MENTALILLNESS

201

Mental Illness refers to different types ofmental disorders which include disorders

of thought, mood or behavior, causing distress andan inability to function fully.

The inability could be in the psychological,social, occupational or interpersonal domains.Persons having mental illness may have troublehandling daily activities, family responsibilities,relationships, or in discharging responsibilities atwork or in school. Their problems could be inmore than one area of their functions.

Signs and SymptomsThere is no clear-cut dividing line between mental

health and mental illness. The signs of common mentalillnesses include depressed or irritable mood, anxious affect,diminished interest, insomnia or hypersomnia, psychomotorretardation/agitation, fatigue, feelings of worthlessness,diminished ability to think, delusions, thoughts of death,hallucinations—visual or auditory, incoherent speech,neglect of personal hygiene, lack of emotions, angryoutbursts, social isolation, persistent feeling of beingwatched, etc. Signs and symptoms occur on a continuum,from mild to severe.

DefinitionThe ICD-10 (WHO, 1992) defines mental

disorders as: ‘the existence of a clinicallyrecognizable set of symptoms or behavior,

associated in most cases with distress and withinterference with personal functions’ (p. 2).

The DSM-IV (APA, 1994) classification givesa fuller definition: a clinically significant behavioralor psychological syndrome or pattern that occursin an individual and that is associated with presentdistress or disability or with a significantly increasedrisk of suffering, pain or an important loss offreedom. In addition, this syndrome or patternmust not be merely an expectable and culturallysanctioned response to a particular event, forexample, the death of a loved one.

EtiologyFor most mental illnesses, the etiology is not

fully clear. However, from epidemiological andother research, we know that the causes are multi-factorial. Various biological, psychological andsocio-cultural factors determine both thevulnerability to psychopathology and the form thatpathology may take.

Irrespective of its original cause, mental illness mustcurrently be considered a manifestation of a behavioral orbiological dysfunction in the individual. Neither deviantbehavior (e.g., political, religious, or sexual) nor conflictsthat are primarily between the individual and the societyare mental disorders unless the deviance or conflict is asymptom of a dysfunction in the individual, as describedabove.

Chapter 1

Introduction

202

Chapter 2

Historical Perspective

The Discipline of Clinical Psychology

From its very inception, Clinical Psychology asa vibrant profession has grown with the

academic, research and clinical work of Dr.Girindrasekar Bose in the early 1920s to currentstate (Prabhu, 1976; 2001a; 2001b; 2004). Eventhough, there were various advances, the actualdevelopment emerged with the establishment, in1954, of the All India Institute of Mental Health(presently, National Institute of Mental Health andNeurosciences (NIMHANS)) in Bangalore andthe commencement of a formal, fulltime trainingprogram there in clinical psychology in the year1956.

The need of associating psychologists in thediagnosis and management of mentally ill was firstrecognized/implemented in the 1920s at theEuropean Mental Hospital [presently CentralInstitute of Psychiatry (CIP)], Ranchi, but theemphasis on the therapeutic role of the clinicalpsychologist was mainly due to the work of Dr.Bose. His immense interest in the dynamic schoolof thought led to the use of a variety of techniques/approaches and psycho-analytical concepts such asdream analysis, free association, repression,hypnosis, yoga, etc., in his day-to-day clinical work.

The first half of the 20th century is a goldenera of psychology in India with Dr. Bose and hiscolleagues providing the much needed impetus toa strong therapeutic orientation (Prabhu, 2004).

The NIMHANS and CIP which came intoexistence in the middle of the 20th century,

extended the intervention components in theclinical psychology training and practice. Over theyears, several contemporary psycho-social methodsof interventions were introduced into clinicalpractice at these institutes, although emphasis andextent of exposure varied between the two centers.Since these two training centers existed in mentalhospital settings, the predominant exposure of thetrainees was to the problems of the mentally ill andthe severely disturbed. The exposure to minormental illnesses, psycho-social aberrations, healthpsychology and psycho-social dimensions ofprimary health conditions was limited. The traineesat these centers did not receive the attention neededto function as a specialist, independently withinthe framework of the profession so that they coulddevelop an appropriate professional identity. Thiswas due to the several limitations inherent in thetraining setting (Prabhu, 2001). Together, about 20candidates per annum, were trained at these twocenters. However, with the dawn of the newcentury, there were changes.

The Road TraversedImpressive progress has been made,

particularly in the last three decades, both in basicas well as in application research in different areasof clinical psychology. This growth has brought insignificant changes in the health field as well as insociety and expanded the scope of clinicalpsychology to a much broader extent thanpreviously thought.

203

Advances in technology played a major rolein bringing about these changes. For example, thecomputer provided a better analogy for cognitivetheories as well as providing a powerful tool forexperimental research. As the information agebegan to unfold, there was an increase in thenumber of research outlets. The expandingscientific literature allowed researchers to focus onspecific and/or specialized problems.

In the light of these recent researchcontributions made in the field of ClinicalPsychology, three major misconceptions aboutclinical psychology can be dispelled (Belloch andOlabarría, 1994).

(1) Historically, the therapeuticinterventions were quite non-specific tovarious disorders and did not have a closeconnection with basic research. Duringthe last three decades, this scenario haschanged dramatically. Today clinicalpsychologists engage in basic researchdesigned to elucidate the physiologicaland cognitive mechanisms of mental andorganic disorders. These developmentsare exemplified in recent research, interalia, on the cognitive evaluation of bodysensations and cognitive schema inanxiety and depressive disorders, panicdisorder, post-traumatic stress disorder,delusion disorders, somatizationdisorders, personality disorders (whichare always thought as treatmentrefractory), has led to specific and highlyeffective short-term psychologicalinterventions.

(2) Clinical psychology was linked with thestudy of emotional disorders such asanxiety or depression. Modern clinicalpsychology, however, can make

substantial contributions to the theoryand treatment of medical disorders, suchas, infertility, dermatological conditions,respiratory disorders, gastrointestinaland bowel diseases, and cardiovasculardiseases. For example, evidence providedsuggests that decreasing interpersonalstress by couple therapy is an effectivetreatment for organically healthy infertilemen, that biofeedback may be a laudabletreatment for epilepsy, tension/vascularheadache, and that behavioral processesare important for the etiology andmanagement of chronic hypertension,one of the risk factors for CV diseases,and various other systemic diseases. Allthese developments have resulted in theemergence of a new field of expertise,one that covers certain aspects whichtraditionally belonged to clinicalpsychology, such as, diagnostic andassessment functions, psychologicaltreatment, etc. and other aspects thatrequire new types of socio-technicalqualifications and contributions. Theseaspects involve interdisciplinary work inand with the community, in healthpromotion and prevention, receiving/giving support for specialized services inhospitals, working with other experts inPrimary Care Centers, engaging andsupporting the network of SocialServices, utilization of new psychologicalinstruments and equipment to deal withchronic conditions. All of this hasdeveloped from an interdisciplinarypoint of view, where “the team is notsimply the sum or juxtaposition ofprofessionals with different skills, but aworking group with a high degree of

204

functional expertise, a result of theintegration of the professionals’contributions to achieve those goals” (cf.Belloch and Olabarría,1994).

This way, placing itself within theframework of health organizations andreferencing to a Health Care model,clinical psychology has cleared its pathfor creating new areas of action as aconsequence of technical and socialresponsibility. This may be the beginningof the institutionalizing differentworking tasks or bureaucratization ofclinical psychology within the healthsystem.

We must emphasize that the publicnetwork of mental health services is themain career path for clinicalpsychologists, though this is not the onlyone. Mentioning their activecontribution to new fields is in order.Some of these are: Care for primaryhealth problems, in their day-to-daytasks associated with their hospitalservices, such as, the efforts and researchwork involving oncology, psychosomaticdisorders, pain, pre- and post-surgerypsychoprophylaxis, in their work withchronic illness, such as, diabetes, asthma,hemophilia, HIV/AIDS, head-injury,dementia, a plethora of skin disordersand so on. These interdisciplinary, butspecific work show an increase in theacknowledged outcome.

Integrated public services areprovided at the Primary Health Carelevel, where support and coordinationof professionals is extremely important.Thus, clinical psychologists have takenover more duties to overcome the

traditional division betweencomprehensive health care (andsubsequent treatment of general healthproblems) and what is known as mentalhealth care. This kind of work has helpedto detect psychopathological cases, toorganize follow-up and simultaneouslyeasing and improving referralprocedures.

Clinical psychologists alsocontribute through teachingpsychological and interpersonal skills toprofessionals in a general health settingto help them manage health problems,change patients’ habits/life style. Ingeneral, the clinical psychologistspromote health in the community, insmall groups and in individuals.

(3) The discipline of Clinical Psychology isnot restricted to the study and treatmentof psychological problems, such as, lowself-esteem or shyness, as demonstratedby recent research. Psychologicalintervention is highly effective in thetreatment of severe mental disorders aswell. Family education and treatmentprevent relapse in the schizophrenics.That Cognitive Behavior Therapy(CBT) is effective in the treatment ofdisorders, such as, anxiety, panic,obsessive-compulsive disorders and indispelling delusion associated with life-long disability, have also been supportedthrough research.

Role of the RCIThe consequential benefits the establishment

of the Rehabilitation Council of India (RCI) are:Clinical Psychology has been recognized as one ofthe core specialities within the mental health sector

205

giving it a professional identity, fostering inter- andintra-professional interaction and groups who worktogether as a team as well as with their own clientsand field of work.

Clinical Psychology gained comparabilitywith regard to other post-graduate degree holdersof health disciplines.

Training ProgramsThe RCI was empowered with the required

statutory authority for standardizing andmonitoring training course for clinicalpsychologists, for granting recognition toinstitutions running the recognized courses, andfor maintaining a central register for qualified

clinical psychologists. Professional interactionamong the clinical psychologists and decisionmaking process as and when deemed necessary wasalso facilitated.

The amended RCI Act in 2000 gave the RCIthe additional responsibility of promoting researchin rehabilitation and special education.

More importantly, the RCI developed a corecompetency model for internship program inClinical Psychology for the first time in 2001. Theregulations of the M.Phil Clinical Psychologytraining program outlined the professional scope,and the nature and core areas of the clinicalpsychologists’ work.

206

Chapter 3

Magnitude of the Problem

In India, over 25 million people suffer frommental illness. Lack of economic resource

together with lack of professionals in the field hasmade the scenario bleak.

Prevalence of Mental IllnessThe epidemiological surveys in many

countries indicate that mental disorders are quitecommon among the general populationworldwide. Generally, the prevalence of all mentaldisorders varies between 10 and 15 per cent of the generalpopulation. Studies have estimated lifetime prevalence ofmental disorders among adults to range from 12.2 to48.6%.

The WHO has estimated that approximately450 million individuals worldwide suffer fromneuropsychiatric disorders in their lifetime.

A large number of epidemiological surveyshave shown the prevalence rates of mentalmorbidity in rural and urban areas ranging from9.5 to 370/1000 in India (Suresh, et al., 2007). Thisis comparable to global rates.

The wide variations observed have beenattributed to a lack of definition providing a clearboundary between psychopathology and normality,a difficulty faced in operationalzing “clinicalsignificance” and “medical necessity”.

TypeApproximately 33% of the number of years

lived with disability (YLD), are due to

neuropsychiatric conditions. Of the 10 leadingcauses of YLD in the world, inclusive of all ages,four are psychiatric conditions, with unipolardepression being the leading cause.

Among individuals aged 15 to 44 years, panicdisorder, drug use disorders, and obsessivecompulsive disorder (OCD) were in the top 20disorders (Robert, et al., 2004).

Among the mental health problems,depression and anxiety disorders are the mostprevalent, followed by substance use disordersamong adults.

Among children the most common areattention deficit and conduct disorders.

India has a high rate of suicides - 89,000persons committed suicide in 1995, increasing to96,000 in 1997 and 104,000 in 1998, which is a 25%increase over the previous year (WHO, 2001a).

AgeHigh prevalence rates from 10 to 15 per cent

among school-age children have been shown. Arecent epidemiological study sponsored by ICMR(Mehta, 2004) indicated the overall prevalence ofmental-behavioral disorders in children to be12.5%, a finding in agreement with an earlier report(Mehta, 1990) of a prevalence rate of 12-13% inschool children.

Young adults, aged 15-44 years, the mosteconomically productive section of the community,

207

is the most affected. It is projected that developingcountries, such as India, will see the mostsubstantial increases in the burden of mentaldisorders in the next two decades. It is estimatedthat mental disorders accounted for 12% ofdisability adjusted life years (DALY) in the year2000, and 13% in the year 2001 (WHO, 2002).

Projections suggest that the health burden due tomental disorders will increase to 15% of DALY by2020 (Murray and Lopez, 1996).

Reducing the stigma, affordable treatmentopportunities, low cost centers, psycho-education,social rehabilitation, vocational training may beeffective solutions for reducing the burden.

208

Chapter 4

Assessment of Mental Illness and Patient Care

Tools/Techniques Employed

The screening scales or instruments employedin a majority of the epidemiological studies

conducted in India, inter alia, include Mental HealthScreening Questionnaire, Questionnaire for theAssessment of Psychiatric State of the Family,Indian Psychiatric Survey Schedule, SocialFunctioning Questionnaire, Psychiatric ScreeningQuestionnaire, Psychiatric Health Questionnaire,Case Record Schedule, Rapid PsychiatricExamination Schedule (Suresh, 2007).

Facilities for the Care of the Mentally IllIn spite of the high burden of mental

disorders which is approximately a sixth of allhealth-related disabilities, and despite the fact thata significant portion of this burden can be reducedby primary and secondary prevention, most peoplein India do not have access to mental health care.This can be attributed to the inadequateinfrastructure including lack of adequate humanresources. When available, treatment is based on apurely medical model focusing on the provisionof drugs and ECT. There is a dearth of facilitiesfor providing psycho- and psycho-social therapies,counseling, and rehabilitation services.

It is well accepted that mental health careis multidisciplinary, involving such professionalsas psychologists, psychiatric nurses andpsychiatric social workers. However, suchmultidisciplinary care is limited to only a fewcenters in our country.

Bed-strength in Hospitals India has 0.25 mental health beds per 10,000

population, approximately 20,000 beds in mentalhospitals and 3,000 beds in general hospitals forpsychiatric patients. Of these, the vast majority(0.20) occupied by chronic patients requiring longstay, are not accessible to the general population.

Patient Care

Family and Community Involvement

Family burden is a complex problem thatseriously affects the treatment of chronic mentallyill patients

The Indian family is a source of strengthwhen it comes to mental illness, but the familystructure, composition, attitudes, obligations, andvalues are changing. In fact, there is a total changein the sociology of the Indian family. Families, theprimary caregivers, are feeling the strain in acountry without a welfare system.

The recent deinstitutionalization process hasreduced the length of hospital stays and steadilypromoted family/community care of the mentallyill. Studies suggest that more than 65 per cent ofthe discharged patients return to their families. Theemotional and economic strain experienced whena relative discharged from a mental hospital returnshome is a burden on the family.

The critical phase of deinstitutionalization,i.e., providing adequate and accessible community

209

alternatives to hospitalization has not progressedsatisfactorily. Thus, quality of life and well-beingof chronic and severely mentally ill who aredischarged from the hospital has not improved asmuch as it should have within the philosophy ofdeinstitutionalization (Amool, 2005).

Mental health literacy needs to be built strongly inthe community to scale up the utilization of availablemental health services. Over 90% of the mentally ill arecared for within their communities, by their familieswithout even receiving a diagnosis.

On the credit side, India has a communitymental health program that consists of integratingbasic mental healthcare into general healthcareservices. The objectives could be:

• training the primary healthcarepersonnel in mental healthcare,

• providing them with adequateneuropsychiatric drugs in primary caresettings,

• supervising primary healthcare staff, and

• establishing a psychiatric unit at thedistrict level.

TreatmentMany people are still unaware that there are effective

treatments for many mental disorders. For example, nearly50-60% of persons with depression will recover withtreatment in three to eight months; with schizophrenia, acombination of regular medication, family education andsupport can reduce the relapse rate from 50% to 10%.

India has 0.4 psychiatrists, 0.04 psychiatricnurses, 0.02 psychologists and 0.02 social workersper 100,000 population (WHO, 2001b). At themost, only 10% receive active psychiatric care asagainst 30 million requiring mental health care.Approximately, 2,50,000 new psychiatric casesmanifest each year. Most turn to faith healers or

temples first. Stigma, discrimination and neglectprevent care and treatment. Thus, even theavailable services for mental disorders are beingpoorly utilized. Nearly two-thirds of persons withknown mental disorders never seek help fromhealth professionals. Instead, they resort to harmfulpractices, visit faith healers and delay treatment tillthe condition deteriorates which compels them toseek treatment from established governmentinstitutions.

WHO RecommendationsEvidence shows that adequate prevention

and treatment of mental disorders can reduce thesuicide rates, irrespective of whether suchinterventions are directed at individuals, families,schools or other sections of the general community(WHO, 2001c).

If access to mental healthcare is to beimproved, mental healthcare must be provided atthe community and primary level.

To address the treatment gap, the WHO(2001d) has outlined the following tenrecommendations:

1. Mental health treatment should beaccessible in primary care.

2. Psychotropic drugs need to be readilyavailable.

3. Care should be shifted away frominstitutions and towards communityfacilities.

4. The public should be educated aboutmental health.

5. Families, communities and consumersshould be involved in advocacy, policy-making and forming self-help groups.

6. National mental health programs shouldbe established.

210

7. The training of mental healthprofessionals should be increased andimproved.

8. Links with other governmental and non-governmental institutions should beincreased.

9. Mental health systems should bemonitored using quality indicators.

10. More support should be provided forresearch.

Though the quality of the care in mentalhospitals has improved tremendously from thecolonial times, infrastructure and other facilitiesare considered still inadequate (Banerjee, 2001).

The WHO has warned that many countries willbe unable to cope with a predicted boom in mental illnessover the next decade. According to WHO, “If we don’tdeal with Mental Illness, there is a burden not only on theMentally Ill, on their families, their communities, there isan economic burden if we don’t take care of people whoneed their care and treatment.”

211

Chapter 5

Manpower Development

Historical PerspectiveThe first training program in clinical psychology inIndia was established at the All India Institute ofMental Health [(presently, National Institute ofMental Health and Neurosciences (NIMHANS)],Bangalore, in the year 1956. Subsequently, thetraining program was replicated at the Hospital forMental Disease [(presently, Central Institute ofPsychiatry (CIP)], Ranchi, in 1962.

In 1951, a training program in clinical psychologycame up at the Benares Hindu University, but

it exited the professional scene without making animpact.

NomenclatureThe nomenclature of the clinical psychology

training program changed several times from theoriginal DMP (Diploma in Medical Psychology)to the current M.Phil in Clinical Psychology morefor various extrinsic reasons than for any issuesrelated to the content of the course itself. However,from the outset it has been a post master’s 2-year,fulltime, regular and structured training programwith emphasis on acquiring professional praxisthrough supervised internship. Since, the traineesreceived financial support, the course had a built-in demand to provide routine clinical services atboth indoor and outdoor facilities.

Current ScenarioFor nearly half a century, the National

Institute of Mental Heath and Neurosciences,

Bangalore and the Central Institute of Psychiatry,Ranchi were the only training centers in clinicalpsychology in the country. Attempts at starting andsustaining training programs in Clinical Psychologymade in Kolkata, Ahmedabad, Varanasi andBangalore being unsuccessful, there was amismatch between the acute demand for thelimited seats available at the two centers due to agrowing interest in clinical psychology.

Centers for Training in ClinicalPsychology

However, with the dawn of the 21st century,things started looking up. Today, training in clinicalpsychology is being offered at 10 recognized centersacross the country with an annual intake of over90 trainees.

Five of the ten training centers found theirlocations in a medical setting, four in the traditionalmental hospital setting, and one has been startedby an NGO catering to rehabilitation needs ofvarious disabled populations.

RCI Involvement

Registration/RequirementsThe degree holders from above centers

qualify for enrolment on the RCI professionalregister thereby increasing the available qualifiedmanpower.

Enrolled professionals are entitled to: (a)hold office (by whatever designation called) in

212

government or in any institution maintained byappropriate authority, (b) practice anywhere inIndia, (c) sign or authenticate any certificaterequired by any law, (d) give any evidence in anycourt as an expert under section 45 of the IndianEvidence Act of 1872 (The Gazette of India, PartII, Section 1, dated Sept. 1992).

Any person who acts in contravention shallbe liable for punishment (which includesimprisonment for a term, up to one year or withfine). Every center which grants the recognizeddegree/certificate such as M.Phil (ClinicalPsychology) is required to furnish all the necessaryinformation, such as, content of the course,examination pattern, requisites for obtainingqualification, etc., required by the RCI, from timeto time.

In view of the above statutes, any graduateor post-graduate degree in Clinical Psychologyother than M.Phil in Clinical Psychology, asoutlined by the RCI, from any center other thanthose listed below, is currently not recognized forpurposes of enrolment on the register.

Not relevant to the practice of clinicalpsychology are such claims as: Taught M.A./M. Sc.psychology without direct patient contact,supervised clinical internship, and hands-ontraining in interventional work pertinent to a widevariety of clinical problems.

A Ph.D. in clinical psychology (after aMaster’s degree in Psychology) involves neither awidespread exposure to clinical situations as inM.Phil training, nor a mandatory examination—theory and practical/clinical—to ensure acquisitionof specified levels of competency. Hence,candidates with a Ph.D. degree, withoutcompleting the two-year clinical internship (as inM.Phil in Clinical Psychology), are considered

ineligible to register as clinical psychologistseffective from March 2007, notwithstanding thetopic of the dissertation which may relate to aclinical area.

Clinical internship of a two-year duration completedwhich involves supervised, hands-on training, in a varietyof clinical situations, subsequent to a post-graduate degreein psychology has been prescribed by the RCI as theminimum required qualification to register as a professionalclinical psychologist in India.

The details of the centers currentlyrecognized as per the notification (Gazette of India,New Delhi, dated November 1, 2006) are asfollows:

(1) Central Institute of Psychiatry,Kanke, Ranchi – 834 006 (Jharkhand)

(2) Manipal University (formerly MAHE),Manipal – 576 104 (Karnataka)

(3) Sri Ramachandra University,(formerly SRMC), Porur,Chennai – 600 116 (Tamil Nadu)

(4) Ranchi Institute of Neuro Psychiatry& Allied Sciences, Kanke,Ranchi – 834 006 (Jharkhand)

(5) Department of Psychology,University of Calcutta,Acharya Prafulla Chandra Road,Kolkata – 700 009 (West Bengal)

(6) Sweekar Rehabilitation Institute,Upkar Circle, Picket,Secunderabad – 500 003 (AndhraPradesh)

Subsequent to above notification, the followinginstitutes have been approved:

(7) Institute of Human Behavior andAllied Sciences,Jhilmil, Dilshad Garden,Delhi – 110 095

213

8) Department of Clinical Psychology,Amity Institute of Behavioral & AlliedSciences,NOIDA (Uttar Pradesh)

9) Institute of Mental Health and Hospital,Billochpura, Agra – 282 002(Uttar Pradesh)

10) Regional Institute of Medical Sciences,Lamphel, Imphal – 795 004 (Manipur)

Inspection by RCIThe RCI is authorized to appoint requisite

inspectors to any University or Institutionanywhere in India, where education forprofessional practice is given, or to attend anyexamination held by the University or Institution(ibid).

Short Term Courses/Workshops/Seminars

Some committed/interested candidates whocould not get enrolled for M.Phil training programcarried on with their mission of serving thementally ill, contributing in one way or the otherin the service domains very closely connected toClinical Psychology.

Some clinical psychology departments,including those in premier institutes, organizeshort-term courses aimed at imparting knowledgein assessment and interventions, to those notformally qualified, in such areas as marital therapy,behavior therapy, cognitive therapy, sex therapy,neuropsychological assessment/rehabilitation, etc.However, such short-term courses, of one to twoweeks’ duration, are found wanting in hands-onexperience under a competent supervisor and alsoin the assessment of the participants’ proficiency.These limitations are understandable given thetime constraints for interaction.

Many senior and superannuatedprofessionals also organize workshops andseminars, of varying durations, through universitydepartments or NGOs on issues such asassessment, using projective and non-projectivetests, counseling, therapy techniques, etc., for thosenot formally trained. Such programs also sufferfrom the lacunae mentioned above.

Those with ExperienceCompetent and resourceful participants do

pick up the necessary techniques and skills at theshort term programs. Coupled with their field/practical experience, they practice in the field ofclinical psychology with such competency as thosetrained formally. They make good, partially at least,the short fall in available human-resources.Denying registration/enrollment to suchcandidates, as per the current rule is viewed asunfair by the RCI.

DiscrepanciesIndia is well placed as far as trained

manpower in general health services is concerned,trained mental health personnel are limited, andmostly based in urban areas.

Compared to the number of psychiatrists,most countries have between two and three timesas many psychologists, social workers andpsychiatric nurses. In India, it is estimated that thereare more psychiatrists in active clinical practice thanthere are trained psychiatric nurses, clinicalpsychologists and psychiatric social workers. Nosystematic efforts are being made to address thisdistortion, by either the professional organizationsor by the Government.

Bridge Course by RCITherefore, a bridge program called

214

Certification Course in Clinical Psychology for in-service candidates was offered by the RCI in theyear 2003.

Entry requirements are: the candidate at thetime of entry to the course should be working full-time with the mentally ill and be able to producean experience certificate (an endorsement on thenature and quantum of work done) by a registeredclinical psychologist (who is a two-year M.Phildegree holder from a recognized center, enrolledalready under the category – clinical psychologist)stating that he/she has put in more than 5 years ofservice in the field (which means certifying clinicalpsychologist should have more than five years ofexperience post-qualification, i.e., post - M.Phil),following the award of post-graduate degree inpsychology (fulltime/regular M.A./M.Sc. with aminimum of 55% marks in aggregate). Application/prospectus can be obtained, free of cost, from anyof the training centers listed in this section.

The objectives of the program are:

(1) Updating with relevant theories asapplicable to clinical practice.

(2) Imparting supervised hands-onexperience in various domains related toclinical psychology practice.

This course, of 6 months’ duration, is run ina few recognized centers which have regular,fulltime, qualified/registered clinical psychologiststo provide the necessary input and supervisedpractical experience and which have adequateclinical material and infrastructures required forimparting academic training/degree.

On successful completion of the training asper the prescribed curricula, the candidates haveto appear for theory/clinical exam conducted by

the respective universities. With registration by theRCI, the successful candidates, become eligible toperform as responsible professionals in clinicalpsychology. Such candidates however, cannotfunction as faculty members in departmentsconducting M.Phil clinical psychology trainingprograms.

Training Centers for Bridge Course(Center code – 002/05)The Professor and HeadDepartment of Clinical PsychologyKasturba Medical CollegeManipal UniversityManipal – 576 104 (Karnataka)

(Center code – 003/05)The Director (Admn.)Regional Institute of Medical SciencesLamphelpatImphal – 795 004 (Manipur)

(Center code – 004/05)The Executive Director and Chairman“Digdarshika”Red Cross Bhawan CampusShivaji Nagar, Bhopal – 462 016

(Center code – 005/05)The Director“Saarthak”24, Hauz Khas VillageNew Delhi – 110 016

Though there is an upward trend, thenumber of professionals currently available is nomatch to the number required to meet the evergrowing demands in the field. Efforts are beingmade towards increasing the number of centersthat can impart the M.Phil level training.

215

District Mental Health Program

The objectives of the District Mental HealthProgram (DMHP) are:

• to ensure availability and accessibilitywith ease, of mental health care for theneedy,

• to integrate mental health care withgeneral health services, and

• to promote community participationand to increase awareness.

The DMHP was first launched in 1996-97in one district each in the States of Andhra Pradesh,Assam, Rajasthan and Tamil Nadu. Currently, theprogram is being implemented in 22 districts inthe country and covers around 40 million people,which is approximately 5% of the population. It isplanned that this program would be extended to100 districts (The Ministry is planning to cover400 districts in the next three years and all 600districts in due course under National mentalHealth Programme. But even if successful, itwill still only cover 150 million people, orapproximately 15% of the country’s population.

Some of the drawbacks of implementing thisprogram are:

• these efforts have been linked tocharismatic leaders rather than thestructural and enduring changes of thehealth system, and

• these programs have been limited to anarea in the country or to a particular

mode of service provision which makesit difficult to replicate or transport toanother area in the country.

Thus, the issue to be addressed on priorityin the country is accessibility. Policy interventionsare needed to increase access to appropriate andquality mental health services by the needy.

Wherever modern health services areavailable, people do avail them even though theytend to seek out religious and traditional healersfor relief of their problems, whether general ormental health related.

Mental Health PolicyThe policy was initially formulated in 1982.

Since the primary health facilities are relatively welldeveloped in India, it was recommended that carefor mental health must form an integral part of thetotal health program and as such should beincluded in national policies and programs relatedto health, education and social welfare.

The national mental health program wasadopted as the mental health policy. The objectivesof the national mental health program are:

(1) To ensure availability and accessibility ofminimum mental health care for all,particularly to the most vulnerable andunder-privileged sections of thepopulation in the foreseeable future.

(2) To encourage application of mentalhealth knowledge in general health careand in social development.

Chapter 6

Government and NGOs

216

(3) To promote community participation inmental health service development andto stimulate efforts towards self help inthe community.

From 1982 to 1995, the program was run asa pilot program. The program is currently beingimplemented in twenty-two districts in the countryand it is to be extended to cover 100 districts withina stipulated time.

The following approaches have been adoptedby the program:

(1) Integration of basic mental health careinto general mental health care services.

(2) Training of primary health carepersonnel in the aspects of mental healthcare.

(3) Provision of adequate neuro-psychiatricdrugs in peripheral health careinstitutions.

(4) Support and supervision of trainedprimary health care personnel.

(5) Establishment of a psychiatric unit at thedistrict level.

(6) Encouraging community participation.

Mental Health LegislationA number of public policy and judicial

enactments have tried to address the issues ofstigma attached to mental illness and the rights ofthe mentally ill.

The Mental Health Act, 1987 with a focusto improve the quality of services/care and protectthe rights of mentally ill has replaced the IndianLunacy Act of 1912. The new Act has been a veryimportant milestone in the development ofmodern psychiatric services in the country.

The Mental Health Act, 1987 has provided newdefinitions, simplified procedures for admission and

discharge. It has also introduced licensing of psychiatrichospitals, separated the mental health authorities at theState and the Central levels. Facilities for children andpersons with addiction have been bifurcated and humanrights of the mentally ill has been promoted.

There are also Acts relevant to marriage anddivorce, Juvenile Justice Act, Persons withDisabilities Act and legal provisions related tosuicide and attempted suicide. The StateGovernments took a long lead time to establishmental health authority and to implement this Act.

Budgetary ProvisionsAccording to a WHO report, 28% of nations

have no specified budget for mental health. Aboutone-third of the people live in countries whichinvest less than 1% of their total health budget inmental health services. India spends just 0.83% ofits total health budget on mental health (WHO2001b), in spite of the fact that the budgetarysupport for the National Mental Health Program(NMHP, 1982) has been increased nearly seven-fold to Rs.1900 million in the Tenth Five Year Plan,up from Rs. 280 million during the Ninth Plan(Khandelwal et al. 2004). This quantum accretionin the resource base is being utilized as under:

(In Rs.)

District Mental Health Program Rs. 633 million

Modernization of Mental Hospitals Rs. 742 million

Strengthening of Medical Colleges Rs. 375 million

IEC initiatives Rs. 100 million

Research and Training Rs. 50 million

This allocation is small as compared to10 - 18% in other countries.

Issues Related to Mentally Ill WomenThe recent national seminar organized by the

National Commission for Women highlighted the

217

difficulties in the lives of the mentally ill womenwho face stigma, discrimination and deprivationof homes.

The Commission’s effort towards drawingup a holistic plan with participation from NGOsfor the care and welfare of women has been viewedas an important step in the right direction.

A study conducted in Delhi with apopulation of 70 million showed nearly 2,500mentally ill women, devoid of hopes, virtually onthe street. Extrapolating for the whole nation, thecountry will have nearly 150,000 mentally-ill,destitute women.

The Commission along with thegovernment departments, State Women’sCommissions and NGOs need to collaborate forestablishing rehabilitation centers, after-care homesand halfway homes across the country year afteryear. Such program should be inclusive ofcounseling and the welfare of the affected, thechildren and the family.

Linking of Services—Mental Health andGeneral Health

Since trained manpower in general healthservices is available in the country to a greaterextent, the development of mental health servicesincluding manpower has been linked with generalhealth services and primary health care.

Training opportunities for various kinds ofmental health personnel are gradually increasingin various academic institutions in the country.

Of recent, there has been a major initiativein the growth of private psychiatric services to filla vacuum that the public mental health serviceshave been slow to address. A number of non-governmental organizations have also initiated

rehabilitation programs, school mental healthprograms and underlining human rights of thementally ill.

Despite all these efforts leading to someprogress, much needs to be done towards training,research, and providing clinical services to promotemental health in all sections of the society.

Role of Non-governmentalOrganizations

Patel and Tara (2003) give an excellentaccount of non-governmental organizations(NGOs) working in various areas of mental healthin different parts of the country. In addition, NGOsalso play a significant role in influencing policymatters.

The NGO perspective on health is that it isan integral component of community developmentand good health is the result of a complexinteraction of social, economic, biological andpsychological factors. Thus, bio-medicallyoriented, hospital based solutions alone areinsufficient to ensure sustainable health change ina community. For example, NGOs often work bothin clinical and non-clinical sectors which exercisea profound influence on child and adult mentalhealth, such as women’s empowerment and non-formal education. Community-based childguidance and development services are the focusof some NGOs. For example, Action for Autismin New Delhi and the Maharashtra DyslexiaAssociation, Mumbai, focus on specific disordersof childhood and adolescents. Whereas, NGOs likeSangath and Manas in Goa, Saarthak andSamadhan in New Delhi, Samikshini in Kolkataprovide multi-disciplinary services for a range ofchildhood and adult mental health problems.

218

Chapter 7

Vision for the Future

Thoughts for Future Growth

In the absence of a certification authority tillrecently in the country, the clinical psychologists’

role as a full-fledged professional wentunrecognized among their peers with consequentlimitations to their effectiveness in treatmentsetting(s).

In India, smaller psychiatric units in generalhospitals or NGOs often employ a single clinicalpsychologist and thus many of them practice in“pockets of isolation”. In addition, for too long,clinical psychologists have not been heldaccountable in clarifying the treatment principlesand the evidence for both efficacy and effectiveness.Therapists are allowed to freely explore a widevariety of treatment approaches as long as no harmis done. This “benign neglect” led to practicesnearly as varied as the number of settings, leavinglittle incentive for practitioners to develop thenecessary skills to objectively evaluate their ownservices.

However, current legislation has broughtabout the accountability hitherto lacking which willhave important ramifications for professionalpractices. With the rapid global change inpsychiatric health care, clinical psychologists of thiscountry will have to upgrade their skills which arecentral to their professional practice. They will haveto gain greater trust of the public as well as theprofessional community.

The field of clinical psychology has

“rediscovered” the intentions of its pioneeringleaders. These intentions include developing apsychology that can contribute to the overall goodof the society. Valuable knowledge and servicesprovided so far will have to continue.

Some urgent issues to be underlined are:

• Developing a new agenda for furtheringand strengthening this field. The needof the hour is determination andcohesiveness among scholars,practitioners, trainers, and employers toachieve the common goal of broadeningthe field of action by becoming asignificant part of public health. Twospecific reasons for this are :

(i) There has been a proliferation ofspecialties within clinicalpsychology. Consequently, this hasdistracted the professionals fromunifying themes that bind themtogether as clinical psychologistseven though there might have beenan increase in knowledge.

(ii) Developing a new agenda relates tosurviving in a competitive market.Why clinical psychology is uniqueamong the health professions mustbe enunciated. The uniqueness isthe science-practice intersectionthat ties what we do to add toknowledge from the study of

219

behavior. The present status is thatdifferent frameworks coexist,sometimes “peacefully”, sometimesin intense “rivalry”. Though co-existence of a spectrum of theoriesand approaches enriches thelearning experience for students andpractitioners, a collective effortshould be made by theprofessionals, from the applied andresearch areas, to supportdissemination of empiricallyvalidated treatment procedures andto enhance linkages betweenresearch and practice.

• Initiation of interaction to develop aworking relationship between theacademic and service settings and tostrengthen the base in teaching, researchand service activities, as is beingemphasized repeatedly (Prabhu 1975;2001b).

• Completion of registration by thequalified clinical psychologists so thattheir practice in the profession could beregulated effectively. A notification tovarious governmental/non-governmental agencies and prospectiveemployers, regarding the requirement ofcompulsory registration under theregulatory body will be effective in thisdirection. Fresh recruitments, at bothState and Central levels, should berestricted to the registered clinicalpsychologists.

• Furnishing the necessary informationabout content of the course, examinationpattern, requisites for obtainingqualification, etc., as required by the

statute and complete the inspection andfollow the approved norms andguidelines.

• To work towards developing therequired manpower to meet the currentand future needs. The Bridge program,already developed by RCI, may bemarketed aggressively and the presentinfrastructure available in the academicinstitutes must be utilized optimally togenerate the required number ofqualified professionals.

• To open independent departments ofClinical Psychology in all mentalinstitutes, mental health centers and inmedical colleges, so that thesedepartments can meet the growingdemands in the service sector and canmobilize/build-up the requiredinfrastructure, in the years to come, tostart short- and long-term trainingprograms in clinical psychology.

• To include an appropriate teaching andtraining module in behavioral sciencesand rehabilitation sciences at theundergraduate level to sensitize thefuture young doctors in thepsychological dimensions of medicaldiseases and rehabilitation processes.

• To conduct and support ContinuingRehabilitation Education (CRE)programs for updating the knowledgefor the clinical psychologists already inthe field. Also to design and offer shortcourses in various specialty areas likeHIV/AIDS, Pain Management, PalliativeCare and issues related to death anddying, rehabilitation of those with headinjury, etc.

220

• Continuous training and upgrading oftheir knowledge and skills by the ClinicalPsychologists to avoid stagnation. Thereis a training need for acquiring newcompetencies to cater to specializedpatient-population and to deal with thedaily heterogeneous demands made onthe clinical psychologists. This impliescontinuous evaluation of the clinicalpsychologists’ actions, services anddomains where they work.

• Training schedules to focus on themethods of interviewing and contactwith the individuals and families,listening skills in dealing with clients,assessing their needs, counseling andidentification of high risk families andclients. Community organization andmobilization of resources are other areasto be taken note of.

• To introduce Conditional Registration–All candidates must obtain RCIregistration (conditional) as soon as theycommence their training at a recognized

center. Regularization may be donedepending on the successful completionof the course.

• Setting up a board/committee to issueStatement of Equivalence (SoE) tooverseas graduates (M.A./M.Sc. inPsychology) intending to continue theirhigher studies and pursue a clinicalpsychology career in India.

• Conforming to the Code of Ethicsestablished by the regulatory body.Information booklets containing informationon the discipline, activities of the professionalsalong with the information where tolodge the grievances should be madeavailable at all service centers. PublicGrievance Cells are to be set up toinvestigate the clients’ discontent by theregulatory body.

There is definitely much to be done. But,given how much has been achieved in these lastfew years, one cannot but be optimistic.

Experts who contributed to the section on Mental IllnessDr. K.B. Kumar (Editor)

221

References

Amool RS (2005). Deinstitutionalization: Promises andChallenges. Indian Journal of Clinical Psychology 32:83-84.

APA (1994). Diagnostic and Statistical Manual of the MentalDisorders-IV. The American Psychological Association,Washington, DC.

Banerjee G (2001). Mental hospitals and healing practices incolonial India. Mental Health Reviews. Accessed fromhttp://www.psyplexus.com/excl/cdmi.html

Belloch A, Olabarría B (1994). Clinical Psychology: CurrentStatus and Future Prospects.

Applied Psychology, 43 (2), 193–211.

Khandelwal SK, Jhingan HP, Ramesh S, Gupta RK, SrivastavaVK (2004). Indian Mental Health - Country Profile.International Review of Psychiatry, 16, 126-141.

Kohn R, Saxena S, Levav I, Saraceno B (2004). The treatmentgap in mental health care. Bulletin of the World HealthOrganization, 82, 11.

Mehta M (2004). Child mental health: New challenges,Indian Journal of Clinical Psychology 31, 5 - 9.

Mehta M (1990). Child mental disorders in rural schoolchildren (ICMR sponsored project).

Murray, CJL and Lopez, AD (1996). The Global Burden ofDisease: A Comprehensive Assessment of Mortalityand Disability from Diseases, Injuries and Risk Factorsin 1990 Projected to 2020, Cambridge, Harvard Schoolof Public Health.

National Mental Health Program for India (1982). NewDelhi: Director General of Health Services,Government of India.

Patel V, Thara R (2003). Meeting the mental health need ofdeveloping countries, Sage, New Delhi.

Prabhu GG (1975). Training Programs in Clinical Psychology.India Journal of Clinical Psychology, 2, 7.

Prabhu GG (1976). New Perspectives in Clinical Psychology.India Journal of Clinical Psychology, 3, 203 – 212.

Prabhu GG (2001a). Indian Clinical Psychologists of theMillennium: The 3G Phenomena. India Journal ofClinical Psychology, 28, 149 - 154.

Prabhu GG (2001b). Identifying Limitations and Gaps in theDevelopment of Clinical Psychology in India. IndiaJournal of Clinical Psychology, 28, 164 - 172.

Prabhu GG (2004) Therapeutic Role of the ClinicalPsychologists: Progress and Problems. India Journal ofClinical Psychology, 31, 42 - 47.

Suresh BM, Chandrashekar CR and Dinesh B (2007).Psychiatric epidemiology in India. Indian Journal ofMedical Research, 126, 183 - 192.

WHO (1992). The ICD-10 classification of mental and behavioraldisorders. Oxford: Oxford University Press.

WHO (2001a). Suicide Prevention: Emerging from the Darkness,Regional Office for South East Asia, New Delhi.

WHO (2001b). Atlas: Country Profiles on Mental HealthResources, 2001, World Health Organization, Geneva.

WHO (2001c). The World Health Report 2001. MentalHealth: New Understanding, New Hope, World HealthOrganization, Geneva.

WHO (2001d). Mental Health: New understanding, New Hope.Geneva: World Health Organization.

WHO (2002). The World Health Report, 2002: Reducing Risks,Promoting Healthy Life. Geneva: World HealthOrganization.

222

Resource List(The author has drawn freely from the following publications and

expresses his indebtedness to their authors and publishers.)

Editorial (2002) - Moving Away from Mental Institutions –Towards Community Mental Health Care. IndianJournal of Community Medicine, 27.

Bhargavi D (1996). Medical Ethics in the Context of theNational Mental Health Programme. Indian Journal ofMedical Ethics, 4 (3).

Soumitra P (2003). Beyond ECT: Priorities in Mental HealthCare in India. Indian Journal of Medial Ethics, 2003,11(1).

Vikram P. Sangath Society for Child Development and FamilyGuidance, Goa, for information see: http://www.goacom.com/community/sangath

Atlas: Country Profiles, 2001, WHO.