theories- Sociological theories are statements of how and why particular facts
about the social world are related. According to these theories mental illness are developed in a
cultural context.
• Social response theories- Social response theories the response to mental illness rather than
the causes.
• Social constructionist theories- It serves as a critique of the medical model. This theory
explains that our realities are shaped through our experiences and our interactions with
others. The cultural rules that define what is normal and abnormal
(Coulter; 1973)
Social class and structure
The term social class and Socio economic status use interchangeably. Social class has
been conceptualized through both structural and processual approaches, whereby the former interprets
class as a matrix of fixed categories in which individuals move up or down a continuum while the
latter interprets as a group identities shaped by common, shared feelings experiences (Wright & Shin
1988). Structural approaches of class analysis typically measure social class through indicators of socio
economic status such as income, occupation, and education. Psychiatric epidemiological surveys since
the late 1930s have reported higher rates of mental illness in low-income communities. The prevalence
rate for mental retardation (6.9), epilepsy (4.4), neurotic disorders (20.7), alcohol/drug addiction (6.9;
and miscellaneous group (3.9) were estimated. Higher prevalence for urban sector, females, age group
of 35-44, married/widowers/divorced, lower socioeconomic status, and nuclear family members were
confirmed. Epilepsy and hysteria were found significantly high in rural communities.
The social causation hypothesis postulates that the people of lower social status do have the
higher chances of stress. And adversity and o encounter negative factors like adversity and stress
make them vulnerable for psychiatric illness.
Social selection hypothesis states that some genetically predisposed persons tend drift down to or
fail to rise out of such positions and become vulnerable to be psychiatrically ill.
Social exclusion has become one of the most frequently discussed topics in social
sciences and it also a main social issue. Poverty and unemployment are the two important social
exclusions.
POVERTY
Poverty is associated with the undermining of a range of key human attributes, including
health. ‘The world’s most ruthless killer and the greatest cause of suffering on earth is extreme
poverty’(World Health Organization (1995)). The measurement of poverty is based on incomes or
consumption levels, and people are considered poor if their consumption or income levels fall below
the ‘poverty line’, which is the minimum level necessary to meet basic needs. Based on the Suresh
Tendulkar panel's recommendations - In 2011-12, the poverty line had been fixed at Rs 27 in rural
areas and Rs 33 in urban areas, levels at which getting two meals may be difficult. The poor are
exposed to greater personal and environmental health risks, are less well nourished, have less
information and are less able to access health care; they thus have a higher risk of illness and disability.
93
 Income inequality produces psychosocial stress, which leads to deteriorating health and
higher mortality over time. The effects of income inequality also spill over into society, causing stress,
frustration and family disruption, which then increase the rates of crime, homicide and violence
(Wilkinson 1997).
Poverty brings along : -
• A lack of opportunity
• Reduced availability and accessibility to resources
• Greater likelihood of experiencing difficult events
• Isolated from larger cultural technology
• Often labeled as sociopathic, violent.
The ‘Drift hypotheses’
Mental disorder results in deterioration in functioning to such an extent that the individual
drifts down to a lower socio-economic state. This theory suggests that the greater proportion of
observed psychiatric symptoms and admissions from poorer areas is the result of inward migration of
people with mental health problems who are attracted to such areas either due to decreasing income or
due to ‘disintegration’. However, this hypothesis is most commonly described for patients with
schizophrenia; there is little evidence of this downward drift in people with other psychiatric disorders.
Poverty and mental health
Mental disorders occur in persons of all genders, ages, and backgrounds. No group is immune
to mental disorders, but the risk is higher among the poor, homeless, the unemployed, persons with low
education……’. (WHO).The state of poverty is associated with causative as well as consequential-
deprivation leading to lack of opportunity, reduced access to and availability of resources and poor
economic conditions. (Langner & Michael, 1963).
3 sub-divisions of poverty (A. Kuruvilla & K.S. Jacob, 2007)

Absolute Poverty: It refers to the deprivation of basic human needs e.g. food, water,
sanitation, clothing, shelter, health care and education.
Relative Poverty: economic inequality in the location or society in which people live.
Positive correlation with emotional distress.
Working Poor: Represented by financial deficiency and restricted standards of living,
negatively correlated with psychological well-being and increased risk of unmet mental health need.
Ex- farmer suicides in India
Poverty and unemployment
Poverty, acting through economic stressors such as unemployment and lack of affordable housing, is
more likely to precede mental illnesses such as depression and anxiety, thus making it an important
risk factor for mental illness.The treatment of mental illness involves significant expenditure and
mental disorders that are chronic require long-term medication. In countries such as India where most
94
people do not have health insurance and have to pay for treatment, this places a huge burden on the
family.
The relationship between impoverishment & mental illness is bi-directional. The lack of
employment results in financial difficulties and poverty results in reduced opportunity to be gainfully
employed. Unemployed persons and those who fail to gain employment have more depressive
symptoms than individuals who find a job.
Children, poverty and mental health
Children from low income families appear to have higher levels of depression and anti-
social behaviour -such as bullying, being cruel, breaking things, cheating or telling lies than children
from more advantaged households. (Goosby BJ,2006). Children in chronically poor families show
lower cognitive performance.
Women, poverty and mental health
Being female is reported to be a risk factor for common mental disorders. Among women in
poverty, there is support for a significant association between economic hardship and reports of
psychological distress due to such issues as being the sole childrearing adult in a household, multiple
roles, unequal power relations with men and a sense of powerlessness.
Research carried out by Leonard Cheshire Centre for Disability and Inclusive Development
at University College London (UCL) in Partnership with RML- Psychiatric department, New Delhi;
published in June 2013. Between November 2011 and June 2012, they interviewed 647 patients
randomly selected during a visit to the psychiatric department of the Ram Manohar Lohith hospital in
Delhi. Patients had been diagnosed either with schizophrenia or severe affective disorders. The
incidence is significantly higher for persons with mental illness who were less likely:
▪ to be employed (42.1% versus 70.2%)
▪ to have an individual income (31.3% versus 52%)
▪ to benefit from food security (45.8% versus 60.9%)
▪ and to have house ownership (58.5% versus 70.2%)

PREJUDICE
Prejudice is the negative feelings experienced on the part of the prejudiced when they are in the
presence of , or merely think about members of the groups they dislike(Brewer & Brown,1998)
.Prejudice is not personal it is an effective reaction toward the category as a whole. In other words,
when we are prejudiced towards some social group, we are predisposed to evaluate its members
negatively because they belong to that group not to our group. The individuals play little role (Turner,
Hogg, Oakes, Reicher, & Wetherell,1987). Research has illustrated that individuals who score higher
on measures of prejudice toward a particular group do tend to process information about that group
differently than individuals who score lower on measure of prejudice. For example , information
relating to the targets of the prejudice is often given more attention or is processed more carefully than
information relating to them (Hungenberg & Bodenhausen,2003) . Each groups have underlying
95
essences, that means some biologically based feature that distinguishes that group from other groups
and can serve as justification for their differential treatment.(Yzerbyt ,Corneille, &Estrada,2001).
Some theorists have suggested that all prejudice are not based on the same type
of negative affect, instead of this specific intergroup emotions, including fear, anger, envy, guilt or
disgust (Glick, 2002; Mackie & Smith,2002) etc.
Research suggests that inducing some negative emotions can lead directly to
prejudice responses (DeSteno , Dasgupta, Bartlett, & Cajdric,2004). In these studies, participants were
first assigned to minimal groups; they were falsely told that they belong to a social group that was
created in the context of the study. Finally, participants were asked to evaluate other members of their
in group or out group. Reaction time to associate positive or negative evaluations words with the in
group and out group differed depending on the type of negative emotions participants experienced.
Incidental feelings, those feelings induced separately or before a target is encountered; as a result,
those feelings are irrelevant to the group being judged but can still affect judgements of the target.
The orgins of prejudice
• Threats to self esteem:
It is a primary concerns fear that our group interests will be undermined or our self
esteem is in jeopardy. Perceiving a threat to our group can lead us to identify more with our in group.
Research suggest that holding prejudiced views of an out- group allows group members to bolster their
own group’s image particularly when it has been threatened(Branscombe & Wann,1994).
Experiencing threat can affect men’s actions toward women they perceive as a threat to
their group’s position ( Rudman and Fairchild, 2004).
Perceived threat can also have consequences for prejudice against immigrants. Studies
suggest that advantaged groups exhibit prejudice toward out- groups most strongly when they are
experiencing a threat to their groups image and interests.
Competition :
Realistic conflict theory: This theory suggest that prejudice stem from direct
competition between various social groups over scarce and valued resources. They may label each
other as enemies, view their group as morally superior, draw the boundaries between themselves and
their opponents more firmly, and under extreme conditions, may come to see the opposing group are
not even human.
Role of social categorization:
Social world is divided into Us( our in –group) Vs them(out- group), it takes an
emotional significance .Social identity theory concerned with the consequence of perceiving ourselves
as a member of a social group and identifying with it. People identify our group are more favourite and
corresponding bias against out- groups. The greater the similarity between the in- group and out-group
, the more positive the reactions to the out –group will be. Hornsey and Hogg (2000), conducted a
study to test these predictions, it was predicted that in the condition where the distinctiveness of their
own subgroup was not threatened, participants would express less bias toward the other group when it
was described as similar rather than dissimilar to their own.
96
TECHNIQUES FOR COUNTERING PREJUDICE
Some of the techniques that social psychologist have developed in their attempts to
reduce prejudice.
• On learning not to hate : According to social learning view, prejudice is acquired through
direct and vicarious experiences in much the same manner as other attitudes. A study conducted
by Sinclair, Dunn & Lowery in 2005, The question of whether all children are equally
influenced by their parents explicit racial attitudes has been examined , it was found that
parental and children’s racial attitudes were positively related only among children with
relatively high identification with their parents. Research has revealed that highly prejudiced
people experience everyday activities and life itself as lower in enjoyment than do people low
in prejudice (Feagin & McKinney, 2003).

• The Potential benefits of contact:

Contact hypothesis: The view that increased contact between members of
various social groups can effective in reducing prejudice between them. The existence of cross group
friendship suggests that members of the out groups do not necessarily dislike members of our in group,
and this knowledge can reduce intergroup anxiety. Social psychologists, Paolini, Hewstone, Cairns &
Voci, 2004 , found that direct contact between the members of the two religious groups and indirect
contact can reducing anxiety about future encounters with the out group members.
• Re categorization: Changing the boundaries.
Re categorization is the shift in boundaries between our in – group (“us”) and our
in- group (“them”). As a result of such re categorization, people formerly viewed as out – group
members may know be viewed as belonging to the in group and consequently are viewed more
positively. Common In group identity model suggest that , to the extent individuals in different
groups view themselves as members of a single social entity, intergroup bias will be reduced (Dovidio,
Gaertner, &Validzic,1998: Gaetner, Dovidio, Bachman & Anastasio,1994).
• The benefits for prejudice reduction:
Research revealed that people can feel collective guilt, based on the actions of
other members of their group, when they are confronted with harm that their groups prejudice
(Branscombe,2004). In a set studies, Powell , Branscombe &Schmitt found that feeling
collective guilt can reduce a racism. Research suggest that, reflecting on racial inequality can
be an effective means of lowering racism., to the extent that the problem is seen as one
involving the in - group.

Learn “just say no” to stereotypes:

We acquire Stereotypes by learning to associate certain characteristics with
various racial or ethnic groups, once such automatic associations are formed, members of these
groups can serve as primes for racial or ethnic stereotypes, which are automatically activated.
Kawakami and others (2000) reasoned that people can learn to not rely on stereotypes they
already possesses. Research results were shown that reliance on stereotypes can be reduced
trough the process of repeatedly saying “no” to them. 97
 • Social influence as a means of reducing prejudice:
The members of our own group like people belonging to another group that is typically the
target of prejudice and it can sometimes serve to weaken such negative reactions (Pettigrew,
1997; Wright, Aron, McLaughlin-volpe, & Ropp,1997). When stereotypic beliefs are said to be
endorsed by our in group and our membership in that group is salient, then the in groups beliefs
are more predictive of prejudice than are our personal belief about the out group (Haslam &
Wilson,20000. This suggest that stereotypes that we believe to be widely shared within our own
group play a critical role in the expression of prejudice.

DISCRIMINATION: GENDER,ETHNICITY AND RACE

Discrimination: It is Prejudice in Action. People with negative attitudes toward various
groups cannot express their views directly. Laws, social pressure, fear of retaliation—all serve to deter
them from putting their prejudiced views into practice. For these reasons, blatant forms of
discrimination—negative actions toward the objects of racial, ethnic, and gender prejudice—have
decreased in recent years in the United States and many other countries (Devine, Plant, & Blair, 2001;
Swim & Campbell, 2001). This is not to suggest that extreme expressions of prejudice do not occur.
On the contrary, dramatic instances of “hate crimes”—crimes based on racial, ethnic, and other types
of prejudice—do occur.
RACE: According to A. W. Green, “a race is a large, biological human grouping, with a
number of distinctive inherited characteristics which vary within a certain range.”
Modern Racism: More Subtle beliefs than blatant feelings of superiority. It consists primarily of
thinking minorities are seeking and receiving more benefits than they deserve and a denial that
discrimination affects their outcomes (McConahay, 19 86; Swim & , Aikan, Hall, & Hunter) , it can
involve concealing prejudice from others in public settings. Research studies result shows many people
want to conceal their racist attitudes—both from others as well as from themselves—and “failing to
even notice race” might seem to be one way of doing so, social psychologists have had to develop
unobtrusive means of studying such attitudes.
MEASURING IMPLICIT RACIAL ATTITUDES: The most straightforward approach to measuring
prejudice is to simply ask people to express their views toward various racial or ethnic groups. Many
attitudes people hold are implicit—they exist and can influence behaviour, but the people holding them
may not be aware of their impact. Bona fide pipeline technique : It is a technique that uses priming
to measure implicit racial attitudes (Banaji & Hardin, 1996; Towles-Schwen & Fazio, 2001). Research
findings using this procedure indicate that people do indeed have implicit racial attitudes that are
automatically elicited, and that such automatically elicited attitudes, in turn, can influence important
forms of behavior such as decisions concerning others and the degree of friendliness that is expressed
in interactions with them (Fazio & Hilden, 2001; Towles-Schwen & Fazio, 2001). The important point
to note is this: Despite the fact that blatant forms of racism and sexism have decreased, automatic
prejudice is very much alive, and, through more subtle kinds of reactions, continues to affect
behaviour. Recent research suggests that it is through social comparison with extreme images of
bigots that many people who are prejudiced can perceive themselves as not matching that prototype
(O’Brien et al., 2010).
ETHNICITY: 98
 It is a sense of people hood or nationhood that is culturally transmitted. Ethnicity refers to
shared cultural practices, perspectives, and distinctions that set apart one group of people from another.
The most common characteristics distinguishing various ethnic groups are ancestry, a sense of history,
language, religion, and forms of dress. Ethnic differences are not inherited; they are learned.
Cultural beliefs and norms influence many aspects of mental illness including ,How
individuals from a given culture communicate and manifest their symptoms,Diagnosis made within a
particular sub culture, their style of coping, their family and community supports, their willingness to
seek treatment.
Mental Health Perceptions Influenced by Culture and Ethnicity
Stigmas around mental illness occur both towards specific populations and from within it.
▪ Rating of people with a mental illness as more dangerous as compared to the ratings of another
race.
▪ Increased desire to be separated from an individual with mental illness
▪ Increased fear of treatment due to perceptions of unfair treatment in the healthcare setting due
to race
▪ Decreased communication about the state of personal mental health to a physician, mental
health professional or even friend
▪ Mental illness reflect poorly on the entire family, diminishing marriage and economic prospects
overall.
The Impact of Culture and Ethnicity on Mental Illness:
The overall prevalence of mental illness is known to be the same across all races; however it is
interesting to discover that there are some differences in mental health divided by culture and ethnicity.
These include:
▪ Incidence of "culture-bound" syndromes or "folk illnesses"; diseases or conditions that are only
recognized within a specific cultural or society – examples include specific sleep disorders and
suppressed-anger syndrome.
▪ Prevalence of mental illness type; depression versus phobias and anxiety as an example.
▪ Post Traumatic Stress Disorder (PTSD) rates, especially in relation to war-zone trauma.
▪ Minority populations also have less access to mental health services, receive poorer quality
services, greater exposure to racism, discrimination, violence and poverty, all of which
adversely affect mental health and are under-represented in research conducted in this field.
CULTURAL BOUND SYNDROMES :
It refers to psychopathological entities that have a geographically defined prevalence, and are
largely determined by the beliefs and assumptions prevalent in the native culture. Eg:-Among Indian
schizophrenics, catatonic rigidity, negativism, stereotypy and delusional jealously are more common.
The quieter behaviour of Indian patients has been explained on the basis of cultural values like control
of anger and aggression. 99
1. Dhat syndrome- consists of various somatic, psychic and sexual symptoms attributed by the
patient to the passing of whitish fluid, believed to be semen (Dhat) in urine.
2. Jhin Jhinia- occur in epidemic form in India, consisting of bizarre and seemingly involuntary
contractions and spasm.
3. Possession syndrome- dissociative and/or conversion symptom attributed to be due to possession
by a deity or goddess or evil forces.
4. Koro - Sudden and intense anxiety that penis (or in females nipple and vulva) will recede into
body leading to death, may occur in epidemics.
5. Culture-bound trichotillomania - seen in persons belonging to a monastic sect of the jain
community in India who display this phenomenon. These people, remove all their hair on the head
manually plucking it out called "Locha". This is done to denote detachment from physical pain.
6. Compulsive spitting - a symptom reported in a variety of psychiatric disorders e.g. seizure
disorder, schizophrenia, mania, anxiety state, OCD, Tourette's syndrome etc.

Race/ Ethnicity & Mental Illness: Race is merely a socially constructed category based upon some
relatively easily identified physical or phonotypical marker. One classic definition of racism and is that
racism is the product of prejudice plus power. Race and ethnicity are linked with mental health and
illness. Various minority or smaller ethnic groups within a large multicultural umbrella conceptualize,
treat and cope with mental disorders much differently than the ‘people of dominant’ culture (Kleinman,
1988). Very often ethnic minority people have to face problems like ‘discrimination’, ‘fear of being
swallowed by dominant culture’, ‘economic and political disparities’, etc. those factors would make
them susceptible for developing mental disorders (Nazroo, 1998; King, 1997; Karlsen & Nazroo,
2002). The fact remains that ethnic minorities are concentrated in particular social settings, typically
inner city and are characterized by deprivation, unemployment, relatively poor housing, high densities
of accommodation, and lack of key facilities such as nursery or day care for children and other
dependence (Harrison, 1989). This can lead to an unexpected level of social isolation, particularly in
high-rise flats, or when cultural norms also restrict interaction with non-family members.
Concentration in such areas, which were in any event typified as having a higher prevalence of
schizophrenia (Giggs, 1986), may have its own effects-especially, perhaps, if a viral agent, one posited
cause of schizophrenia, should prove to be implicated. A unique cause of stress, however, for ethnic
minority populations is the increasing level of racist abuse and harassment- a more direct and
immediate threat than the institutional racism. While this abuse was unquestionably racist have been
recorded, and attacks involving arson or actual bodily harm are apparently on the increase. Ethnicity
has been recognized as an important variable in suicide research. Several authors have reported
variations across cultures in the lifetime rates of suicide attempts (Sartorius et al, 1983; La Vecchia et
al, 1994; Weissman et al, 1996). Interestingly, the rates are relatively favourable in less developed
countries, in contrast with the upward trends (particularly for men) in several developed ones.

Social Change & Mental Illness: Impact of Modernization, Industrialization, Urbanization &
Globalization on Mental Health:
100
 Broadly globalization may be defined as a process in which the traditional boundaries
separate- in which the traditional boundaries separating individuals and societies gradually
increasingly recede. This process is changing increasingly recede. This process is changing the nature
of human interaction in many the nature of human interaction in many spheres: economic, political,
social, cultural, spheres: economic, political, social, cultural, environmental and technological. It is
changing the way we perceive time and space, and the way we think about the world and the way we
think about the world and ourselves (Kunitz, 2000; Lee, 2000). Different philosophical and
ideological approaches have led to polarized views about the impact of globalization on individuals
and society. However, the process clearly has both negative and positive results and it is likely to
create both losers and winners. Societies alter rapidly through urbanization, acculturation,
modernization, and social and cultural change. Despite evidence that all mental disorders are psycho
biosocial in origin and that the quality of social environment is related to the risk of mental illness, it
is difficult to predict the impact of globalisation on the prevalence and course of psychiatric
disorders. What is certain, however, is that mental disorders can no longer be dissociated from the
global context that frames our lives. According to Kirmayer & Minas (2000), globalisation affects
psychiatry in three main ways: through its effect on the forms of individual and collective identity,
through the impact of economic inequalities on mental health, and through the shaping and
dissemination of psychiatric knowledge itself. They identify both the tendency for communities to
reassert their distinctive ethnic identity, and the creolisation’ of identity and of the cultural idioms
through which emotional distress is communicated. The key factor in globalisation is urbanisation.
Urbanisation is the relative increase of the urban population as a proportion of the total population
(Harpham et al, 1988), and it is occurring on a scale never before experienced. Kleinman (1991)
observed that urbanisation has led to a massive increase in behavioural disturbance – especially
associated with breakdown of families, including abandonment of and violence to spouses, children
and the elderly – as well as depressive and anxiety disorders (although he cautions that the apparent
increase in the latter disorders may be due to more accurate reporting). Harpham (1994) presented a
model of the interlinking of urbanisation and mental disorders in which long-term difficulties,
increased life events and reduced social support act as mediating factors. Chronic difficulties such as
poor, overcrowded physical environments, high levels of violence and accidents, insecure tenure and
poor housing have all been shown to be associated with depression. There have been suggestions that
social deviance could be traced to many of the social processes accompanying urbanisation, including
competition, class conflict, accommodation and assimilation (Park et al, 1925). Marsella (1995)
proposed that urban settings represent a natural laboratory for studying the roots of traditional mental
disorders such as depression, schizophrenia and neurosis, and that a conceptual framework which
considers the stress associated with problems of housing, work, marriage, child rearing, security and
other urban difficulties in simultaneous interaction with the resources available for their resolution or
attenuation provides the best understanding of the determinants of psychopathological disorder in
urban populations. Other researchers (Desjarlais et al, 1995; Bibeau, 1997) emphasise the link
between mental health and poverty, economic disparity and underdevelopment. Urban crowding,
poor working conditions or underemployment, chronic hunger, gender discrimination, limited
education and human rights violations are all thought to weaken and devastate both individuals and
the social supports that could serve as buffers against mental health problems. Moreover, economic
factors determine the availability and quality of mental health services. 101
Culture & Mental Illness: Culture has been described as a manmade part of the environment. It varies
with time, and place and persons; hence its influences also vary with them and in different areas.
Cultural aspects of mental disorders can be viewed from different angles like culture influencing the
knowledge of and attitudes towards mental disorders; culture determining certain culture bound
syndrome etc. Psychiatric signs and symptoms appear to occur with different rates across cultures and
languages (Westermeyer, 1973). Because psychiatric conditions may vary across ethnic groups as a
result of cultural, historical, nutritional, genetic and other factors (Westermeyer,1973). Particular signs
or symptoms may be under-reported or over reported in a culture due to their taboo status or their
valued status. Mental health becomes vital when one talks about the interpersonal communication,
professional and social life as per the socio-cultural background of the concerned people. A mentally
normal person in a society may not be considered normal in other setup. There is some behaviour
which are sanctioned by one particular culture and disapproved in another. Culturally sanctioned and
lauded norms and rules related behavioural expression pertaining to ‘talking’, ‘interacting with others’,
‘gestures’ and every other thing can vary culture to culture (Comer, 2001). The distinction between
cultural explanations of symptoms and true syndromes is often problematic. Folk beliefs about mental
illness are rarely found in written form, fall outside of the scientific tradition, and are often magical,
integrative, and definitive. Mystical theories include fate, astronomical influences, predestination, bad
luck, ominous sensations, nightmares, contact with menstrual blood or a corpse, violation of taboos,
speaking forbidden words, trespassing, and improper conduct toward kinsmen, strangers, social
superiors, or spirits. Animistic theories include soul loss and aggressive acts by spirits. Magical
theories ascribe illness to the use of sorcery or witchcraft; Magical techniques include spells; hexes;
prayers; curses. Although scientifically irrational, they offer explanations for life’s vagaries and make
the seeming capriciousness of pathology more acceptable. Scientific and folk beliefs are ritualistic and,
in regard to mental illness, have successes and failures. Both systems may function simultaneously
within a culture and within a person. A mentally disturbed person may seek psychiatric help and, at the
same time, indulge in folk therapies (Karno & Edgerton, 1974).

CRIME AND DELIQUENCY

Beginning in the early twentieth century, theories about the causes of crime began
to move away from biological and psychological causes of human behavior toward social environment
explanations, such as slum life and the society at large (Gelles & Levine, 1999). The sociological study
of crime and delinquency has focused either on the social structural factors (e.g., poverty and social
disorganization) believed to generate such behavior or on the arenas (e.g., family, school, and peer
groups) in which socialization to conventional or criminal values and behavior are affected. Several
psychological theories have been used to understand crime and delinquency. Criminology is defined by
Webster’s dictionary as ‘‘the scientific study of crime as a social phenomenon, of criminals, and of
penal treatment’’ (http:// www.merriamwebster.com/dictionary/criminology). In one criminology
textbook, Sheley (2000) defined the term more narrowly as the ‘‘scientific study of crime as a social
phenomenon’’ and reflected the dominant role sociology has played in the study of crime and
delinquency . However, psychological theories have also been influential in shaping the way society
thinks about crime and delinquency and in shaping policies that relate to these issues (Sampson &
Laub, 2003). 102
 There are two classical sociological theories of crime and delinquency:
(1) The theory of anomie by Durkeim: : Anomie is a condition of normlessness. According to Emile
Durkhiem (1997/1951), “ when there is a sudden change, the normative structure of the regulating
norms of the society is slackened, hence man does not know what is wrong or what is right, his
impulses are excessive: to satisfy them, he seeks anomie.” In the words of Merton (1938), “anomie
may be conceived as breakdown in the cultural structure occurring particularly when there is an acute
distinction between cultural norms and goals and the socially structure capacities of members of the
group to act accord with them.”
(2) The theory of slum and Chicago School: The Chicago School believed that the causes of crime
were primarily entrenched in one area of American society— the city slums—and people became
criminal by learning deviant cultural norms and values (Short, 2002). Rejecting the social Darwinism
of the time, criminologists in the Chicago School rejected crime as a matter of individual pathology;
they viewed crime as a social problem in which the poor were driven by their environment into a life of
crime due to criminal values’ replacing conventional ones and being transmitted from one generation
to the next (Short).
Social disorganization has a very close relationship with gross
deviation from the social stream and non-compliance to values and norms of society, which in turn
leads to marked imbalance in society. In sociology, the Social disorganization theory was developed to
reach at roots of deviance, criminality and effect of social problem on human psyche. This approach is
closely related to ecological theories. Social disorganization theory says that social problems have
neighborhood ecological characteristics; means that people belong to disadvantaged neighborhoods are
participants in a subculture in which delinquency was approved behavior and that criminality was
acquired in a social and cultural setting through a process of interaction. A core principle of social
disorganization theory is that place matters -- i.e., one's residential location -- as much or more than
one's individual characteristics (age, gender, race) in shaping the likelihood that a person will become
involved in illegal or deviant activities. Delinquent people are at high risk of developing maladaptive
behaviour to deal with crisis and stress, e.g. substance addiction, involvement in violence, accidents
and self-harm. The concept of social disorganization is defined in terms of the absence or breakdown
of certain types of relationships among people, and is intimately tied to conceptions of those properties
of relationships that are indicative of social or communal “organization.” Relationships among people
in a given territory are presumed to be especially “organized” when there high levels of involvement
across age-levels in activities coordinated by representatives of communal institutions (e.g. family-
heads, community leaders and elders, spiritual leaders, school organizations and local officials). Such
organized interaction is presumed to be closely and reciprocally associated with the development of a
sense of community or communal bonds among people in close geographic proximity to one another.
In the 19th Century Thomas and Znaniecki (1918-1920) purported the idea that a person's thinking
processes and attitudes are constructed by the interaction between that person's situation and his or her
behaviour. Attitudes are not the end products of innately defined process but stem from a process of
acculturation. Any proposed action will have social importance to an individual both because it relates
to the objective situation within which the subject has to act, and because it has been shaped by
attitudes formed through a lifetime of social and cultural experiences. This is based on the "four
wishes" of the “Thomas theorem” developed by American Sociologist William Issac Thomas in 1928, 103
viz., "If men define situations as real, they are real in their consequences". These four wishes are the
desire for new experiences, the desire for recognition, the desire for domination, and the desire for
security. Combined with the cultural values of a pre-existing situation, the four wishes give rise to
certain attitudes which are subjectively defined meanings and shared experience, strongly emphasized
and embodied in specific institutions. The root of new attitudes arises from the formation of new
relationships and interaction between the person and the world outside the community (Sutherland,
1939; Merton, 1957; Sampson & Grove, 1989).

Psychological theories of crime and delinquency:

Theories of crime and delinquency tend to use either macro- or micro-
levels of analysis. The field of sociology has addressed crime and delinquency at the macro-level,
primarily looking for societal and environmental influences that lead to criminal behaviour.
Psychological theories tend to address crime and delinquency at the individual level.
Learning theories: Social learning theorists posit that the conditions by which behavior is
shaped include internal and external forces, and that behavior itself is a determinant of future behavior
(Bandura, 1969). Deviant, criminal or delinquent behavior, like all behavior, results from this model of
causation. Learning theories have been influential in understanding criminal behavior. A theory of
differential association was posited; criminal behavior occurs in a context of cultural conflict where
association with criminals increasescriminal behavior(Sutherland,1939).
Intelligence theories: criminal behavior was caused by low intelligence (Goddard, 1914, as
cited in Shoemaker, 2005). Many researchers continue to be concerned about the misinterpretation of
IQ-delinquency data because a narrow focus on IQ as a cause of delinquency can direct researchers to
misleading conclusions about heredity, race, and class (McGloin, Pratt, & Maahs, 2004). Some studies
have reported that delinquents have lower IQ scores than nondelinquents (Hirschi & Hindelang, 1977),
and a connection between low IQ and delinquency has been posited (Lynam et al., 1993). In their
influential review, Hirschi and Hindelang concluded that intelligence had an effect on delinquency, and
this effect had an inverse correlation that was independent of class and race.
Personality theories:
Theories that explain crime and delinquency as a result of personality traits focus on delinquency
as an externalizing behavior representing internal pathology. Representing a large literature, two
prominent theories are the psychodynamic-psychoanalytical theory and the personality trait theory.
Theories of Psychopathy
Theories of psychopathy are used to describe more serious and violent delinquent acts.
Theorists view serious and persistent crime and delinquency as an outward manifestation of mental
illness. Antisocial personality disorder (APDhas been closely studied in connection with crime and
delinquency (Shoemaker, 2005; Siegel et al., 2006). Psychopathy was described as a ‘‘socially
devastating personality disorder defined by a constellation of affective, interpersonal, and behavioural
characteristics.

MIGRATION:
Migration is the process of social change whereby an individual moves from one cultural
setting to another for the purposes of settling down either permanently or for a prolonged period. Such
a shift can be for any number of reasons, commonly economic, political or educational betterment. The
process of migration can be classified into three types, such as: The migratory process can be seen104as
three stages. The first stage is called as pre-migration, is when the individuals who want to migrate
take decisions about it and plans the move. The second stage is the physical transition from one place
to another, involving all the necessary psychological and social steps. The third stage, post-migration,
is when the individuals deal with the social and cultural frameworks of the new society learns new
roles and become interested in transforming their group. Though such shift can inevitably be stressful
to concerned people and stress can lead to mental illness. The preparation, the migrants undertake,
their acceptance by the new host community and the process of migration itself are some of the macro
factors in the origin of mental disorders. The micro factors include personality traits, psychological
robustness, cultural identity, and the social support and acceptance of others in their own ethnic group.
The findings on prevalence of common mental disorders across different ethnic and migrant
populations are equivocal. The process of migration and subsequent cultural and social adjustment also
play a key role in the mental health of the individual (Bhurga & Jones, 2001). Though there is a
overlap between psychological and social theories. Crime and delinquency explained in terms of some
psychological theories.

RELIGION AND GENDER RELATED ISSUES IN INDIA :

In this chapter, the relation between religion and mental health and vice versa has been described.
From primitive times different religions have different beliefs and systems of worshipping. Every
religion with their belief system has implications on mental health and illness. We described how
Hindu system of beliefs and rituals may have an effect in causation of various mental illnesses. It is
also described how religion can help an individual to sustain one's life in various domains. The
relationship between different religion and symptomatology is described. The impact and outcome of
religion on mental health have been highlighted.

Religion
Is an organized system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the
sacred or transcendent (God, higher power, or ultimate truth/reality)?.[3]
Religion which evolved due to basic psychological need of mankind later metamorphosed.
Gradually religious practices developed into dogmas and superstitions. Though most religions
continued changing with time many became completely fossilized. From mental health
perspective religion provides much -needed guidelines, which can help individuals to devise a
course for their lives. Stresses and strains as well as uncertainties of life can be tolerated more
easily by the believers. However, many outmoded rituals and belief systems might inhibit
positive growth and may lead to mental ill-health.[1] In studying the relationship of spirituality
with health,

EVIDENCE OF RELIGIOSITY ON MENTAL HEALTH:

• A very important dimension of religiosity is religious commitment, which reflects the influence
105
that religious beliefs have on a person's decisions and lifestyle. According to the Harvard
 psychologist Gordon Allport a persons’ religious orientation may be intrinsic and/or
extrinsic:[3]

• The intrinsic orientation is associated with healthier personality and mental status, while the
extrinsic orientation is associated with the opposite. Extrinsic religiosity is associated with
dogmatism, prejudice, fear of death, and anxiety, it “does a good job of measuring the sort of
religion that gives religion a bad name.

Positive outcomes of religion and health

• Decreased smoking and alcohol consumption,

• Suicidal ideations were lowered.

• Religious tradition had more impact than the home.

HOW RELIGION COULD INFLUENCE MENTAL HEALTH

• Healthy behavior and life styles

• Social support

• Belief and cognitive processes influence how people deal with stress suffering life
problems. Many patients use religion to cope with medical and non-medical problems.

CLINICAL IMPLICATIONS
In the presence of psychopathology, religion may be part of it, contributing to the symptoms
(obsessions or delusions for example). Sometimes, religion may become rigid and inflexible, and be
associated with magical thinking and resistance. It may be helpful to integrate the patient into society,
or motivate him/her to seek treatment (promoting guilt that motivates treatment in a pedophilic for
instance). It may hinder treatment if it forbids psychotherapy or the use of medication. It has been
described the elements of a functional theology, present in all religions, which may promote good
mental health. They are: Awareness of God, acceptance of the grace and love of God, repentance and
social responsibility, faith and trust, involvement in organized religion, fellowship, ethic, and tolerance
and openness to the experiences of others.
RELIGION AND MENTAL ILLNESS : INDIAN PERSPECTIVES
Religious beliefs and practices are often contributory to the development of certain
psychiatric disorders more so as regards to obsessions, anxiety and depression. Somehow, this aspect
of psychopathology has not been given due consideration. For instance, Freud observed remarkable
similarity between obsessive behavior patterns and religious practices in view of their fixed,
stereotyped and rigid character, their being meaningless and the anxiety that follows when specific
action is not properly performed. Religion often creates guilt by setting high moral standards while, on
the other hand, it also provides a number of methods of alleviating guilt such as confession, prayer,
charity etc. 106
Dhat syndrome
Sexual hypochondriasis Dhat (WIG 1958) is common in India. There is multiple neurasthenic
symptoms associated with passage of semen in urine. It occurs in young Indian males.
Obsessive compulsive disorder
The explanation might be obsessive compulsive symptoms particularly related to cleanliness
are socially accepted to family than other neurotic illness. Hindus excessive preoccupation with
cleanliness, on the other hand, may give rise to gastro intestinal hypochondriasis.
Depression
It is quite common in India. There is often a guilt feeling in Indian depressed patients.
Acute psychogenic psychosis
Due to rigid conformism and suppression of aggressive impulses sudden outbursts in form of
acute psychosis are common.

Possession spells
It is widely common in India and has its root in religious beliefs, mental illness as a state of
being possessed by someone. Such beliefs are still common, especially in rural populations. It occurs
mostly in hysterical background but sometimes is reported in association with functional psychosis .
Gender & Mental Illness:
Sex and gender are sometimes used interchangeably; that is, to refer to a person’s
biological sex, or differences between groups divided on the basis of their biological sex. Sex and
gender issues in psychopathology have attracted comment on a range of fronts: historical (Showalter,
1987), feminist (Chesler, 1972) and sociologist (Miles, 1988), as well as psychological (Ussher, 1991).
Various studies shows there are apparently sex differences in the risk of psychopathological problems.
Women predominate in particular categories of psychopathological disorders, such depression,
phobias, anxiety, and eating disorders (Brisco, 1982), where there is a higher incidence among men of
conditions such as alcoholism, sexual disorders, and criminal behaviour( Al-Issa, 1982). The
possibility that there is some kind of conflation of females and psychopathological behaviour has a
long history (Showalter, 1987) and is well illustrated in a classic study of Broverman et la (1970). This
study indicates that there are expectations as to the parallels between female and pathological
behaviour. It is also suggested that when women and men present with the same symptoms, such as
anxiety and restlessness, women are more likely to be treated as though they have a psychological
problems, whereas the men will receive more physical therapies (Cooperstock, 1981). This may apply
to women who actually seek help and enter the statistic with a diagnosis of mental illness, but
community surveys also indicates levels of psychological problems among women (Clancy & Gove,
1974). One aspect of a women’s psychology that has been identified as relevant to an understanding of
her vulnerability to mental health problems in her personality. Rothblum (1987) notes female
characteristic of the depressive can be viewed as intensifications of normal female characteristics.
Hammen & Peters (1977) found that both depressed men and women were rated high on femininity;
that is, femininity was equated with the symptoms displayed by the patients. Similar observations have
been made about the preponderance of women in the statistics for phobias (Brehony, 1983). In 107
the
clinical literature, agoraphobia people were described as having the personality traits of passivity,
dependency, avoidance, and non assertiveness (Brehony, 1983). There are also characteristics which
females are expected to exhibit, and for which girls are reinforced. There is a clear relationship
between the extreme helplessness and dependency of the agoraphobic, and the social expectations for
women (Fodor, 1974). Abramson et al (1978) suggest that depression arises from internal attribution of
this lack of control, from people blaming themselves for their current situation. Hammen (1982)
reports on studies showing the tendency of women to attribute success to external causes but failure to
internal sources. Beck & Greenberg (1974) suggest that actual reality of women’s social powerlessness
may well be associated with the subjective helplessness and hopelessness characteristic of depression.
It is possible that the operation of sex stereotypes may be of significance in a women’s acquisition of
her negative view of herself and her sex (Rothblum, 1973). It may also be that gender –appropriate
behaviour affects the way women express distress, and hence the particular form of pathological
behaviour they display. It has been suggested that depression is for women what alcoholism is for men
(Weissman & Klerman, 1977), and that the difference is related to culturally accepted ways of
behaving. In considering the affect of social roles in mental health, it will be seen that for women, the
roles themselves, attempts to reject them, and conflict between them can all have pathological
consequences. Women’s work is low in ‘recognition and reward ‘(Nairne & Smith, 1984). In a society
in which earning power equates with status, women are low earners (Usshar, 1991). Status and reward
are also factors already discussed as important in understanding psychological problems. A women’s
feeling of lack of control in her life may reflect the reality of her social situation.

SUMMARY AND CONCLUSION:

In conclusion it can definitely be said that there is sufficient evidence to imply that
mental disorder have definite aetiological association with various socio-cultural and economic factors
and ideal interventions of mental disorders should include equal appraisal to biological, psychological
and social aspects. And such a social view of mental disease can stimulate relational alternatives to the
traditional, self-contained biologically based psychiatry. The biomedical model alone cannot
adequately explain the social consequences of illness and the implications of social factors in
promoting mental health. Different theories and hypotheses related to social factors add another
dimension to our understanding of mental health and mental disorder. This also adds to and enriches
the existing interventional strategies. Such theories have only broadened and strengthened the
understanding already established by the biomedical models.

108
Introduction

Disability is inseparable part of the human condition. Most of the individuals can be temporarily or
permanently impaired at some point in life. The disabled person can be seen in the extended
families and the family members take up the responsibility for supporting and caring the disabled
member of the family. Due to medical advances and technology, wider availability of health
insurance, and a generally higher standard of living that provides more services and support, people
who would have died in the past now survive with a disability. To meet minimum standards of
practice, therefore, counselors will be required to become proficient in disability issues (Hayes,
2001; Hulnick & Hulnick, 1989). Indeed, Humes, Szymanski, and Hohenshil (1989) suggested that
counselors have not facilitated the personal growth and development of their clients with
disabilities. Since 1970s, the responses to disability have changed largely by the self-organization of
people with disabilities and thus there is a growing tendency to see disability as a human rights
issue. Historically, disabled persons are provided with segregating facilities such as residential
institutions and special schools. Now, there is a major shift towards the inclusion with the
community, education and medically focused solutions have taken more interactive approaches in
recognizing the environmental factors and further more. National and international initiatives such
as the United Nations Standard Rules on the Equalization of Opportunities of Persons with
Disabilities have incorporated their human rights.

The World Health Organization (WHO 1976) distinguished between impairment, disability and
handicap.

➢ Impairment is any loss or abnormality of psychological, physiological or anatomical

structure or function.
➢ Disability is any restriction or lack (resulting from an impairment) of ability to perform
an activity in the manner or within the range considered normal for a human being.
➢ Handicap is a disadvantage, for a given individual, resulting from impairment or a
disability, which prevents the fulfillment of a role that is considered normal (depending
on age, sex and social and cultural factors), for the same individual.

WHO issued International Classification of Functioning, Disability and Health (ICF) which
dynamic interaction between health conditions (personal factors) and contextual factors

109
(environmental factors) influences the functioning and disability, which is depicted as a bio-
psycho-social model. Thus Disability is complex, dynamic, multidimensional, and contested. It also
refers to difficulties encountered in any or all three areas of functioning: impairments, activity
limitations and participation restrictions.

The framework of disability within an individual is varying in which disability is rapidly interacting
among the individual, the disability, and the contextual factors (Dembo, 1982; Higgins, 1992).
Disability is counted on to one of the several other important aspects of the individual’s self-identity
rather than the single defining and representing characteristic of the individual. It also gives
meaning to the critical part of the individual’s self-identity. A person’s environment plays a major
role in determining the experience and the degree of disability. It contributes for the good and bad
prognosis depending upon its direction and accessibility. Inaccessible environments create disability
by creating barriers to participation and inclusion. Health is also affected by environmental factors,
such as safe water and sanitation, nutrition, poverty, working conditions, climate, or access to health
care. The World Health Organization (WHO) Commission on Social Determinants of Health has
argued that unequal distribution is a major cause of poor health, and hence of disability. The ICF
also have recognized personal factors, such as motivation and self-esteem, which determines the
participation of disabled person in society. Though it is not better conceptualized, the degree of the
influence these factors are decided by the person’s capacities to perform actions and the actual
performance of those actions in real life. Modification of the environments is assumed to give better
results in boosting the performance.
Disability in Indian Context

In India different definitions of disability conditions have been introduced for various purposes and
also based on various criteria of abnormality or pathologic conditions following medical model. In
absence of a conceptual framework based on the social model in the Indian context, no
standardization for evaluating disability across methods has been achieved. In common use,
different terms such as disabled, handicapped, crippled, physically challenged, are used inter-
changeably in indicating the pathological conditions. According to the Census 2001, there are
thousand people with disabilities in India who constitute 2.13 % of the total population
(Census 2001). Out of the 21,906,769 people with disabilities, 12,605,635 are
males and

110
9,301,134 females and this includes persons with visual, hearing, speech, locomotor and mental
disabilities (Census 2001).In 2002, the NSSO estimated that the incidence rates for males were 77
and 75 per 100,000 respectively The incidence rate was highest in Andhra Pradesh and lowest in
Assam (NSSO 2002). Incidence rates have declined during 1991-2002 for all types of disability
groups in lower and high age groups, however, the incidence rates for loco motor disabilities among
the age groups of 15-29 years have increased.

Persons with Disability Act

Through the Act is built upon the premise of equal opportunity, protection of rights and full
participation, it provides definitions of disabled person following the medical model. According to
the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act,
1995, "Person with disability" means a person suffering from not less than forty per cent of any
disability as certified by a medical authority (any hospital or institution, specified for the purposes
of this Act by notification by the appropriate Government). As per the act different types of
disability are

➢ Blindness refers to a condition where a person suffers from any of the following
conditions, (i) Total absence of sight. (ii) Visual acuity not exceeding 6/60 or 20/200
(snellen) in the better eye with correcting lenses; (iii) Limitation of the field of vision
subtending an angle of 20 degree or worse.
➢ Leprosy cured person means any person who has been cured of leprosy but is suffering
from- (i) Loss of sensation in hands or feet as well as loss of sensation and paresis in the
eye and eye-lid but with no manifest deformity; (ii) Manifest deformity and paresis; but
having sufficient mobility in their hands and feet to enable them to engage in normal
economic activity; (iii) Extreme physical deformity as well as advanced age which
prevents him from undertaking any gainful occupation, and the expression "leprosy
cured" shall be construed accordingly.
➢ Hearing impairment means loss of sixty decibels or more in the better ear in the
conversational range of' frequencies.
➢ Loco motor disability means disability of the bones, joints muscles leading to
substantial restriction of the movement of the limbs or any form of cerebral palsy. 111
 ➢ Mental retardation means a condition of arrested or incomplete development of mind
of a person which is specially characterized by sub normality of intelligence
➢ Mental illness means any mental disorder other than mental retardation.

With regard to definitions adopted by PWD Act, Census of India stated "the concepts and
definitions of disabilities coupled with measuring its extent and its types contained in the PWD Act,
1995 were found to be extremely difficult to canvass even in normal circumstances assuming
people had time, were willing and forthcoming to share this information and there was an expert
investigator to elicit this information." Census therefore used its own version of definitions of
disabilities. Census of India 2001 defined five types of disabilities:- (i) seeing, (ii) speech, (iii)
hearing, (iv) movement, and (v) mental.

Seeing disability: A person who cannot see at all (has no perception of light) or has blurred vision
even with the help of spectacles. A person with proper vision only in one eye was also treated as
visually disabled. A person may have blurred vision and had no occasion to test whether her/his
eyesight would improve by using spectacles - such persons were treated as visually disabled.

Speech disability: A person who is dumb or whose speech is not understood by a listener of normal
comprehension and hearing was considered to have speech disability. Persons who stammer but
whose speech is comprehensible were not classified as disabled by speech.

Hearing disability: A person who cannot hear at all (deaf), or can hear only loud sounds was
considered to have hearing disability. A person who is able to hear using hearing aid, was not
considered as disabled under this category. If a person cannot hear through one ear but her/his other
ear is functioning normally, she/ he were still considered to have hearing disability.

Movement Disability: A person, who lacks limbs or is unable to use the limbs normally, was
considered to have movement disability. Absence of a part of a limb like a finger or a toe was not
considered as disability. However, absence of all the fingers or toes or a thumb make a person
disabled by movement. If any part of the body is deformed, the person was also treated as disabled
and covered under this category. A person, who cannot move herself/himself without the aid of
another person or without the aid of stick, etc., was treated as disabled. Similarly, a

112
person who is unable to move or lift or pick up any small article placed near her/him was also
treated as disabled in movement.

PWD ACT 2016

The PWD (Equal Opportunities, Protection of Rights, and Full Participations) Act, 1995 was
enacted to give an effect to the “Proclamation on the Full Participation and Equality of the People
with Disabilities in the Asian and Pacific Region.” The Proclamation was issued in a meeting of the
Economic and Social Commission for Asia and the Pacific Region in December 1992 at Beijing, to
launch the “Asian and Pacific Decade of Disabled Persons 1993–2002.” The Act listed seven
conditions of disabilities, which were blindness, low vision, leprosy cured, hearing impairment,
loco-motor disability, mental retardation, and mental illness

The amendment in the current act stressed on non-discrimination, full and effective participation
and inclusion in society, respect for difference and acceptance of disabilities as part of human
diversity and humanity, equality of opportunity, accessibility, equality between men and women,
respect for the evolving capacities of children with disabilities, and respect for the right of children
with disabilities to preserve their identities. The principle reflects a shift from the concept of
disability from a social welfare concern to a human rights issue. It also extended the types of
disability from 7 to 21 conditions which includes cerebral palsy, dwarfism, muscular dystrophy,
acid attack victims, hard of hearing, speech and language disability, specific learning disabilities,
autism spectrum disorders, chronic neurological disorders such as multiple sclerosis and Parkinson's
disease, blood disorders such as haemophilia, thalassemia, and sickle cell anaemia, and multiple
disabilities. The nomenclature mental retardation is replaced by intellectual disability which is
defined as “a condition characterized by significant limitation both in intellectual functioning and in
adaptive behavior in everyday social and practical skills including specific learning disabilities and
autism spectrum disorders. The Act provides an elaborate definition of mental illness which is “a
substantial disorder of thinking, mood, perception, orientation, or memory that grossly impairs
judgment, behavior, and capacity to recognize reality or ability to meet the ordinary demands of life
but does not include retardation which is a condition of arrested or incomplete development of mind
of a person, especially characterized by sub-normality of intelligence.” Persons with benchmark
disabilities are defined as those with at least 40% of any of the above disability. The RPWD Act,
2016 provides that 113
“the appropriate Government shall ensure that the PWD enjoy the right to equality, life with dignity,
and respect for his or her own integrity equally with others, equal protection and safety in situations
of risk, armed conflict, humanitarian emergencies, and natural disasters are to be provided to PWD.
Children with disability are not to be separated from parents except on the order of a competent
court and information about reproductive rights and family planning to the PWD is to be ensured.
Accessibility in voting and access to justice without discrimination to the PWD are to be ensured.
Public documents are to be made available in accessible formats.

On perusal of the Act, it is observed that though mental illness has been included as a condition of
disability, special needs of persons with mental illness (PMI) and their families have not been
properly addressed. The Act criminalizes the service provider and the family for providing
treatment of persons with severe mental illness without their permission even though the person
may be at a clear risk to himself or to others. The section 7(2) has been inserted for a good cause of
protecting PWD from acts of abuse, violence and exploitation. While ignoring the role and
importance of family in the care of PMI, the Act is silent on how the vast support system would be
built for such a large country with millions of persons suffering from severe mental illness. Even if
any support system is actually built in urban and semi urban areas, still it is doubtful about how
PMI living in remote villages would get access to them where even the most basic health facility is
not available.
Other Factors Influencing Disability

It is found that poverty is the biggest causal factor of disability in India because disabled persons are
more likely to suffer from malnutrition, live in crowded & unsanitary conditions (increasing risk of
infectious disease) have limited access to medical care, be poorly educated, not immunize their
children, lack adequate care during pregnancy and birth and have multiple pregnancies. A South
Indian study by Thomas (2005) demonstrated that the area of residence and monthly income is also
a significant contributing factor. The children with disability are more common among low income
family than high income family. The results suggested that comparatively small differences in
social status can be associated with significant differences in the health status. (Natale et al 1992).
Similarly, the World Bank reported in 2007 that in India, disability is associated with lower socio-
economic status.

114
A cross-sectional study conducted in Delhi reveals that loco-motor disabilities constitute a severe
socioeconomic burden on parents of the disabled children. Further reports showed that 80% of the
disabled children were not getting any social security payments and 90% had no special concessions
for medical and other educational purposes. Joshi et al (2003) found that 87.5% of the elderly
people in India were reported to have minimal to severe disabilities and 66% that were distressed
either physically or psychologically, or both and also showed that increasing numbers of
morbidities were associated with increasing disability (r=0.52, d.f.=198, p<0.01).

The British Department for International Development (DFID) has recognized disability as a major
cause of social exclusion and it also contributes for both the cause and consequence of poverty
(DFID 2000). Yeo states that the disabled individual’s experience of discrimination from birth or
from time of disablement determine the relationship of chronic poverty with disability and
impairment because such types of experiences can provide ways for lack of resources, lower
expectations, poor health and poor education. Hence chronic poverty condition is also a risk factor
for illness, injury and impairment, and in turn again causing disability. Several studies that the
prevalence of disability is lower in relatively privileged socioeconomic groups in both developed
and developing countries. (Parker et al 1994; Melzer et al 2000; Rautio et al 2001; Seeman et al
2001).

The personal characteristics influencing the disability include gender, age and genetic inheritance,
family background and status, education, training and skills, occupation and work history, and
previous medical history. Mental capital and mental well-being are critical to the healthy
functioning of individuals, families, communities and society (Foresight 2008). The personal and
subjective experience of illness and disability may diverge from objective measures such as
assumptions, perceptions and expectations (by the individual, family, health professionals and
employers, which may interact and reinforce each other), attitudes and beliefs, emotions, mood,
values, goals, expectations, psychological distress and coping strategies, motivation and effort. The
relative importance of these factors may vary in different individuals and settings over time.

115
 Models of
disability
Models of disability provide a framework for understanding the way in which people with
impairments experience disability. They also provide a reference for society as laws, regulations
and structures are developed that impact on the lives of disabled people. A growing interest in
models of disability has emerged in recent years, led by a variety of counseling practitioners,
educators, and policy makers (Bickenbach, Somnath, Badley, & Ustun, 1999; Humes et al., 1989;
Melia, Pledger, & Wilson, 2003; Olkin & Pledger, 2003; Smart, 2004; Tate & Pledger, 2003). This
lack of training and the resulting failure to provide services may be due to the powerful influence of
models of disability, because these models determine in which academic disciplines the experience
of disability is studied and taught.

The medical model

It may be summarized as a mechanistic view of the body, in which illness is simply a fault in the
machine that should be fixed. It has oversimplified approach towards the disability. It understands
illness by recognizing patterns of symptoms and signs infer underlying pathology and apply therapy
to that pathology and expect the patient to recover. Because of its focus on biological pathology and
its treatment (Virchow 1858), it is also described as a disease model or biomedical model. This
approach has led to dramatic medical advances. More specifically, it has worked effectively with
the diseases where it is possible to identify biological pathology for which there is effective
treatment as well (Schultz et al 2000). This model defines disability as completely an individual
experience and is lending scientific credibility in terms of mechanical jargons. Thus individual is
responsible for the problem and his capacity decides the effectiveness of the treatment.

Due to individualization, the Biomedical Model is not capable of dealing with the issues of social
justice. By definition it is not an interactional model, hence does not look for inter professional
collaboration for the treatment. Although biological (e.g. genetic and biochemical) factors play an
important role in mental illness, this model ignores psychological and socio-cultural factors is
inadequate for mental illness (Kiesler 1999). It does not include the patient or their unique human
116
attributes and subjective experience (Engel 1980, Peters 1996). Since the medical model is
simplistic, assumes that all illness has a single cause and that treating the disease will restore

117
health, and fails to take account of the personal and social dimensions of sickness and disability
(Wade &Halligan 2004). It also demands particular kind of doctor-patient relationship. It surely
remains the best approach to the treatment of disease and acute physical injury, dealing with
functional somatic syndromes, illness without discernible disease and common health problems
(Wade &Halligan 2004). But it does not provide a strong basis for the treatment and policy
considerations of chronic conditions, which include most disabilities (Smart, 2005). In short, the
Biomedical Model is much stronger, in both diagnosis and treatment, when dealing with physical
disabilities. This narrow emphasis presents difficulties because the definition of disability is
enlarging and evolving beyond that of only physical disabilities to include such impairments as
learning disabilities, mental illness, and other disorders.

Social Model
It is proposed by Finkelstein and Oliver in 1983. The social model represents the perspective of
disabled people. Whatever its lack of scientific evidence, it is based on the personal experience and
views of disabled people (Peters 1996), and has considerable social and political acceptance and
reality. It may best be described as a social exclusion model or a social oppression model. This
model focuses on to the society and the empowerment of disabled people. This has been described
as ‘a shift from disablement to enablement’ (Masala &Petretto 2008). Management of disability
requires social restructuring and is the collective responsibility of society at large; here the disability
becomes a political rather than a medical issue. The social model is widely accepted as the
conceptual basis for social inclusion and antidiscrimination policies, although legislative definitions
of ‘disabled people’ tend to revert to a medical model (Donoghue 2003). The model views that
disabled people are disadvantaged by society’s failure to accommodate everyone’s abilities
Disabled people are oppressed by current social and economic institutions
It can be best applied to people with severe medical conditions and permanent physical or mental
impairment but under weigh the understanding of the individual’s health condition, and takes
symptoms and disability at face value and generally ignores personal/psychological influences on
illness, sickness and disability although the empowerment model does recognize the importance of
personal responsibility (Finkelstein 1996, Duckworth 2001) and also fails to consider interactions
between the person, health and social context.
Medical and social models imply that the disabled person is the passive victim and bears little or no
responsibility for his or her incapacity or rehabilitation. 118
The Bio-Psycho-Social Model
Engel (1980) introduced and argued for the need of a bio-psychosocial model. He shifted the focus
from disease to illness, stressing that psychosocial factors influence the course of any illness and
that healthcare must take account of the subjective experience of illness as well as objective
biomedical data. He argued for better integration of mind and body, included the social context of
illness, and laid out the three-dimensional framework of the model. This is a dynamic systems
approach rather than the linear causality and factor-analytical and focuses on the interaction
between biological, psychological and social factors influence the course and outcome of any
illness. ICF tried to reconcile the medical and social models of disability and to balance the
individual and social perspectives, even if it did not fully satisfy either side (Masala & Petretto
2008). It shifted the focus from the medical ‘cause’ and the process of disablement to the universal
human experience of ‘functioning’ associated with (ill) health.
This model combines and balances the medical and social models and recognizes that some action
must be at an individual and social level to deal with that person’s health problem to benefit all sick
and disabled people. Any health problem occurs within a unique person, who is in a particular
social context: these may be regarded as increasing levels or hierarchies of complexity that build up
from biological to social to produce the whole (Engel 1977, 1980, Peters 1996).
It has been argued that interactions between the individual and their social context and between
health and social well-being are the major contributors to (ill) health (Kiesler 1999, Cacioppo et al
2000, Glouberman 2001, Gilbert 2002, Buck et al 2006). It should be noted that interactions are
two-way: sickness and disability are not only influenced by their social context; people can and do
modify, select and even create their social environment (Llewellyn & Hogan 2000). Howard (2003)
went so far as to call this an interactional model, which is dynamic and emphasizes processes. So,
an apparently simple intervention on one dimension does not necessarily have a direct and
predictable effect. Rather, any intervention may influence the complex interactions in unforeseen
ways with indirect and sometimes perverse effects. Multiple interventions at several levels may be
required. This is characteristic of many health and social policy interventions.
Livneh (2001) proposed that investigation of the process of psycho social adaptation to Chronic
Illness and Disability (CID) and found the importance of considering antecedents or triggering

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events, the dynamic process of adaptation itself and psychosocial outcome categories that reflect
differing views of adaptation to CID.
Many international organizations vary in their approach to the management and treatment of
disabled people’s needs: for example the WHO promotes a medical rehabilitation approach to
disability issues; UNESCO promotes inclusive education policies; the International Labor
Organization (ILO) has a policy of including disabled people in their employment; UNICEF
focuses on prevention of impairment in children through health and immunization programmes.

Assessme
nt
In order to prescribe guidelines for evaluation and assessment of mental illness and procedure for
certification a committee was constituted by the Department of Health, Government of India in
2001. Requirement of an assessment procedure, led the Executive Council of the IPS Committee to
develop an official IPS scale for psychiatric disabilities. The scale was developed in 2001 and it was
named as IDEAS (Indian Disability Evaluation and Assessment Scale). There are four areas as
under-

1. Self Care: It includes taking care of body hygiene, grooming, health including bathing, toileting,
dressing, eating and taking care of one’s health

2. Interpersonal Activities [Social Relationship]: Includes initiating and maintaining interactions

with others in contextual and social appropriate manner.

3. Communication and Understanding: Includes communication and conversation with others by

producing and comprehending spoken, written, nonverbal messages.

4. Work: Three areas are included Employment (Performing in work/job), Housework (Performing
in house work) and Education (Performing in Education- School / college).

Scoring is done using a scale from 0 to 4. Total score’s interpretation is that 0 degree detect no
disability, 1-7 degree detects less than 40% disability, 8 and above detects more than 40% disability.

The certificate can be issued by the psychiatrist and it is accepted if the medical board comprising of
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any two MS / Principal / Director as chairman Psychiatrist as member &/ or Physician as member.
The proposed score for global disability is that 0 score no disability, 1-7 score <40% and 8 & more
score >40% disability and accepted as 0 score no disability, 01- 06 score mild disability (40%), 7-
13 score moderate (40-70%), 14-19 score severe (71-99%), 20 score profound (100%). Patients
eligible for disability benefits are those diagnosed with Schizophrenia, Bipolar Disorder, Dementia,
and Obsessive Compulsive Disorder. Duration of Illness must be two years. For scoring purposes,
number of months he was symptomatic in the last 2 year. Frequency of Re-certification is 2 years.

Impact of disability certificates on

privacy and welfare
Despite the advantages it affords, the Act also presents a challenge for the disabled in another area of
their health and rights namely, the protection of their privacy. These privacy concerns arise because
of the way the Act is implemented and what individuals must do in order to qualify for benefits
under its provisions. Specifically, individuals seeking benefits must obtain a disability certificate
from a specified government healthcare provider. The certificate itself needs to display a photograph
(certified by due authority), as well as the name and address of the individual, which can increase the
risk of confidentiality breach should the certificate be misplaced or stolen, or merely viewed by un
authorized persons. Further, the certificate details include not only the diagnosis, but also the
duration of illness and degree of disability

Gaps to be filled: Lack of Surveillance Systems: The preliminary step to conduct research in any
field demands a baseline data about the prevalence, incidence and distribution of a disease. Due to
the lack of a universal definition of disability and its types and categories, there are no reliable
figures available for the prevalence of disability in India. The differences seen in the estimates of
Census (2001) and NSSO (2002) are the best indications of the discrepancies in understanding and
the conceptualization of the term ‘disability’. There is a major issue of under reported cases of
disability in the country because of the lack of national level registration and identification system of
the persons with disability. The social stigma attached to the disability is also likely to contribute to
under-estimation.

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 Assignment-Unit IX

Rehabilitation policies

Submitted by

Deena K Varghese

1st year M. Phil clinical psychology

IMHANS, Calicut

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 The fundamental aim of mental health legislation is to protect, promote and improve the
lives and mental well-being of citizens. Mental health legislations were initially drafted to
safeguard the public from dangerous patients by isolating them from the public. WHO health
report (2001) it was reported that 67% of countries in South-Asia have mentalhealth legislation
and rest of the 33% have no such law. Mental health care in India over the last 25years has been
an intense period of growth and innovation.

Mental Health act (1987)

Mental health act was drafted by parliamentin 1987 but it came into effect in all the states
andunion territories of India in April 1993. This actreplaces the Indian Lunacy act of 1912,
which hadearlier replaced the Indian Lunatic Asylum act of1858. MHA (1987) is divided into 10
chapters consisting of 98 sections. The advantage of the Mental Health 1987 is that the act is
conceptually definitely many steps aheadof ILA (Indian Lunacy Act), 1912, trying to keep pace
with advances in psychopathology andpsychopharmacology.Most of the sections of the act are in
accordance with mental health act 1959 and the mental health (amendment) act 1982 of England
and mental health act 1960 of Scotland with minor differences.

Objectives of the act

1.To establish central and state authorities for licensing and supervising the psychiatric hospitals.
2.To establish such psychiatric hospitals and nursing homes.
3.To provide a check on working of these hospitals.
4.To provide for the custody of mentally ill persons who are unable to look after themselves and
are
dangerous for themselves and or, others.
5.To protect the society from dangerous manifestations of mentally ill.
6.To regulate procedure of admission and discharge of mentally ill persons to the psychiatric
hospitals or nursing homes either on voluntary basis or on request.
7.To safeguard the rights of these detained individuals.
8.To protect citizens from being detained unnecessarily.
9. To provide for the maintenance charges of mentally ill persons undergoing treatment in such
hospitals.

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10.To provide legal aid to poor mentally ill criminals at state expenses
11.To change offensive terminologies of Indian Lunacy act to new soother ones

Chapter I: Deals with preliminaries of the act, definitions and provides for change of offensive
terminologies used in Indian Lunacy act 1912.

Chapter III: It lays down the guidelines for establishment and maintenance of psychiatric
hospitals and nursing homes. There is a provision for licensing authorities to process applications
for license which have to be renewed every five years.

Chapter II: Deals with the procedures for establishment of mental health authorities at central
and state levels.

Chapter IV: It deals with the procedures of admission and detention of mentally ill in
psychiatric hospitals.

Chapter VI: It deals with the judicial inquisition regarding alleged mentally ill persons
possessing property and its management.

Chapter VII: It deals with the maintenance of mentally ill persons in a psychiatric hospital or
psychiatric nursing homes.

Chapter VIII: It deals with the protection of human rights of mentally ill persons

Chapter VIII & Chapter IX: These sections pertained to “Penalties and Procedures” and
“Miscellaneous” no changes are suggested for these.

Advantages of MHA, 1987

✓ More humane approach to problems of mentally ill persons by changing the terminology
e.g.lunatics and criminal lunatics have been replaced by the term mentally ill person and
mentally illprisoner etc.
✓ Establishment of licensing authorities (Central and State Mental Health Authorities) to
provide a check on licensing and working of mental health hospitals. This will help in
improving standards of mental health care.
✓ New chapters on management of their property and protection of human rights
have been included.

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 ✓ Procedure for admission and discharge of voluntary patients have been simplified and
liberalized. In this act, no consent from two visitors is required as well as no written
request isrequired.
✓ Minor can be admitted with the consent of a guardian under this act.This provision is not
there inthe Indian Lunacy Act, 1912
✓ Separate provision for admission of involuntary patients under category “Admissions
UnderSpecial Circumstances”
✓ Special center for special population like drug addicts, under 16 years, mentally ill
prisoners etc.
✓ Establishment and maintenance of psychiatric hospitals and psychiatric nursing homes
in
private sector which was not in the earlier law
✓ Discharge procedure have been made easy and more simplified
✓ There is new different addition in this law like protection of human rights of mentally ill
persons,penalties, cost of maintenance and management of properties of mentally ill
persons
✓ Prohibition on any research on subjects without proper consent.

Critical aspects of MHA 1987

✓ In the law, A Mentally ill person is defined as a "person who is in need of treatment by
reason of any mental disorder other than mental retardation”. The definition does not
specify the types of mental illness to be included; this can lead to
misuse of the term and is attached with stigma for the person labelled "mentally ill".
Mentally retarded subjects have been excluded. Mentally retarded subjects need
separate services in the form of rehabilitation, prevention etc. A law for helping victims
of mental illness should not exclude victims of profound mental retardation from its
purview, as they too are in great need for treatment and care. They too should have
access to psychiatric Hospitals. If the law presumes that profound mentally retarded
persons could be adequately taken care of in the existing institutions for the mentally
retarded, it is certainly not based on ground realities.
✓ Act adopts different views for Govt. and private hospitals. Definitions of psychiatric
hospitals and psychiatric nursing homes” excludes government hospitals and is

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 discriminatory. In this case a uniform policy should be adopted. At the time of conception
of law, private psychiatry was still in infancy and the growth anddevelopment of private
psychiatry was neither foreseen nor predicted. That might be the reasonthe law in its
current form seems to be biased against private psychiatry.
✓ Licensing authorities do not have a doctor who may be in a better position to assess the
facilities and services of these centers. There should be budgetary provisions in the law.
Provision should be there for checking the working of licensing authorities and powers
vested in them to be limited.
✓ Although the act provides for a simpler discharge procedure, but no provisions are
made for after discharge care and rehabilitation, of patients.
✓ In case no relative comes forward for discharge of patient, will that person be detained
indefinitely in hospital. Who will bear the expenses in such case? If Govt., then for
how long. Adequate provisions to be provided for long term treatment and expenses on
treatment. If this is not possible, then community mental health centers should be opened
to provide such care. Treatment should be based on concept of socialization and not on
hospitalization.
✓ Research on such subjects can be carried out by consent of guardian. This provision
violates human rights.
✓ Legal considerations have been given more weightage in comparison to medical ones
✓ Failed to remove the criminal flavor by keeping the power of criminal court to exert its
control over admissions and discharge of non-criminal mentally ill persons
✓ No importance to family and community psychiatry
✓ There are no provisions for punishing the relatives and officers requesting unnecessary
detention of a person to such hospitals
✓ Much stress is laid on hospital admission and treatment. This again increases the cost of
health care. No provisions are made for home treatment
✓ The act has no provision for transportation of an unwilling patient except by police.
✓ Other than children and addicts even separate places are to be provided for elderly,
destitute and women.

United Nations Convention on the Rights of Persons with Disability (UNCRPD) promotes,
protects, and ensures the full and equal enjoyment of all human rights and fundamental freedoms

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by all persons with disabilities, and promotes respect for their inherent dignity. Since India was
among the first countries to ratify the UNCRPD (2007), all the Acts are being amended in order
to have conformity with the provisions in it.

MENTAL HEALTH CARE ACT, 2017

MENTAL HEALTH CARE ACT

The new act defines “mental illness” as a substantial disorder of thinking, mood,
perception, orientation, or memory that grossly impairs judgment or ability to meet the ordinary
demands of life, mental conditions associated with the abuse of alcohol and drugs.” This act
rescinds/revoked the existing Mental Healthcare Act 1987 which had been widely criticized for
not recognizing the rights of a mentally ill person and paving the way for isolating such
dangerous patients.

Advantages of mental health care Act

The act is progressive, and rights based in nature. The whole dedicated Chapter (v) on
“Rights of the persons with mental illness” is the heart and soul of this legislation. This is highly
significant step to make the act as patient-centric. There is a mention of the right to access MHC
and treatment at affordable cost, good quality which is acceptable to person with mental illness,
their family members, and caregivers. The onus will be on appropriate Government to make such
provisions for range of services including outpatient and inpatient services, half-way homes,
sheltered accommodation, supported accommodation, hospital- and community-based
rehabilitation, free cost of medicines, specialized services of child and adolescent, and old age
mental health. The appropriate Government will ensure necessary budgetary provisions for
effective implementation along with integration of mental health services into general health care
at all levels of health. Every person with mental health illness will have right to protection from
cruel, inhuman, and degrading treatment.

The key feature in this act is the provision for medical insurance for treatment of mental
illness at par with physical illness by all insurers. Mental health insurance has remained a
neglected area for long. This new feature will have huge and significant impact for the persons
with mental illness, family, and caregivers. The other feature is that it clearly describes the
“Duties of appropriate Government.” This is a unique feature as the appropriate Government will

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have responsibility to plan, design, and implement programs for mental health such activities
related to promotion, prevention, reduction of suicide, stigma. The important aspect will also to
address the human resource needs which include training of medical officers and other persons.

There is a mention of decriminalization of attempted suicide. It is specifically stated that

there is a presumption of severe stress in person with attempted suicide and such person shall not
be tried and punished under the said code. Moreover, it is highlighted that the appropriate
Government will be bound not only to provide care, treatment, and rehabilitation of such persons
but also to take measures to reduce its recurrence. This is an important and progressive step
which will have positive implication throughout the country.

As per new provisions, ECT has not to be performed without anesthesia, and there is no
ECT for the minor. Sterilization shall not be performed in such patients neither they will be put
into solitary confinement nor isolation.

Evaluation of mental health care act

However, the act mainly focuses on the rights of the persons with mental illness only
during treatment in hospital and it is completely silent about the care of the persons with mental
illness in community. MHC priorities need to be shifted from psychotic disorders to common
mental disorders and from mental hospitals to primary health centers. Increase in invisible
mental problems such as suicidal attempts, aggression and violence, widespread use of
substances, and increasing marital discord and divorce rates emphasizes the need to prioritize
and make a paradigm shift in the strategies to promote and provide appropriate mental health
services in the community.

On a closer look, this act premises on a hypothesis that the MHC providers and family
members are the main violators of the rights of the persons with mental illness, which is
unfortunate. On the other hand, the act does not consider of family members’ significant
contribution, caregivers’ burden, isolation, frustration, and violence they undergo because of
persons with mental illness. It is silent on the role and contribution of family members in
providing care. Unlike the West, in India, family is the key resource in the care of patients with
mental illness. Families assume the role of primary caregivers for two reasons. First, it is because
of the Indian tradition of interdependence and concern for near and dear ones in adversities.

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Second, there is a paucity of trained mental health professionals required to cater to most of the
population; hence, the clinicians depend on the family. Thus, having an adequate family support
is the need of the patient, clinician, and the healthcare administrators. Unfortunately, that act
does not foster the need to support the family members in providing care.The Mental Health Act,
1987 was not implemented across the country because of severe shortage of resources; however,
a new act, 2017 has been introduced without addressing the issues which haunted the Mental
Health Act, 1987.

National Mental Health Programme (NMHP) (National policy) advocates integration of

mental health into general and primary health care. However, the Bill mandates all the
establishments to take license for treating patients; this may come in the way of integrating
mental health into general health and, thus, the implementation of the policy. Many private
hospitals and nursing homes may refuse to treat patients with mental illness reporting that they
do not have license to do so. Hence, the proposed act should be in line with the NMHP (Mental
health policy). To encourage treatment in general hospitals, they need to keep those
establishments out of the purview of licensing.

This issue of capacity to make MHC and treatment decisions is inadequate and may have
dangerous consequences because person with mental illness may refuse treatment due to (a)
absent insight, (b) severe mood symptoms, and (c) his/her symptoms are coming in the way of
decision-making. Family members usually find it difficult to manage individuals with serious
mental illnesses, who have no insight, and usually, they refuse admission and treatment. This
clause by default considers that everyone has capacity and one must prove that person with
mental illness lacks capacity before initiating involuntary treatment. One must approach the
mental health board to take permission to initiate involuntary treatment. There is no scope to take
guardians’ consent to initiate involuntary treatment under the new act. This will add an enormous
burden to family members and MHC providers in treating involuntary patients with severe
mental disorders. It has been stated very rightly that in the regulation of involuntary treatment, a
balance must be found between duties of care and protection and the right to self-determination.

An advance directive tells what medical treatment a person does or does not want if he or
she is not able to make his or her wishes known. Person with mental illness may revoke, amend,
or cancel advanced directives many times in a day, and family members will be finding difficult

133
to handle such situations. Only the mental health board has powers to amend or overrule the
advance directive. This needs to be done in very short time to enable the treatment (24–48 h). If
patient has written costly treatment or private/corporate hospital (which family cannot afford) in
advance directives, then who will bear the cost of costly treatment. Considering the available
human resources (Medical and Judicial), economic constraint, and our collective community
efforts in treating patients with mental illness, our Indian population is not ready for such
advanced directives.This advance directive operates on the basic premise that “if a person
develops mental illness” Which mental illness? If multiple illnesses occur? If it becomes
comorbid with physical illness? What severity? Under what circumstances? Above issues are
wide open and threaten everyone. If an MHC provider writes an advance directive, he/she need
to write for each disorder “if I develop mania,” “If I develop schizophrenia,” like a textbook,
how he/she should be care or not to be cared. This advance directive will welcome more
litigations and heavy burden on family members.

The district-level mental health review boards, which are quasi-judicial bodies overseeing
the effective implementation of the MHC delivery system, could introduce new hurdles for
treatment delivery and unnecessary delay. This could be simply because of non-availability of
judicial workforce and other resources to operate at every district levels. If these issues are not
addressed, this may cause delay in initiating treatment, which may cause enormous amount of
stress on the care providers. Delay in addressing the issue can defeat the purpose of the Bill. If
these boards do not operate on day-to-day basis at each hospital level, then this can cause serious
adversarial impact on the MHC of the person. Unfortunately, MHC is taking an ugly turn similar
to western country where involuntary MHC is argued in the court of law. MHC is becoming a
tedious, prolonged, and costly judicial proceeding. These mental health review boards need to
have time limit (<72 h) to take decision, especially regarding capacity to consent for treatment
issues. The mainstream judicial system is incapable of handling such complaints because of lack
of sensitivity and being clogged with a huge redundancy of mainstream cases. These boards need
to move away from tardy judicial process/procedures.

Punishments are too harsh and there is no provision for whether contravention is
accidental or due to practical difficulties or deliberate.Unlike the other patients, behavior and
responses of mentally ill are different, especially in patients with paranoid delusions. Such

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people are likely to complain against hospital/doctors or other personnel which he may feel true
because of his/her illness but are not true. This litigation-based MHC can give rise to a defensive
practice, and tendency to avoid care of such patients will only harm such patients and their
family members. This will also increase the cost of MHC.

NATIONAL MENTAL HEALTH PROGRAMME

Cognizance of the need to include mental health care in the general public health care
system was taken by the National Institute of Mental Health and Neuro Sciences (NIMHANS),
Bangalore by starting of a “Community Mental Health Unit” in 1975. Around the same time a
multi-country collaborative project was initiated by the WHO to propose a model for integrating
mental health with general health services and providing basic mental health care by trained
health workers and doctors as an integral part of primary health care. This was carried out in 7
developing countries, viz. Brazil, Colombia, Egypt, India, Philippines, Senegal and Sudan. The
department of psychiatry at the Post Graduate Institute of Medical Education and Research
(PGIMER) in Chandigarh was the center in India and the model was developed in the Raipur
Rani block in Haryana state.

The Government of India has launched the National MentalHealth Programme (NMHP)
in1982, with the following objectives.

1. To ensure the availability and accessibility of minimum mental healthcare for allin the
foreseeable future, particularly to the most vulnerable and underprivilegedsections of the
population.
2. To encourage the application of mental health knowledge in general healthcareand in social
development;

3. To promote community participation in the mental health service developmentand to stimulate

efforts towards self-help in the community.

The original NMHP guidelines carried many ambiguities. Most importantly, no

budgetary estimates or provisions were made for the implementation of the Programme. There
was lack of clarity regarding who should fund the Programme – the central government of India
or the state governments who perpetually had inadequate funds for health care. Great doubts
were expressed about the feasibility of implementing the Programme in larger populations and in

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real world settings as almost all the pilots and feasibility projects were carried out by only
research and training institutes and in smaller populations of up to 40, 000.

The NIMHANS in 1985 developed a programme to operationalize and implement the

NMHP in a district. Bellary district with a population of about 20 lakhs (2 million), located about
350 km away from Bangalore was chosen for the pilot development of a district level mental
health programme. This study continued till 1995, and the conclusions were made that mental
health care delivery was possible in the primary health care setting and primary care physicians
could be adequately trained to provide such care. Appropriate supervision / support from the
program officer / psychiatrist empowers the public health care system to provide pertinent
mental health care to the population. This pioneering exercise resulted in the formulation of the
“Bellary Model” of the District Mental Health Programme (DMHP), which formed the crux of
the NMHP. The Ministry of Health and Family Welfare, Govt. of India formulated District
Mental Health Programme (under National Mental Health Programme) as a fully centrally
funded 5-year pilot scheme. The Programme was to be implemented in two phases, the Phase I
was to be taken up during 1996-97, and the Phase II was to be a continuation of the Programme
during the IX Five Year Plan period (1997-2002).

The District Mental Health Program (DMHP) was launched under NMHP in the year
1996 (in IX Five Year Plan) with the followingcomponents:

1. Early detection & treatment.

2. Training: imparting short term training to general physicians for diagnosis and
treatment of common mental illnesses with limited number of drugs under
guidance of specialist. The Health workers are being trained in identifying
mentally ill persons.
3. IEC: Public awareness generation.
4. Monitoring: the purpose is for simple Record Keeping.

Starting with 4 districts in 1996, the program was expanded to 27 districts by the end ofthe
IX plan. The NMHP was re-strategized in the year 2003 (in X Five Year Plan) with the
followingcomponents:

1. Extension of DMHP to 100 districts

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 2. Up gradation of Psychiatry wings of Government Medical Colleges/ General
Hospitals
3. Modernization of State Mental hospitals
4. IEC
5. Monitoring & Evaluation

In the XI Five Year Plan, the NMHP has the following components/schemes:

1. District Mental Health Programme (DMHP)

2. Manpower Development Schemes - Centers of Excellence and Setting Up/Strengthening
PG Training Departments of Mental Health Specialties
3. Modernization of State-Run Mental Hospitals
4. Up gradation of Psychiatric Wings of Medical Colleges/General Hospitals
5. IEC
6. Training & Research
7. Monitoring & Evaluation

The description about each component has given below

District mental health programme

The main objective of DMHP is to provide Community Mental Health Services and
integration of mental health with General health services through decentralization of treatment
from Specialized Mental Hospital based care to primary health care services. Presently the
DMHP is being implemented in 123 districts of the country. The team of workers at the district
under the program consists of a Psychiatrist, a Clinical Psychologist, a Psychiatric Social worker,
a Psychiatry/Community Nurse, a Program Manager, a Program/Case Registry Assistant and a
Record Keeper.

Modernization of State-Run Mental Hospitals

The assistance under this scheme is provided for modernization of state-run mental
hospitals from custodial care to comprehensive management. The grant covers activities such as
construction/repair of existing building(s), purchase of cots and equipment’s, provision of
infrastructure such as water- tanks and toilet facilities etc.

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Upgradation of Psychiatric Wings of Medical Colleges/General Hospitals

Every medical college should ideally have a Department of Psychiatry with minimum of
three faculty members and inpatient facilities of about 30 beds as per the norms laid down by the
Medical Council of India. Out of the existing medical colleges in the country, approximately
1/3rd of them do not have adequate psychiatric services. This is a scheme for strengthening of
the psychiatric wings of government medical colleges/hospitals which provides for a one-time
grant of Rs.50 lakhs for up gradation of infrastructure and equipment as per the existing norms.

Manpower Development Scheme

In order to improve the training infrastructure in mental health, Government of India has
approved the Manpower Development Components of NMHP for 11th Five Year Plan. It
has two schemes which are as follows:

A. Centers of Excellence (Scheme A)

Under Scheme-A, at least 11 Centers of Excellence in mental health were to be established in the
IXth plan period by upgrading existing mental health institutions/hospitals.

B. Setting Up/ Strengthening PG Training Departments of Mental Health

Specialties (Scheme B)

To provide further impetus to manpower development in Mental Health, Government

Medical Colleges/ Hospitals are supported to start PG courses in Mental Health or to increase the
intake capacity for PG training in Mental Health. It includes definite plan with timelines for
initiating/ increasing PG courses in Psychiatry, Clinical Psychology, PSW and Psychiatric
Nursing

IEC Activities

NMHP has dedicated funds for IEC activities for the purpose of increasing awareness and
removal of stigma for mental illness.

National Rural Health Mission (NRHM) was launched by Government of India in 2005
to carry out imperative changes in the basic health care delivery system for better delivery of
primary health care. Currently the NRHM along with the National Urban Health Mission

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(NUHM) constitute the National Health Mission (NHM). The integration of DMHP with the
NHM has been initiated and is expected to contribute numerous advantages to the DMHP such
as optimal use of existing infrastructure at various levels of health care delivery system and
sustenance of DMHP beyond the expiry of the period of central assistance by its integration in
the district health system. An integrated IEC under NHM, involvement of NHM infrastructure
for training related to mental health at the district level, use of NHM machinery for procurement
of drugs to be used in DMHP and building of credible referral chains for appropriate
management of cases detected at lower levels of the health care delivery system are all additional
advantages of integration of DMHP with NHM. However, specific details and mechanisms of
such integration are yet to be developed comprehensively.

The new Mental Health Policy, 2014 and the National Health Policy, 2015, both
recognize the basic premise of the NMHP, 1982, namely, integration with the primary care
approach to identify those in need of such services and refer them to the appropriate site and
follow-up with medication and tele-medicine linkages.

Evaluation of NMHP

The program has been partly successful in terms of enhancing its reach to community,
improving service delivery, and getting increased budgetary allocation, but at the same time, its
impact was limited by financial and human resource constraints, lack of community
participation, ineffective training, poor NGO/private partnership, and lack of a robust monitoring
and evaluation (M and E) system.Though the district has been the main administering unit of
DMHP, as envisaged under the DMHP, setting psychiatric units only at the level of a district
may not be enough in addressing the mental health needs of the population at the subdistrict level
or those lower in the hierarchy. A recent study from north India reports a very high psychiatric
patients’ attendance at the subdistrict level, and in the absence of a trained psychiatrist at this
level, mental illnesses remain undiagnosed and untreated. there has been a lack of leadership at
all levels (central, state, and districts). Further, fragmentation of responsibilities at all levels has
been another cause for poor implementation and performance of DMHP. For example, at the
central level, MOHFW is responsible for health provision, whereas the rehabilitation part is
mainly looked after by the Ministry of Social Justice and Empowerment (MOSJE).

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THE PERSONS WITH DISABILITIES (EQUAL OPPORTUNITIES, PROTECTION OF
RIGHTS AND FULL PARTICIPATION) ACT 1995

The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act 1995 (PwD Act) is the most important piece of legislation enacted by the
Parliament in the history of disability movement in India. It became enforceable on Wednesday,
7 February 1996. The passing of this Act gave effect to the proclamation on the full participation
and equality of people with disabilities in the Asian and Pacific Regions.

The PWD Act is a combination of service-oriented and right-based (mainly

socioeconomic) legislation, and is based on the following principles:

• Prohibition of discrimination on the ground of disability in different spheres of life.

• Positive discrimination in favor of persons with disabilities
• Grant of relaxation/concession to disabled persons to overcome their specific disabilities
• Inclusion of persons with disabilities in main stream through specific policies andprograms

The PWD Act consists of 14 Chapters and 74 Sections, which are further divided
intoseveral sub-sections. The Act defines seven broader categories of disabilities. They are the
following

• Blindness
• Low vision
• Leprosy – cured
• Hearing impairment
• Locomotor Disability
• Mental retardation
• Mental Illness

It further categorizes ‘personwith disability’ according to the degree of disability: mild,

moderate, severe, orprofound. Only those who belong to moderate, severe, or profound

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categories ofdisability listed above, and have over 40% disability been entitled to benefit under
the Act. The main objectives of the Persons with Disabilities Act are summarized as below:

• To ensure that the government takes responsibility for prevention of disabilities,

protection of the rights of persons with disabilities, provision of medical care, education,
training, employment and rehabilitation of persons with disabilities.
• To create a barrier- free environment for persons with disabilities.
• To remove any discrimination against persons with disabilities in the sharing of
development benefits
• To protect persons with disabilities against abuses and exploitation.
• To lay down strategies that will ensure comprehensive programmes and services and
equal opportunities for persons with disabilities.
• To make special provisions for including persons with disabilities in mainstream society.
• To establish Co-ordination Committees and Executive Committees at the Central and
State levels in order to ensure the full implementation of the provisions under the Act.

Critical evaluation

Persons with Disabilities Act, 1995 Act has made an effort to place positiveobligations on
the state to provide for access to education, employment, healthcare,barrier-free environment and
social security for disabled persons.

At the time of the drafting/enactment of the PWD Act, there was already a shift in
thedefinition of disability throughout the world from a medical problem to a social modelof
disability, which emphasizes and enhances disability rights within the human rightsperspective.
The definitions of disability under the Disabilities Discrimination Act 1995of UK and the
American with Disabilities Act 1990 (which were enacted almost at thesame time or even before
the enactment of the PWD Act) recognize a social model ofdisability. The PWD Act has tried to
define disability byway of listing separate categories of disability based on
certainmedical/physical characteristics. Even the medically defined disability under the Act it not
complete, as ithas left out many of the important medical categories that are recognized or
defined asdisability world over.

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 Many of the provisions made by the Act in support of persons with disabilities come
with the rider “within the limits of economic capacity”13. Thus, it is very easy for theappropriate
authorities to get away without effectively implementing the provisions ofthe Act.

Employment is really a problem for person with disabilities. The Act provides for
employment to only those people who come under the three categories of disability (namely
blindness orlow vision; hearing impairment; and locomotor disability or cerebral palsy, with a
1percent reservation for each category) whereas the Act defines seven categories ofdisability.
The persons with mental illness and mentaldisability are expressly left out of it irrespective of
the extent and severity of the illness. The Act provides reservation forthe employment of the
disabled persons in government sector only. Further, Section 39 which states reservation of 3 per
cent seats in governmentinstitutions and government-aided institutions is mentioned under the
employmentchapter and not under that of education. In order to deny seats to the disabled,
theconvenient excuse taken by educational institutions is that the Act talks aboutreservation of
jobs and not admissions in educational institutions. In fact, this confusionin Section 39 led to
several interpretation and re-interpretation in various Court cases. The Act doesn’t define
parameters of inclusive education.

Another major weakness of the PWD Act is that it does not provide for a
powerfulimplementing body. very few power and facilities have been provided to the Chief
Commissioner and Commissioners for Persons withDisabilities. Thefundamental limitation of
the office is that its only legal sanction in case of a breach isto “take up the matter with the
appropriate authorities”20. The Office does not itself haveenforcement powers of a court or
administrative tribunal; it can and does make orders but cannot enforce compliance.

The Act does not explicitly talk anything about consultation/ participation of the disabled
persons and their organizations in the design and development of policies and programmes,
including interventions or monitoring of the specific programmes. The Act has failed to ensure
social protection and adequate standard of living to persons with disabilities24. It does not
specifically provide rights to basic services such as food, clothing, and access to clean water,
sanitation, and other livelihood opportunities, etc. The mental disability category was simply
incorporated in theAct without providing them any rights, entitlement or services. Additionally,
the PWDAct has failed to incorporate any specific provisions to address the concerns of the

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mostvulnerable and disadvantaged disabled persons - such as women and children with
disabilities,people with disability due to old-age.

The Rights of Persons with Disabilities Act, 2016

After India signed and ratified the UNCRPD in 2007, the process of enacting a new
legislation in place of the Persons with Disabilities Act, 1995 (PWD Act, 1995) began in 2010 to
make it compliant with the UNCRPD. After series of consultation meetings and drafting process,
the Rights of PWD Act, 2016 (RPWD Act, 2016) was passed by both the houses of the
Parliament. It was notified on December 28, 2016 after receiving the presidential assent.

In the RPWD Act, 2016, the list has been expanded from 7 to 21 conditions and it now
also includes cerebral palsy, dwarfism, muscular dystrophy, acid attack victims, hard of hearing,
speech and language disability, specific learning disabilities, autism spectrum disorders, chronic
neurological disorders such as multiple sclerosis and Parkinson's disease, blood disorders such as
hemophilia, thalassemia, and sickle cell anemia, and multiple disabilities. The nomenclature
mental retardation is replaced by intellectual disability which is defined as “a condition
characterized by significant limitation both in intellectual functioning (reasoning, learning,
problem-solving) and in adaptive behavior which covers a range of every day social and practical
skills including specific learning disabilities and autism spectrum disorders.” The Act provides
an elaborate definition of mental illness which is “a substantial disorder of thinking, mood,
perception, orientation, or memory that grossly impairs judgment, behavior, and capacity to
recognize reality or ability to meet the ordinary demands of life but does not include retardation
which is a condition of arrested or incomplete development of mind of a person, especially
characterized by sub normality of intelligence.” Persons with benchmark disabilities are defined
as those with at least 40% of any of the above disability.

The RPWD Act, 2016 provides that “the appropriate Government shall ensure that the
PWD enjoy the right to equality, life with dignity, and respect for his or her own integrity
equally with others.” The Government is to take steps to utilize the capacity of the PWD by
providing appropriate environment. The Bill provides for the access to inclusive education,
vocational training, and self-employment of disabled persons without discrimination and

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buildings, campuses, and various facilities are to be made accessible to the PWD and their
special needs are to be addressed. All Government institutions of higher education and those
getting aid from the Government are required to reserve at least 5% of seats for persons with
benchmark disabilities. Four percent reservation for persons with benchmark disabilities is to be
provided in posts of all Government establishments with differential quotas for different forms of
disabilities. Incentives to employer in private sector are to be given who provide 5% reservation
for persons with benchmark disability. Standards of accessibility in physical environment,
different modes of transports, public building and areas are to be laid down which are to be
observed mandatorily and a 5-year time limit is provided to make existing public building
accessible.

Critical evaluation

On perusal of the Act, it is observed that though mental illness has been included as a
condition of disability, special needs of persons with mental illness (PMI) and their families have
not been properly addressed. PWD with mental illness require special and different types of
attention and care due to the nature of their illnesses. In our country, where personnel resources
in mental health care are extremely scarce, family is a very important asset in the management of
mental illness. Under section 7(2) of the Act, any person or registered organization, who or
which has reason to believe that an act of abuse, violence, or exploitation has been, is being or
likely to be committed against any PWD, may give information to the local Executive Magistrate
who shall take immediate steps to stop or prevent its occurrence and pass appropriate order to
protect the PWD.

Vast number of PMI with high support needs have no support available to them except
that of their family members. If the importance of family for this purpose is discouraged, persons
living with mental illness and intellectual impairments may get abandoned and may be left to
roam on the streets. Section 38 provides that any person with benchmark disability, who
considers himself to need high support, or any person or organization on his or her behalf, may
apply to an authority to provide high support. Thus, the Act puts the onus to seek support upon
the PWD, relies excessively on the NGOs, and fails to see the importance of the family.
Moreover, it denies the possibility that a person living with mental illness or with intellectual
disability may not be able to seek support at all or may not be able to take a decision even when

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all the supports are made available. While ignoring the role and importance of family in the care
of PMI, the Act is silent on how the vast support system would be built for such a large country
with millions of persons suffering from severe mental illness.

Disproportionately, lower number of jobs reserved for persons living with mental illness,
persons with intellectual impairment, autism, specific learning disability and multiple disability
(1% for all five taken together) also suggest an assumption of incapacity of the PMI. Chapters of
education, vocational, and self-employment are silent on the specific measures that need to be
taken to ensure the realization of the rights for PMI.

THE NATIONAL TRUST FOR THE WELFARE OF PERSONS WITH

AUTISM,CEREBRAL PALSY, MENTAL RETARDATION ANDMULTIPLE
DISABILITIES ACT, 1999

The National Trust is a statutory body under the Ministry of Social Justice and
Empowerment, Government of India, setup under the “National Trust for the welfare of persons
with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities” Act (Act 44 of
1999). The focus of the act is to enable and empower the persons suffering from above
mentioned four disabilities.NTA 1999 provides for the constitution of a national body for the
welfare of people with autism, cerebral palsy, mental retardation, and multiple disabilities. This
Act consists of 9 chapters and 36 sections.

The objectives of the Trust shall be –

• To enable and empower persons with disability to live as independently and as
fully as possible within and as close to the community to which they belong
• To strengthen facilities to provide support to persons with disability to live within
their own families
• To extend support to registered organizations to provide need-based services
during period of crisis in the family of persons with disability
• To deal with problems of persons with disability who do not have family support
• To promote measures for the care and protection of persons with disability in the
event of death of their parents or guardians

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 • To evolve procedure for the appointment of guardians and trustees for persons
with disability requiring such protection
• To facilitate the realization of equal opportunities, protection of rights and full
participation of persons with disability
• To do any other act which incident to the aforesaid objects is.
Thrust areas
• Campaign for effecting positive attitudinal change
• Programme which foster inclusion and independence by
- Creating barrier – free environment
- Developing skills.
- Promoting self-help groups.
• Training and Support of Care givers and community members.
• Formation of local level committees to grant approval forguardianship.
• Development of sustainable models for Day Care, Home Based,Respite and
ResidentialCare.
• Research in the four areas of Disabilities.
• Advocacy for the rights of persons with four disabilities.
• Programme for persons with severe disabilities and womenwith disabilities.
Coordinating and implementing agencies
• National Trust
• District level local committees.
• Registered Parents Associations and Non-Governmental Organizations.
This Act also encourages and supports the formation of Parent’s Associations where persons
with intellectual, severe and multiple disabilities are themselves unable or unwilling to engage in
self-advocacy.
Evaluation of National Trust Act, 1999
One of the criticisms that the National Trust Act has been facing is the appointment of
guardians for taking care of and making proxy decisions on behalf of the disabled. By doing so,
the very purpose of empowerment, equality, rights and full participation goal is defeated, and the
person is degraded. Asserting that everyone should make their own decisions does not mean that
everyone does not need help, assistance and support in doing so. It should rather be a ‘shared

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decision’ making or ‘assisted decision’ making or ‘informed decision’ making. The combination
of ownership (patients) and responsibility (guardians) is most empowering. Definitely, it is not
‘decision making’ by proxy. Considering the need to provide facilities to persons with disability
to live within their own families in the community, providing protection/care/support in the
absence of family member/s is a boon to mentally ill patients and their family members.
However, there was a resistance regarding provision of benefits under this act for the person with
mental illness. Persons with mental illness were asked to utilize Mental Health Act 1987,
Chapter-6 titled Judicial Inquisition regarding alleged mentally ill person possessing property,
custody of his person and management of his property. The guardianship procedure under this
act is very tedious and needs longstanding painful judicial procedure when compared to the
procedure under NTA1999. Hence, there is an urgent need to include persons with mental illness
under the purview of National Trust Act or else the Mental Health Act must be suitably
modified.

RecentDevelopments in India-

Prevention of ID is possible through improved antenatal care, antenatal screening for

common disorders which can cause disability later in life. Genetic Centre at Government
Medical College, Chandigarh, is the first public hospital to start antenatal and newborn screening
program. The antenatal screening include screening for Down syndrome and neural tubal defects,
while new born screening through heel prick method includes congenital adrenal hyperplasia
(CAH), congenital hypothyroidism (CH), and glucose-6-phosphate dehydrogenase deficiency
(G6PD) deficiency. Depending upon the prevalence of genetic and chromosomal disorders in
different communities and availability of funds, it is possible to screen for more disorders.

Universal Immunization Programme, particularly the use of measles, mumps, and rubella
(MMR) vaccine and is still very crucial in the prevention of ID. Follow-up of ‘high risk’ infants
for early intervention must be considered. Thus, there is huge scope of prevention of these
avoidable and treatable causes. Prenatal screening of high-risk cases and newborn screening for
inborn errors of metabolism should be included in the Reproductive and Child Health Program
and Nation Rural Health Mission. The cases which could not be prevented through primary
prevention must be identified early through community outreach programs and Aanganwadi
Workers (AWW) under Integrated Child Development Scheme (ICDS). Early Intervention

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Program (EIP) through early stimulation can play crucial role in minimizing the influence of
disorder in causing disability.

Rehabilitation Council of India Act (RCI), 1992

The Rehabilitation Council of India(RCI) was set up as a registered society in 1986.On

September,1992 the RCI Act was enacted by Parliament and it became a Statutory Body on 22
June 1993.The Act was amended by Parliament in 2000 to make it more broad-based.The
mandate given to RCI is to regulate and monitor services given to persons with disability,
tostandardizesyllabi and to maintain a Central Rehabilitation Register of all qualified
professionals and personnel working in the field of Rehabilitation and Special Education. The
Act also prescribes punitive action against unqualified persons delivering services to persons
with disability.

Though the above Act was passed in 1992 and notified in 1993, the disability sector and
NGOs came to know about it only in 1994. Even though everyone wanted standardization of
training and recognition of the people working in the disability field, NGOs working in the area
of disability opposed it very strongly. There are two main reasons for this opposition from the
disability sector. The first reason relates to the conceptualization of the Act and is more
fundamental in nature. At a time when the entire world is moving towards advocating the
philosophy of mainstreaming inclusion integration, viewed objectively and impersonally. The
RCI Act is more in the direction of segregation. It makes it mandatory for medical and para-
medical professionals, teachers, counsellors. and volunteers etc., to do RCI approved training
and register themselves with RCI before doing any work with the people with disabilities. This
means a person withdisabilityto avail of any of the above services (medical, education, therapy
etc.) will first have to find such professionals who are registered with RCI. It also implies that
non-RCI registered professionals would not like to see a person with disability for fear of
punitive action by the RCI. This totally alienates people with disabilities and pushes them into a
scenario of complete segregation from the rest of the society.

Inadequate definition of the term rehabilitation professional as the educational

qualifications to be registered range from a three-month certificate course after the X standard to
a five year or more post graduate degree qualification in various areas of rehabilitation. Only
those rehabilitation professionals could register who underwent a course run under the auspices

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of the RCI. The RCI in its effort to churn out rehabilitation professionals have set minimum
standards of education, training and experience. These were unacceptable to
rehabilitationprofessionals with high qualifications and many years of experience, as dilutions of
standard would have adverse impact on quality of care of persons with disability. This has
resulted in an undesirable situation where highly qualified rehabilitation professionals were
denied registration, whereas persons with a certificate of a one-month' s bridge course could.

The RCI Act, 1992 required Special Educators to be registered with the Act but teachers
in the normal schools were required to be registered under the National Council of teacher
Education (NCTE) Act. It, therefore, means that children with disability for inclusive education
in normal schools could not be taught by regular teachers because these teachers are
not registered with the NCTE. This works against the interest of' Inclusive
Education', which could come to a stop.As of today, RCI is duplicating services and does not
establish linkages with the existingeducational infrastructure in India. For example, the NCTE
Act, the AICTE Act, Councils for other para-medical courses with the help of Universities could
do the same work related to standardization of training and registration of professionals.

The Council is required to:

1. Determine minimum standards of education.
2. Make recommendations to the Department regarding recognition ofqualifications granted by
Universities, etc., in India for rehabilitation professionals.
3. Make recommendations to the Department regarding recognition ofqualification by
institutions outside India.
4. Conduct Inspection in examinations.
5. Register rehabilitation professionals/other personnel and
6. Determine privileges and professional conduct of registered persons.

In the amendments, definitions of terms such as ‘autism’, ‘cerebral palsy’, and ‘Persons
with disabilities’, etc. were clarified.“Handicapped” was replaced by `Person with Disability.
Mental Retardation was defined as condition of arrested or incomplete development of the mind
which is specifically characterized by impairment of adaptive behavior manifested during the
developmental period which contributes to the overall level of intelligence, i.e. cognitive,
language, motor and Social abilities.The Act needed to keep up with the needs of persons with

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disability, hence these additional categories of professionals need to be included in the schedule.
Any other category of Professionals included from time to time such as ophthalmic technicians,
rehabilitation care- givers, therapeutic recreation Specialists and medical Practitioners or
professional / personnel registered with any recognized Council of Govt. of India (optional).It
notesthat anyone offering services to people with disability, who do not have qualifications
recognized by RCI, could be prosecuted.

Juvenile Justice act

Children are recognized worldwide as supremely assets of the Nation.Child or juvenile

delinquency is an alarmingly increasing problem causing a source of concern in all over the
world. Act of delinquency may include: Running away from home without the permission of
parents,
Habitual behavior beyond the control of parents, Spending time idly beyond limits, use of vulgar
languages, wandering about railroads, streets market places, Visiting gambling center,
committing sexual offences, Shoplifting, Stealing etc.

The first legislation on juvenile justice in India came in 1850 with the Apprentice Act
which required that children between the ages of 10-18 convicted in courts to be provided
vocational training as part of their rehabilitation process. This act was transplanted by the
Reformatory Schools Act, 1897 and later came The Children Act of 1960. The Juvenile Justice
Act, 1986 was the primary legal framework for juvenile justice in India. The Act provided for a
special approach towards the prevention and treatment of juvenile delinquency and provided
a framework for the protection, treatment and rehabilitation of children in the purview of the
juvenile justice system.Juvenile Justice Act, 1986 was applied uniformly throughout India except
state of Jammu and Kashmir. Prior to this law each state had its own enactment on juvenile
justice with there being differences in the way juveniles were treated by different state legal
systems. In a landmark step, the Government of India, repealing the juvenile justice Act 1986,
introduced juvenile justice (Care and Protection of Children) Act in 2000 and further, amended ,
it in 2006, so as to make it responsive to the emerging needs in the tiled of juvenile justice, and

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making it, compatible with UNCRC standards. The juvenile justice act on 2015 had significant
changes.

This is an act which aims to:

• Consolidate and amend the law relating to juveniles in conflict with law and children in
need of care and protection.
• Provide for proper care, protection, treatment and cater to their development needs.
• Provide a child-friendly approach keeping their best interest in mind while dealing with
them.

The central functions of the juvenile justice system are: to provide for the care, protection,
treatment, development and rehabilitation of neglected or delinquent juveniles and for the
adjudication of matters relating to, and disposition of delinquent juveniles in the light of the
avowed policy of providing opportunities to such Children to become useful citizens for any
country. Crime and the Treatment of Offenders identified three models of juvenile justice system
based on contemporary approaches to dealing with juvenile offenders namely; The due
procedural model, The social welfare model, and the participatory process model.

Juvenile Justice act 2015

The Juvenile Justice (Care and Protection of Children) Act (henceforth, JJ Act) passed by
the Indian Parliament on the 22 December 2015 aims to amend the existing Juvenile Justice
(Care and Protection of Children) Act of 2000 by attempting to examine the mental faculties of
the child who commits a crime and not focus on the age. The larger question is about the
rationale behind keeping 18 years as cut-off mark for adulthood when there is a looming debate
about whether human brain is completely developed until that age.

This Act was passed in the background of therelease of one of the convicts of the
infamous
Delhi rape case of December 2012,2 on thepretext that he was below 18 years of agewhen the
crime was committed and asaccording to existing laws had to be treated asa juvenile. There were
strong protests fromseveral quarters of the civil society against therelease of the convict. The
governmentintroduced the Act in order to respond directlyto the doubts raised about the

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competence ofthe existing law as a deterrent and, at the sametime, to review for the possibilities
ofredefining the content and scope of lawsconcerning juveniles.

Highlights of the Act

Age Cap: Continuing with the age cap ofjuvenile at 18 years, this act introduces a newcategory
of 16-18 years who could be convictedas adults in case of heinous crimes
(offenceswithpunishment of 7 years or more underIndian Penal Code) [JJ Act, Sec. 2(33)].

Boards & Committees: The 1986 Actestablished Juvenile Welfare Boards andJuvenile Court.
The 2000 Act skipped theestablishment of a special court, but theJuvenile Welfare Boards were
carried on andChild Welfare Committees were established.However, the 2015 Act carries the
provision for3 members on the Boards (Metropolitan orjudicial Magistrate + 2 Social Workers)
(JJ Act,Sec. 4); establishes Child Welfare Committee (JJAct, Sec. 27); and revives theChildren’s
Courtfor every district (The Commissions for theProtection of Child Rights Act 2005, Sec.
25;Protection of Children Against Sexual OffencesAct 2012, Sec. 28). In the former two bodies,
atleast one-woman member is mandatory whichwas also present in the 1986 and 2000 Act.

Adoption: Establishment for State AdoptionResource Agency and Central AdoptionResource

Agency which monitors, regulates,make rules, etc. regarding the adoption ofchildren (JJ Act,
Sec. 67-68). It further lays downcriteria for prospective parents’ adoption whichwas absent in
earlier Acts. This clause wouldhelp in speeding the adoption process. Monthlyvisit by
ChildWelfare Committees to foster family has been added

Child Care Institutions: Unlike the Act of 2000,the registration of Child Care Institutions has
been made mandatory (JJ Act, Sec. 41).

Analysis of the Act

Carrying forward the spirit of reformation andrehabilitation of juvenile justice, the

Actcontinues with the segregation between‘children in need of care and protection’ and‘children
in conflict with law’ (JJ Act, Sec. 2).While the former includes children, who are inadverse
conditions, requiring state support tobecome responsible citizens, the later are thosechildren who
have committed crimes.The National Crime Records statistics show thatthough there was an
increase in juvenilecrimes, not all these crimes were committed‘intentionally’.Thus, it is held
that if suchchildren are provided with healthy atmosphere,they can grow to become

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responsiblecitizens.As a result, the Act includes a clause foradoption of such children by
allowingintercountry adoption in case foster parents are notavailable in the country (JJ Act, Sec.
36). In
order to stop child trafficking, the Act ensuresstricter offences for people who are involved in
supplying drugs to children. In fact, thepunishment is harsher in this case compared tophysical
assault (JJ Act, Sec. 76-78).Further, incases where families surrender their childrendue toadverse
conditions, the Act hasincreased the time period to take them backbefore they can be given for
adoption from onemonth to two months as compared to whatwas in the original Bill that was
tabled in LokSabha in August, 2014 [JJ Act, Sec. 36(3)]. Thischange, however, assumesthat
family atmosphere is the most conduciveatmosphere for a child’s development. It doesnot take
into consideration the fact that 80.2%of criminal acts, as reported by National CrimesRecords,
are committed by children who arewith family (Crimes in India, 2014: 132). If it isso, rather than
over-emphasizing on the familyas a mechanical unit to counter crime bychildren, the Act should
have aimed at family asa repository of emotional and holisticdevelopment of child. This would
require stateintervention in providing accessibility toresources to families where it is lacking, and
onthe other hand to help in developing emotionalbonds within family through counseling.
Effortslike these can help in reducing crime amongchildren and instilling in them a sense of
rightand wrong which can be a deterrent incompelling circumstances. Therefore, the ambitof
Child Welfare Committees could have beenenlarged to ensure such interventions as andwhen
required. Also, the law in its current formlooks retrogressive as the financial/continuedsupport
which was available to children fromtime to time until the age of 21 after they hadleft children’s
home has been reduced to one-time support. This unfortunately puts themback to the vicious
cycle of poverty anddestitution, which, as warned by the NationalCrimes Records, is one of the
main reasons forincreasing crime rate among juveniles

Under the ‘children in conflict with law’category, the government taking

intoconsideration the differential treatmentbetween adult and child that has beenenshrined in the
United Nations Convention onRights of Children (UNCRC), continues to definechildren under
same benchmark of 18 years butwith differential treatment of children between16-18 years who
are accused of being involvedin heinous crimes. The Standing Committee ofthe Parliament
observed that this clauseviolated the UNCRC as it created a sub-categorywithin the definition of
juvenile. The UNCRCstates that signatory countries should treatevery child under the age of 18

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years in thesame manner and not try them as adults. TheAct of 2000 was enacted to implement
theUNCRC guidelines in the Indian context. Theamendment to the act in the current
formcategorizes crimes committed by juveniles intofollowing: (i) heinous offences [those
withminimum punishment of seven years ofimprisonment under Indian Penal Code (IPC) orany
other law], (ii) serious offences (three toseven years of imprisonment), and (iii) pettyoffences
(below three years of imprisonment)(JJ Act, Sec. 7). It is maintained that a juvenilecannot be
given life imprisonment without thepossibility of release or death penalty. Underthe new Act, a
juvenile in conflict with law canbe required to spend a maximum of three yearsin a special home
or fit facility. However, ajuvenile in the age group of 16-18 years may betried as adults if the
crime falls in the categoryof heinous offence, irrespective of date ofapprehension. Also, a
juvenile between 16-18years of age who has committed a seriousoffence and apprehended after
the age of 21years, may be tried as an adult. By inserting thisclause ‘irrespective of
apprehension,’ this Acttries to plug the holes of the earlier Act thathad let go off those child
criminals who hadintentionally committed a crime takingadvantage of age.

The government introduced Juvenile Justice care and protection of children) amendment
bill, 2018 in Lokwhich seeks to empower district magistrates to pass orders for adoption of
children to reduce the time taken for issuing such directions. Currently, there is an inordinate
delay in issuing adoption orders by the courts due to “heavy work load”.

ETHICAL ISSUES IN PSYCHIATRIC PRACTICE

National and international ethical guidelines

The World Psychiatric Association (WPA) prepared the Declaration of Hawaii in 1977
after extensive discussion. This was updated in Vienna in 1983. The revision in 1996 was called
the Madrid Declaration. There is also a Standing Committee for ethical issues. The UN General
Assembly in 1991 specially considered the question of ‘Principles for the protection of persons
with mental illness and for the improvement of mental health’. In India, the National Human
Rights Commission’s publication, Quality assurance in mental health, provides guidelines for the
care of mentally ill in psychiatric institutions.

The UN principles for the protection of persons with mental illness and the improvement
of mental health care (1991) recognize the enjoyment of the highest attainable standard of

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physical and mental health as the right of every human being. In 1996, WHO developed the
Mental Health Care Law: Ten Basic Principles as a further interpretation of the MI Principles
and as a guide to assist countries in developing mental health laws. The WHO also developed
Guidelines for the Promotion of Human Rights of Persons with Mental Disorders, which is a tool
to help understand and interpret the UN principles 1991 (known as MI Principles) and evaluate
human rights conditions in institutions.

The principles with respect to the treatment of persons with mental illness can be summarized as
follows:

• The aim of psychiatry is to treat mental illness and promote health to the best of his or her
(psychiatrist’s) ability, consistent with accepted scientific knowledge and ethical principles; •
Every psychiatrist should offer to the patient the best available therapy to his knowledge and if
accepted must treat him or her with the solicitude and respect due to the dignity of all human
beings;

• The psychiatrist aspires for a therapeutic relationship that is founded on mutual agreement. At
its optimum it requires trust, confidentiality, cooperation and mutual responsibility;

• The psychiatrist should inform the patient of the nature of the condition, therapeutic procedure
including possible alternatives and of the possible outcome;

• No procedure shall be performed, nor treatment given against or independent of a patient’s own
will, unless because of mental illness, the patient cannot form a judgment as to what is in his or
her best interest and without which treatment serious impairment is likely to occur to the health
of the patient or others;

• As soon as the conditions for compulsory treatment no longer apply, the psychiatrist should
release the patient from the compulsory nature of the treatment and if further therapy is
necessary should obtain voluntary consent;

• The value of positive mental health for every human being and the rights of all persons with
mental disorders and with disabilities as full citizens of their countries should be recognized;

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• All recipients of mental health services, regardless of age, gender, ethnic group or disorder
must be treated in the same manner as other citizens in need of health care and their basic human
rights and freedoms should be respected;

• The World Medical Association and its member associations have always sought to advance
the cause of human rights for all people and have frequently taken actions endeavoring to
alleviate violations of human rights;

• Members of the medical profession are often amongst the first to become aware of violations of
human rights;

• Medical associations have an essential role to play in calling attention to such violations in their
countries.

The UN Convention on the Rights of the Persons with Disabilities (2006) marks a
“paradigm shift” in attitudes and approaches to persons with disabilities. It takes to a new height
the movement from viewing persons with disabilities as “objects” of charity, medical treatment
and social protection towards viewing persons with disabilities as “subjects” with rights, who are
capable of claiming those rights and making decisions for their lives based on their free, and
informed consent as well as being active members of society. It has proposed a comprehensive
definition of persons with disabilities as ‘all those who have long-term physical, mental,
intellectual and sensory impairments (Article 1). The Convention calls upon nations to take
specific actions to protect the rights of people with mental disability.

Ethics in Clinical Psychology

The American Psychological Association's (APA's) Ethical Principles of Psychologists
and Code of Conduct (hereinafter referred to as the Ethics Code) consists of an Introduction, a
Preamble, five General Principles (A – E), and specific Ethical Standards.The Preamble and
General Principles are aspirational goals to guide psychologists toward the highest ideals of
psychology. Although the Preamble and General Principles are not themselves enforceable rules,
they should be considered by psychologists in arriving at an ethical course of action. The Ethical
Standards set forth enforceable rules for conduct as psychologists.

General Principles

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Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom
they work and take care to do no harm.

Principle B: Fidelity and Responsibility Psychologists establish relationships of trust with those
with whom they work. They are aware of their professional and scientific responsibilities to
society and to the specific communities in which they work.

Principle C: Integrity Psychologists seek to promote accuracy, honesty, and truthfulness in the
science, teaching, and practice of psychology.

Principle D: Justice Psychologists recognize that fairness and justice entitle all persons to access
to and benefit from the contributions of psychology and to equal quality in the processes,
procedures, and services being conducted by psychologists.

Principle E: Respect for People's Rights and Dignity Psychologists respect the dignity and worth
of all people, and the rights of individuals to privacy, confidentiality, and self-determination.

Ethical standards:

Resolving ethical issues:

If psychologists learn of misuse or misrepresentation of their work, they take reasonable

steps to correct or minimize the misuse or misrepresentation. If psychologists' ethical
responsibilities conflict with law, regulations, or other governing legal authority, or demands of
an organization with which psychologists are affiliated or for whom they are working conflict
with this Ethics Code, psychologists make known their commitment to the Ethics Code and take
steps to resolve the conflict. When psychologists believe that there may have been an ethical
violation by another psychologist, they attempt to resolve the issue by bringing it to the attention
of that individual, if an informal resolution appears appropriate and the intervention does not
violate any confidentiality rights that may be involved. Informal Resolution of Ethical Violations
is not resolved properly in that fashion, psychologists take further action appropriate to the
situation. Such action might include referral to state or national committees on professional
ethics, to state licensing boards, or to the appropriate institutional authorities. This standard does
not apply when an intervention would violate confidentiality rights or when psychologists have
been retained to review the work of another psychologist whose professional conduct is in

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question.Psychologists should cooperate in ethics investigations, proceedings, and resulting
requirements of the APA or any affiliated state psychological association to which they
belong.Psychologists do not file or encourage the filing of ethics complaints that are made with
reckless disregard for or willful ignorance of facts that would disprove the allegation.

Research and Publication

When institutional approval is required, psychologists provide accurate information about

their research proposals and obtain approval prior to conducting the research. They conduct the
research in accordance with the approved research protocol.When obtaining informed consent as
required in Standard 3.10, Informed Consent, psychologists inform participants about (1) the
purpose of the research, expected duration, and procedures; (2) their right to decline to
participate and to withdraw from the research once participation has begun; (3) the foreseeable
consequences of declining or withdrawing; (4) reasonably foreseeable factors that may be
expected to influence their willingness to participate such as potential risks, discomfort, or
adverse effects; (5) any prospective research benefits; (6) limits of confidentiality; (7) incentives
for participation; and (8) whom to contact for questions about the research and research
participants’ rights. They provide opportunity for the prospective participants to ask questions
and receive answers.Psychologists obtain informed consent from research participants prior to
recording their voices or images for data collection unless (1) the research consists solely of
naturalistic observations in public places, and it is not anticipated that the recording will be used
in a manner that could cause personal identification or harm, or (2) the research design includes
deception, and consent for the use of the recording is obtained during debriefing.Psychologists
do not conduct a study involving deception unless they have determined that the use of deceptive
techniques is justified by the study’s significant prospective scientific, educational, or applied
value and that effective non- deceptive alternative procedures are not feasible.Psychologists
explain any deception that is an integral feature of the design and conduct of an experiment to
participants as early as is feasible, preferably at the conclusion of their participation, but no later
than at the conclusion of the data collection, and permit participants to withdraw their
data.Psychologists do not fabricate data while reporting research. If psychologists discover
significant errors in their published data, they take reasonable steps to correct such errors in a
correction, retraction, erratum, or other appropriate publication means.

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 ROLE OF GOVERNMENT AND VOLUNTARY ORGANIZATION IN MENTAL
HEALTH

Despite some caviling about the quantum, the government remains the biggest single
spender in the mental health sector. While most new interventions remain isolated and confined
to urban areas, it is only the public health system through large programs which can reach the
rural masses. Apart from the National and District Mental Health Programs, the National Rural
Health Mission is on its way to becoming the vehicle for delivering mental health as a part of
integrated primary care at the cutting edge of the public healthcare system. Seeing that it partners
with existing private and alternative care providers in a nonthreatening manner, shall help such
large interventions synergize and succeed.

Assistance and concessions for people with disability

A “disability certificate” is necessary to access benefits afforded under the Persons with
Disabilities Act (1995) in India. In India, the 2001 census identified 21.9 million people with
disabilities, though the number has been estimated to be as high as 70 million. One social
provision intended to alleviate the burden of disability for these individuals is the Persons with
Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act of 1995 [PWD
Act]. According to the Act, disability includes blindness, low vision, cured leprosy, hearing
impairment, locomotor disability, mental retardation, and mental illness. The PWD Act
constitutes an important step towards enabling the disabled in India. Based on the provisions of
the Act those who are 40 per cent disabled, as certified by a governmental medical authority, are
entitled to receive benefits from the government of India (GoI). A certain percentage of
government jobs, for example, is reserved for those with certified disabilities. Educational
institutions that receive aid from the GoI must reserve at least three per cent of their seats for
persons with disabilities. Travel concessions and tax rebates are also available for the disabled
and their escorts or caregivers.Individuals seeking benefits must obtain a disability certificate
from a specified government healthcare provider. The certificate itself needs to display a
photograph (certified by due authority), as well as the name and address of the individual.

IDEAS was applied in all the patients who fulfilled the selection criteria to measure
the disability. IDEAS is best suited for the purpose of measuring and certifyingdisability. It has
four items: Self Care, Interpersonal Activities (Social Relationships), Communication and
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Understanding, and Work.Each item is scored between 0-4, i.e., from no to profound disability,
adding scores on 4 items gives the ‘total disability score’. Global disability score is calculated by
adding the ‘total disability score’ and MI2Y score (months in two years - a score ranging
between 1 and 4, depending on the number of months in the last two years the patient exhibited
symptoms). Global disability score of 0 (i.e., 0%) corresponds to ‘no disability’, a score between
1-7 (i.e., 40 per cent corresponds to moderate to profound disability. The Rehabilitation
Committee of Indian Psychiatric Society developed this scale13. It has been tested at various
centers. The alpha value was 0.8682, indicating good internal consistency between the items. It
has good criterion validity and at face value, the instrument appeared to be measuring the desired
qualities. Criterion validity was established by comparing IDEAS with SAPD (Schedule for the
Assessment of Psychiatric Disability) which has been standardized in India.

Role of Non-Governmental Organization in Mental Health

The paucity of treatment facilities and psychiatrists in the Government sector has
widened the treatment gap in mental health. Non-governmental organizations (NGOs) have
played a significant role in the last few decades in not only helping bridge this gap, but also by
creating low cost replicable models of care. NGOs are active in a wide array of areas such as
child mental health, schizophrenia and psychotic conditions, drug and alcohol abuse, dementia
etc. Their activities have included treatment, rehabilitation, community care, research, training
and capacity building, awareness and lobbying.

Most MHNGOs serve a defined community; however, the work of some has spread to
more than one center or geographical region. Examples of such NGOs are the Alzheimer and
Related Disorders Society of India (ARDSI), which was started in Cochin, and has now spread to
more than a dozen centers in India. Similarly, the Richmond Fellowship Society has three
centers. The oldest MHNGOs in India are probably those working in the field of child mental
health, and, mental retardation. This may not be surprising given the close nature of the
relationship between mental retardation and the concept of childhood disabilities which has been
one of the bedrocks of the NGO movement for several decades. The concept of child mental
health has broadened from its earlier focus on mental retardation to include the far commoner
mental health problems seen in children, such as autism, hyperactivity and conduct disorders.

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MHNGOs such as Sangath Society (Goa) and Umeed and the Research Society (Mumbai)
provide outpatient and school-based services for such problems.

Other than mental retardation, the other early MHNGOs had care and treatment and
rehabilitation as their priorities and developed appropriate models of rehabilitation in diverse
settings and for diverse clinical populations. Their primary focus was on severe mental disorders
and many of these MHNGOs (such as the Schizophrenia Research Foundation (SCARF) in
Chennai, Manas in West Bengal, the Medico-Pastoral Association (MPA) in Bangalore, and
Shristi in Madurai were started by psychiatrists who already held full-time faculty positions in
the local medical school. These MHNGOs were started to fulfill the need for a broader, holistic
approach to the management of severe mental disorders. Thus, activities ranging from family
counseling to vocational rehabilitation, which were rarely provided in psychiatric out-patient
clinics, were given greater attention. Another area of mental health which attracted considerable
interest and attention was substance abuse. Alcohol abuse and drug abuse captured the public
imagination and received considerable media interest in the 1970s and 80s. This public attention
and the obvious need for community-based rehabilitation services for persons affected by
substance abuse led to the development of numerous MHNGOs working in this area. The TTK
Hospital in Chennai, the TRADA in Karalla and Karnataka, Parivarthan in Maharashtra, Kripa
Foundation, Alcoholics Anonymous and the Samaritans in many parts of the country and the
National Addiction Research Center in Mumbai are examples of MHNGOs focusing on
substance abuse problems.MHNGOs providing community-based counseling and suicide
prevention activities have mushroomed. Reports highlighting the rising rates of suicide in India,
amongst young people, have alerted health professionals and the community about this serious
mental health problem. Sneha (Chennai), MPA (Bangalore) and Saarthak (Delhi) work on
suicide prevention activities; The activities of the Bapu Trust (Pune) demonstrate how the
feminist theory can contribute to the discourse on the linkages between women’s lives in a
gender-biased society and their mental health. Banyan (Chennai) provides shelter and care for
women living with mental disorders.

While most state-run organizations focus on medical treatment, psycho-social

rehabilitation (PSR) is sadly a neglected though major aspect of MHNGO programs. The
absence of trained staff to carry out PSR activities has, however, kept it away from mainstream

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psychiatric services. Hence, many NGOs have taken it upon themselves to develop modules of
PSR in both urban and rural areas. The programs include a spectrum of activities such as
individual and group counseling, vocational rehabilitation and livelihood skills training,
cognitive retraining, family support and counseling, self-help groups, recreation and leisure
activities.

NGOs have initiated a number of community-based mental health programs emphasizing

on services in a variety of community, including home-based, settings and offer a range of PSR
activities. These programs range from primary prevention activities such as suicide prevention to
provision of treatment in community clinics, increasing awareness and providing community-
based rehabilitation (CBR). NGOs are arguably better placed to approach and win the trust of
local communities, establish ties with them and locate their programs in and for the community.
Examples of primary prevention programs are the telephone help lines for depressed and suicidal
persons, early intervention for babies born at risk for developmental delay and education
programs in schools and workplaces for prevention of substance abuse.Secondary prevention
focuses on minimizing the handicaps associated with an existing mental disorder. Examples of
such programs include CBR programs for child and adult mental disabilities and school
programs to help children with hyperactivity and dyslexia stay in school. CBR is an essential
ingredient of community care programs. SCARF, as part of vocational support activities, has
distributed livestock, cows and helped expansion of petty shops in rural areas to help persons
with schizophrenia. This is not just a means of livelihood but has also improved their functioning
and involvement in many ways. Empowerment of the local community is equally important and
involvement of key and influential persons in the community such as teachers, religious heads,
and local administrators has yielded good results.Community programs gained much
significance when the tsunami left in its wake several psycho-social problems which required
intensive counseling, support and sometimes medication to allay anxiety and depression. NGOs
like SNEHA (Chennai) provided a range of community-based counseling and mental health
interventions in the aftermath of this disaster.

Until relatively recently, MHNGOs were primarily concerned with service provision and
advocacy related activities. This has changed so much in recent years that today MHNGOs are at
the forefront of ground-breaking health research in India. The SCARF studies on schizophrenia

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are the most widely-cited research on the subject from any developing countries (Thara and
McCreadie 1998). All three published studies of dementia in the community in India are from
work done by MHNGOs (REF). Sangath’s studies on the treatment of depression are amongst
the largest such studies from India (Patel et al. 2003), Sangath’s Manas project is the largest trial
for a mental health treatment from any developing country. Ashagram’s community program for
schizophrenia has generated the first scientific evidence of the use of the CBR approach for
rehabilitation of a mental disorder (Chatterjee et al. 2003). The experience of CBR in Ashagram
has led to the initiation of the first randomized controlled trial of this approach in three sites in
India.

MHNGOs have made raising awareness in different sectors of the community, such as
health workers, teachers and lay persons, a priority area. Documentation and dissemination of
relevant facts and research, and lobbying policy makers for changes in the law are vital
instruments for improving mental healthcare. A prominent example of the success of efforts of
MHNGOs is the inclusion of mental disabilities in the disability legislation of the country. The
film festival organized by SCARF called the “Frame of Mind,” which features several films
portraying mental illness and an international competition for short films on mental health and
stigma, is a huge success and has had three editions so far. Similar festivals have since been held
in other cities like Kolkata. Many NGOs use short films to spread awareness about their
work/cause. Many publish regular newsletters and host web sites marking the close affinity of
MHNGOs with contemporary technological advances. Many MHNGOs adopt methods to
enhance the effectiveness of care through empowerment of affected persons and their families.
Support groups are widely used to ensure that persons recovering from substance abuse can
remain sober. The globally recognized organization, Alcoholics Anonymous, is an example of
the kind of support group philosophy which becomes the core to the process of treatment of
alcohol dependence. Support groups are also evident in the residential and day care facilities
geared to those with severe mental disorders. Some MHNGOs run support groups not for those
directly affected by a disorder, but for their families.

Strengths of NGOs

• Working in partnerships: One of the great strengths of MHNGOs is their ability to strike
up collaborations and partnerships with other agencies or individuals with ease; unlike

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 the public health sector where layers of permissions stifle the scope for collaboration and
unlike the private health sector where collaborations may be perceived as a threat to the
practice. Most MHGNO activities are provided by multidisciplinary teams of doctors,
therapists, health workers, other professionals and volunteers. Partnerships are built not
only between medical and non-medical professionals, but also between professionals and
families. The close collaboration between academics, clinicians, social workers,
rehabilitation workers, remedial teachers, clinical and educational psychologists are a
distinct feature which marks MHNGOs as being a very different breed of animal from
traditional psychiatric clinics in hospitals or private psychiatry.

• Innovations in practice: MHNGOs are, typically, closer to the community they serve and
hence in a better position to be more sensitive to changing needs and perceptions.
Further, MHNGO services may be attached with much less stigma than formal
psychiatric services, and may thus attract a much wider range of clients. Clinical support,
involving diagnosis and treatment of specific mental disorders, is the key to many
MHNGO activities. The success of MHNGOs lies in providing services which are
accessible, such as through outreach camps, which rely on available human resources,
such as the community participatory model of rehabilitation. Many MHNGOs provide a
wide range of services which are especially suited for severe and childhood mental health
problems. By taking up the process of promoting attitudinal changes in the community
and amongst policy makers, MHNGOs also play a key role in advocacy for changes
which can benefit all persons with mental illness.

• Transparency in administration: The activities of MHNGOs are driven not by profit but
by the desire to achieve a basic quality of care for all clients, irrespective of their ability
to pay. They are governed by a relative flexible set of regulations. Employment and
promotional avenues can be based on merit as opposed to the traditional governmental
holy grail of seniority. Because they are dependent on external funding, MHNGOs are
constantly kept on their toes in achieving program objectives and ensuring fiscal
accountability. MHNGOs can explore, with remarkable entrepreneurial dynamism,
collaborations with any other organization or individual to achieve their objectives.

Limitations of NGOs

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• Sustainability: A key problem facing most MHNGOs is the source of their funding,
which is largely project-based. The periodic fund raising required to augment resources
can take up a good deal of time and energy. Staff members have no guarantee of
employment beyond a defined project period. Therefore, some MHNGOs suffer a high
turnover of staff. This is partly because staffs are appointed on specific funded projects
and their continuity depends on the funding available. There might be a temptation to
dilute goals and objectives as a response to availability of funding. Donor funding is
notoriously fickle; priorities change over time, and MHNGOs often reinvent their
objectives to keep afloat. The recent trend for massive investment in HIV/AIDS related
work, though important in its objectives, is concentrating the bulk of donor money to this
one-disease issue. Many MHNGOs and, indeed, some MHNGOs are adding HIV/AIDS
as core priorities to secure these funds. While this may broaden the scope of MHNGOs
by enabling an integration of existing priorities with new ones, there is equally a need not
to allow the focus on mental health to be diluted to the point that it becomes irrelevant

• Accountability: Some MHNGOs have poorly established mechanisms for evaluation and
monitoring. Although networking is actively sought for project collaboration, there is no
similar zeal for review and monitoring from external assessors. There has been
considerable public concern regarding the misuse of funds and lack of financial
accountability of NGOs in general. Although this may not be as significant an issue in the
context of MHNGOs where funds are scarce, MHNGOs would be well advised to ensure
transparency in accounting for their funds. As MHNGOs become larger and more
professionalized, there is a danger of increasing bureaucratization with increasing
administrative costs. MHNGOs should be wary of this from the beginning since it could
well dampen creativity and flexibility, two elements which give MHNGOs their unique
flavor.

• Scope: Finally, and perhaps the most important limitation is the limited scope of
individual MHNGOs. The world of most MHNGOs is confined to a city or a few
villages. There is, however, a need to transplant the wide experience of these onto a
larger canvas, ideally through influencing policies and programs for the entire state and
country. For changes to occur on this wider canvas there is little doubt that the public or

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 government health sector must play a key and leading role. MHNGOs can, in this
context, be seen as innovators who develop locally relevant models which can then be
implemented on a national scale.

PSYCHOSOCIAL REHABILITATION IN INDIA

Psychosocial Rehabilitation is a process, which provides opportunities for persons who are
impaired, disabled, handicapped by mental disorders, to reach optimum level of independent
living functioning in the community (WHO, 1996). It is initiated by a health or a mental health
professional, in collaboration with the patients’ families and community, and supported by the
policy planner, focused at developing and implementing an individualized program that seeks to
maximize the patient’s assets and minimize his disabilities in the area of socio-occupational
functioning, centering around the philosophy of mobilizing and utilizing resources available to
the community, with the final objective of mainstreaming the client.

• Rehabilitation services can be classified under four main models of intervention –

Recovery, Respite, Rescue, and Retention. These models continue to be relevant in
modern psychiatric care. The aim of the recovery model is to empower persons with
mental illness to function in their daily lives, restore their self-esteem, and improve the
overall quality of life. The model is geared toward individuals who have shown
improvement in their psychiatric illness and are ready to undergo rehabilitation and
retraining and assume social roles. The respite model is largely for clients who are
clinically stable but have residual symptoms, mild-to-moderate disability, and who have
difficulty returning to pre- illness level of functioning. The rescue model reaches out to
the clinically unstable, wandering, and homeless mentally ill who suffer from moderate-
to-severe disability and is carried out under the aegis of community-based initiatives. The
retention model utilizes minimal staff intervention to provide help to those whose
families are not very supportive or not engaged with their treatment and at times offers
respite to families. These models provided the start for several halfway, group and long
stay homes and community outreach programs to be initiated.
• The history of psychiatry in India was developed on similar lines as that in other parts of
the world. The earliest records of mental health institutions showed the evidence
regarding existed mental hospitals in India. There was a mental hospital at Dhar, near

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 Mandu, in Madhya Pradesh, established by Mohammed Khilji in the 15th century
between 1436 – 1469 A.D. The Lunatic asylums in India were established after the
British East Indian Company came to India. The principle behind these asylums was to
separate the mentally ill from mainstream of the society. The Indian Lunatic Asylum Act
- 1858, was enacted by the British government and which was in force in India during
late 19th century. In these periods, the lunatic asylums were under the supervision of a
medical officer who worked as Physician or as Civil Surgeon. In 1895, Dr. W. R. Rice, I.
M. S., Surgeon General, took a survey about functions and conditions of lunatic asylums
in India. In the recommendations he stressed that the importance of Occupational
Therapy for persons with mentally ill in the lunatic asylums as part of psychiatric
treatment. It was landmark in the field of psychosocial rehabilitation in India. Then
numbers of occupational therapy department were established in almost all the Lunatic
asylums during this period. Between 1870s to 1890s, there was a rehabilitation
programme for the mentally ill at Mysore Lunatic Asylum, Mysore. The programme was
called as “Work Therapy”. In this programme, the persons with mental illness were
involved in the field of agriculture for all the activities. In early 20th century major
revolution was occurred in India in the field of psychosocial rehabilitation. The Indian
Lunacy Act was enacted in 1912 by the British government. It was to develop conditions
and functions of the lunatic asylums and improve the care of the mentally ill. The word
Lunatic asylum was replaced by the name called “Mental Hospital”. In 1929, The Indian
Association for Mental Hygiene was founded by Dr. Barkeley Hill. One of the major
objectives of association was to encourage the study of mental health in the community.
Subsequently The Indian Psychiatric Society (IPS) was established on 7th January 1947
by a group of Indian Psychiatrists.
• The major developments in the history of Psychosocial Rehabilitation were occurred in
the post-independence period. Evidence shows that there was a Department of
occupational therapy for the mentally ill at Central Institute of Psychiatry (CIP), Ranchi,
Bihar, in 1950s. In 1954, the involvement of family in the psychiatric treatment was
initiated by Dr. Vidya Sagar, at Amritsar Hospital in Punjab. He encouraged the family
members to stay in the hospital and to participate in the process of treatment. It gave an
impetus to the family members to understand the illness of their wards. The importance

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 of rehabilitation programme for the mental ill was emphasized during the stay in the
ward. In 1960, the first day care center for the mentally ill was established by the All
India Institute of Mental Health, Bangalore. It offered various vocational training such as
carpentry, weaving, tailoring, candle making etc. In 1960s, the Mental Health Centre was
started at Christian Medical College Hospital at Vellore, Tamil Nadu. The family
members were stayed along with the patients and participated in the treatment. The
occupational therapy was started in this center. The patients were involved in various
vocational training like tailoring, basket making, carpentry and etc. In 1962, the Day
hospital was started in the Institute of Mental Health, Madras. It offered different
vocational training for the mentally ill such weaving, tailoring, gardening, basket making
and mat making. In 1964, the first voluntary organization for the persons with mentally
illness was established by a group of people at Bangalore, called Medico Pastoral
Association (MPA). The organization had initially organized counselling services and
group activities. While organizing programmes the felt need of group was identified by
the organization. In response to the needs of this group of persons, Halfway home was
established by the association in 1972. This was a first Halfway home in India for persons
with mental illness. In 1970s, home based rehabilitation programme for schizophrenics
was started by NIMHANS, Bangalore. It was focused on patients who were not able to
avail the mental health facilities due to distance of the hospital from home, social stigma,
difficulty in drug compliance and the inability of the family in understanding the illness.
The therapeutic interventions such as counselling, psychoeducation, home based
rehabilitation activities, identify important signs of relapse were given to the family
members by a trained nurse. The ALMA ATA declaration was proclaimed in 1970. There
were many components in the declaration and the 7th component was the promotion of
mental health through primary health care system in the community. It focused on care of
the mentally ill persons in the community.
• The International Year of Disabled was celebrated by the United Nations in 1981.
Subsequently it was celebrated by the Government of India in the same year. This gave a
lot of impetus to the professionals to offer community-based rehabilitation services for
the people with disability. In 1982, National Mental Health Programme (NMHP) was
inceptioned by the Government of India. It was a landmark in the field of psychosocial

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rehabilitation. It was implemented with three objectives i.e., to ensure availability of
minimum mental health care for all, to encourage the application of mental health
knowledge in general health care and to promote community participation in the mental
health services. The last objective of the programme had three components and the
second component was emphasized on psychiatric rehabilitation for the mentally ill
persons in the community. In 1982, a workshop on “Psychosocial Rehabilitation” was
conducted by Dr. M. Ranganathan, at the National Institute of Mental Health And Neuro
Sciences (NIMHANS), Bangalore. It was conducted for mental health professionals in
the field of psychosocial rehabilitation. It was enriched the knowledge and skills. In 1983,
Schizophrenia Care and Research Foundation (SCARF) was established by Dr. Saratha
Menon at Madras to provide various skills training for the mentally ill. In response to the
needs of the community, the organization launched the community-based day care center
in 1985, near Chennai. It has been offering various vocational training such as printing,
tailoring, mat weaving, soap making and candle making. In 1984, there was a center
called “Family run rehabilitation center for the mentally ill” at Bangalore. It was
managed by the family association of Air Force, Bangalore, with the help of National
Institute of Mental Health and Neuro Sciences (NIMHANS). It offered vocational
training and counselling services for the chronic mental ill persons. It was continued till
1989. In 1985, the community-based rehabilitation programme was launched by the
United Nations. Initially it was focused on people with disabilities like locomotor
disability, blind, and hearing impairment and multiple disabilities. Off late this concept
was absorbed into the field of mental health. In 1986, World Association for
Psychosocial Rehabilitation (Indian Chapter) (WAPR - IC) was established by Dr.
Sarathamenon at Madras. It has brought together the people who are working in the field
of psychosocial rehabilitation like mental health professionals, families of persons with
mental illness, and voluntary organizations working for the mentally ill persons. In 1986,
The Richmond Fellowship Society (India) was founded by Dr. Naranyana Reddy at
Bangalore, to offer skills training for the mentally ill and develop the professional
manpower in the field of psychosocial rehabilitation. Based on their experience and felt
need of the community, the organization started the model Half-way Home in 1989, Long
Stay Group Home in 1995, and community-based Day care with vocational training

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 facilities in 1997 at Bangalore. In 1999, The Richmond Fellowship Post Graduate
College for Psychosocial Rehabilitation, Bangalore was established and managed by the
Richmond Fellowship Society (India). It is the first of its kind in India in the field of
Psychosocial Rehabilitation. It offers two years regular course and degree in M.Sc. in
Psychosocial Rehabilitation.
• Action for Mental Illness (ACMI) India, a NGO, was founded in 2003 to advocate for the
rights and needs of persons with mental illness. The architects behind the same were Dr.
Nirmala Srinivasan, a caregiver and disability activist and Director and Trustee, ACMI
and Mrs. Laila Ollapally, an advocate at the Karnataka High Court. ACMI advocates for
policy, legal and service delivery issues relating to mental illness. ACMI has also
launched Families Alliance on Mental Illness for families to build awareness, advocate,
and take action. ACMI and AMEND, also a self-help group of family caregivers in
Bengaluru, have done immense service in bringing together family caregivers.The
Chittadhama Trust was founded by Dr. Swaminath, a psychiatrist by profession and a few
of his colleagues to provide residential care and rehabilitation for homeless persons with
mental illness in 2010. It was started at HD Kote in Mysore district with the help of a
group of psychiatrists, psychologists, and psychiatric social workers. The Trust also
makes conscious efforts to reunite the rehabilitated persons with their families.

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 INTRODUCTION TO PSYCHOPATHOLOGY

Abnormal psychology is the field of psychology which specializes in the development and
integration of psychological principles for the understanding of abnormal behaviour (Coleman).
According to Kisker, abnormal psychology is a specialized field of psychology dealing with
personality disturbances and behavioural disorders. It is the study of deviation or variance from
so called normal pattern (Mahoney). Abnormality also known as mental disorder, psychiatric
diagnosis or more brodly Psychopathology become very familiar with the definitions of various
forms of abnormal behavior and the ways in which it differs from normal behavior.

Normality and Abnormality

This criteria can be grouped into: a) Descriptive – They indicate the types of behaviours
considered normal or abnormal and b) Explanatory- This concerned with assumed process
underlying abnormal behaviour.

Descriptive criteriais classified into: Statistical and Non- statistical criteria

a) Statistical criteria: According to this, average is normal. A person is abnormal when he
deviates from the average. This criterion is inadequate in several ways. Firstly, any
deviation from the average or majority would be abnormal. A genius would be as
abnormal as a mentally retarded person. We can’t label a person who deviate in a positive
or favourable as abnormal. They may be called “superior” or “above average” but not
“abnormal”.
b) Non- statistical criteria further classified into Ethical/ Moral, criteria for social
conformity, criteria for idea/ perfection and legal criteria.
I. Ethical/Moral- According to this, a person is considered to the abnormal if he or
she act in an immoral manner. This criteria is based on the value judgements
made by people who observe behaviour. For being taken as normal, the behaviour
should be appropriate and desirable from the view point of ethics or morality. The
main issue of this criteria is that morality is not an absolute concept, What is
moral or immoral may depends on the culture and time.
II. Criteria of social conformity:- According to this, those who conform to social
norms are considered as normal and those who do not care for them labelled as
abnormal. This would be based on the assumption that normality is what the
majority of the people follow.
III. Criteria of ideal or perfection:- According to this, normal behaviour is equated
with perfect or ideal behaviour. A few persons attain a level of perfection which is
difficult to attained by the majority. Problem with this perspective is that there is

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 no ideal behaviour and perfection of behaviour differ from person to person, place
to place and time to time.
IV. Legal criteria:- According to this, a law abiding citizen is normal but the one who
violates the law is labelled as abnormal. The legal criteria can’t be made areliable
or valid criteria for the judgement of normality or abnormality

Explanatory Criteria classified as Pathological/ medical criteria, psychological criteria and

adjustment criteria.
a) Pathological/ medical criteria:- Normality and abnormality of the behaviour depends on
the functioning of the nervous system. In this way all abnormal people are affected with
some mental illness or disease.
b) Psychological criteria:- Psychological functioning whether defective or normal is the
deciding factor of the abnormal or normal behaviour. When analysing this criteria, it is
seen that abnormality is linked with some malfunctioning of certain psychological
systems
c) Adjustment criteria:- A person is said to be normal or abnormal based on how one feels
adjusted or maladjusted with their self and their environment. The normal people always
integrate or adjust their needs, motives, emotions, interests, aspirations and other
cognitive aspects with those of other members of the society and thus excersise a proper
balance between their own self actualization and their contribution towards social welfare
and progress.
In the 1990s, Jerome Wakefield introduceda theory that give a simplified (in comparison with
the multifaceted criteria above) definition ofmental disordersknown asharmful dysfunction
theory of mental disorders. The theory defines -Harmful is a value term based on social norms,
and dysfunction is a scientific term referring to the failure of a mental mechanism to perform a
natural function for which it was designed by evolution. Thus, the concept of disorder combines
value and scientific components. But this definition was against the traditionally labelled
psychopathological criteria and continues to be debated along with other definitions in this field.
The clinical psychologists widely use the definition based on DSM. . The DSM is generally
considered the official source of definitions for mental disorders, and it is widely accepted and
used among mental health professionals.

In DSM-IV-TR, mental disorder is defined as a clinically significant behavioral or psychological

syndrome or pattern that occurs in an individual and that is associated with present distress (e.g.,
a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
or with a significantly increased risk of suffering, death, pain, disability, or an important loss of
freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally
sanctioned response to a particular event, for example, the death of a loved one. Whatever its

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original cause, it must currently be considered a manifestation of a behavioral, psychological, or
biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or
sexual) nor conflicts that are primarily between the individual and society are mental disorders
unless the deviance or conflict is a symptom of a dysfunction in the individual.
ClassificationOf Abnormality
Classification is the process of reducing the complexity of phenomena by arranging them into
categories according to some established criteria for one or more purposes. The classification of
mental disorders consists of specific mental disorders that are grouped into various classes on the
basis of some shared phenomenological characteristics. The ultimate purpose of classification is
to improve treatment and prevention efforts. Ideally, a classification of disorders is based on
knowledge of etiology or pathophysiology, because this increases the likelihood of improving
treatment and prevention efforts. The purposes of a classification of mental disorders involve
communication, control, and comprehension.
• Communication:-This involves using names of categories as standard shorthand ways of
summarizing a great deal of information. When indicating that an individual has a
particular disorder, this confers information about the cluster of clinical features that the
individual is experiencing without listing all of the specific features that together
constitute the disorder. For communication to be effective, there must be a high level of
agreement among users of the classification.
• Control:- This primarily refers to the prevention of their occurrence or the modification
of their course with treatment. Control also helps to get an idea about the course of a
condition.
• Comprehension:-Classification should provide comprehension or understanding of the
causes of mental disorders and the processes involved in their development and
maintenance thus helps to more effective treatment and prevention (i.e., better control).
History Of Classification
According to Menninger and colleagues, the first specific description of a mental illness
appeared in approximately 3000 bc in a depiction of senile deterioration ascribed to Prince Ptah-
hotep. The syndromes of melancholia and hysteria appeared in the Sumerian and Egyptian
literature as far back as 2600 bc. In the Ebers papyrus (approximately 1500 bc), senile
deterioration and alcoholism were described. In India, in approximately 1400 bc, a classification
of psychiatric disorders was included in the medical classification system of Ayur-Veda.
Hippocrates (approximately 460 to 370 BC) introduced the concept of psychiatric illness
into medicine. His writings described acute mental disturbances with fever (perhaps delirium),
acute mental disturbances without fever (probably analogous to functional psychoses but called
mania), chronic disturbance without fever (called melancholia), hysteria (broader than its later
use), and Scythian disease (similar to transvestism).

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 Physician Thomas Sydenham (1624 to 1689), all illness, despite the difference in
appearance between the different syndromes, was attributed to a single pathogenic process, a
disturbance of the humoral balance or a disturbance in the tensions of the solid tissues.
Sydenham believed that each illness had a specific cause. He called for the study of morbid
processes and likened the investigation of the specificity of diseases to the botanist's search for
species of plants.
Philippe Pinel (1745 to 1826) simplified the complex diagnostic systems into four
fundamental clinical types: mania (conditions with acute excitement or fury), melancholia
(depressive disorders and delusions with limited topics), dementia (lack of cohesion in ideas),
and idiotism (idiocy and organic dementia). Pinel thus reacted against the specific disease entity
tradition of Sydenham and went back to a noncomplex hippocratic system of classification. All
mental illnesses were in a category of physical illnesses called neuroses, which were defined as
functional diseases of the nervous system—that is, illnesses that were not accompanied by fever,
inflammation, hemorrhage, or anatomical lesion.
By the 19th century, mental disorder began to be regarded consistently as the manifestation
of physical pathology, and scientists searched for specific lesions, parallel to the investigation of
bodily diseases. Benedict-Augustin Morel (1809 to 1873) was the first to use the course of an
illness as a basis for classification. His demenceprecore was not a disease entity but a particular
form of the course of mental disease.
Karl Ludwig Kahlbaum (1828 to 1899), a German descriptive psychiatrist who
foreshadowed Emil Kraepelin, introduced the concepts of (1) the temporary symptom complex,
as opposed to the underlying disease, (2) the distinction between organic and nonorganic mental
disorder, and (3) the consideration of the patient's age at the time of onset and the characteristic
development of the disorder as bases for classification.
Antoine Bayle in 1822 that progressive paresis was a specific organic disease of the brain
and the discovery of Paul Broca (1824 to 1880) in 1861 that some forms of aphasia were related
to definite lesions of the cortex increased attempts to base all classifications of mental disorders
on demonstrated brain lesions or disturbances in vascular and nutritional physiology. Thus
Wilhelm Griesinger (1818 to 1868) to coin the slogan “mental diseases are brain diseases.”
Because the knowledge of brain pathology was limited, he recognized the need for a provisional
functional category for mental illnesses with as-yet-unknown somatic pathology.
Kraepelin (1856 to 1926) synthesized three approaches: the clinical-descriptive, the somatic, and
the consideration of the course of the disorder. He viewed mental illnesses as organic disease
entities that could be classified on the basis of knowledge about their causes, courses, and
outcomes. He brought the manic and depressive disturbances together into one illness, manic-
depressive psychosis, and distinguished it, on the basis of its periods of remission, from the
chronic deteriorating illness called dementia praecox, which Eugen Bleuler later renamed
schizophrenia. Kraepelin also recognized paranoia as distinct from dementia praecox,
distinguished delirium from dementia, and, for the first time in a classification system of mental

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disorders, included the concepts of psychogenic neuroses and psychopathic personalities (the
“born criminal,” the “unstable,” “pathological liars and swindlers,” and “litigious paranoiacs”).
Sigmund Freud divide the neuroses into the actual neuroses, the result of dammed-up sexual
excitation, and the psychoneuroses, the result of unconscious conflict and compromise symptom
formation. As interest in the actual neuroses diminished, the term neurosis came to be
synonymous with psychoneurosis. Freud recognized only the following subtypes of neurosis:
anxiety neurosis, anxiety hysteria (phobia), obsessive-compulsive neurosis, and hysteria. Freud's
dynamic concepts and interest in the psychopathology of everyday life led to an expansion of the
boundaries of what was considered mental illness to include mild forms of personality deviation.
As Hagop S. Akiskal and William McKinney noted, despite the advances in the understanding of
mental disorders in the past 50 years, the major categories of mental disorders in the standard
classification systems are based primarily on the concepts of Kraepelin and Bleuler—organic
mental disorders, affective disorders, and schizophrenia—and Freud—neuroses and personality
disorders

Clinical Criteria of Abnormality

Historically, psychiatry emerged as a discipline when shared systems of diagnosis based on
informal rules of categorization emerging out of everyday experience were developed not only to
aid the drawing of appropriate distinctions between ‘health and illness’ but also to better
charecterise different disorders in psychiatric settings. The publication of ICD-9 in 1977 and
DSM-Ш in 1980 represented the start of the modern era of classification. The reasons for
emergence of models:
• Active attempt to shift away from a pre dominantly psychodynamic approach to mental
health and illness, where boundaries between health and disorder were vague and poorly
specified
• Move towards a more scientific approach, which shared a common frame of reference
with mainstream medicine- a pronounced bio-medical focus (Spitz & Endicott, 1978)
• To bring psychiatry back closer to other medical specialities, as governmental and private
insurance had cut reimbursements to psychiatry due to the confusion and lack of
reliability of mental disorder diagnosis (Wilson, 1993)
• The clinical utility (ease to use, ability to improve communication and inform treatment
planning; Mullins-Sweatt&Widiger, 2009) and scientific approach (Kendler, 1990) are
the main cause of emergence of models.
The main approaches of clinical criteria of abnormality are: Categorical approach, Dimensional
approach, Protypical approach, Hybrid approach and Etiological approach.Categorical
approach considers illness as being either present or absent. Dimensional approach regards that
symptoms of disorder exist on a continuum from normal to severely ill. Prototypical approach

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where description of a disorder is taken as marker for the disorder. Hybrid approach combines
categorical and dimensional approaches. Etiological approach tends to find reason for the set of
symptoms, which could be biological, psychological or social.
Categorical Approach
Emil Kraeplin who introduced this method. This regards mental disorders as qualitatively
different from variation across the normal range of expression in the population, and as having
their own pattern rather than distinct causes. Here, the disorder differs from normality in both
degree and kind. This approach classifies mental disorders involving assessment of whether an
individual hasa disorder on the basis of symptoms and characteristics that is described as typical
of the disorder ie this considers illness as being either present or absent. For a particular case the
set of symptoms either constitutes a disorder or not, and there are no “in between” diagnosis. If
symptoms of two disorders are present a comorbid disorders eg generalized anxiety disorder and
depressive disorder existing as comorbid disorders. According to this approach disorder is
distinct from normalcy i.e, either one is illor not ill.
Eg.Mr. A. has depressive disorder which is distinct from “normal” functioning.It is separate from
dysthymia and anxiety disorders which are taken as other disorders and with the treatment if he
improves adequately, he would not be depressed (i.e depression will either be present or absent)
This approach introduces clear and explicit criteria for making diagnosis for identifying the
presence of a disorder. Using the top down approach of a categorical or disease model expert
clinicians use their own experience, the existing literature and new data in order to define
diagnostic criteria for a specific mental disorder. The DSM system is based on the categorical
model with the main assumption that psychiatric disorders are separate disease entities.
Categorical model has been widely used in psychiatry since the publication of DSM Ш in 1980
and has improved the reliability of psychiatric diagnoses. It mainly focused on epidemiological
and clinical research as well as treatment. This model facilitate decision making (eg whether a
patient needs a certain medication, or to get hospitalized). The main issues are:
• If one seeks to reduce comorbidity by reducing categories, one is faced with increasing
levels of heterogeneity and vice versa (Morgan, Hynd, Riccio& Hall, 1996; Sonuga-
Barke, 1998)
• The strict application of categorical diagnostic rules can also result in individual with
significant symptoms and impairments, but who fall just short of the diagnostic criteria,
being denied support and treatment.
• This model evaluate the presence and absence of a disorder and do not allow for
evaluation of the severity of disorder in question.
• Because of the artificial boundaries of disorders many patients do not fit any one
category. Consequently, diagnosis of Not otherwise specified are popular in many
clinical settings
Dimensional Approach

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This regard disorder as an extreme expression of normal variation in the population and
emphasizes continuity in underlying causes. This quantifies a person’s symptoms or other
characteristics of interest and represents them on one or more scales or continuums, rather than
assigning them to a mental disorder category. Here the disorder and normality differ only in the
degree but not the kind. The therapist can note the variety of cognitions, moods and behaviours
with which the patient presents and quantify them on scale. The symptoms of disorder exist on a
dimension which is a continuum from normal to severely ill. It can be envisioned in terms of
number (count) of symptoms(eg. Five out of eight symptoms to diagnose major depressive
disorder) and severity of each symptom group (eg. Positive,negative, disorganised, cognitive,
affective dimensions of schizophrenia).
The Strength of this approach:
• From a research point of view dimensions have been found to some times have greater
predictive validity than do their diagnostic counterparts (Fergusson &Horwood, 1995)
• More detailed information on each symptom
• It takes into account a wider range of factors (more than categorical approach)
• A profile is created than labelling
Disadvantages:
• The communication among clinicians using the dimensional model is more difficult than
with the categorical model
• The clinical utility of dimensional models is yet to be determined
Dimensional models are more complex and more difficult to use than categorical models,
because, providing too much information can be a hindrance rather than help to clinicians,
especially if the information is not clinically relevant.
Example: Mr. A according to the dimensional approach, sadness exist on a continuum with
severity ranging from normal to severely pathological. The grading of individual symptoms and
overall sadness from mild to moderate to severe depression. The treatment response can be
monitored by using severity scales.
Prototypal Model
This model depends upon the similarity with the prototypical description of a typical case, the
disorder is labelledto be either present or absent. According to this approach, there may be a
large number of disorders depends on the prototypes and descriptions. This is related to the ideal
type classificatory concept. Actual cases that matches the ideal type in all respects are rare. An
ideal typology, according to Jespers, consists of a series of opposites, such as introversion vs
extroversion, or submission vs dominance. By comparing these individual to these contrasting
poles, the persons’ personality and behaviour is illuminated.
Hybrid Approach

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It represents a combination of categorical and dimensional approaches. It utilizes categorical
approach for broad diagnostic group and dimensional approach for severity of the disorder.
Present day ICD and DSM use this approach to some extent. Example: The diagnosis of
depressive episode suggests a broad categorical diagnosis, while ratings of severity into mild,
moderate, and severe represent dimensionality. DSM 5 used hybrid approach more effectively. A
categorical diagnosis can be made (e.g., schizophrenia spectrum and other psychotic disorders),
but an additional dimensional construct would be applicable for most disorders to convey
severity. The DSM 5, retains the categorical diagnosis but introduces dimensionality on a larger
scale.Eg., conceptualizing the case of Mr. A from the hybrid perspective, categorical diagnosis
would be of major depressive disorder single episode, while severity would be measured by
clinical global impression (CGI) of the past 1 week (rated from 0 to 7). The progress can be
measured by change in CGI over time. Even when episode is in remission, sub syndromal
symptoms can be measured using CGI.
Etiological Approach
This approach tends to find the “reason” for the set of symptoms. The reasons could be
biological, psychological or social. It has been propounded persuasively for some psychiatric
disorders like autism. But this approach is difficult to use for psychiatric disorders with the
present understanding of etiology which is usually multifactorial. This emphasize the interplay
between the genetic and environmental factors in most of the disorders. The role of each factor
can be hardly quantified with certain degree of precision. It may be unclear whether a factor
causes the disorder or merely unmasks it in susceptible individuals.
Classification Systems
There are two major psychiatric classification systems in use: theInternational Classification of
Disease (ICD-10) system, published by the World Health Organization, and the Diagnostic
andStatistical Manual of Mental Disorders (DSM), published by the American Psychiatric
Association. The ICD-10 system is widely used in Europe and many other countries, whereas the
DSM system is the standard guide for the United States. Certain differences in the way symptoms
are grouped in these two systems can sometimes result in a different classification
on the DSM than on the ICD-10.
The DSM
The first edition of the manual (DSM-I) appeared in 1952 and was largely an outgrowth of
attempts to standardize diagnostic practices in use among military personnel in World War II.
The 1968 DSM-II reflected the additional insights gleaned from a markedly expanded post war
research effort in mental health sponsored by the federal government. Over time, practitioners
recognized a defect in both these early efforts: The various types of disorders identified were
described in narrative and jargon-laden terms that proved too vague for mental health
professionals to agree on their meaning. The result was a serious limitation of diagnostic
reliability; that is, two professionals examining the same patient might very well come up with
completely different impressions of what disorder(s) the patient had. To address this clinical and

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scientific impasse, the DSM-III of 1980 introduced a radically different approach, one intended
to remove, as much as possible, the element of subjective judgment from the diagnostic process.
It did so by adopting an “operational” method of defining the various disorders that would
officially be recognized. This innovation
meant that the DSM system would now specify the exact observations that must be made for a
given diagnostic label to be applied. In a typical case, a specific number of signs or
symptoms from a designated list must be present before a diagnosis can properly be assigned.
The new approach, continued in the DSM-III’s revised version of 1987 (DSM-III-R) and
in the 1994 DSM-IV, clearly enhanced diagnostic reliability and made efforts to incorporate
cultural and ethnic considerations. As an example of the operational approach to diagnosis,
the DSM-IV-TR diagnostic criteria for dysthymic disorder are reproduced in the DSM-IV-TR
The number of recognized mental disorders has increased enormously from DSM-I to DSM-IV,
due both to the addition of new diagnoses and to the elaborate subdivision of older
ones.
THE FIVE AXES OF DSM-IV-TR:DSM-IV-TR evaluates an individual according to five foci, or
axes. The first three axes assess an individual’s present clinical status or condition:

Axis I. The particular clinical syndromes or other conditions that may be a focus of clinical
attention:-Thiswould include schizophrenia, generalized anxiety disorder,
major depression, and substance dependence. Axis I conditions are roughly analogous to the
various illnesses and diseases recognized in general medicine.
● Axis II. Personality disorders. A very broad group of disorders that encompasses a variety of
problematic ways of relating to the world, such as histrionic personality disorder, paranoid
personality disorder, or antisocial personality disorder. This also refers to an early-developing,
persistent, and pervasive pattern of disregard for accepted standards of conduct, including legal
strictures. Axis II provides a means of coding for long-standing maladaptive
personality traits that may or may not be involved in the development and expression of an Axis
I disorder. Mental retardation is also diagnosed as an Axis II condition.
● Axis III. General medical conditions. The general medical conditions potentially relevant to
understanding or managing the case. Axis III of DSM-IV-TR may be used in conjunction with an
Axis I diagnosis qualified by the phrase “Due to [a specifically designated general medical
condition]”—for example, where a major depressive disorder is conceived as resulting from
unremitting pain associated with some chronic medical disease.

The last two DSM-IV-TR axes are used to assess broader aspects of an individual’s situation:

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● Axis IV. Psychosocial and environmental problems. This group deals with the stressors that
may have contributedto the current disorder, particularly those that havebeen present during the
prior year. The diagnostician isinvited to use a checklist approach for various categoriesof
problems—family, economic, occupational, legal, andso forth. For example, the phrase
“Problems with primarysupport group” may be included when a family disruption
is judged to have contributed to the disorder.

● Axis V. Global assessment of functioning. This is where clinicians indicate how well the
individual is coping at the present time.

Axes IV and V, first introduced in DSM-III, are significant additions. Knowing what
frustrations and demands a person has been facing is important for understanding the
context in which the problem behavior has developed. And someone’s general level of
functioning conveys important information that is not necessarily contained in the entries
for the other axes and indicates how well the individual is coping with his or her problems. Some
clinicians argued that it limits a patient’s right to privacy by revealing, for example,
a recent divorce (Axis IV) or a suicide attempt (Axis V). Because of such concerns, Axes IV and
V are now considered optional for diagnosis and in fact are rarely used in most
clinical settings.
The DSM-5 was publishedin May 2013 find ways of harmonizing structural, conceptual and
disorder specific differences.

The limitations of DSM:

• The real problems of real patients often do not fit into the precise lists of signs and
symptoms that are at the heart of the modern DSM effort.The disorders people actually
have are often not so finely differentiated as the DSM grid on which they must be
mapped. Increasingly fine differentiation also produces more and more recognized types
of disorder.

• Diagnostic Reliability- The unintended effect is to sacrifice validity in an effort to

maximize reliability. This makes little sense. The part of the problem may be the
continuing reliance on a diagnostic system that is based on categories rather than
dimensions. Simply put, the coding of a symptom as adichotomous variable (i.e., present

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 or absent) can negatively affect the reliability of symptom coding compared to rating the
same symptom as a continuous variable. For example, blends of anxiety and depression
are extremely common in a clinical population, and they typically show much overlap
(correlation) in quantitative scientific investigations as well. Nevertheless, the DSM treats
the two as generically distinct forms of disorder, and as a consequence, a person who is
clinically both anxious and depressed may receive two diagnoses, one for each of the
supposedly separate conditions.

• Diagnostic Validity:- Kendell and Jablensky (2003) viewed diagnostic validity as an

indication that a disorder is a discrete entity that has clear boundaries with other disorders.
Kendell and Jablensky suggested that very few mental disorders have demonstrated diagnostic
validity. A prime example of a diagnosis with questionable validity is acute stress disorder
(ASD). This month following exposure to a traumatic stressor. As Harvey and Bryant (2002)
noted, ASD was introduced into DSM-IV to fill a vacuum that existed around the diagnosis of
PTSD. A diagnosis of PTSD cannot be applied to such symptoms if they occur within a month of
the traumatic event ASD was defined, therefore, as a disorder in which PTSD-like disorders
occurred shortly after the trauma. If symptoms of ASD persist for more than a month after the
event, then a diagnosis of PTSD may be appropriate and the ASD diagnosis would be
superseded. This opens the possibility that researchers might be able to establish the nature of
connections between initial distress following trauma (i.e., ASD) and more chronic distress (i.e.,
PTSD).

• Categorical Versus Dimensional Classification :-Comorbidity is a clinical fact. When a

categorical classification system is used, the presence ofcomorbidity contradicts the
assumption that diagnostic categories are discrete and nonoverlapping.The DSM-IV
explicitly acknowledges that each category of mental disorder need not be a
discreteentity—yet doing so opens up the possibility that a dimensional system may
better represent the natureof mental disorders. As noted in the DSM-IV, there are no
commonly agreed upon dimensional systemsthat could replace the DSM-IV categorical
approach.

The ICD
ICD is the foundation for the identification of health trends and statistics globally, and the
international standard for reporting diseases and health conditions. It is the diagnostic
classification standard for all clinical and research purposes. ICD defines the universe of
diseases, disorders, injuries and other related health conditions, listed in a comprehensive,
hierarchical fashion that allows for:

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 • easy storage, retrieval and analysis of health information for evidenced-based decision-
making;
• sharing and comparing health information between hospitals, regions, settings and
countries; and
• data comparisons in the same location across different time periods.
Uses include monitoring of the incidence and prevalence of diseases, observing reimbursements
and resource allocation trends, and keeping track of safety and quality guidelines. They also
include the counting of deaths as well as diseases, injuries, symptoms, reasons for encounter,
factors that influence health status, and external causes of disease

In 1948, the World Health Organization (WHO) assumed the responsibility for revising what had
previously been called the International List of Causes of Death and that had been revised every
10 or 20 years since its inception in 1900. The sixth revision was renamed the Manual of the
International Classification of Diseases, Injuries, and Causes of Death (ICD-6) and contained, for
the first time, a classification of mental disorders, entitled “mental, psychoneurotic, and
personality disorders.” It contained ten categories of psychosis, nine categories of
psychoneurosis, and seven categories of disorders of character, behavior, and intelligence.

The ICD has been revised and published in a series of editions to reflect advances in health and
medical science over time. ICD-10 was endorsed in May 1990 by the Forty-third World Health
Assembly. It is cited in more than 20,000 scientific articles and used by more than 100 countries
around the world. ICD helps for the identification of health trends and statistics globally, and the
international standard for reporting diseases and health conditions. It is the diagnostic
classification standard for all clinical and research purposes. The chapter ‘F’ classifies
psychiatric disorders as metal behavioural disorders, code them on as alphanumeric system from
F00 to F99. The versions of ICD-10 are
a) Clinical Description of Diagnostic Guidelines (CDDG)
b) Diagnostic criteria for research (DCR)
c) Multi axial classification version
d) Primary care version
Now ICD have its 11th version published in June 2018. The study conducted by Rydelius (2012)
summarized the changes in as compared to ICD 11. In ICD-11 there will not be a separate
section on disorders in childhood and adolescence and disorders of psychological development.
ICD-11 will be arranged on a “life-time-axis” basis. The disorders with childhood onset and
mental retardation (to be called Intellectual Developmental Disorders) be included in a
neurodevelopmental cluster together with schizophrenia and primary psychotic disorders, while

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childhood presentations of other disorder will be included in other clusters. ICD-11 will
specifically address both cultural and developmental aspects of disorders and focus also upon a
manual for primary care.
Disadvantages-This classification is not suitable in cases where few or no information about
patient is available. In such case only symptoms of disease can be coded that can be caused by
several different medical condition that can be regularly coded if we have enough information to
confirm diagnosis.
The Classification committee of WONCA (World Organization and Academic Association of
the general Practitioners) has produced a clinical coding system known as ICPC (International
Classification for Primary Care). It allows classification of the patient’s reason for encounter
(RFE), the problems/diagnosis managed, interventions, and the ordering of these data in an
episode of care structure.
Above mentioned tasks cannot be achieved using ICD 10 classification. The definitive diagnosis
that can be coded using ICD can be achieved after several visits of patient and rarely during the
first visit.
The clinical interview and Diagnosis
The interview is the principal means of assessment in clinical psychiatry. Psychiatric interviews
are analogous to the history and physical in a general medical assessment, and they share the
major features of other types of medical interviews (Mackinnon and Yudofsky, 1986); they
systematically survey subjective and objective aspects of illness, and generate a differential
diagnosis and plan for further evaluation and treatment.
In psychiatry, descriptive information about signs, symptoms and course over time is used to
assign a diagnosis to the presenting problem. A consistent scheme should be used each time for
recording the interview, although the interview need not follow a fixed and rigid method. The
interview technique should have flexibility, varying according to appropriate clinical
circumstances. Whenever possible, the patient should be seen first. During the interview
session(s), the patient should be put at ease and an empathic relationship should be established.
In psychiatric assessment, history taking interview and mental status examination need not
always be conducted separately (though they must be recorded individually). During assessment,
the interviewer should observe any abnormalities in verbal and nonverbal
communication and make note of them. It is helpful to record patient’s responses verbatim
rather than only naming the signs (for example, rather than just writing delusion of persecution,
it is better to record in addition: “my neighbour is trying topoison me”). It is best done in the
patient’s own spoken language, whenever possible. It is useful to ask open-ended and non-
directive Questions. Confidentiality must always be observed.

1)Identifying Data

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The patient’s name should be recorded, Age, Sex, Marital status, Education, Occupation,
Income, Residential and Office Address(es), Religion, and Socioeconomic background, as
appropriate according to the setting.

2).Informants. A list of all informants, their reliability, and level of cooperation; also previous
hospital records, if available. The reliability is assed based on 5C’s : Consistency, Coherence,
Chronological information, Closeness with the patient and Concern for the patient

3).Chief Complaint: The chief complaint is the patient’s responses to the question, “What brings
you to see me/to the hospital today?” or some variant. It is usually quoted verbatim, placed
within quotation marks, and should be no more than one or two sentences. Some of the
additional points which should be noted include:
1. Onset of present illness/symptom.
2. Duration of present illness/symptom.
3. Course of symptoms/illness.
4. Predisposing factors.
5. Precipitating factors (include life stressors).
6. Perpetuating and/or relieving factors.

4).History of present illness: The present illness history should begin with a brief description of
the major symptoms which brought the patient to psychiatric attention. The most troubling
symptoms should be detailed initially; later a more thorough review will be stated. As a
minimum, the approximate time since the patient was last at his baselinelevel of functioning, and
in what way he is different from that now, should be described, and any known stressors, the
sequence of symptom development, and the beneficial or deleterious effects
of interventions included. How far back in a patient’s history to go, especially when he has
chronic psychiatric illness, is sometimes problematic. In patients who have required repeated
hospitalization, a summary of events since last discharge (if within 6 months) or last stable
baseline is indicated. It is rare that more than 6 months of history be included in the history of the
present illness, and detailed history is more commonly given on the past month. A more
expanded description of the history of the present illness would include events in a patient’s life
at the onset of symptoms, as well as exactly how the symptoms have affected the patient’s
occupational functioning and important relationships. Any concurrent medical illness symptoms,
medication usage (and particularly changes), alterations in the sleep–wake cycle, appetite
disturbances and eating patterns should be noted; significant negative findings should also be
remarked upon.

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 5). Negative history:- For ruling out an organic etiology. These include; histories of trauma,
fever, projective vomiting, hypertension, confusion, disorientation etc.

6) Past Psychiatric and medical history: Previous psychiatric diagnoses. Chronological list of
episodes of psychiatric inpatient and outpatient care. Chronological list of episodes of medical
orsurgical illness. Episodes of symptoms for which no treatment was sought. Any illness treated
by doctors, previous drug treatment, drug allergy, any non prescribed/ alternative medications
taken.

7) Family history: Family tree with details of names, ages and relationship were drawn. It should
be noted whether the family is a nuclear, extended nuclear or joint family. Any consanguineous
relationships should be noted. The age and cause of death (if any) of family members should be
asked. Family history of similar or other psychiatric illnesses, major medical illnesses, alcohol or
drug dependence and suicide (and suicidal attempts) should be recorded. About the socio-
economic condition, leadership patteren, role functions and communication within the family.
8) Personal history: this includes
• Birth (antenatal, natal and postnatal period)and developmental history, childhood and
adolescence history, education,
• occupational history-relationships with supervisors and peers at work, reasons for job
change.
• Menstrual history: The regularity and duration of menses, the lengthof each cycle, any
abnormalities, the last menstrualperiod, the number of children born, and terminationof
pregnancy (if any) should be asked for.
• sexual history-Early sexual teaching: earliest sexual experiences, experience of being
sexually abused, attitudes toward sexual behavior. Dating history, precautions taken to
prevent sexually transmitted diseases and/or pregnancy. Episodes of impotence and
reaction. Masturbating patterns and fantasies. Preoccupation with particular sexual
practices, current sexual functioning, length of significant relationships, ages of partners.
and marital history and use and abuse of alcohol, tobacco and drugs.
• Marital history- time of marriage, arranged/ self, age of both partners, education,
occupation, health and personality of partner, quality of relationship, any separation/
divorce. No.of children, their ages etc should be noted.
• Use and abuse of alchohol, tobacco and drugs- initiation, pattern of use, withdrawal,
tolerance, impairment in social personal, and occupational spheres. Any implication on
current illness may be described.

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9) Premorbid personality: Relationship with friends and family, Attitude towards self,
predominant mood, intellectual activities, hobbies and interest, Character- interpersonal
relationship, moral and religious attitudes, attitude towards work and responsibility, energy
levels and work initiatives. Fantasy life.

Mental Status Examination

Mental status examination is a standardised format in which the clinician records the psychiatric
signs and
symptoms present at the time of the interview.

General appearance and behaviour- Describe appearance, physical charecteristics, cleanliness,

hair, clothes and dressing. Eye to eye contact, facial expression, use of postures and gestures,
rapport could be established or not, attitude towards examiner, co-operativeness and
psychomotor activity.

Speech- note the tone, tempo, volume, rate and prosody

Thought-Stream and form- Spontaneity, productivity, flight of ideas, prolixity, poverty of

content of
speech, and thought block should be mentioned here. The ‘continuity’ of thought is assessed;
Whether the thought processes are relevant to the questions asked; Any loosening of
associations, tangentiality, circumstantiality, illogical thinking, perseveration, or verbigeration is
noted.
possession and content-Any preoccupations; Obsessions (recurrent, irrational, intrusive,
egodystonic,
ego-alien ideas. Contents of phobias (irrational fears); Delusions (false, unshakable beliefs) or
Over-valued
ideas; Explore for delusions/ideas of persecution, reference, grandeur, love, jealousy (infidelity),
guilt, nihilism, poverty, somatic (hypochondriacal) symptoms, hopeless ness, helpless ness,
worthlessness, and suicidal
ideation. Delusions of control, thought insertion, thought withdrawal, and thought broad casting
are Schneiderian first rank symptoms (SFRS). The presence of neologisms should be recorded
here

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Mood- subjective and objective assessment

Perceptions- record the presence of illusions and hallucinations

Cognitive functions- includes
Orientation to time , place and person

Attention and concentration as easily arousable and maintained based on digit span test, serial
substractionetc

Memory- Immediate memory (digit span test), Recent memory- applies to scales of minute to
days and remote memory ( based on important life events)

Intelligence- According to the educational and sociocultural background of patient.Abstraction(

similarities, dissimilarities and proverb), Arithmetic calculation, General fund of knowledge (
current events, famous person in the country, five major rivers, seasons, crops growing in a
particular time etc)

Judgement- Judgement is the ability to assess a situation correctly and act appropriately within
that situation. Both social and test judgement are assessed.

i. Social judgement is observed during the hospital stay and during the interview session. It
includes an evaluation of ‘personal judgement’.

ii. Test judgement is assessed by asking the patient what he would do in certain test situations,
such as ‘a house on fi re’, or ‘a man lying on the road’, or ‘a sealed, stamped, addressed envelope
lying on a street.

Insight: Insight is the degree of awareness and understanding that the patient has regarding his
illness. Insight is rated on a 6-point scale from one to six.
1. Complete denial of illness.
2. Slight awareness of being sick and needing help, but denying it at the same time.

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3. Awareness of being sick, but it is attributed to external or physical factors.
4. Awareness of being sick, due to something unknown in self.
5. Intellectual Insight: Awareness of being ill and that the symptoms/failures in social adjustment
are due to own particular irrational feelings/thoughts; yet does not apply this knowledge to the
current/future experiences.
6. True Emotional Insight: It is different from intellectual insight in that the awareness leads to
significant basic changes in the future behaviour.

Diagnostic Formulation
The interviewer may summarize the findings of the session in the form of a biopsychosocial
formulation. The biopsychosocial conditions that contribute to the development, onset, and
course of a psychiatric disorder can be classified according to their impact as predisposing,
precipitating, perpetuating, or protective factors. The interviewer also assesses the patient's assets
and strengths. This evaluation should be made in descriptive terms. It includes the patient's
knowledge, interest, skills, aptitude, experience, education, and employment status, all items that
are closely related to the protective factors. Then MSE are presented so that helps to plan the
diagnosis and management. Also discuss the points in favour and in against for each diagnosis
being considered. A differential diagnosis that weighs the pros and cons for a group of Axis I
and II psychiatric disorders may then take the place of a specific diagnosis. The advantage of the
differential diagnosis is that it comprehensively captures the perimeter of psychopathology that
the interviewer takes into account.
Treatment and prognosis
The interviewer answers the patient's asked or unasked questions. The interviewer decides first
which level of care the patient requires. He or she discusses with the patient the diverse treatment
options and their possible adverse effects. The interviewer may identify the immediate targets of
treatment and tell the patient what to expect if he or she cooperates. The interviewer's
interventions are most effective if he or she has been able to forge an alliance with the patient. If
the patient is severely disabled, such as being suicidal, homicidal, violent, or psychotic, or has
lost impulse control, is disoriented, or intoxicated, the patient may need hospitalization. Most
patients can be treated as outpatients without interruption of their work schedule. Some need
temporary disability or home supervision.
The interviewer designs a biopsychosocial treatment plan. To improve the biological condition,
the interviewer may use medication. Most psychotropic medications have a delayed onset of
action, as, for example, the selective serotonin reuptake inhibitors (SSRIs) and mood stabilizers.
Therefore, the interviewer may, for the immediate temporary effect, combine substances with
delayed onset of action with those with an immediate onset, such as anxiolytics, low dosages of
atypical neuroleptics, and, in rarer cases, stimulants.

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Social conditions may be improved, for instance, by activating family support, with short-term
relief of stress by sick leave, by arranging vocational rehabilitation, or by facilitating the
ventilation of traumatic events. Strategies used in interpersonal psychotherapy may help.
Referral to a psychologist or social worker as case manager may be considered. The interviewer
may contrast the natural history of the untreated disorder with the course that may be achieved if
the patient cooperates fully and the treatment is effective. The patient's clear understanding of the
difference can be a strong motivating factor for the patient's compliance.

References
Butcher, J. N., Mineka, S &Hooley, J.M.(2013). Abnormal psychology. Boston: Pearson.
Kay. J., & Tasman, A. (2006). Essentials of Psychiatry. John Wiley & sons: USA
Ahuja, N.,(2011). A Short Textbook of Psychiatry (7thed). New Delhi. Jaypee
Brothers Medical Publishers (P) Ltd.
Sadock, B. J., &Sadock, V. A.(2005). Kaplan &Sadock's Comprehensive Textbook of Psychiatry
(8th Edn). Lippincott Williams &Wilkins :Newyork .

2011 by SAGE Publications, London pomerantz, Andrew M.

Clinical psychology: Science, practice, and culture/Andrew M. Pomerantz.–2nd ed.
1959-
Introduction to clinical psychology : an evidence-based approach/John Hunsley, Catherine M.
Lee.Usa john weily

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PSF-CHAPTER 12

Introduction

Stigma of mental illness and all that is attached to it – patients who suffer from mental disorders,
their families, psychiatric institutions, psychotropic medications – is the main obstacle to better
mental health care and better quality of life people who have an illness, their families, of their
communities and of health service staff that deals with psychiatric disorders.

It is a basic component of the negative discrimination that people with mental illness experience
every day. It blocks access to facilities and options that have been created to help people
impaired by mental illness. Stigma is pernicious and research indicates that despite advances of
psychiatry and medicine it continues to grow and has far reaching consequences on the field of
mental health.

People’s attitudes and beliefs predict their behaviour (Ajzen&Fishbein, 1980). People’s beliefs
and attitudes about mental illness might predict whether they disclose their symptoms and seek
treatment and support. Knowledge and beliefs that can aid in the recognition, management, or
prevention of mental health disorders are defined as mental health literacy (Jorm et al., 1997).
Tracking attitudes toward mental illness can serve as an indicator of the public’s mental health
literacy.

For all these reasons, it is imperative to understand the attitudes associated with mental health in
general and stigma in particular in order to formulate strategies to combat it at both the
individual as well as the societal level.

Conceptualizing Attitude

One of the first definitions of attitudes was given by Allport (1935), “A mental and neutral state
of readiness, organized through experience, exerting a directive or dynamic influence upon the
individual’s response to call objects and situations to which it is related” A more recent
definition by Eagly and Chaiken (1998) underscores the component of evaluation in the concept

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of attitude, “A psychological tendency that is expressed by evaluating a particular entity with
some degree of favour or disfavour.

Recent criticisms of such definitions of attitude focus on the fact that attitude is not a ‘fixed’
construct but an evaluation that is formed when needed in keeping with the context, rather than
an enduring personal disposition. (Barsalou, 2005; Smith &Semin, 2004; Schwartz, 2007)

Therefore, attitudes can be seen as potentially adaptive reactions to environmental demands.

Such a view is in sync with empirical evidence pointing toward attitude variability across time
and situation. (Banaji&Hepihetz, 2010)

Attitudes are often conceptualized as stemming from two separate modes of operations of the
mind, i.e. the conscious and the unconscious. Hence there could be some attitudes that are
deliberate and of which one is aware while others are more automatic and less conscious and
these hidden attitudes are of particular interest when studying phenomena such as prejudice and
intergroup relations. According to the three-component model of attitudes (Zanna& Rempel,
1988), attitudes express beliefs, feelings and past behaviours regarding the attitude object.
Fishbein’s expected value model (1963) conceptualizes attitudes entirely as a function of beliefs
i.e. the evaluative component of the beliefs held about an attitude-object.

Katz (1960) proposed four functions of attitudes considered relevant even today in the study of
attitude. These include a Utilitarian function referring to those attitudes that help individuals
obtain rewards and avoid punishment, knowledge function which refers to attitudes that foster
understanding and meaning making about situations and experiences, Ego defensive or
externalization function which refers to attitudes that protect the person from psychic threats.
Katz associated this function with prejudice, utilizing the psychodynamic principles of defense
mechanisms hypothesizing that individuals may project feelings of inferiority onto stigmatized
outgroups. Finally, the value expressive function talks about attitudes that help individuals
express their core or foundational aspects of themselves. Research indicates that these attitudes
are most resistant to change (Maio& Olson, 1995) Further, in Smith et al. (1956) in their seminal
work, suggested that attitudes serve object appraisal, social adjustment and externalization
functions.

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Prejudice is typically conceptualized as an attitude that has a cognitive component (negative
beliefs) an affective component (eg. hate), and a conative component (eg. a behavioural
predisposition to behave negatively toward a certain group of people)

Allport defines prejudice as ‘an antipathy based on faulty and inflexible generalization.’ It may
be felt or expressed. It may be directed toward a group or an individual. Recent
conceptualizations of prejudice try and combine an individual as well as a group level focus. In
this vein, Eagly and Deikman (2005) view prejudice as a mechanism that maintains status and
role differences between groups but also emphasize how individual reactions contribute to the
process. People who deviate from the traditional role arouse negative reactions and others who
maintain the status quo are reinforced with positive reactions.

Keeping in mind the complex nature of prejudice, Dovido (2008) has proposed the following
definition of prejudice which states, ‘prejudice and individual-level attitude toward groups and
their members that creates or maintains hierarchical status relations between groups.

Lippman (1992) introduced the term of ‘stereotype’ in social psychology, while classical
conceptualizations of stereotype look at it as a construct that is an inflexible and faulty thought
process, more recent research emphasizes their functional and dynamic aspects as simplifying
complex environments. Stereotypes are cognitive schemas used by social perceivers to process
information about others (Hilton & von Hippel, 1996)

Stereotypes encourage the perceiver to expect behaviours that are consistent with the stereotype.
It is due to this aspect of stereotype that it promotes discrimination by systematically influencing
perceptions, interpretations and judgements.

According to Allport (1954), discrimination involved denying individuals or group of people

equality of treatment which they wish. Discrimination is generally seen as biased behaviour
which include not only actions that directly harm or disadvantage another group, but those that
unfairly favour one’s own group. An outgroup seen as threatening may elicit fear and hostile
actions.

Stereotypes and prejudice have been conceived as explicit responses – beliefs and attitudes
people know they hold, subject to deliberate control in their expression (Fazio, Jackson, Dunton

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et al., 1995), in contrast to these explicitly, conscious, and deliberative processes, implicit
prejudices and stereotypes involve a lack of awareness and unintentional activation.

Conceptualizing Stigma

Stigma has been described as a cluster of negative attitudes and beliefs that motivate the general
public of fear, reject, avoid and discriminate against people with mental illnesses. The prevailing
view of health-related stigma is that refers to perceived, enacted, or anticipated avoidance or
social exclusion. (Weiss, Ramakrishna &Somma 2006; Goffman 1963)

The impact of stigma is twofold. Public stigma is the reaction that the general population has to
people with mental illness. Self-stigma is the prejudice which people with mental illness turn
against themselves.

Stigma is an insidious social force that has been associated with an endless number of attributes,
circumstances, health conditions and social groups – with the literature primarily concentrated on
race, sexuality, mental illness and HIV/AIDS (Manzo, 2004).

Current literature articulates three interacting levels of stigma: social, structural and internalized
(Corrigan, Kerr et al, 2005; Herek, 2007). Social stigma is also known as public or enacted
stigma and exists at the group level and is focused on the phenomenon of large social groups
endorsing stereotypes about and acting against a stigmatized group. (Corrigan, Kerr et al, 2005).
Structural stigma is also called institutional stigma, and this is focused at the macro level and
refers to the rules, policies, and procedures of private and public entities in positions of powers
that restrict the rights and opportunities of people with mental illness (Corrigan, Kerr at al.,
2005). In this form of stigma, cultural ideology is embodied in institutional practices.

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Internalized stigma is also referred to as self or felt stigma, exists at the individual (i.e., micro)
level and in the context of mental illness, ca be described as a process whereby affected
individuals endorse stereotypes about mental illness, anticipate social rejection, consider
stereotype to be self-relevant, and believe they are devalued members of society (Corrigan, Kerr
et al., 2005)

Further distinctions have been made between felt stigma and self-stigma. Whereas felt stigma
refers to negative consequences resulting from an individual’s awareness of how society
perceives, and will likely act toward the group to which they belong, elf stigma refers to the
process of an individual accepting society’s negative evaluation and incorporating it into his or
her own personal value system and sense of self.

Weiss et al. (2006) define health-related stigma as: “a social process, experienced or anticipated,
characterised by exclusion, rejection, blame or devaluation that results from experience,
perception or reasonable anticipation of an adverse social judgement about a person or group.

Mental illness in media

Several themes describe misconceptions about mental illness and corresponding stigmatizing
attitudes media analyses of film and print have identified three: people with mental illness are
homicidal maniacs who need to be feared; they have childlike perceptions of the world that
should be marvelled, or they are responsible for their illness because they are of weak character.
(Gabbard G.O, 1992; Hyler S.E, Gabbard G.O, 1991; Mayer A, Barry D.D, 1992)

Discrimination and Public Attitude

According to a review on public attitudes towards mental illness, majority of them that there is
misinformation, fear and mentally ill which makes the public stigmatize and reject them (Prabhu,
G. G., Raghuram, A., Verma, N., &Maridass, A. 1984)

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Several studies appear to reiterate that people disapprove of persons with psychiatric disabilities
significantly more than persona with related conditions such as physical illness. (Corrigan P.W,
River L.P, Lundin R.K et al., 2000; Socall D.W, Holtgraves T., 1992; Weiner B, Perry R.P,
Magnusson J., 1988) Severe mental illness has been likened to drug addiction, prostitution, and
criminality (Skinner et al., 1995). Research respondents are less likely to pity persons with
mental illness, instead reacting to psychiatric disability with anger and believing that help is not
deserved (Corrigan et al, 2000; Socall et al., 1992)

The behavioural impact (or discrimination) that results from public stigma may take four forms:
withholding help, avoidance, coercive treatment, and segregated institutions. Previous studies
have shown that the public will withhold help to some minority groups because of corresponding
stigma (Weiner B, Perry R.P, Magnusson J., 1988; Piliavin I.M, Rodin J, Piliavin J.A., 1968)

A more extreme form of this behaviour is social avoidance, where the public strives to not
interact with people with mental illness altogether. The 1996 General Social Survey (GSS), in
which a probability sample of 1444 adults in the United States was interviewed, it was found that
more than a half of respondents are unwilling to: spend an evening socializing, work next to, or
have a family member marry a person with mental illness (Martin J.K, Pescosolido B.A, Tuch
S.A., 2000)

Discrimination can also appear in public opinion about how to treat people with mental illness,
for example the public endorses segregation in institutions as the best service for people with
serious psychiatric disorders (Brockington I, Hall P, Levings J et =al., 1993)

In a paper that compared population surveys conducted in Germany on public attitudes about
schizophrenia, depression and alcohol dependence in 1990 and 2011, found that the probability
of the public recommending seeing a mental health professional increased considerably, resulting
in a majority of respondents in 2011 supporting specialty care for individuals with these
disorders (Angermeyer, M. C., Matschinger, H., &Schomerus, G., 2013)

In 2011, respondents expressed a stronger desire for social distance from people with
schizophrenia than two decades earlier. (Angermeyer, M. C., Matschinger, H., &Schomerus, G.,
2013)

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However, due to various factors such as different aspects being studied (including knowledge,
conceptions, information etc.), different phenomena being studied (including psychosis, neurosis,
mentally ill, mental patient, emotionally disturbed person etc.), different tools and techniques and
different methodology followed seems to indicate equivocality in the findings reported by
various investigations which limits the generalizability of the studies. (Prabhu, G. G., Raghuram,
A., Verma, N., &Maridass, A. 1984)

Emotional reaction to people with mental illness

There is a paucity of research on the emotional reactions of people with regard to the mental
illness apart from those describing a fear of violence and threat of safety. (Thornicroft C., Rose,
D., Kassam, A., &Sartorious N., 2005) One of the few studies in this area was carried out in
south-eastern USA, in which students were asked to imagine meeting people who either had or
did not have a diagnosis of schizophrenia. All three physiological measures of stress (brow
muscle tension, palm skin conductance and heart rate) were raised during imaginary meetings
with ‘labelled’ compared with ‘non-labelled’ individuals. (Corrigan, P. 2005)

Whereas in 2011 respondents tended to express more fear from people with schizophrenia and
felt more uncomfortable and insecure with them than in 1990, they showed more prosocial
reactions (need to help, compassion) and reacted with less fear to people with depression than
previously. (Angermeyer, M. C., Matschinger, H., &Schomerus, G., 2013)

Self – stigma

One might think that people with psychiatric disability, living in a society that widely endorses
stigmatizing ideas, will internalize these ideas and believe that they are less valued because of
their psychiatric disorder. Self-esteem suffers, as does confidence in one’s future (Allport G.W.,
1954; Holmes P.E, River L.P., 1998) Given this research, models of self-stigma need to account
for the deleterious effects of prejudice on an individual’s conception of him or herself (Corrigan,
P. W., & Watson, A. C., 2002). Different types of stigma on different types of people could
create very different mental health outcomes. Studies have shown the relationship between

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stigma and self-esteem is contingent upon situational contexts and collective representations of
the label to the individuals (Crocker, 1999).

However, research also suggests that, instead of being diminished by the stigma, many persons
become righteously angry because of the prejudice that they have experienced (Chamberlin J.,
1998; Crocker J, Major B., 1989). This kind of reaction empowers people to change their roles in
the mental health system, becoming more active participants in their treatment plan and often
pushing for improvements in the quality of services (Corrigan P.W., in press)

If stigmatized individuals view the negative acts as not legitimate, they would either show
righteous anger or feel indifferent, depending on how much they identify with the group.
Therefore, it is not surprising that a large unexplained variance is left in the stigma– mental
health relationship. According to a meta-analysis of stigma and mental-illness future research
should explore whether the variations come from psychometric limitations or different
mechanisms by which stigma operates in different conditions (Mak, W. W., Poon, C. Y., Pun, L.
Y., & Cheung, S. F., 2007).

Other psychosocial variables associated with internalized stigma include hope, self-esteem,
empowerment/mastery, self-efficacy, quality of life, and social support/integration (Livingston,
J. D., & Boyd, J. E., 2010).

Mental health literacy

Jorm et al (1997) introduced the term ‘mental health literacy ‘and have defined it as ‘knowledge
and belies about mental disorders which aid their recognition, management of prevention.’
Mental health literacy consists of several components including; the ability to recognise specific
disorders or different types of psychological distress, knowledge and belies about risk factors and
causes, knowledge and beliefs about self-help interventions, knowledge and beliefs about
professional; help available, attitudes which facilitate recognition appropriate help-seeking and
knowledge of how seek mental health information.

The need for the public to have greater mental health literacy is highlighted by the high lifetime
prevalence of mental disorders (up to 50%, according to Kessler et al., 1994).

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Depression and schizophrenia are most often seen by the public as caused by the social
environment, particularly recent stressors (Matschinger&Angermeyer, 1996)

Biological factors are seen by the public as less important than environmental ones (Jorm et al,
1997). Providing the label ‘schizophrenia’ to a vignette has also been found to increase the
likelihood that biological rather than psychological causes are seen as responsible
(Angermeyer&Matschinger, 1996)

Given that only a minority of people who meet diagnostic criteria for a mental disorder seek
professional help (Lin et al, 1996), self-help skills are of great importance. When the public were
asked to rate a range of interventions for likely helpfulness, self-help interventions were found to
be at the top of the list in both Australia and the UK (Rippere, 1979, Jorm et al, 1997)

When the public are asked about various therapies, strikingly consistent findings across many
countries is very negative beliefs about medication for a range of mental disorders with most
negative belief centring around dangerous and irreversible side-effects. (Jorm et al, 1997)

The Indian Context

While fewer studies have been conducted on stigma and its correlates to mental health in India, it
is important to understand these variables in its relevant context as if would be misleading to
transplant finding of studies conducted in a particular setting.

India has a unique socio-cultural heritage along with a religious background characterised by
fatalism and an external locus of control along with increasing connectivity and exposure to mass
media, these are some of the factors that can have far-reaching effects on the public attitude to
mental illness. In non-western cultures like India, supernatural phenomena such as witchcraft and
possession by evil spirits, are seen as important causes of mental disorders (Razali et al, 1996)

In a three-decade long study by Verma, eight specific misconceptions were identified by him that
were prevalent in the north-east part of India. It is believed that all mental illnesses are the same,
they are caused by shock, sexual starvation or possession and that mentally ill persons are
capable of no understanding.

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In a study based on Nunally’s tests educated layman and mental health professionals were
studied. It was found that the mental health information held by educated laymen are not well
crystallized, yet their views are not markedly different from experts since both had neutral
opinions. (Bhasumallik and Bhattacharya, 1983)

In order to capture the Indian context more accurately, a scale was developed covering thirteen
major factors including folk therapy, psychological stress, organic causation, non-restrained
behaviour, weak cognitive control etc. it was found that the educated lay person viewed the
mentally ill as aggressive, violent and dangerous (Prabhu,1975)

In a vignette study customised to India’s socio-cultural context, it was found that psychological
persuasion, social manipulation, medical intervention, dietary regulation, medical health
consultation, magico-religious practises and not seeking any help were seven ways of handling
deviant behaviour in various combinations and sequences that further depend on the socio-
economic background and education of the person. (Malhotra & Wig, 1983)

A study that attempted to look at the influence of socio-demographic variables on the opinions of
the mentally ill showed that compared to the urban population, the rural population was more
authoritarian, socially restrictive and thought in terms of interpersonal aetiology. Men expressed
more benevolent attitudes when compared with women and mental hygiene ideology did not
show a relationship with any of the socio-demographic factors. (Kshama&Channabasavanna,
1974)

More recently, in a study by VaishnaviChallapallisri and Lloyd V. Dempster in 2015, the

attitudes of practising psychiatrists in Hyderabad was studied through a prospective survey of
seven common psychiatric disorders for eight specified perceptions was conducted. This study
revealed a significant gender difference, with women showing more negative perception toward
eating disorders, depression, dementia, alcoholism and schizophrenic patients. Overall, drug
addiction and alcoholism elicited most negative perceptions.

In a study by Santosh Loganathan and R. Srinivasa Murthy in 2011 gender issues were explored
from a sociocultural perspective related to stigma among people suffering from schizophrenia in
India. Stigma experiences were assessed by conducting semi-structured interviews with 200
patients attending psychiatry clinics. The resulting narratives were examined through thematic

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content analysis. Men with schizophrenia reported being unmarried, hid their innless in job
applications and from others, and experienced ridicule and shame. They reported experience of
stigma to be most acute at places of employment. Women reported experiences of stigma in
relation to marriage, pregnancy and childbirth. Both men and women revealed specific cultural
myths about their illness.

In order to counter stigma attached to mental disorders, a mental health literacy survey in a rural
area of Maharashtra. The researchers’ findings revealed mixed attitude to people with mental
disorders. While most people believed that people suffering from mental illness are able to fulfil
their roles in society, however most participants felt that these people were dangerous, erratic
and should be avoided. (Michelle Kermode et al., 2009)

Nosology:the branch of medical science dealing with the classification of diseases.

Taxonomy:the branch of science concerned with classification.

The classification of mental disorders is also known as psychiatric nosology or psychiatric

taxonomy. It represents a key aspect of psychiatry and other mental health professions and is an
important issue for people who may be diagnosed. There are currently two widely established
systems for classifying mental disorders:

• Chapter V of the International Classification of Diseases (ICD-10) produced by the

World Health Organization (WHO)

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the
American Psychiatric Association (APA).

Both list categories of disorders thought to be distinct types, and have deliberately converged
their codes in recent revisions so that the manuals are often broadly comparable, although
significant differences remain. Other classification schemes may be in use more locally, for
example the Chinese Classification of Mental Disorders. Other manuals have some limited use
by those of alternative theoretical persuasions, such as the Psychodynamic Diagnostic Manual.

The widely used DSM and ICD classifications employ operational definitions.There is a
significant scientific debate about the relative validity of a "categorical" versus a "dimensional"

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approach to classification, as well as significant controversy about the role of science and values
in classification schemes and the professional, legal and social uses to which they are put.

ICD-10

The International Classification of Diseases (ICD) is an international standard diagnostic

classification for a wide variety of health conditions. The ICD-10 states that mental disorder is
"not an exact term", although is generally used "...to imply the existence of a clinically
recognisable set of symptoms or behaviours associated in most cases with distress and with
interference with personal functions." Chapter V focuses on "mental and behavioural disorders"
and consists of 10 main groups:

• F0: Organic, including symptomatic, mental disorders

• F1: Mental and behavioural disorders due to use of psychoactive substances

• F2: Schizophrenia, schizotypal and delusional disorders

• F3: Mood [affective] disorders

• F4: Neurotic, stress-related and somatoform disorders

• F5: Behavioural syndromes associated with physiological disturbances and physical

factors

• F6: Disorders of personality and behaviour in adult persons

• F7: Mental retardation

• F8: Disorders of psychological development

• F9: Behavioural and emotional disorders with onset usually occurring in childhood and
adolescence

• In addition, a group of "unspecified mental disorders".

Within each group there are more specific subcategories. The WHO is revising their
classifications in this section as part of the development of the ICD-11 (revision due by 2018)
and an "International Advisory Group" has been established to guide this.[13]

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DSM-IV

The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. It was
produced by the American Psychiatric Association and it characterizes mental disorder as "a
clinically significant behavioral or psychological syndrome or pattern that occurs in an
individual,...is associated with present distress...or disability...or with a significant increased risk
of suffering" but that "...no definition adequately specifies precise boundaries for the concept of
'mental disorder'...different situations call for different definitions" (APA, 1994 and 2000). The
DSM also states that "there is no assumption that each category of mental disorder is a
completely discrete entity with absolute boundaries dividing it from other mental disorders or
from no mental disorders."

The DSM-IV-TR (Text Revision, 2000) consisted of five axes (domains) on which disorder
could be assessed. The five axes were:

Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental
Retardation)

Axis II: Personality Disorders and Mental Retardation

Axis III: General Medical Conditions (must be connected to a Mental Disorder)

Axis IV: Psychosocial and Environmental Problems (for example limited social support
network)

Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are
evaluated on a continuum between mental health and extreme mental disorder)

The axis classification system was removed in the DSM-5 and is now mostly of historical
significance.[14] The main categories of disorder in the DSM are:

DSM Group Examples

Disorders usually first diagnosed in infancy, childhood or adolescence. *Disorders such as

ADHD and epilepsy have also been referred to as developmental disorders and developmental
disabilities.

Mental retardation, ADHD

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Delirium, dementia, and amnesia and other cognitive disorders

Alzheimer's disease

Mental disorders due to a general medical condition AIDS-related psychosis

Substance-related disorders

Alcohol abuse

Schizophrenia and other psychotic disorders

Delusional disorder

Mood disorders

Major depressive disorder, Bipolar disorder

Anxiety disorders

Generalized anxiety disorder, Social anxiety disorder

Somatoform disorders

Somatization disorder

Factitious disorders

Münchausen syndrome

Dissociative disorders

Dissociative identity disorder

Sexual and gender identity disorders

Dyspareunia, Gender identity disorder

Eating disorders

Anorexia nervosa, Bulimia nervosa

Sleep disorders

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Insomnia

Impulse control disorders not elsewhere classified Kleptomania

Adjustment disorders

Adjustment disorder

Personality disorders

Narcissistic personality disorder

Other conditions that may be a focus of clinical attention Tardive dyskinesia, Child abuse

The Varnashrama Dharma System

This is the cosmically defined social system that has, more than anything
else, held the diverse forms of Hinduism together since shortly before the beginning of the
common era. After the writing of the Upanishads, most of the major ideas of Hinduism
were in place, but the articulation of those ideas into a social reality came with the writing
of the Dharma Shastras, particularly the Laws of Manu (ca. 200 B.C.E.). In this system, the
interrelationships of karma, dharma, and varnafound their most systematic articulation. I
am listing only the basic parts here; we will discuss how the parts fit together in class.
The Four VARNAS
These are the four main divisions in the classical Hindu social system. Where one is born
depends on one's karma from previous rebirths. (See Noss, 82, 91-92; Smith, 55-59)
brahma (priests, religious and intellectual elite)
ksatriya (warriors, political elite, rulers)
vaishya (business and tradespeople)
shudra (laborers and lowest classes).
The Four ASHRAMAS
These are the four main stages of life that are appropriate for male members of the upper
three varnas. The four ashramas are:
brahmacarya "student"

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grihastha "householder"
vanaprastha "forest-dweller"
sannyasa "renunciant"
In discussing this system, it is important to understand how concepts we treated in the
previous section relate to the varnasand ashramas. If you are not already familiar with the
concepts of karma, samsara, moksha, brahman, and atman, please review them. In addition
we will need to discuss the important concept, dharma as part of the Varnashrama system.
Readings on dharma are outlined in the following section. All of these concepts are
essentially untranslatable and are indispensable for understanding this basic systematic
formulation of Hindu life.
Each varna and ashram has its own specified dharma. What may be desirable for one section
of society may be degrading for another. For example, absolute non-violence, which includes
refraining from animal sacrifice, is essential for the priestly class but considered wholly
unworthy of a kshatriya (warrior). Generating wealth and producing children are essential for
householders, but intimate contact with money and women is spiritually suicidal for the
renunciate. Underlying all these apparent differences is the common goal of advancing in
spiritual life based on sanatana-dharma. Without the spiritual equality and sense of service
inherent in sanatanadharma, varnashrama-dharma tends to degrade into the rigid and
exploitative caste system.

The social body and its components are likened to the human form.
Society is compared to a body with the brahmanasas the head, kshatriyasas the arms, vaishyasas
the belly (or thighs) and the shudrasas the legs. Social functions are determined according to this
analogy. For example, the brahmanasare the eyes and mouth of society. They provide a spiritual
vision for society and teach people accordingly. Just as the arms are raised to de fend the body,
the kshatriya'smain duty is to protect society. The vaishya'smain duty is material nourishment,
and the shudrasupports all other sections of society. The ashrams are sometimes related to the
same metaphor, with the successive stages of student life, household life, retirement and
renunciation represented by the legs, belly, arms and head respectively.

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The Four Ashramas and Varnas
Hindu life is structured by what is known as Varnashrama Dharma, which is concerned with an
understanding of one's personal and social roles within the totality of life. The four Ashramas are
seen in ideal terms as the four stages through which a maturing human life should pass. Whilst in
contemporary life it is not often lived precisely in these terms, its broad outlines remain a
powerful influence upon the Hindu perception of life. Associated with the broad, ideal classes of
the four varnas, are many thousands of groups known as jatis, many of which are linked with
traditional occupational groups. Examples include the following: Patidars, which are
traditionally, traders Mochis, which are traditionally, shoemakers Lohanas, which are
traditionally, traders Anavil Brahmins, which are traditionally, agriculturalists Khattris, which
are traditionally traders Rarhi Brahmins, which are traditionally, priests Baidyas, which are
traditionally, doctors. Some jatis, officially known in India as the "scheduled castes" but now
often preferring the self-description of Dalit (oppressed), were among those whom Mahatma
Gandhi called Harijans, or “Children of God”.

Emotions

• Component of personality arising out of the contact of ego or “ahamkara” with the
external world.

• It is an experience that represents the relation between the ego and the outside world.

• Emotions - seen as arising from desires.

• Strong emphasis on sukha and dukha (pleasure and pain) as the two opposites

• Manomayakosa(Mind) - influences both the food sheath and the vital air sheath

• Allowing emotions to interfere with one’s judgment and awareness is considered a

weakness.

• The traditional Indian thought lays great emphasis on desires in the causation of
suffering, misery and pain.

• Emotions are seen as modification of desire or attachment.

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• According to Patanjali’s Yoga Shastra, suffering is due to ignorance about one’s true
“Self” (avidya)

• The misperception lies in the acceptance of external objects as the true self.

• Suffering/dukha arises from within and not from the outside world

• One of the reasons why emotions are philosophically interesting in India and the West is
their relationship with the mental phenomenon of vijnana or jnana which is translated as
“cognition”.

• The relationship between emotion and cognition is important for any account of reason
and rationality.

• The mind is like a veritable battlefield. The whole of the Gita is in reply to this question.

• The personality in the Gita is compared to a chariot drawn by horses - the horses
represent the senses, and buddhi (intellect) is the charioteer, the reins denote the mind.

• Gita advocates the attainment of a state of evenness of mind - Samatham, its steadiness -
Sthitapradnyaand peace - Shanti (Venkoba Rao, 1980).

• Geeta and Psychotherapy

• Lord Krishna represents the master healer of the minds of humanity.

• Arjunasymbolises the person in a state of anguish.

• Gita depicts the arousal of a gloomy and dejected Arjuna, who is torn between
intellectual doubts, ethical dilemma and filial bondage.

• Arjuna′s arousal is from three areas of inactivity - from ignorance to knowledge, from
apathy to a positive feeling and from inertia to purposeful activity.

• Lord Krishna did not force the ideas but suggested that certain things have been
discussed, and it was up to Arjuna to act as he liked (Yathaichchatitatha kuru).

• In psychotherapy, the client is not taught or forced to do certain things but is encouraged
to choose positive and viable options after intellectual and emotional discussion.

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• The final decision to act was taken by Arjuna while Lord Krishna only cleared his doubts.
Lord Krishna gave advice in such a manner that Arjuna was left with no alternative but to
fight.

• Bhagavad-Gita stresses on the effectiveness of being able to control and manage

emotions.

• Arjuna - Emotional perception and assimilation.

• Krishna - Cause of emotional turmoil: Desire and Anger.

• The Bhagavad-Gita refers to the emotionally intelligent person as a ‘Sthithapragnya’ (the

emotionally stable person).

• STHITHAPRAGNYA

• Remains unperturbed in the face of calamity, and takes good or evil with equanimity.

• Neither happy when something good happens, nor is he affected when things go against
him. Does not mean he lacks sensitivity.

• Ability to keep his emotions in check and the skill of withdrawing his feelings away from
the object of pleasure or pain.

• The Rasa Theory

• Strong emphasis on the experiential aspect of emotions.

• Rasa or aesthetic relish or aesthetic mood is central to this approach to understanding

affective experiences

• Sage Bharata conceptualized the rasa theory in the context of drama and theatre.

• Physiological/behavioral, cognitive, and feelings are dealt with in detail.

• Narrative Components of Rasa

• Vi-bhava – Eliciting conditions including background information, settings, events and

action tendencies (Source)

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 • Anu-bhava – Consequences, including eight types of involuntary somatic responses
(sweating, fainting, weeping) and action tendencies.

• Vyabhicari – bhava: The accompanying mental states, transitory emotions (secondary

side effects including emotions, feelings and cognitive states)

• As the tradition of Alankara-shastra developed from the sixth through tenth centuries, a
ninth rasa was contentiously endorsed by certain scholars.

• This rasa was only widely accepted after an extended philosophical and aesthetic
theorization by Abhinavagupta.

• Ninth rasa added: Santam (peace/tranquility).

• NAVARASA

• Transitory Emotions

• Permanent emotions are considered as permanent mental traces (samskaras).

• These when accompanied with source (vibhava), transitory emotions (vyabhicaribhava),

and expressions (anubhava) can give rise to rasa.

Transitory emotions are not innate and they give rise to permanent emotions and
disappear after the permanent emotions show up

• Transitory emotions represent the day-to-day normal life where similar emotions are
expressed and experienced in changing situations.

• Accessory emotions are transitory states, i.e., vyabhicaribhava and are subordinate to the
permanent emotional dispositions.

• According to Yoga, sentient pleasure arises due to the gratification of desires and rational
happiness is due to the eradication of desires

• One’s own uncontrollable cravings and desire - seen as a direct path towards dukha or
suffering

• If desires are not contained, they develop into negative emotions like greed, anger, fear,
etc, leading to mental agitation and outbursts.

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• If directed universally and do not arise from selfish motives - Beneficial

• The emotional experience of “love” means, being in harmony with one and all.

• If associated with attachment and possessiveness it becomes self-centered.

• According to Bharathamuni’sNatyashastra - the science of dramatics, affective

experiences, whether due to negative emotions or positive emotions are enjoyed and
relished.

• Vedantic literature considers unintelligent and inappropriate expressions of emotions

further leading to pain and sorrow.

• Ahamkara, Aatman and Emotions

• This state of being happy is seen as transitory and is experienced due to the ego or
“ahamkara” abiding in external objects and hence, it is wholly dependent on the external
objects.

• “Happiness” or “bliss” (ananda) is the true nature of “self” or atman.

• It includes oneness of existence (sat), consciousness (chit) and bliss (anand).

• This state is the conquest and transcendence of pleasure and pain or the egocentric
emotions.

• Emotional Disorders

• Unmad was the term for psychosis.

• Mental disorders were named after Gods and devils.

• The terminology and clinical picture does not correlate well with modern terminology.

• However, approximate and loose correlation is as follows - Endogenous disorders were

provoked by humours or tridoshas. They are:

• Vatonmad - similar to schizophrenia,

• Pittonmad - similar to mania,

• Kaphonmad - similar to depression, and

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 • Tridoshonmad - Depression.

• Exogenous disorders resembling schizophrenia were -

Bhujanggrahavyadhi,Rakshasagrahavyadhi,Pishachhagrahavyadhi,asuragrahavyadhi
etc.

• Those resembling mania were -

Daivagrahavyadhi,YakshagrahavyadhiandGandharvagrahavyadhi.Pitrugrahavyadhi
resembled depression

• CAUSATIVE FACTORS

• Weak will and nervous temperament.

• Wrong diet.

• Lack of healthy habits, indulgence in wrong activities,

• Preoccupation with shatripus, that is, preoccupation with primary instincts, namely Kama
(lust), Krodha (anger), Lobha (greed), Mada (Pride or aggression), Moha (desire), and
Matsar (jealousy).

• Exhaustion

• Demonological possessions

PERSONALITY

Indian concepts of personality are derived from

various philosophical traditions

Vedanta

Samkhya

Yoga

Jainism

Buddhism

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NATURE OF SELF

In the Indian context, the nature of self and nature of reality are the two central topics of
inquiry in the Upanishads.

The Upanishadic sages regarded Brahman as the ultimate principle of reality, characterized by
Sat, Chitand Anand.

The core of every individual is identical with the Brahman and hence the Self is identical with
the Brahman, as it is stated very clearly in the AdvaitaVedantic Model of personality.

VEDANTIC JIVA

The Vedanticjiva is conceived as a five layered entity, with the inner most layer of the jiva
being where the true Self resides, which is identical with the Brahman.

Since the human being or the Vedanticjiva has Brahman as his innermost layer, blissfulness
becomes a part of his essential nature.

As customarily, an individual is caught up in the narrow confines of ego; this gives rise to
ignorance and a highly distorted understanding of self.In the words of Paranjpe (1998). Major
cause of human suffering was the ‘most fundamental attributional error’, by the virtue of which
the true self gets wrongly identified with the nonself, and vice versa. It is only with expanding
self -awareness that one can move beyond the erroneous identification with limited
consciousness.DIMENSIONS OF THE JIVA Five dimensions are involved in forming the
human personality.

1) physical self,

2) energy self,

3) intellectual self,

4) mental self, and

5) blissful self.

FIVE SHEATHS OF PESONALITY GIVEN IN UPANISHADS

Annamaya (food sheath) Is the segment of nourished by ‘anna’, that is food.

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 Pranamaya (vital air sheath), is that segment which is nourished by ‘prana’, that is, bioenergy.

Manomaya (mental sheath) is the segment nourished by education.

Vijnanamaya (intellectual sheath), is nourished by ego

Anandamaya (bliss sheath) is the segment nourished by emotionsThefive fold method to attain
to such state of heightened perfection and purity are : self-effort, self-control, self-reliance, self-
sacrifice, and self-knowledge.

INTEGRAL YOGA PHILOSOPHY

Sri Aurobindo’s integral yoga philosophy views personality in terms of evolution of

consciousness.

Consciousness is seen as the fundamental thing of the universe.

Pure consciousness, termed as the purusa, is manifested in various forms of prakriti.

In humans, conscious awareness can fully emerge and grow in its higher forms and ultimately
merge with the One.

Sri Aurobindo emphasized on simultaneous activity of the concentric system and a vertical
system.

The concentric system is like a series of rings or sheaths.

The outermost circle is comprised of awareness of physical body, awareness of vital (pranic)
body or sheath, and awareness of mental sheath. These three types of consciousness are
interconnected.

The inner circle is composed of the inner mind, inner vital, inner physical and is the bridge
between the outer consciousness and psychic being that is the true center of the person.

The innermost core is called as Psychic being which is a spark of the Divine (Supreme
Energy) present in all of us and in everything. It is also called as Atman.

The psychic center is the soul that participates in the evolution and itself undergoes a dynamic
development. It is important to note here that our fundamental identity is spiritual and this

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identity consists of two aspects: the spirit, atman or Self, on one hand, and the soul, psychic
being, antaratman, on the other.

Discovery of the psychic center profoundly changes the entire experience of living; there is a
steady light of inner guidance, a peaceful, loving presence, fresh, and there is self-existent bliss
in the center of our being.

With the discovery of the psychic center and its surfacing, higher ranges of mind become
accessible through sadhna.

Higher levels of consciousness in the vertical plane includes

Higher mind

Illumined mind

Intuitive mind,

Overmind

Supermind.VEDAS

Among the four Vedas rig veda, samaveda, yajurveda and atharvaveda, atharvaveda deals with
mental health and personality.

Singh (1977) says that the atharva it mainly deals with the concepts of 'Triguna‘ both physical,
i.e., 'vata', 'pitta', and 'kapha'; as well as mental, i.e., 'satva', 'rajas' and 'tamas‘.

Atharvaveda has a certain norm, i.e., optimal functioning of the 'trigunas', and any deviation
results in abnormality.TRIGUNAS (Gupta 1977)

Personality types

Satvika intellectual, pure, strong, healthy, possessing long life and equanimity

Rajasik emotional, passionate, fiery and restless.

Tamasic vegetative, lustful, ignorant anddull.

TRIDOSHAS (Gupta 1977)

Constitutional types

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Vata- asthenic body build, tall and lean

Pitta- Pyknik body, short and obese

Kapha- athletic body build, muscular, well built

TRIGUNA AND PERSONALITY PSYCHOLOGY

The concept of Guna dates back to Atharva Veda, it was discussed in Bhagawat Gita and later
included in Sankhya Darsana.

The three guna

Sattva called as stability

Rajas called as activation

Tamas called as inertia.

Manas has been ascribed the functions which are mental functions and mental processes and
are considered to be manifestations of Triguna.

THE BUDDHA’S EIGHTFOLD PATH

Includes aspiring toward

right (or complete) perspective,

right intention,

right speech,

right action,

right livelihood,

right effort,

right awareness, and

right concentration.

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 The first two are said to produce wisdom, the next four to change conduct, and the final two to
improve meditation

PERSONALITY TYPES OF BUDDHISM

Ragacharith- attached

Doshacharith- envy, aggression

Mohacharith- dull, idle

Buddhicharith- rational

Vithakkacharith- imaginative

Sadvacharith- disciplined

YOGA AND UNDERSTANDING OF PERSONALITY

Yoga, which is considered to be the advanced branch of Indian psychology, is a

comprehensive practical view of self culture.

Self culture means the physical, mental, moral, and spiritual unfolding of an individual.

Yoga aims at the understandings and evolution of personality.

Yogasutra, attributed to the scholar Patanjali in the second century C.E., through its eight
‘limbs’ or steps laid the basis for Ashtong Yoga, one of many disciplines purported to ‘quiet the
mind,’ transcend one’s usual identity, and ‘know God’ (Yati, 2009).

The first three are concerned with ethical purification; the middle two with psychophysical
control; and the last three with progressive control of the psychic apparatus culminating in
Samadhi (Neki, 1978).

EIGHT LIMBS OF YOGA (VERMA, 1979)

Yama Comprises five abstentions. (a) Ahimsa (nonviolence), (b) Satya (truthfulness), (c) Asteya
(not stealing or avoidance of misappropriations in thought and action), (d) Brahmacharya (sexual

abstinence, some interpret this as regulated sexual activity) and (e) Aparigraha
(nonacquisitiveness) Niyama Has five observances. (a) Shauch (purity in thought, word and

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action), (b) Santosh (contentment), (c) Tapas (selfdenial, not to pamper body),(d) Swadhyaya
(selfenlightenment, objective study of self) and (e) Ishwarapranidhana (submission to God′s will,
being one with God).

Asana Right posture conducive for meditation.

Pranayama Right breathing technique, regular, slow, deep breathing with proper pauses.

Pratyahara To keep one away from distracting stimuli so as not to disturb the meditation.

Dharanaa concentration.

Dhyan meditation

Samadhi The ultimate step which implies contemplation leading to enlightenment

DETRIMENTAL ASPECTS OF PERSONALITY

Five kleshas (afflictions)

avidya (ignorance),

asmita (egotism),

raga (personal likes),

dwesha (personal dislikes)

abhinivesha (possessiveness).

Yoga deals with the healthy personality and further development of it. It is only recently that
Yoga is being applied with clinical cases with positive findings.

Thus yoga is a preventive measure and also a curative one.

BHAGVADGITA

The most popular work on Yoga is the Bhagavad-gita which is itself the part of the great
Indian epic Mahabharata.

In Bhagvad-gitaKrishna(the Self) guides Arjuna (the ego).

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 The scriptures deals with basic concepts such as nature of existence, nature of self and our true
relationship to God.

NATURE OF SELF

Shining self that exist in all of us is the center of our personality signifying truth and
permanence.

It is by understanding the hidden self in us we will ultimately discover the Supreme Self, that
exist in all of us and in whom we all exist.

BhagavadGita searches for a permanent reality that makes life more meaningful, stable,
peaceful and purposeful thereforeit discards layer after layer of untruth that surrounds us and
reveals the shining self. According to the BhagavadGita the external world is unreal not
because it does not exist, but because it is unstable and ever changing.

Since it is based upon impermanence, it cannot be relied upon as the vehicle of truth and it
should not become the purpose of ones existence.

He who clings to such an unstable phenomenon is bound to suffer as he is bound to engage

himself in desperate actions to retain his unstable possessions and experience constant anxiety,
anger, fear and envy.

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