Psychotherapy - Choices in the Indian Context
by Dr. K. Nagaraja Rao (drknrao@vsnl.com)

The definitions of psychotherapy vary from simple tasks like consoling, helping, taking care of, in fact the  gamut of human interactions at one end,
to special psychological techniques adopted by trained mental health professionals in a planned and systematic manner for relieving symptoms or 
promoting personal growth of a person. 

However,  some divide psychotherapy into formal and non-formal.

Non-formal psychotherapy is practised in many forms by professionals and non-professionals. 

Religious discourses, personality development workshops/courses, Lay counselling, Advice, Sympathetic and empathetic expressions etc. fall into this category.

In formal terms if psychotherapy is to be considered as a professional technique needing special training and approach, I opt to choose a restrictive definition that 
it is a systematic, specialised technique of interpersonal communication to relieve distress using psychological principles.
During this process interpersonal communication, is to be reduced to psychological principles derived from a school 
of thought. That means when a patient, a client or a person is talking the therapist should be able to reduce it to
psychological principles. When the therapist is talking the psychological principles are to be expressed in common
or lay person's language. This process is schematically represented below:

INTERPERSONAL COMMUNICATION
(in layman's terms or in a simple language)
or
PSYCHOLOGICAL PRINCIPLES
or
SCHOOLS OF THOUGHT

The Indian Scene

Professor J.S. Neki has classified psychotherapy in India under following headings;

A) Mystico-metaphysical traditions

1) The Buddhist traditions
2) The Yogic traditions
3) The Bhakti (devotional) traditions

B) Medical traditions :

1) Hindu tradition represented by Ayurvedic principles.
2) Unani tradition deals with emotions, mental states and their effects on the body and their applications.
3) British tradition introduced western system of medicine in India and the psychotherapy was mainly psychoanalytical.

C) Indian recent trends :

Phase I : Psychoanalytical Psychotherapies (1920-1965)
Phase II  Emergence of Indian Modifications (1960 onwards)

Phase I 

1. In India, the Psychoanalytical movement was started by Giridra Sekhar Bose. He founded the Indian Psychoanalytical Society in 1922. He proposed the original views about repression that it was a result of psychological opposition of infantile wishes and not due to social and biological factors as suggested by Freud. He also proposed a theoretical ego in contrast to Freud's Practical ego. Bose influenced many Psychiatrists, who later merged their concepts with the Freudian theories. They were also influenced by Lt. Col Owen Berkley-Hill of Ranchi and Klein. Some of the noted names of Psychotherapists from Calcutta are S.C. Mitra, T.C. Sinha and D.N. Nandi.

2. The Bombay school: It was originated by an Italian Psychoanalyst Emilio Servadio who kindled interest in Dr Masani, Marfatia and D.M. Bassa.

3. Others

1. Satyanand of Delhi who was influenced and analysed by Melaine Klein. He attempted to graft psychoanalytic thoughts on Indian mythology and philosophy and proposed the theory of total Psychoanalysis or soul analysis. He was successful in handling primary narcissism and primary illusion.
2. Vasavada a Jungian analyst tried to see links between east and west and believed that parallels existed between Psychoanalysis and the existential analysis on the one hand and Yogic practices on the other.
3. B.K. Ramanujam and others at BM Institute, Ahmedabad tried to use Psychoanalytic principles in family therapy.
4. Shakuntala Dubey from Delhi opines that even now Psychoanalytic Psychotherapy can be practised in India with certain modifications.

Phase II,  (1960 Onwards):

The first discontent of the practice of Western Psychotherapy in India was struck by Surya and Jayaram in 1964. They emphasised the importance of local language and situational direct support rather than intrapsychic explanations.

Dhairyam and Pande opined that Western Psychotherapy was rooted in ethno- and socio-dynamics of Juda-Christian way of life. They highlighted the role of Indian culture and philosophy with emphasis on spiritual independence and growth, in contrast to dependence on material, physical and emotional realms.
As a result of sensitivity arising from perception of the specific expectation of Indian patients and its relative poor relevance of western Psychotherapy to non Juda-Christian cultures led to rediscovery and reformation of indigenous therapeutic paradigms within the Indian tradition.

The new paradigms either dealt on the content or the process of Psychotherapy.

CONTENT : In the realm of content, attention was focused on;

a) Bhagavadgita by Govindaswamy, Satyananda, Ramachandra Rao, Venkoba Rao and Parvathi Devi.

b) Vahia, Kapur and others have tried to integrate Yogic principles in Psychotherapy.

c) Surya has focussed more on ethno-dynamics and socio-dynamics which is supposed to determine the structure of the Indian Ego.

d) Neki stressed the importance of classifying libido into sexual and affectional. He emphasised the oedipal situation in India as the affectional strivings leading to its fulfilment through channels of libido. He has also remarked on social dependency as a faulty personality and that parents foster dependency while themselves modelling dependability, which assist  in the personal development of an Indian child.

e) Shamasunder of Bangalore is working on Psychotherapeutic thoughts in Indian mythological and philosophical treaties.

PROCESSES :

Dhariyam, Neki and Carstairs suggested that in India the relationship between Psychotherapist and patient is one that of Guru and Chela (disciple/pupil/shishya), without the element of western transference. The Guru here is an emancipated person living in a society who emphasises self discipline rather than self expression. He at times helps directly in decision making and provides insight in consonance with the culture. Prof. Vidyasagar reported great success in his psychotherapeutic work while using this model of relationship.

E.M. Hoch, a Swiss Psychiatrist while working in India emphasised  the need fo integrating the dynamic concepts of local traditions and culture in dealing with illiterate population.

A group of Psychotherapists from NIMHANS (National Institute of Mental Health and Neuro-Sciences, Bangalore) have attempted to develop techniques that can be used by a variety of mental health professionals.

Inspite of the fact that many Psychotherapists are interested, inclined and committed to Psychotherapy, there seems to be a general decline in interest in Psychotherapy. In India, this has been attributed mainly to:

(1) Impracticability of Psychotherapy of western origin. 
(2) Individualistic and unsystematic nature of Psychotherapy. 
(3) Insufficiency of practical training. 
(4) A belief that a Psychotherapist should adhere to a specific school of Psychotherapy.

I have attempted to briefly answer some of these issues as follows.

1. Many Indian Psychiatrists have commented upon the unsuitability of western Psychotherapy in the Indian setting. The main objections raised are: 
(i) The concepts of Psychoanalysis are not in consonance with Indian culture. 
(ii) It's non-directive technique is unsuitable for many patients. 
(iii) Many other western schools of thought (other than Psychoanalysis) contain eastern ideas (e.g. Existential Psychotherapy) with psychotherapy can easily be blended either way. For example.

2. I also think that almost all forms of psychotherapy are to some extent individualistic. Extreme rigidity many a times has given birth to splintered schools of Psychotherapy. Therefore individualistic approach should be welcomed as long as one does not digress too much from central and core concepts of a school of thoughts. 

3. Not many training centres impart the required depth of knowledge or skills and techniques in psychotherapy during the post graduate training. The post-graduate is expected to know at least the basic principles of important schools of psychotherapy which are too numerous. therefore it is left to the post-graduate to pick up a school of psychotherapy and practice it later after one's qualification. This is left entirely to one's interest, inquisitiveness and imagination.

4. I am of the opinion that it is possible for a Psychotherapist to practise with more than one form of Psychotherapy and use different technique in different patients. I have tried using following different types of Psychotherapies in my clinical practice.

1) Existential Psychotherapy
2) Self esteem analysis
3) Personality trait changing therapy
4) Psychophysiological Psychotherapy

I will attempt to briefly elaborate on them here.

1) Existential Psychotherapy :

Existentialism has enough Indian thoughts and therefore can easily be Indianised. I have been using this in my patients for over a decade. An article was published in the Indian Journal of Psychiatry in October 1990 issue. While practising this form of Psychotherapy I found that the personality traits determined its success to some extent. The Obsessive, Hysteric, Avoident, and Borderline benefit in that order. The Passive-aggressive and the Narcissist do not benefit much. 

The existential principles which I have followed are as follows.

Man's relation to the object is not same as the relation of object to object. The object enters the experience and constitutes his being in the world. However we experience "the surface of the thing or phenomenon" but not "the thing in itself or noumenon". The experiences are subjected to perceptual interpretations which are influenced by factors like past experiences, knowledge, current mood state, interest, prejudice etc. Therefore what we explain of this world and society is a secondary (phenomenological) experience and not a primary (noumenological) experience.
Existence basically is the relationship of a man with another man and society in particular and universe in general. Though man and society can not be separated out the starting point is the man as a being within the society. In this context man is a responding being. Every inter-personal action and reaction caters to personal affirmation of existence. Any action or reaction which does not reassure and reaffirm the existence it create existential anxiety. This leads to vicious circle of action and reaction.

Existentialism deals with basic question of existence, birth, life, death and miseries which are common to all human beings. To be explicit it is to be understood that; 

1) Human birth is natural & involuntary. 
2) At birth one is placed in a concrete and historical environment. 
3) During development the logically ordered society subjects one to distorted  reality of oneself and others and one is forced to be involved in social existence to cope with existential, social and death anxiety. 

What is to be emphasised is the uniqueness of human being and that the cause of suffering is the experience by the sufferer but not the cause per se. Self realisation is the final goal of this type of psychotherapy which de-emphasises symptoms or complaints. It urges one to stand out and over as an unique person while being part of the world.

2) Self Esteem Analysis :

In my clinical experience with regarding to self esteem I have found two groups of patients. One group have high self esteem. They feel that they have not got what they deserve. They harbour a feeling of "martyr's complex". They have difficulty in seeing other's point of view. They are usually resistant to Psychotherapy and use rationalisation as the main defence. They opt for a rigid pattern for the way of life. Psychotherapy with such patients takes long time and is difficult. In contrast the second group who have low self esteem succumb to guilt and feel that they deserve nothing or they are not capable of anything. They respond well to reassurance and psychotherapy. Thus making a distinction between people with high and low self esteem helps in planning treatment and predicting the prognosis.

3) Personality Trait Changing Therapy :

Interpersonal problems appear to be intensified by contrasting personality traits. Each one has a specific personality that determines one's way of thinking and interactions. If one's thinking and actions are approved by others there will be good adjustment between the two. If it does not result, there will emerge interpersonal problems. I have often found this situation in marital disharmony. I would like to exemplify some of the interpersonal problems arising out of conflicting personality traits that I have encountered in my clinical practice.

1) An hysterical wife who is an extrovert and attention seeking is disliked and trouble by a schizoid or a paranoid husband who is an introvert and suspicious.

2) A passive aggressive personality partner does not get along so well with an obsessive personality partner, as the former is habitually procrastinating and casual in work whereas the later wants things to be done quickly and methodically.

3) A narcissistic partner demands so much of attention which will be difficult to meet.

4) An obsessive partner devoting more time to work is considered as emotionally unsympathetic and emotionally less caring, hence, such persons fail to get the needed co-operation from others.

In such cases explaining to the distressed individuals about their personality traits which hinder successful interpersonal relations helps them in improving their relations with others.

4) Psycho-physiological Psychotherapy:
Some of the psychologically distressed patients who come mainly with somatic symptoms deny psychological problems. However, they may show physiological changes in their body when discussing about their life events. these changes could be recognised either by observation or by biofeedback gadgets. This will enable the therapist to show to the patient  the reaction of the body to psychological factors and then take recourse to any psychotherapeutic procedure.

[First given as the Presidential Address to the Annual Conference of the Indian Psychiatric Society - Karnataka Branch held at Devanagre, Karnataka on 30th August 1998. It was published in the 1st Issue, (i.e. September-October issue of 1998) of the Indian Psychiatric Society - Karnataka Branch Newsletter, Editor Dr. Swaminath G. It is reproduced here with the kind permission of the author and the editor.]