Handbook of Psychiatric Social Work

Chapter 1
PSYCHIATRIC SOCIAL WORK IN CHILD AND ADOLESCENT

MENTAL HEALTH FIELD
V. Indiramma,1 Kavita Jangam,2 and P. Seema Uthaman 3
Introduction
In today's world a vulnerable group needing recognition beyond generic

documents and principles is that of children. Perhaps more than most other groups,
children need special protection because of their fragile state of development.
Children are readily susceptible to abuse and neglect. Certainly in the United States
and in many other countries, children have occupied special status in need of protection
because of their maturing stage of development. The Department of Cchildren and
Family Services in Illinois oversees the safety of children and views the following as
a child's basic rights:
l The right be protected against neglect, cruelty, abuse, and exploitation;

l The right to safe housing, health care, and education that prepares them for
the future;
l The right to be unique person whose individuality is protected from violation;
l The right to prepare for responsibilities of parenthood, family life, and
citizenship;
l The right to maintain relationships with people who are important to them;
l The right to a stable family;
l The right to safe, nurturing relationships intended to last a life time.
The Universal Declaration of Human Rights and other UN documents echo

a similar need to protect the child. As indicated in the Declaration on the Rights of
the Child, "the child, by reason of his physical and mental immaturity, needs special
safeguards and care, including appropriate legal protection, before as well as after
birth"(United Nations 1989).
In the preamble to the convention on the Rights of the Child, states that "in
all countries in the world, there are children living in exceptionally difficult conditions,
and that such children need special consideration". States duly account for the
"importance of the traditions and cultural values of each people for the protection
and harmonious development of the child" and further recognize the "importance of
international co-operation for improving the living conditions of children in every
country, in particular in the developing countries", Goals stated in the preamble
indicate that governments of countries adopting the convention truly recognize the
need to protect the children.
1. Assistant Professor. 2. Ph.D. Scholar. 3. Psychiatric Social Worker.
Handbook of Psychiatric Social Work 1

It is interesting and exciting experience to work with children and their family
members in order to help them develop healthy personality. A wider understanding
of child development now throws a clearer light on deviations from normal pattern;
knowledge of the nature and causes of mental health problems in children is steadily
increasing; new and effective methods of treatment are evolving; and clinical and
education services for children with mental disorders are growing in scope and
sophistication. Mental health is a growing concern of all persons, young and old,
not because of humanitarian orientation or because of increasing incidence of mental
health problems, but it is realized that much of the waste caused by mental illness is
avoidable (Bernard, 1965).
Children constitute 40% of our total population and the most precious
resource of a nation and it would be sensible to assure their welfare, emotional and
physical well-being regardless of the prevailing political climate or the priority of
the advocacy group. In recent times, the physical wellbeing of children has sought
the attention of the national level policies in many countries, but the mental health of
the children is yet to gain it due place.
The concept of mental health
The basic concept of mental health is a controversial notion, based upon the
philosophical premise of the separation of mind and body. Out of this questionable
dichotomy was born the concept of 'mental health' as analogous to the medical concept
of 'physical health'. Even within a medical model this view has distinct limitations.
In medicine, health has largely been viewed as the absence of identifiable pathology.
An individual is healthy when he or she is not sick. For years psychologists have
pointed to the fact that in behaviour disorders, or so-called mental illness, the simple
identification of similar disease entities was the exception rather than the rule. Some
psychologists (Eysenk, 1960) have called for the entire notion of disease entities to
be banished from the realm of modern psychology.
The White house conference, preliminary Reports (1930) quote "mental

health may be defined as the adjustment of individuals to themselves and the world
at large with a maximum of effectiveness, satisfactions, cheerfulness and socially
considerate behaviour and the ability of facing and accepting the realities of life".
Mental health field encompasses three sets of objectives (Stevenson, 1956):
l One of these has to do with mentally sick persons. For them the objective is
the restoration of health.
l A second set has to do with those people who are mentally healthy but who
may become ill if they are not protected from conditions that are generally
conducive to mental illness or conditions to which they as individuals are
especially susceptible . The objective here is prevention.
l The third objective has to do with upbuilding of mental health of normal
persons, quite apart from any question of disease or infirmity. This is positive
mental health.
Concept of positive mental health
The psychiatric social workers who are working in the child mental health
setup are concerned about positive mental health of children which is based on the
recognition that all children have potentials or talents, sometimes very modest and
sometimes great, that may either be allowed to languish or at the other extreme, may
be developed to the fullest. It is these abilities cultivated to a higher level that
constitute positive mental health.
Children and mental health
There is growing concern about children's mental health. As they are the
future citizens of our country and most precious resource of a nation, it would be
sensible to assure their welfare, emotional and physical wellbeing regardless of the
prevailing political climate or the priority if the advocacy group. The National Policy
for Children (1974) affirmed the constitutional provisions and declared that the policy
of the state is to provide adequate services to children to ensure their full physical,
mental and social development. Fundamental facts about children (A manual on
child mental health and psychosocial development by WHO 1982) are:
l Children need to be healthy and happy to become productive and contented

adults.
l We have to know how they think and what they can do at different ages to help
them with any problem they have.
l Children think, feel and learn differently at different stages.
l Children can only grow up happy if they have other people around them who
are interested in them.
l The general health of a child also affects how he thinks and feels.
l Children of opposite sex behave differently.
l There are many things children cannot do for themselves and they need much
help from adults.
l If the children feel sad, angry or afraid or anxious much of the time, they may
have problems for which they need help.
l Children cannot develop their personality to the fuller extent unless they feel
at home with themselves and with other people round them.
l Children who are burdened with anxiety and self doubt cannot commit to
themselves whole heartedly to learning but exhaust their energies in fighting
the private battle that rages within themselves.
l The disturbed child strives continuously to satisfy his needs and to resolve his
conflicts. He demands to be heard and consequently disturbs the entire
classroom.
l In every class, there may be 3-4 children who are deviant in behaviour to a
significant degree.
l In addition, there are many children who cannot and do not express their
problems and feelings and they need help from a skilled professional.
l Teachers must be aware of and sensitive to the needs of these children.
Family influences
There are variety of ways in which the family influences children. There are
many lasting benefits to children when parent and home are structured, yet flexible,
and where adults demonstrate positive attitudes and behaviour toward school learning.
The benefits include higher school achievement rates, higher attendance rates, lower
delinquency and dropout rates, and increased high school completion and college
university admission rates(Ziegler,1987).
Providing stimulation to learn

The availability of appropriate play materials in the home, throughout infancy
and toddler hood, has a positive effect on achievement in early elementary school,
particularly in reading achievement (Bradley, 1988). It is especially important for
the home to have manipulative that encourage the young child to have a variety of
sensory experiences, and to be able to develop finer and gross motor skills.
Social / Cultural exposure

Parents who provide an array of enriching cultural and social experiences
during pre school and early elementary school have children who perform better on
achievement tests and are rated as more task oriented by their teachers (Bradley et al,
1988).Social and cultural activities that are recommended include frequent use of
libraries, museums, Zoos, historical sites, and other places of interest.
Problem-solving strategies
Parents who expose their preschoolers to problem-solving strategies are more
likely to have children who use them (Freund, 1990). Mothers who interact with
preschool children in problem-solving tasks, and expose them to open-ended questions
about that task, have children who later demonstrate greater independent performance
with similar tasks requiring problem-solving skills.
Style of parent-child interaction

Authoritative: An authoritative parent-child interaction balances acceptance
with limits, and is positively related to self-esteem, social acceptability, and
achievement in young children ( Elings, 1988; Estrada et al, 1987; Bradley et al,
1988). The authoritative parent seeks democracy. The authoritative style is warm,
responsive to the child's needs, and consistently sensitive. At the same time, it imposes
reasonable limits without resorting to belittling or punishments that are abusive,
punitive, or inappropriate for the child's stage of development. Authoritative parenting
seeks to enhance the happiness of both the child and parent.
Warm and responsive
Parents who are responsive to the needs of their young children through
their active participation and assistance in the child's play have children who
demonstrate socially acceptable classroom behaviour at age ten. The research suggests
that responsive parenting in early childhood enables children to feel more comfortable
in social interactions and act more responsibly themselves in situations encountered
later in childhood (Bradley et al, 1988).According to a study by Estrads, mothers
who display affection are responsive, flexible, and accepting and who refrain from
punitive or harsh punishment have children at the age 4 who are more likely to play
independently. By the age six, children are more likely to choose challenging games
and activities that they self-initiate (Estrada et al, 1987).
Structure and routine

Modeling and teaching order, structure and daily routine in the home are
essential for the development of good school work habits in children (Bloom, 1981).
Suggestions for providing positive structure, routine, and limits on the children in
early childhood include regulating television and videotape viewing, enforcing regular
bed time hours, assigning age-appropriate chores, providing regular physical exercise,
and monitoring non nutritious snacking. A 1989 study to investigate the relationship
between paternal child rearing practices and motivation to achieve in preschoolers
found that fathers in their homes appeared to have preschool children who
demonstrated greater achievement and motivation in school (Nogy, 1989).
Family involvement
The respect between teacher and parent is a critical element in helping a
child develop positive self-esteem. While the amount of time parents spend involved
with their child's school is important, research shows that if a child knows that the
family and school agree and respect each other, the impact on the child's evolving
self-image is greatest (Greenberg 1988). Active family involvement in early childhood
education shows a demonstrable effect on a preschooler's mastery of basic skills
needed for elementary school success. Less active forms of family involvement,
including attendance at special events, parent organizations, and parent teacher
conferences, show little impact on behaviour or progress reports that measure mastery
of basic skills.
Overt conflict in the family is hard for children to deal with, particularly if it
is violent, sustained and frequent. Some children become directly involved in the
conflict and are harmed both physically and psychologically. The child's reaction to
the conflict is often complex, ill-absorbed and distressing even if not always expressed.
Some children will try to distract their parents from the arguments by whatever means,
often with the result that they themselves are blamed for the conflict. A child's method
of distracting may be to display disruptive or aggressive behaviour or self-harm, with
the result that the parents sometimes unite to chastise him. Children also need help to
realize that their parents are changing and have to cope with themselves.
Parenting
'Parenting' may be defined as purposive activities aimed at ensuring the

survival and development of children. The word 'parenting', from its root, is more
concerned with the activity of developing and educating than who does it. In modern
parlance, however, 'parent' denotes the biological relationship of a mother or father
to a child. We qualify it by such words as 'adoptive' or 'foster parents', 'parent surrogates'
or 'carers', to keep the biological relationship distinct. On the other hand, the verb 'to
parent' (or more commonly, 'parenting') denotes a process, an activity and interaction,
usually by grownups with children, but not necessarily or exclusively their own.
Usually is an important qualification because there are also 'parental children' or
young carers who engage in parenting activities with their disabled or otherwise
needy parents, or younger siblings (Barnett and Parker 1998).
Parents do many things for and about their children, in a multitude of contexts,
throughout their common life spans, aimed at promoting children's welfare. Given
the enormous range of what parents do parsimony demands finding the core activities
that are necessary and sufficient for 'good enough parenting'. These appear to fall
into three groups: care, control and development. Each of these has two facets: 1)
The prevention of adversity and anything that might harm the child; and 2) The
promotion of the positive and anything that might help the child. These are usually
age and culture appropriate, since what may be helpful with a young child may not
be so with an older one, and what may be acceptable in one culture is not necessarily
so in another.
Knowledge and understanding are concerned with parents' abilities to

recognize focally their children's 'needs' through the lifespan, arising either from a
deficit in the child or the urge for positive enhancement. A parent has to understand
what the child's behaviour /condition signifies before responding appropriately to it.
Knowledge and understanding are the essential starting point of active parenting.
Motivation for parenting entails elements of the biological urge to have children;
cultural pressures; personal and social support for parenting; and constraints on it
(Eggebeen and Knoester, 2001). Inconsistency, on the part of a parent, for example,
may be more detrimental to a child who benefits from regularity and predictability
than to a child with an easy going and flexible temperament.
Some theories of parenting focus primarily on the emotional context of parent-

child relationships. For example, attachment theory holds that parents who provide
emotionally supportive, care giving, characterized by warmth, sensitivity, nurturance
and contingent responsiveness, cultivate secure attachment with their children, which
in turn promotes positive developmental outcomes (Bowlby, 1969; Ainsworth et al,
1972). Emotional stability and emotionality may influence several aspects of
parenting. Less emotionally stable parents tend to overreact to negative events or
circumstances, such as their children's misbehaviors (Belsky et al, 1995). Even
emotionally stable parents get moody at times, however, and these transient moods
may influence parenting.
Since most of the parents especially who have children with mental health
problems (especially Behaviour problems) indulge in faulty child rearing practices,
lack proper role models, there is a need to give training to them in 'effective parenting'
these children. At the same time it is very important to handle family issues like
discord in the family, support system, strength in the family system to manage
behaviour problems in children and to manipulate the environment. Parent training
programme is one of the important functions of psychiatric social workers in the
child mental health set up.
Origin and historical aspects of psychiatric social work
Psychiatric social work had a relatively recent origin in the United States of
America. In the beginning of 20th century, Miss Mary C. Jarrett who was working
in the Boston Psychopathic Hospital carefully studied and outlined social aspects of
mental patients. In 1905, the Massachusetts General Hospital established a social
service department and workers in this department were used by neurological clinic
as an aid for both more accurate diagnosis and effective treatment.
Initially social work was mainly concerned with the practical day-to-day
needs of the poor, the deviant and the disadvantaged (Goldstein, 1975). During the
19th century social workers employed a meager set of skills and techniques applicable
to the limited goals of determining people's eligibility for basic commodities and
services and then providing them. However, around the turn of this century social
workers became more concerned with people suffering from emotional and
interpersonal difficulties; and an interest in mental hospital aftercare led to
specialization in psychiatric social work.
A great deal of emphasis has been put on children's welfare. Social services
for children seek to provide opportunities for healthy growth and development to all
children. Our constitution says that children and youth be protected against
exploitation, moral and material abandonment. Besides the services for normal
children, there are special services for the orphan, the destitute, the delinquent, and
the physically and mentally challenged children. These children need special care,
generally in an institutional set up.
The social work contribution is to help family members and sometimes the
children directly with problems of development like speech and language disorder,
learning disabilities, behavior disorders, failure in establishing control, e.g. persisting
enuresis and encopresis; neurotic disorders, e.g. .children with fears, phobias, anxiety,
depression; abnormal reactions to loss, separation and bereavement, psychosomatic
illness, other psychiatric and organic disorders.

Child guidance treatment and its principles
Child guidance methods originated in the pioneering work of Haley in USA.

As a psychiatrist to a juvenile court in Chicago the first scientific study of juvenile
delinquents was attempted by him. Stevenson and Smith defined child guidance as
'attempts to marshal the resources of the community on behalf of children who are in
distress because of unsatisfied inner needs, or are seriously at outs with their
environment -children whose development is thrown out of balance by difficulties
which reveal themselves in unhealthy traits, unacceptable behaviour, or inability to
cope with social and scholastic expectations' (Steven and Smith-American CGCs
1934).
Child Guidance is one of the medico social amenities and may best be defined
as a centre for the organized and scientific study and treatment of maladjustment in
children. The problems of children are not disease entities but symptoms or
manifestations of a disordered or maladjusted personality. Thus when a child is
referred to a child guidance clinic, one finds very often that there are associated
problems in addition to the main problem for which his /her parents have brought
him/her to the clinic.
The term Psychiatric Social Work was coined by Adolf Mayer and the first
psychiatric social worker was appointed in Manhattan State hospital in 1905. the
first psychiatric social worker was appointed in C.G.C. in Chicago in the year 1909.
Children with psychiatric disorders were first seen at the Bethlehem Royal Hospital
as long ago as 1800 and Henry Maudslay was unusual among psychiatrists of his day
in appreciating the importance of psychiatric disorders arising in childhood.
Work of Healay and Bronner in C.G.C. influenced the multidisciplinary

approach. To begin with the role of psychiatric social workers in the past was data
collection, liaison between clinics and agencies carrying the recommendations to
schools, social agencies and courts. With the growing awareness of interpersonal
relationship in the development of psychiatric disorder and it was clear that only
advice did not change the environment. After II world war following the disaster
and because of lot of homeless and orphan children, a new dimension for social
workers became prominent. Direct contact with children and coordinating service
in a multidisciplinary team became popular.
Indian scenario
The first psychiatric social worker to be appointed in a psychiatric setting in

India was in the year 1937, when the Tata Graduate School of Social Work in Bombay
(now Tata Institute of Social Sciences-TISS) appointed a psychiatric social worker
in their Child Guidance Clinic. The social worker concentrated mainly in helping
the families of the children who were referred to the clinic for treatment of various
types of behavioural and emotional problems. In the subsequent decade, a few more
social workers trained in psychiatry were appointed in psychiatric settings dealing
with emotional problems of both children and adults.
Gradually psychiatric social workers were appointed in mental hospitals in

Madras, Ranchi and the All India Institute of mental health( now national Institute of
mental health and neurosciences-NIMHANS) Bangalore. NIMHANS is the second
institute where first psychiatric social worker was appointed in the child guidance
clinic in the year 1978, though child guidance clinic was there since 1950s. Since
1978 psychiatric social worker was also involved in training and teaching M.Phil
(PSW) students in child guidance clinic (now Child and Adolescent Psychiatry unit).
Today psychiatric social workers work with children directly, their families
and schools. The psychiatric social workers with training are capable of handling
varieties of cases in the child mental health settings. For example: they work with
MR children, children with other developmental disabilities like autism, learning
disabilities, attention deficit hyperactivity disorder, emotional problems, obsessive-
compulsive disorders, adolescent adjustment problems, and psychosis where
psychosocial intervention is essential. They are involved in counseling, behavior
modification, parent training programmes, school mental health programmes and so
on, to work towards preventive, promotive and rehabilitative aspects of child mental
health.
The fundamental objective of child guidance is to aid socially and emotionally

maladjusted children. In the beginning, it was designed to handle children's problems
on an individual treatment basis. Interest in mental illness and in delinquency
contributed to the rise of child guidance movement in genuine ways by considering
environmental factors too. The growth of knowledge within social work itself should
not be neglected. However, the accumulating experiences of social workers in their
various specialties, gave strength to the child guidance movement (Stroup, 1965).
In India there are very few full fledged teams of mental health professionals, including
psychiatric social workers. Some clinics have psychiatric social workers as persons
in charge of child guidance clinic and psychiatrists and psychologists as part time
workers. In some other clinics there are only psychiatrists and psychologists and no
social workers appointed. Most of the social workers who are working in child
guidance clinics and family counseling centers are not trained psychiatric social
workers. The number of trained psychiatric social workers to work with children can
be counted in fingers. With the growing awareness of interpersonal relationships
and child-rearing practices and other psychosocial factors like anomalous family
situations, parental marital disharmony, separation, divorce, adoption, child labour,
child abuse, street children, school problems, children in conflict with law and so on,
there is definitely an urgent need of psychiatric social workers to work in the child
mental health set up for psycho social intervention.

Mental health problems in children
Every child is unique, and so is their development. Children are vulnerable
to mental health problems. These problems vary according to their age, the biological
and psycho social factors. Knowledge about these problems becomes very essential
for the mental health professionals as many of them can be better treated, if identified
at an early stage. Following are the most commonly seen mental health problems in
children.
Developmental problems
Speech delay
In infants, vocalizations develop greatly during the first year. The young
child's understanding of gesture is developing at the same time and frequently he can
respond to and wave "bye bye" before he can say it. For a brief period before speech
emerges, gestures may be used to communicate. The first meaningful words normally
appear about 12 months of age but there is considerable variation, so that in some
5% of children this occurs by 8 months and in another 5% it does not occur until
after 18 months. The child who is slow to talk poses a common problem of considerable
interest to the professionals working in the field of child psychiatry. One of the most
frequent disorders associated with speech delay is mental retardation. Hence many
children who are slow to speak are wrongly thought to be mentally retarded when
infact they are of normal intelligence. Deafness, cerebral palsy, and developmental
disorders are the next commonest conditions associated with mild to moderate delays
in the acquisition of speech.
Mental retardation
It is a sub average general intellectual functioning, resulting in or associated
with concurrent impairments in adaptive behavior and manifested during the
developmental period. Children with mental retardation will have delays in more
than one area of development, such as motor, speech, social and adaptive milestones.
Depending upon their Intelligent Quotient (IQ) scores, those having mental retardation
can be classified in to 4 groups: Mild, Moderate, Severe and Profound. The common
causes are genetic factors, maternal exposure to medications, maternal exposure to
infections during pregnancy, complications in delivery, low birth weight, seizures,
meningitis, encephalitis, poor nutrition etc.
Pervasive development disorders

This group of disorders is characterized by qualitative abnormalities in
reciprocal social interactions and in patterns of communication, and by restricted,
stereotyped, repetitive repertoire of interests and activities. These qualitative
abnormalities are a pervasive feature of the individual's functioning in all situations,
although they may vary in degree. In most cases, development is abnormal from
infancy and, with only a few exceptions, the conditions become manifest during the
first 5 years of life. It is usual, but not invariable, for there to be some degree of
general cognitive impairment but the disorders are defined in terms of behavior that
is deviant in relation to mental age. Till today the exact cause of autism is not known,
hence there is no single medicine to cure this disorder. The universally accepted only
treatment for this condition is training.
Attention deficit hyperactivity disorder

This disorder is characterized by an early onset (before 7 years of age) and
the combination of overactive, poorly modulated behavior with marked inattention,
lack of persistent task involvement, restlessness, impulsive tendencies and a high
degree of distractibility. These characteristics are pervasive across situations and
persistent over time.
Specific learning disabilities

The term, "Learning Disabilities" is widely applied to problems that pose
obstacles to educational achievement. Learning difficulties can occur in the context
of global delays in development or more specifically, where there are circumscribed
deficits in cognitive processes. These include reading difficulties, difficulties with
writing/spelling (dyslexia), and / or arithmetic difficulties (dyscalculia).
Emotional and conduct disorders

Emotional disorders are those which are distressing to the child and it is an
internalizing problem whereas conduct disorders are those which are distressing to
others in the environment.
Emotional disorders
Enuresis
Enuresis or 'wetting' can be defined as involuntary emptying of the bladder
in the absence of an organic cause in a child over the age of 5 years. Enuresis may be
nocturnal (happening only in night, diurnal (by day), or both. Factors sometimes
associated with wetting include:
l A family history of bed-wetting in parents or sibs

l Unsettling events in the pre school period, such as instability of family
relationships, divorce, or separation, or a history of unplanned separation of
the child from his family.
l The presence of behavioral problems in the child and
l General developmental delay
Encopresis
Encopresis involves the passage of feces of normal or near normal consistency
in inappropriate places (including clothing). It may alternate with soiling- the passage

of liquid or semisolid feces into clothing. A variety of factors in the parents, child,
and in parent-child interaction have been identified as probably causative.
School refusal
In school refusal, an irrational fear of school attendance is the core symptom.
Fear may be based partly or fully on fear of separation from home or from one or
both parents. It may, however, also be specific to school attendance or some aspect
of it. The problem usually shows itself first at the time of change of school or after a
period of absence for some other reason, such as a minor illness. The onset may be
acute, but is more often gradual with absences building up over a few weeks.
Unwillingness to go to school may be expressed openly- the child, for example,
saying that he dislikes a particular teacher, or that he has been bullied at school.
Alternatively, the refusal may present with physical symptoms of tension and anxiety,
more or less obviously linked to school attendance. Abdominal pain, headache, nausea,
limb pains, attack of palpitations, and a range of more unusual symptoms may be
present.
Fear and anxiety

Fear is an inevitable and necessary emotion in everyday life. However
particular fear may outlive their purpose. Fear during infancy is mainly related to
actual events in immediate environment. As the child grows older, fantasy and
imagination come to play a great role with the child's increasing ability to reflect on
past events and to anticipate the future. With increasing age, there is a decrease in
fears of tangible and immediate situations, specific objects, noises, falling and danger
of falling, strange objects and persons. On the other hand, fears of imagery creatures,
of the dark or being alone or abandoned increase. Fear about something may lead to
a state called anxiety which can develop in children who are emotionally quite resilient
and stable. These anxiety prone children may have been different from their sibs
since early childhood in terms of their sensitivity and over reaction to stress, and
their tendency to be worried over new situations. Sometimes anxiety states are
precipitated by an actual frightening experience or an accident. In other cases, there
is contagion of anxiety from chronically anxious and dependent parents.
Phobic states
Phobic states are emotional disorders in which there is an abnormally intense
dread of certain objects, or specific situations which normally do not have that effect.
Both fears and phobias involve similar behavioral expressions, subjective feelings
and accompanying physiological change, but in phobias the responses are excessive,
persistent and maladaptive. The phobic states most commonly encountered in children
involve fears of animals, death, insects, the dark, noise and school.
Conversion / dissociative disorders

In conversion disorder physical symptoms or mental symptoms which usually
signify physical disease are present in the absence of evidence of such physical disease.
Conversion is said to occur when an emotional conflict is transformed into a physical
disability. This may occur in a way that has obvious symbolic significance. Conversion
disorder can usually be seen as a type of 'abnormal illness behavior' occurring when
a child develops a need to be a patient when he is not physically ill even when he has
to suffer inconveniences. Being ill can be seen as a pattern of behavior. A physically
ill child behaves appropriately when he goes to the doctor, takes time off school,
acknowledges sympathy, etc. The child can be seen to be enjoying the benefits of the
'sick role'.
Obsessive compulsive disorder

Normal children often show rituals in their early years. Particularly between
the ages of 4 and 8 years, children may take great care to avoid the cracks while
walking on pavements, hate to be parted from favorite toys, or line up their possessions
in a very particular way. Such behaviors persist into adult life in the form of
superstitious beliefs and practices. When irrational thoughts or behavior of this type
become handicapping, they form part of an obsessive-compulsive disorder. Obsessions
are recurrent and persistent ideas that are experienced as senseless and which the
individual tries to suppress. Compulsions on the other hand, are repetitive forms of
purposeful behavior performed in response to an obsession and aimed in some way
at warding off the obsessive ideas or some dreaded event
Conduct disorders
All children show, at times, behavior which contravenes social norms or
personal or property rights. Most will go through brief periods of stealing and lying.
A substantial minority go through phases when they bully other children, are
aggressive in other ways, or truant from school. The child with so- called conduct
disorder is different only in the extent and severity of difficult behavior. In ICD 10
(World health organization, 1992) conduct disorders are divided into those confined
to the family context, and into unsocialized, socialized, and oppositional defiant
types.
Major mental illnesses / Psychosis
Schizophrenia
Schizophrenia is a condition with characteristic disorders of thought,
perception, mood and sometimes posture. The condition most commonly presents
for the first time in adolescence or early adulthood. It may, however, present in
characteristic form before puberty. The characteristic features are:
l Thought disorder: The child or young person is likely to have difficulty
expressing his thoughts, and be incoherent and apparently illogical.
l Delusions: These are false beliefs which are impossible to change. They usually
take a paranoid form, i.e. the child or young person believes those around him
are hostile and threatening.
l Hallucinations: These are false perceptions without sensory stimulation.
l Disorder of motility: Catatonic behavior in which the young person takes up
abnormal postures or enters into an unresponsive state or 'stupor'.
Bipolar affective disorders

According to the International Classification of Disorders (ICD 10)
disturbances of mood or affect is classified into 2 groups, unipolar or bipolar disorders
and depressive disorders. In the first group, there are reasonably clear cut episodes
of hypomania and/ or severe depression often with psychotic features. In depressive
disorders only depressive episodes will be occurring. In general, the personality of
children and young people who suffer from bipolar disorders is excellent with good
school attainment and peer relationships. Bipolar disorders are rare before puberty,
but increase in frequency of presentation during adolescence.
Specific issues in adolescence

Adolescence is generally considered as a period of storm and stress. This
stage of development is marked by physical and psychological changes. Social changes
also occur when a child gets into adolescence. Because of the changes in the hormonal
levels, the child becomes more stubborn. As they are neither children nor adults they
tend to get confused about their roles. During this stage of development children
consider their peers as the role models and tend to disobey their parents. This creates
problems in the family.
The rapid physical changes and the onset of menarche pose more tension in the
adolescents. The commonly seen problems in adolescents are:
l Adjustmental Problems
l Drug and alcohol abuse
l Behavioral and conduct disturbances
l High risk sexual behaviors
l Identity crisis
l Interpersonal relationship problems
Psychosocial interventions with children
In all the above mentioned mental health problems in children, the Psychiatric Social
Worker play an important role in Psycho social interventions, working with individual
child, parents and other family members. Some of the intervention techniques are as
follows:
Behavior modification
Behavior modification is a system of treatment for changing behaviors. The

techniques are based on learning theories and involve direct teaching and learning.
In this system, there is a lot of emphasis on direct observation, measurement and
recording of behaviors. Some key concepts of behavior modification are:
1. Goal specification: This means a very specific and detailed description of the
desired changes in the behavior.
2. Task Analysis: This means breaking the activity to be learned into several
sequential steps to make it convenient for the person to learn.
3. ABC Analysis: This analysis is frequently required for drawing a management
plan for problem behaviors and involves the analysis of Antecedents, Behaviors
and their Consequences. Such an analysis leads to a thorough understanding
of problem behaviors and helps in choosing proper techniques.
4. Rewards and reinforcers: The term rewards means pleasant events following
a given behavior and which increases the frequency of occurrence of that
behavior. Rewards are extremely useful to develop and strengthen new skills
in children. To be of good use, the rewards should be given a) immediately b)
consistently c) appropriately and d) contingently.
Behavior Modifications are best used with children who have mental retardation
and other developmental disorders.
Case work with children
Case work is one of the important methods of social work. This method is
used in dealing with children as well as adults who have mental health problems. In
case work, the social worker helps the individual child to solve some of his/ her
problems. Children are helped to develop their self esteem and sense of competence,
helping them to cope with their problems in a better way etc. Anger management
issues are also sometimes taught as part of case work. Here, the child is asked to
identify the situations that make him angry by doing the Antecedent- Behavior-
Consequences (ABC) analysis. Techniques like relaxation, reverse counting, diverting
attention etc. are explained to the child. Psycho education about the nature, the
symptoms, the treatment and the prognosis of the illness is also given as part of case
work with children.
Play therapy
Play is one of the important mediums to work with children who are very
young or who have difficulties in expressing their feelings. Use of play helps the
therapist to establish a good working relationship with children. Through play, some
of the inhibited conflicts in the minds of children can be brought out. If the child has
some particular liking or disliking to any of the family members can also be understood
through play therapy.
Group work with children and adolescents

Group work can be done with children who have a common problem or
difficulty. The minimum number of children required for any group is 5 and the
maximum is 12. Group itself has a healing effect on its members. It's easy for children
to explain their specific problems in a group rather than in individual sessions.
Children feel accepted in the group and change is also more likely to happen in the
group compared to individual work. Adolescents can be taught about health, sex and
sexuality issues through group work. Inhibitions are seen to be less in group sessions.
Working with parents
As children are very small and not able to express their problems and needs,
(especially very small children below 5 years of age) it is important to work with
parents to understand children and their background. Very often children develop
behavior problems because of the faulty upbringing and adverse environmental
influences. Hence, it is very important to work with parents and significant others in
the family where the child is growing. Parental attitude, their rearing practices and
their expectations are taken into consideration in addition to handling parental stress
and coping strategies. When parents are handled, children show improvement in
their behavior.
Training
Training is one of the most important treatment methods for children who
have developmental problems. Training can be done by the parents or the immediate
care takers of these children. The main areas for training in developmental disorders
are:
l Self help skills like brushing, eating, bathing, toileting, dressing and undressing
l Attention enhancement tasks
l Socialization skills like how to mingle with people, what needs to be done
when someone comes home
l Communication skills like how to indicate needs, how to verbalize feelings,
etc.
Training needs and methods will differ for different groups of children. To
have any observable changes, the trainings should be given for long periods.
Group intervention
The group therapy for the parents of disturbed children is an important
intervention. This is purely educational and supportive to the parents of psychiatrically
disturbed children as well as the parents of mentally retarded children. The natural
tendency of parents to discuss child- rearing problems with other parents can be
channeled into constructive process through group discussion facilitated by
professional leadership, setting appropriate goals. The contents of the groups are as
follows:
l Psycho Education: nature of illness, training misconceptions, cardinal
symptoms, prognosis etc.
l Teaching behavioral management techniques: reinforcements, timeout, ignoring
etc.
l Healthy child rearing practices
l Family relationships / involvement in child's activities
l Expectations
l Interaction
l Empowerment
l Supportive therapy.
Individual/ marital work with parents

Whenever parents have any personal or marital problems which come in the
way of child's healthy development, they are taken for individual work separately.
Specific issues related to the problems their child has will also be discussed in such
sessions. Supportive work is done on individual basis with the parents when and
where it is required. Psycho education regarding the nature of their child's illness,
the symptoms, medications and the prognosis are also discussed with parents in
individual sessions. For parents of very young children, the healthy child rearing
practices are taught to them. Disciplining issues and how to handle temper tantrums
etc. are also discussed in individual sessions with the parents.
Rehabilitation
Rehabilitation is a way of re-integrating the child into his/ her environment.
In child guidance clinics, rehabilitation is an important area for psychiatric social
work intervention. The different modes of rehabilitating a child are: placing the child
under institutional care if they don't have any family members, placement of children
with development delays in special schools for better training and development,
mobilizing resources in the form of financial support for those who cannot afford the
treatment charges, enhancing community and social support by initiating home visits,
school visits, agency visits, etc. It could also be assisting the family and the child in
availing educational and financial benefits in the form of National Open schooling
for children having Learning Disabilities, disability benefits for the physically and
mentally challenged children.
Psychiatric Social Work Practice in Child Care Institutions
The 1989 UN convention on the Rights of the Child guarantees every child
the right to family. The family is the natural environment for the optimum development
and well being of all its members, especially the child. If the family is unable, unwilling
or not present to provide a loving and nurturing environment, the child has the right
to grow up in an alternative setting. One of the alternatives is child care institutions.
In fact, in India the traditional response to child destitution is the institutionalization
of children. Institutions thus have been playing an important role in providing services
to children who are deprived of a natural family and are run by the government as
well as private bodies.
In addition to government run institutions, there are institutions run by the

private organizations, some of them generate funds by themselves, while others receive
aid from private funding agencies. Childcare institutions are varied not only in
numbers, but also in the nature of services provided to the children. The care called
by different names as adoption centers, shelter homes, orphanages, hostels for poor
students, ashrama schools, etc., and in case of government institutions they are known
as observation homes, Juvenile homes, Fit Persons institutions, Backward class and
Minorities Hostels etc. Institutions provide different kind of services ranging from
adoption, foster care, day care to residential care.
Large number of children and adolescents are accessing the services from
these institutions and for many of the children institutions are the only source of
support. However, many studies and reports suggest that child care institutions have
detrimental effects over child's growth and development instead of promotive/
rehabilitative effects on children. Majority number of children and adolescents
experience some sort of emotional and behavioural disturbances as it is difficult to
provide personalized care in the institutions as well as limited opportunities for
children to experience familial warmth and emotional experiences. Most of the studies
on child care institutions and lives of children institutions indicate that the longer the
children stay in institutions, the greater is the likelihood of emotional or behavioural
disturbances and cognitive impairment.
Circumstances that cause children to live in institutional care
l Children who are orphans and have no primary or secondary social support
l Children who have families but families are not able to take care of them due
to some dire circumstances such as poverty
l Children who have experienced sexual or physical abuse in the family
l Children who have run away from family
l Children in conflict with law
l Children rescued from trafficking or labour or beggary
l Children with mental retardation or severe mental illnesses
l Children with HIV/AIDS or serious physical ailments
Psychiatric social work in observation homes for children in conflict with law
Children and adolescents detained in observation homes for the crimes which
they have committed tend to exhibit various behavioural as well as emotional problems
such as conduct problems, drug abuse, depression, anger dis-control, low frustration
tolerance and so on. The correctional nature of activities tends to ignore the
rehabilitative approach for the children in conflict with law. Somehow this area has
been ignored by the social workers. Work with such children should aim at
reintegrating them in the mainstream of the society. Practice and research have
consistently shown that therapeutic inputs, preventive and promotive programs can
bring about significant behavioural changes in such children and adolescents. Both
group work as well as case work can be done with these children. But research
shows that group work is found to be more effective with these children. The group
serves as a means of diminishing feelings of isolation and enhancing social skills of
these children and adolescents. Group work with these children also addresses the
issues of distorted learning, impaired abilities of self mastery and control. Group
work also ensures that greater number of children take treatment compared to
individual therapy. Group setting in such institutions affords an extremely good
opportunity for training another therapist. The issues which can be dealt in group
work with these children are:
1. Anger management
2. Life skill education
3. Stress management
4. Adolescent enrichment programs
5. Value orientation
6. substance abuse related issues
Psychiatric social work with children in need of protection

This category comprises of children:
1. Orphans
2. Street children
3. Victims of child labour
4. Victims of physical or sexual abuse
5. Victims of neglect
Functions of the psychiatric social worker
Assessment
Neglected children, abused children or vulnerable children who are in need
of care and protection, call for complete holistic assessment. The training of the
psychiatric social work actually enables the psychiatric social workers to do a thorough
assessment of such children. The assessment of such children consists of forensic
interview of children who are physically or sexually abused, family assessment,
assessment of psychosocial problems, assessment of child's mental health, and so
on. This assessment is a very important task as the psychiatric social workers can set
the target of psychosocial interventions as well as other therapeutic interventions
based on this complete assessment. The inputs on assessment can also help other
professionals in the child protection system such as Child Welfare Committee, Juvenile
Justice Board etc in planning the interventions. Therefore, it has been recommended
that there should be presence of mental health professionals preferably psychiatric
social workers in such committees so that holistic assessment and interventions can
be planned.
Case work
Psychiatric social workers can be the key personnel in planning to
psychosocial intervention for such children. The training of Psychiatric social workers
enables the psychiatric social workers to understand the social diagnosis as well as
social dynamics of children coming from vulnerable situations. Following which the
psychiatric social workers can plan the effective and appropriate psychosocial
interventions for them. Case work may include family study, family counseling and
therapy, individual therapy, placement of the child, resource mobilization, school
interventions and so on.
Multidisciplinary team work

As mentioned earlier, psychiatric social workers with their training and skills
can become the integral part of some of the systems such as child welfare committee,
juvenile justice board, child protection units, family counseling centers, child guidance
clinics, school management boards etc. In such systems, psychiatric social workers
can team up with other professionals such as psychologists, child psychiatrists, child
protection officers, child development project officers, advocates, educationalists,
counselors and policy makers. The multidisciplinary approach would be to facilitate
the holistic care and protection to children coming from vulnerable backgrounds.
Training the personnel of child care organization

Some of the data available on the various agencies in India that deal with
children and the state of therapeutic interventions shows that there is dearth of
counseling and therapeutic services. A study done on child care institutions in
Karnataka in 2001 shows that there is a lacunae in providing counseling and
therapeutic services. The situation is worse in Government institutions where there
is even absence of counselors. V. B. Khandekar in his paper on "integration counseling
services in destitute homes and correctional institutions" says that counseling and
guidance services are not given the importance they should have been in these
institutions. Child Guidance Centers in India is yet another source of providing
therapeutic services to the children. But considering the population of children in
the country, the number of CGCs is grossly inadequate. These services are also
conspicuous by their absence in the rural areas. School counsellors are the other set
of professionals who can provide effective counselling services but very few schools
have provision for counsellors. Considering all these issues, it becomes extremely
important for the psychiatric social workers to reach such organizations and extend
services to the children. But on the other hand, due to lack of trained professionals,
it becomes difficult to reach all the organizations and institutions for extending
support. For this purpose, training the personnel of child care institutions would be
very effective in providing services to maximum number of psychologically and
behaviorally disturbed children. The training may consist of counseling skills,
interviewing skills, life skill education, health promotion and so on.
School Mental Health Program
Schools play a crucial and a formative role in the spheres of cognitive,

language, emotional, social and moral development of children and adolescents.
Children and adolescents face various challenges in academic life, social life, and
family environment. Competition in schools and colleges, generation gap, relationship
problems in family, peer pressure, burden of academic activities, etc pose greater
demand on child's capacities and as a result many children and adolescents are having
various stressors and emotional disturbances. WHO reports that nearly one in every
five children will have emotional and bahavioural disorders at sometime in their
youth regardless of region or socioeconomic status. Studies have consistently shown
that almost 10% of the children in schools have emotional as well as behavioral
problems out of which 3 % of children suffer from serious emotional disturbances. It
becomes very important to address this population and provide appropriate
interventions as early as possible. To address such a large number of populations,
schools are found to be appropriate and effective agencies to deliver the interventions
to children and the adolescents.
Schools as one of the socializing agents for the child's life have profound
impact on child's overall growth and development. Large numbers of children attend
schools at least in the early childhood. Schools also play a very crucial role in building
one's self esteem and a sense of competence. Mental wellbeing of the children is
directly correlated with the child's motivation to stay and learn in the school. Thus
school mental health programs aim towards bringing about positive mental wellbeing
in children as well as providing experiences that will strengthen children's coping
abilities to counter the environmental stressors and disadvantages encountered in
their growing years.
The mental health programs implemented by the CGC's can be both

environment centered as well as child centered which includes working with the
schools to improve the general academic environment as well as working with children
on individual or group level. In school mental health programs, contributions and
participation of the teachers, school counselors are equally important. In fact, the
comprehensive school metal health program includes the instructions and training to
the teachers from all the levels of education.
School related problems in children and adolescents

1. School refusal
2. Specific learning disabilities
3. Conduct disorder
4. Emotional disorders
5. Neurotic disorders
Mental Health Programmes in Schools
Life skills education

Life skills education is a novel promotional program that teaches generic
life skills through participatory learning methods of games, debates, role plays and
group discussion. It aims at enhancing abilities of children and adolescents in dealing
with life stressors and promotes psychosocial competence among them. WHO (1998)
talks about ten life skills such as problem solving, decision making, creative thinking
critical thinking, self awareness, empathy, effective interpersonal relationships,
effective communication, dealing with stress and coping with emotions. Promotion
of these ten life skills aims at reducing the morbidity in students and reduces the
drop out rate in the schools.
Health promotion
Health promotion programs emphasize on the behaviour and health model
and aims at promotion of positive health behaviours in the children and adolescents.
These programs address the various psychosocial issues and problems such as drug
abuse, smoking, mental ill health and so on.
Sex and sexuality education

Current emerging issues of adolescents such as teenage pregnancy, suicides, running
away, and sexual abuse indicate the need of sex education in schools. Issues of
pregnancy, menstruation, gender differences, marriage and intimate relationships,
early sexual experimentation, sexual abuse, and HIV/ AIDS can be effectively taken
up in the school set up. Many of the problems can be prevented through sex and
sexuality education in the schools. Sex and sexuality education can be taught using
life skills approach.
Mental health orientation programs for teachers in schools

Teachers can best recognize the problems in their students. Teachers can
identify children with SLD, Mental retardation, behavioural and emotional problems.
But many times it has been observed that teachers ignore some of the significant
behaviour problems in the children and fail to identify problems at the early stage
which would facilitate early intervention and treatment for the child. For this purpose,
conducting mental health orientation programs for the teacher trainees or the teachers
will empower the teachers to identify the problems behaviours in children and seek
early interventions and treatment for them. The component of the training would be
orientation to causes of behaviour problems, commonly seen emotional and conduct
problems in children and adolescent, Specific Learning Disabilities, Mental
retardation, epilepsy, psychosis, orientation about referral agencies, remedial
education and counseling techniques.
Teachers as trainers for life skills

To reach the large number of children and adolescents, we have fewer
resources and trained professionals. In such situations, teachers can be involved in
training in life skill education program for children and adolescents. In the Life skill
education program the teachers are trained in life skills issues so as to transfer these
skills to the adolescents. Experience of working with secondary school teachers has
shown that teachers can be trained to impart LSE effectively. It has been also observed
that there is a significant change in the attitudinal approach of the teachers who are
trained in LSE. Teachers can also be trained in student enrichment programs which
would cover developing healthy study habits, preparing for the examination, and
stress management. This could be incorporated in the school curriculum and could
be conducted on regular basis.
Teachers as counselors
Considering the multifarious problems pertaining to achievement, adjustment,
learning, competitions, value conflicts and other activities of school life, it is essential
that they require timely assistance, guidance and suggestions, specially from teachers
in respect of various psychological and interpersonal difficulties. For this purpose,
the school teachers would be equipped with the practical knowledge of psychology
of working of growing children, types of psychological and psychiatric problems
and their early signs and symptoms, interpersonal relationship skills, principles of
interviewing and listening, sources of referrals, and ways and means of collaborating
with mental health agencies. This knowledge could be applied in day to day interaction
with the children, in the class room / hostels and in times of crisis. Counseling skills
training could be appropriately incorporated into the teachers - training curricula at
different levels - T Ch., B. Ed., and M. Ed. These mental health inputs no doubt
would prepare the teachers in mastering the skills of counseling. At the same time, to
effectively function as teacher - counselor, it is essential to have a thorough
understanding of the positive principles of mental health. *
School social work services

Many schools are offering counseling and guidance services through full
time psychologists and psychiatric social workers (school social workers). Based on
the work these counselors carry out in the schools, their services could be viewed as
follows:
I. Individual services
The student with the problem is identified and interviewed individually and
his / her problems are understood from biological and psychosocial point of view.
Depending on the problems, psychologists or schools social workers offer counseling/
psychotherapy sessions. Usually, students with problems are identified by the teachers
and referred to the school social workers. In case, they require other services, they
are referred to the nearby psychiatric clinics / child guidance clinics.
II. Group work services

Here children or adolescents are selected on the basis of the nature of
problems, temperamental traits and sociability. The counselors act as a therapeutic
agent in enabling the groups to have positive interactions in such a way that they
understand each other and solve their problems mutually. The group support provides
effective solution to the problems of the adolescents specially.
III. Parent teacher association meeting

The school social worker could introduce topics related to mental health of
children and role of parents and teachers in parent teacher associations. It is a forum
to work closely with parents. In such meetings, social worker could enlist the
participation of other mental health professionals like psychiatrists, psychiatric social
workers, play therapists and occupational therapists. Active participation of parents,
teachers and school administrators in discussing school problems and possible
solutions could go a long way in improving the physical, psychological and social
competence of children and adolescents. The areas discussed in such meetings are,
mental health problems in children and adolescents, normal child development,
parenting skills, parents support in school related issues and so on.
Research in the area of child and adolescent psychiatric social work
The psychiatric social work research in the area of child and adolescent
mental health pressing on the need for more of intervention based and evidence
based experimental research. At present, there is a great need for testing the efficacy
of different psychosocial approaches and techniques with children and adolescents.
Many researchers in the area of child and adolescent mental health have been involved
in experimental studies. Most of these studies have focused on the efficacy of life
skill education on different groups of children such as street children, juvenile
offenders, school children and adolescents. There are some studies which focus on
testing the efficacy of different techniques such as group work with adolescents,
behavioural modification with conduct disorder children, and supportive
psychotherapy with emotionally disturbed children, play therapy with abused children,
brief psychotherapy with disturbed children. There have also been some studies which
were conducted for parents of disturbed children such as efficacy of home based
training programs for parents of mentally retarded and autistic children, efficacy of
group work intervention with parents of disturbed children, supportive therapy with
parents of disturbed children and so on.
Further researchers have pointed out that, attention should be paid to other
contexts such as home, school or institutions. It has also been felt that the intervention
based research highlights the need to tailor the techniques appropriate to the population
and the stages of development. Process and outcome evaluations have been found to
be important in gaining insight into therapy or intervention effectiveness for which
both qualitative as well as quantitative research methods need to be used in a
complementary manner.

Chapter 2
CHILDLINE SERVICES FOR TROUBLED CHILDREN IN THE
COMMUNITY
K. Chandramukhi,1 & G. S. Udaya Kumar,2
Introduction
The family relationships are based on both hereditary and emotional bond
between parents and children. Many parents see their children as an extension of
themselves. As Gibran (1986) stated "the children are the perfect extension and
expression of the couple's love and caring. But most adults would be shocked if they
realize that a child in their care felt so desperate that they turned to an anonymous
help line to be heard. What leads children to make statements as ' I can't imagine not
being frightened' ' I don't think I can go on any more' (Macleod and Morris, 1996)
and how can we as adults improve our systems for giving children the support they
need in these circumstances?
The basic requirements for normal psychosocial development of a child

includes a warm and accepting environment with stable parents or parent substitutes
who are sensitive to the child's emotional needs and who provide appropriate
interaction and opportunities for play and consistent discipline, supervision and
support. According to United Nations Child Rights Convention (1991), children should
enjoy right to survival, education, good health, to free expression, to be heard, to
enjoy their own language. The children, whose needs are not met, have risk of normal
social, emotional and cognitive developmental processes. The psychosocial
developments of children are strongly associated with the quality of parent - child
interaction. There is a substantial increase in the rate of mental health problems in
children who are unwanted, experience rejection, hostility, markedly inconsistent
patterns of punishment or families with serious family discord. Many teachers, and
parents underestimate the potentials of children in promoting positive values and
ignore the process of their involvement in decision making (Lloyd, 1997).
The level of distress experienced by each child in any stressful situation will
depend on the nature of stressful event and perceptions of its harmfulness. Lazarus
and Abramovitz (1962) identified that the experience of stress was dependent on the
person's interpretation, perception or appraisal of how significant a harmful,
threatening and challenging event might be. A child will be distressed when he / she
is neglected (physical, emotional and educational neglect) or abused (physical,
emotional and sexual abuse) by the parents or relatives. The children especially in
urban setting who could not present their problems to primary and secondary networks
1. Psychiatric Social Worker 2. Associate. professor

(relatives, neighbors, and teachers) they would present their problems in the formal
service setting such as Hospitals, Child Guidance Clinics etc. Significant proportion
of children may fail to get into contact with these clinical settings and often found on
streets.
Unfortunately, we live in a society where even a child with a secure family is

not safe enough from abuse and breach of rights. Children who are in need of care
and protection (with no shelter, no family, and no protection) are especially vulnerable.
And when their rights are denied, which happens quite often, they have no one to
complain to, or to help them. There were a large number of services that aimed at
protecting children's rights, but they either remained untapped or were not popularized
well enough for the children to start using them.
The need was primarily to create an outreach for these children. More so the
vulnerable sections, such as girls, children with disability and children with mental
illness. The large number of these children, estimated by UNICEF to be around
800,000 in urban India alone, created a need gap for a nationwide help line to help
them live a better life. CHILDLINE is an organization, attempts to reach out to such
children who run away from home, neglected and abused, working as child labor.
We seek to provide a mechanism to reach out to these children and taking care of
their needs. The primary gaps that made creation of CHILDLINE necessary are:
Lack of immediate assistance when needed and no access to services

In India unfortunately, a large number of children are denied their right to
survival. The need for an emergency outreach service to respond to the immediate
needs of children for medical assistance, shelter and protection from abuse was widely
and urgently felt.
Lack of awareness about available resources

The lack of awareness amongst children / concerned adults about existing
services was a primary reason for these services lacking success. A comprehensive
resource directory of existing services, a mandate of CHILDLINE, helps ensure
optimum utilization of services.
Lack of co-ordinated effort between government and voluntary organizations

A partnership between government and non- government organisations is
essential to effectively reach out to children in need. The CHILDLINE strategy
therefore elicits and encourages this partnership so essential for a child friendly
protection system.
Lack of children's participation in programs

Most programs are not sympathetic to children's decisions, views and
opinions. They remain mere recipients of help without empathizing with their actual
needs. This acts as a barrier for building trust amongst children. Children's
participation in all aspects of programme planning, implementation and evaluation
is therefore an inbuilt component of the CHILDLINE service.
Child protection not on the national agenda

Since child rights is not on the agenda of key government departments and
decision-making authorities, child protection issues are mostly left on the backburner
and forgotten. This has resulted in a social setup, which is not child friendly and thus
leaves children vulnerable to breach of their rights. It is essential to ensure that
children's voices and issues are heard and placed on the agenda of the nation.
CHILDLINE is an organization, attempts to reach out to such children who run away
from home, neglected and abused, working as child labor.
CHILDLINE India Foundation (CIF) is a project of the Ministry of Social

Justice and empowerment (Government of India) in partnerships with State
Governments, NGOs, Corporate Sector, UNICEF and concerned individuals. CIF is
responsible for the establishment of CHILDLINE centers across the country, for
ensuring the quality of and monitoring the service throughout the country. CIF also
functions as a center for awareness, advocacy and training on issues related to child
protection.
CHILDLINE evokes a variety of responses. 'A glamorous concept', 'its elitist',

'Will children actually call to talk about their problems?', 'In developing countries,
telephone infrastructure is minimal', 'Will CHILDLINE be just one more service for
children?… the perceptions to starting CHILDLINE are varied. The following terms
will help us to understand CHILDLINE and also to have a better perception.
National: CHILDLINE is a project of the Ministry of Social Justice and

Empowerment, Government of India in partnership with NGOs, UNICEF, the State
Government and the corporate sector.
24- hour: CHILDLINE is accessible at all times
Free phone: Any child / concerned adult can call 1098 free of charge
Emergency: A crisis period in the child's life during which intervention is required.
This period could last from the time of the call to such time that withdrawing assistance
would put the child back into crisis.
Outreach services: CHILDLINE reaches out to meet the child who dials 1098.
Additionally CHILDLINE focused on creating awareness about 1098 amongst the
most marginalized group of children in the city / district through extensive outreach.
Children in need of care and protection: Up to the age of 18 years and in extreme
emergencies up to 25 years, children who are denied their rights, especially street
children, child laborers, children who have been abused, child victims of the flesh
trade, differently abled children, child addicts, children in conflict with law, children
in institutions, mentally ill children, children affected by HIV / AIDS, children affected
by conflicts and disasters, child political refugees, and children whose families are
in crisis. CHILDLINE aims to reach out to the most marginalized in the city / district.
Link children: CHILDLINE provides emergency assistance and then refers the child
to other organizations for long-term rehabilitation.
The aims and objectives

l To reach out to every child in need of care and protection by responding to
emergencies on 1098.
l To ensure access of technology to the most marginalized in urban as well as
rural areas and connectivity of 1098 through government telephone exchanges
as well as private exchanges.
l To work together with the Allied systems to create child friendly systems
l To advocate for services for children that are inaccessible, non existent or
inadequate.
l To strive for excellence in quality service to children in need of special care
and protection and to ensure that the best interests of the child are secured.
l To provide a platform of networking amongst organizations and to provide
linkages to support systems which facilitate the rehabilitation of children in
need of care and protection.
l To create a family of NGOs and Government organizations working within
the framework of a national vision and policy for children
l To learn from the experiences of CHILDLINE and the data generated and
jointly determine strategies to reach out more effectively to children.
The history of CHILDLINE

The history of CHILDLINE has been a process of building partnerships -
with children, NGO's, Government, academic organizations, bilateral organizations,
the corporate sector and the community. The concept of CHILDLINE as a service
was evolved when children conveyed their need for assistance when they had a
problem, especially when other day care services are not available. They wanted a
service that was available when they were ill or injured, when they were frightened
or angry, when they needed to talk or they needed to complain. For them CHILDLINE
was their service, to use to talk about to other friends and to abuse, if they were not
happy with CHILDLINE.
It took four years of planning with street boys, organizations working with
children and the telephone department before the service could be initiated on June
20, 1996 in Mumbai as a field action project of the Department of Family and Child
Welfare, Tata Institute of Social Sciences. Two years later (June 23- 25, 1998) the
Ministry of Social Justice and Empowerment (SJ&E) organized a workshop to
determine the need for a national phone service for children. There were 117
participants from 28 cities at the workshops to discuss the need for the service. At
the workshop, it was decided that the Ministry of Social Justice and Empowerment
(SJ&E) would support the replication of CHILDLINE across India in a phased manner.
CHILDLINE would have a national identity, retain its logo, number and colors across
the country.
CHILDLINE India Foundation (CIF)
In May 1999, CHILDLINE India Foundation (CIF) was registered as a project
of the Ministry of Social Justice and Empowerment (SJ&E) in partnership with
UNICEF, NGOs, State Government and the private sector. CIF, appointed by the
Ministry, acts as a Nodal agency for CHILDLINE across the country. Its functions
include monitoring of service delivery, developing training modules, research and
documentation, awareness and advocacy on issues related to child protection. It also
scrutinizes applications for funds, conducts follow - up with the Ministry and ensures
disbursal to the CHILDLINE cities. The CIF advocates for changes in policy and
law on issues related to children. The governing board of CIF is chaired by the
Secretary - Social Justice and Empowerment and has two representatives from the
Ministry of Social Justice and Empowerment (SJ&E), representatives from the
Ministry of Railways, Health, Law AND judiciary, Information and Broadcasting
and Telecommunications. UNICEF and the corporate sector are also represented on
the Board. The Governing Board also includes representatives from academic
institutions and individual members.
The operational strategy

A call coming into a CHILDINE Center is attended to by one of the team members
who work in shifts. This ensures that the calls coming in are attended to, all 24 hours
at the phone- receiving center. Depending on the nature of the call, be it by a child or
an adult, the team member responds to it effectively. This response could be by
going to meet with the child first and then linking him or her to medical help, shelter,
repatriation, rescue from abuse or even intensive counseling. If the team member
feels that some time will be involved in reaching out to the child in terms of physical
distance, then assistance from a support organization that is located in the vicinity of
the caller, is sought. After the emergency intervention measures are taken by the
CHILDLINE agency, the next step is to link the child with long- term rehabilitation.
This involves referral and networking with other organizations providing specialized
services. In this process from Response to Rehabilitation, the children's participation
is an integral component. The following chart depicts the working of CHILDLINE.

Dialing 1098 (Ten-Nine – Eight)
Child / Concerned adult contacts CHILDLINE by dialing 1098 or coming

directly to the phone receiving center
Hello CHILDLINE?
The CHILDLINE team receives and responds to the calls
Crisis Intervention
Direct assistance: Medical, shelter, protection from abuse, repatriation, death,

missing children, intensive counseling.
On phone: Emotional support and guidance, information and referral to

services for children, information about CHILDLINE, silent calls.
Long - term rehabilitation
Referral and Networking with other organizations providing specialized

services, repatriation, involving family members, creating volunteer base for
long-term follow- up of children.
Structure of CHILDLINE
To achieve the aims and objectives, a partnership effort is essential. The
roles of the various partners are based on their expertise and are clearly defined. The
basic structure of CHILDLINE includes the CHILDLINE advisory Board (CAB),
Nodal organization, Collaborative organization, Support organization and resource
organizations.
In order to implement the operational strategy, CHILDLINE works through various

government and non-government organizations at both the city and district level.
Each organization in the CHILDLINE structure has a definite role to play.
City Advisory Board
(Planning for and review of CHILDINE)
Nodal Organisation Collaborative Organization

(Training, research, documentation, (Call receiving center, case follow up,
networking, awareness) outreach and awareness)
Support organization
(Outreach, Awareness,
Resource organization
Case Follow)
All of us
(Call 1098, awareness, volunteer time, expertise,
resources)
The CHILDLINE structure at the city / district is based on the core philosophy
of CHILDLINE- partnership. CHILDLINE thus provides a platform for networking
between organizations, Allied Systems and Government partners.
The non-hierarchal structure formation at the city / district level also focuses
on utilizing existing resources and not creating any additional infrastructure. At the
district level, CHILDLINE aims to strengthen existing village level mechanisms by
involving village Panchayats, self help groups etc.
The structure at the district level is more community based and preventive in
approach so as to stem the flow of problems into urban areas. In cities, CHILDLINE
takes on the community-based approach ensuring long term linkages to rehabilitate
the child.
The service is presently operational in 73 cities. The basic objectives of the

CHILDLINE Service are as follows
l To respond to children in emergency situations and refer them to relevant
Governmental and Non- Governmental Organisations;
l To create a structure which ensures the protection of the rights of the child as
ratified in the UN Convention on the Rights of the Child and The Juvenile
Justice (Care and Protection of Children) Act, 2000;
l To provide a platform for networking amongst organizations and to strengthen
the support systems which facilitate the rehabilitation for children in especially
difficult circumstances;
l To sensitize agencies such as the public, hospitals, municipal corporations
and the railways towards the problems faced by these children;
l To provide an opportunity to public to respond to the needs of children in
difficult circumstances.
CHILDLINE has responded to over 10 million calls from children/concerned
adults over the years. These calls have been for medical assistance, shelter,
repatriation, missing children, protection from abuse, emotional support and guidance,
information and referral to services, death related calls etc. Started in June 1996, as
field action project of Department of Family and Child Welfare, the CHILDLINE
service proved to be an efficient link between children in need and rehabilitation
services. CHILDLINE is supported by the Ministry of Women and Child Development
and works through network of NGOs, Allied systems, Bi Lateral and Multilateral
Agencies, the corporate sector and children.
What does CHILDLINE do?
CHILDLINE reaches out, in every possible way, to children in need of help.

We use a multi-pronged approach to empower and help children in distress. We
believe that responding to calls and crisis intervention should go hand in hand with
sensitizing the allied services and government functionaries. Working across various
levels, we aim for a holistic approach in our efforts for attaining our objectives.
Whom does CHILDLINE reach out to?
CHILDLINE works for the protection of the rights of all children in general.
But our special focus is on all children in need of care and protection, especially the
more vulnerable sections that include:
l Street children and youth living alone on the streets

l Child laborers working in the unorganized and organized sectors
l Children affected by physical / sexual / emotional abuse in family, schools or
government and non-governmental institutions.
l Children who need emotional support and guidance
l Children of commercial sex workers and Child victims of the flesh trade
l Victims of child trafficking
l Children abandoned by parents or guardians, Missing children, Run away
children
l Children who are victims of substance abuse
l Children in conflict with the law and Children in institutions
l Mentally challenged children
l HIV / AIDS infected children
l Children affected by conflict and disaster and Child political refugees
l Children whose families are in crises
While responding to calls from children, CHILDLINE team members across

the country had varied experiences. Children calling 1098 had various expectations;
the team had faced variety of problems in responding to these calls. These experiences,
problems and expectations were put down and it was noticed that there were important
learnings for the team that were applicable to all CHILDLINE's overall stands on
issues and its beliefs. Thus the following CHILDLINE credo was emerged.
- We are a special family

- Every call is important
- Children's views are respected
- We cannot work alone
- We are transparent and accountable
Children call CHILDLINE for the following assistance:
l Medical assistance
l Shelter facility
l Repatriation
l Protection form abuse
l Death related calls
l Missing children
l Emotional support and guidance
l Referral to services
l Information about CHILDLINE and volunteers
l Silent calls
l Other calls - Blank, wrong, abusive, administrative, friendly, phone testing
Research on childline
Akister and Johnson's (2002) study identifies what parents might expect from
a confidential helpline and highlights areas of parental concern in the task of child
rearing. It is clear that there is a perceived need by parents for input into the parenting
process; parents were seeking information and advice rather than support.
Chiari (2003) opines that Telephone care has been demonstrated to be an

useful way to provide a continuous support for patients and their families in the
management of some critical situations.
Williams and Fosarelli (1987), in their research found that Loneliness or

boredom accounted for 68% of the calls, with fewer calls for help with homework
(8%), interpersonal problems (6%), medical problems (3%), and fears (2%). Medical
calls were mostly for minor infectious illness.
Ayaya and Esamai (2001) report that Street children have a high incidence
of childhood diseases. Respiratory (12.1%) and skin diseases (50.9%) were the leading
causes of morbidity. Drug abuse was rampant among the street children but none of
the school children abused any drug. The malnutrition rate was high with 31.1% and
41.9% of the children being stunted and underweight, respectively.

Case Vignette 1
In the 3rd week of August 2005, Suja, A 15 year old girl was rescued from a
liquor bar popularly called as the Beer Bar by a police station and CHILDLINE
Mumbai. She was then sent to the Child Welfare Committee (CWC) as per the
provisions of the Juvenile Justice Act 2000. The CWC transferred her to an Institution
Asha meant for rescued minors.
Jagruthi, an NGO, decided to follow up on behalf of Suja. After a few

meetings Suja developed trust in the social workers of Jagruthi. Suja revealed that
both her parents were dead and that she had just a step mother. Suja had stayed with
her maternal uncle in a village in Rajasthan. It was the wife of this uncle who had
then brought her to a city and forced her to work in a liquor bar as a dance girl.
Suja's family in Rajasthan was informed that Suja was in the custody of the
CWC and that they should report to the same at the earliest.
In the first week of October 2006 a woman named Nandadevi approached

the CWC to claim Suja. Nanadadevi was given the custody of Suja against a bond
that she would regularly submit a progress report of Suja to the CWC.
As a part of the follow up, CHILDLINE and Jagruthi made a home visit in
two weeks' time at he address given by Nandadevi. Neither Suja nor Nandadevi
could be traced there. No neighbor was willing to talk about them and informed that
the duo could be seen only after midnight. Everything sounded suspicious.
Around this time yet another woman named Gangadevi approached the CWC
seeking the custody of Suja. She had brought photographs, ration card and such
other documents to establish her identity and claim. In the meantime, Nandadevi
was contacted and asked to physically report to the CWC along with Suja. When
Suja was produced before the CWC yet another woman named Ms. Leela alias Suma
was found to be accompanying Suja. During the investigation which followed, Suja
revealed that the two women Nandadevi and Leela alias Suma were the ones who
had forced her to work in the liquor bar. Suja expressed a desire to go back home
with Gangadevi.
The social worker of Jagruthi however requested the CWC not to hand over
the girl to Gangadevi without detailed investigations into the authenticity and
suitability of Gangadevi and that the best interests of Suja should be given supreme
importance rather than the pleas and merits of the claimants. After interrogating all
the concerned persons and Suja herself, the CWC decided to hand over Suja to
Gangadevi. Jagruthi immediately got in touch with CHILDLINE Rajasthan and
informed them about Suja and explained to them the need to do regular follow - up
so as to prevent any chances of Suja being re- trafficked.

Case Vignette 2
Neelu, a girl child of 16 years, belonged to a resourceless peasant family
who lived in a remote village in a remote village in Andra Pradesh. A neighbouring
woman Sujatha assured Neelu's father that she could place Neelu as a domestic servant
in a decent family in Pune. Her father agreed and sent Neelu with the neighbour. In
a week's time, Sujatha returned to the village and assured Neelu's domestic servant
and the lady of the house had also given some money as advance salary. Neelu'
family was very happy to hear that and thanked Sujatha for her help.
Almost three months later Neelu's father received a telephone call at request
phone number. Neelu was on the line. Neelu informed her father that neighbour
Sujatha had sold her out to a brothel in Pune and the brothel keeper had ruined her
life by forcing her to sell sex. Neelu pleaded that she had been living an extremely
traumtised life in the flesh trade and requested her father to rescue her forthwith.
The shocked and shattered father approached a voluntary organization RISE

which worked in that area. RISE got in touch with yet another organization Prajwala
in Andhra Pradesh. Prajwala got in touch with the Anti Trafficking Center (ATC) of
Prerana. The ATC got in touch with one of the NACSET (network Against Commercial
Sexual Exploitation and Trafficking) founder members an organization Snehalaya in
Ahmednagar, which is 2 hours from Pune. Dr. G.K. of Snehalaya, Ahmednagar did
not waste any time and the same night left of Pune to get Neelu rescued. Dr. G.K.
approached the local police station took a police team in plain clothes for the search
and scanned all the suspected buildings without divulging what he was looking for
as he feared that once the facts were made public, the traffickers would have whisked
Neelu away from that place.
There were difficulties in identification, as the team had no photograph of

Neelu and none of the team members could speak Telugu, the language Neelu spoke.
Dr. G.K. could not get Neelu out in the first round. He prepared for a second round
and sought many more details of Neelu including some photograph for identification
etc. The ATC sought the same from RISE.
Prerana also suggested to RISE to send Neelu's father to Pune to ensure a

proper rescue. Prerana then contacted yet another organistion Vanchit Vikas, which
was a member of a network that worked in the red light area of Pune. Vanchit Vikas
agreed to provide accommodation in the city for Neelu's father and the other team
members from Andhra Pradesh. Simultaneously the CHILDLINE team of Pune was
contacted who instantly agreed to take the responsibility for the rescue and for the
follow up. Prerana also contacted the Maharashtra police for help.
The steps in the second round of rescue were worked out and rehearsed with
all those concerned.

As soon as Neelu's father, the Social workers of RISE and of Prajwala reached
Pune they were accommodated in a local hotel and the very next day along with the
CHILDLINE team and the police they went to the brothel. Though Neelu had been
made by the brothel - keeper to hide in a hole inside the brothel she was rescued and
had an emotional reunion with her father. The local police station, which helped
enthusiastically all the while, became a little uninterested in filing an FIR against the
traffickers. Many suggestions were made to settle the issue there and then with some
hefty compensation from the brothel keeper.
Prerana advised strongly against any such settlements at the police station
and in fact mailed detailed guidelines on how to file an FIR and what must be
mentioned in it, to CHILDLINE Pune. It was also conveyed to the team that it should
insist on a proper medical examination of the girl, proper age verification test as well
as if possible, registering a crime under the Maharashtra Control of Organised Crime
Act 1991 besides the ITP Act and not merely get Neelu picked up under the JJ Act as
a child in need of care and protection.
Several messages were given to the intervening team that the building where
all the irregularities were being carried out belonged to a senior IPS officer and no
efforts on the part of the social workers cause any harm to the criminals. The
intervening team consulted Prerana members who reassured the team that such stories
were a part of the crime scene mainly to dissuade the complainant from insisting on
a proper legal action and that it was not the first time it had come across such stories.
That instantly relieved the tension in the situation and the team insisted on going
ahead with the complaint undaunted by the stories. CHILDLINE and the members
of RISE and Prajwala all insisted on a proper FIR and the completion of age
verification medical examination and such other procedures with respect to the victim
girl. The FIR took unreasonably long time but it was completed nonetheless, though
after midnight. The procedures were completed and the girl was placed in an
Observation home.
The Observation: This is an excellent example of a well-orchestrated joint

action of a number of voluntary sector agencies, their networks and the CHILDLINE.
Networks build confidence which individual organizations find difficult to exhibit.
Networks are essential to counter organized crime. Traffickers are no strangers they
are often hidden in one's own environment. Job promise is one important lure used
by the traffickers to procure victims.
Conclusion
CHILDLINE interventions have increased over the years. Ten years down
the line the number 1098 now rings in 80 cities. There has been an increase in the
number of children calling CHILDLINE. But the basic health care and other facilities
available for children who are in need of care and protection have not shown a
proportionate rise. The result is that though CHILDLINE with whatever resources
that are available has been able to link up most children to long term services, there
are many who do not have that option. This calls for better health care, educational,
shelter, vocational and other facilities for children. There should be adequate linkages
with state governments and with corporates and individuals so as to ensure the active
involvement of all, if the needs of all children in distress are to be addressed.
There is a lack of basic infrastructure for meeting the needs of children in

need of care and protection. This refers to non- institutional structures like shelters
for short stays till they are linked to long term rehabilitation. There is also lack of
infrastructure to meet the needs of groups of children with special needs like disabled,
girl children and mentally ill. A large number of such children do not know which
way to turn to in moments of distress, they are left to fend for themselves with the
result that more often than not they fall victims to abuse. Existing facilities focus on
rehabilitation of specific groups of children.
Another challenge is to understand the symptoms / reasons why children

leave homes, what causes familial conflict and to work towards ensuring prevention.
There is need to address aspects that contribute to the situation of children in need of
care and protection and include necessary services and programmes.
CHILDLINE continues to confirm their motto of protecting all children in

need of care and protection. Best practices continue to evolve and respond to
contemporary requirements as and when the situation demands. Renewed efforts
have been made to lobby for child friendly policies and change, and press upon
policy makers the need of the hour; to identify gaps in services which will contribute
in formulating new policies for child protection; to put forth the constraints of working
within restricted parameters - limited means of livelihood available to children,
shortage of shelters, protection homes, especially for girls shortage of short stay
homes and juvenile homes and delays in legal procedures.
Poverty, though often cited as a major factor, is not the only one. Loss of
traditional sources of livelihood, growing unemployment, religio-cultural practices,
forced migration, natural and manmade calamities have all contributed to the increase
in the problem.
To tackle the issues of concern in an effective manner there should be proper

implementation of laws and policies. Proper implementation needs a paradigm shift
in mindset and a change in attitudes. This obviously requires a concerted effort towards
a mass awareness across the nation about issues related to child protection, in order
to ensure that the voices of children are heard and their need based issues are placed
on national agenda.

Chapter 3
CHILD ABUSE: PSYCHIATRIC SOCIAL WORK INTERVENTIONS
Kavita Jangam,1 & D. Muralidhar,2
Introduction
Child abuse is a state of emotional, physical, economic and sexual

maltreatment meted out to a person below the age of eighteen and is a globally
prevalent phenomenon. However, in India, as in many other countries, there has
been no understanding of the extent, magnitude and trends of the problem. The
growing complexities of life and the dramatic changes brought about by socio-
economic transitions in India have played a major role in increasing the vulnerability
of children to various and newer forms of abuse.
Child abuse has serious physical and psycho-social consequences which

adversely affect the health and overall well-being of a child. According to WHO:
''Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-
treatment, sexual abuse, neglect or negligent treatment or commercial or other
exploitation, resulting in actual or potential harm to the child's health, survival,
development or dignity in the context of a relationship of responsibility, trust or
power.''
Child abuse is a violation of the basic human rights of a child and is an

outcome of a set of inter-related familial, social, psychological and economic factors.
The problem of child abuse and human rights violations is one of the most critical
matters on the international human rights agenda. In the Indian context, acceptance
of child rights as primary inviolable rights is fairly recent, as is the universal
understanding of it. This chapter of the book aims at sensitizing the mental health
professionals especially psychiatric social workers who would like to dedicate their
services to the abused millions in the country. The chapter presents lots of facts and
findings and also the practical work in the area of child abuse especially child sexual
abuse. This chapter consists of incidents of child abuse in India, impact of abuse on
children, some of the basic psychosocial intervention with abused children, and
protocol for assessment and evaluation of abused children. Special need for the
specialized skills in dealing with abused children has been emphasized in this chapter.
Since the authors are working more on the Child sexual abuse issues, more of the
information related to child sexual abuse has been included in this chapter.
1.Ph.D Scholar in the deartment of Psychiatric Social Work and Junior Consultant in Child Psychiatry Unit
2. Additional Professor, Department of Psychiatric Social Work and Consultant in Adult Psychiatry unit

Definition of child abuse
The term 'Child Abuse' may have different connotations in different cultural
milieu and socio-economic situations. A universal definition of child abuse in the
Indian context does not exist and has yet to be defined. According to World Health
Organization (1999):
l Physical Abuse: Physical abuse is the inflicting of physical injury upon a child.
This may include burning, hitting, punching, shaking, kicking, beating or
otherwise harming a child. The parent or caretaker may not have intended to
hurt the child. It may, however, be the result of over-discipline or physical
punishment that is inappropriate to the child's age.
l Sexual Abuse: Sexual abuse is inappropriate sexual behaviour with a child. It

includes fondling a child's genitals, making the child fondle the adult's genitals,
intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation. To
be considered 'child abuse', these acts have to be committed by a person
responsible for the care of a child (for example a baby-sitter, a parent, or a
daycare provider), or related to the child. If a stranger commits these acts, it
would be considered sexual assault and handled solely by the police and
criminal courts.
l Emotional Abuse: Emotional abuse is also known as verbal abuse, mental

abuse, and psychological maltreatment. It includes acts or the failures to act
by parents or caretakers that have caused or could cause, serious behavioural,
cognitive, emotional, or mental trauma. This can include parents/caretakers
using extreme and/or bizarre forms of punishment, such as confinement in a
closet or dark room or being tied to a chair for long periods of time or threatening
or terrorizing a child. Less severe acts, but no less damaging, are belittling or
rejecting treatment, using derogatory terms to describe the child, habitual
tendency to blame the child or make him/her a scapegoat.
l Neglect: It is the failure to provide for the child's basic needs. Neglect can be
physical, educational, or emotional. Physical neglect can include not providing
adequate food or clothing, appropriate medical care, supervision, or proper
weather protection (heat or cold). It may include abandonment. Educational
neglect includes failure to provide appropriate schooling or special educational
needs, allowing excessive truancies. Psychological neglect includes the lack
of any emotional support and love, never attending to the child, substance
abuse including allowing the child to participate in drug and alcohol use.
Incidence of child abuse in India
Ministry of Women and Child Development, Government of India conducted

a research study on child abuse in India, (2007). It was a national study covering
about 13 states of India. They covered about 12,447 children and 17,220 other
respondents for the study.
The specific objectives of the study were:
l To assess the magnitude and forms of child abuse in India;
l To study the profile of the abused children and the social and economic
circumstances leading to their abuse;
l To facilitate analysis of the existing legal framework to deal with the problem
of child abuse in the country; and
l To recommend strategies and program interventions for preventing and
addressing issues of child abuse.
The findings of the study are as follows
It has very clearly emerged that across different kinds of abuse, it is young
children, in the 5-12 year group, who are most at risk of abuse and exploitation.
Physical abuse
1. Two out of every three children were physically abused.

2. Out of 69% children physically abused in 13 sample states, 54.68% were boys.
3. Over 50% children in all the 13 sample states were being subjected to one or
the other form of physical abuse.
4. Out of those children physically abused in family situations, 88.6% were
physically abused by parents.
5. 65% of school going children reported facing corporal punishment i.e. two
out of three children were victims of corporal punishment.
6. 62% of the corporal punishment was in goverment and municipal school.
7. The State of Andhra Pradesh, Assam, Bihar and Delhi have almost consistently
reported higher rates of abuse in all forms as compared to other states.
8. Most children did not report the matter to anyone.
9. 50.2% children worked seven days a week.
Sexual abuse
1. 53.22% children reported having faced one or more forms of sexual abuse.
2. Andhra Pradesh, Assam, Bihar and Delhi reported the highest percentage of
sexual abuse among both boys and girls.
3. 21.90% child respondents reported facing severe forms of sexual abuse and
50.76% other forms of sexual abuse.
4. Out of the child respondents, 5.69% reported being sexually assaulted.
5. Children in Assam, Andhra Pradesh, Bihar and Delhi reported the highest
incidence of sexual assault.

6. Children on street, children at work and children in institutional care reported
the highest incidence of sexual assault.
7. 50% abuses are persons known to the child or in a position of trust and
responsibility.
8. Most children did not report the matter to anyone.
Some other studies particularly related to child sexual abuse show shocking incident
rate of CSA in India:
Institution Year Place Findings
World Health India 1 out of 10 children at given

Organization 1998 point of time are sexually
abused.
1 out of 3 girls & 1 out of 10

Tata Institute of 1985 Bombay, India boys are sexually abused
Social Sciences
Samvada, Ratnam Bangalore, (348 girl students) 47 %
1996 molested15 % seriously
sexually abused, 75 % abusers
are adult family members
Early Multi-center (357 school girl children) and

Sakshi (NGO)
1990’s study: Delhi, 600 women
Mumbai, 63 % are victims of CSA50 %
Calcutta, Goa, abusers are from families
Chennai itself76 % of women sexually
abused in childhood. i.e.,456
women:40% abused by family
member71%abused by relatives
and family friends)35 % were
abused between ages of 12 to
16
Banjara Academy 2004 Bangalore,
Sample from different settings
– schools, call centers, colleges
etc, sample size- 1028
835 respondents reported
having sexual abuse
experience.

Emotional abuse and girl child neglect
1. Every second child reported facing emotional abuse.

2. Equal percentage of both girls and boys reported facing emotional abuse.
3. In 83% of the cases parents were the abusers.
4. 48.4% of girls wished they were boys.
This was the recent most study which shows the shockingly high prevalence
of different forms of child abuse prevalent in India. This was the reported data, but
there are large numbers of cases which go unreported due to various socio-cultural
circumstances. Large number of children are abused and assaulted in other forms of
abuse such as child labour, child trafficking, child prostitution, street children and so
on. The data shows more shocking prevalence of such cases.
Child prostitution.
A survey by the country's Central Social Welfare Board has found that:
1. It is estimated that 2 million children are forced in prostitution in our country
between the ages of five and fifteen years.
2. Girls between the ages of ten and fourteen years are the most vulnerable.
3. 15% of these child prostitutes are below fifteen years of age and 25 % between
the ages fifteen and eighteen years.
4. 5,00,000 children - little boys included - are forced into this trade every single
year.
Street children is yet another category which needs to be studied carefully in

relation to the Child Sexual Abuse as literature suggest that majority of street children
experience sexual abuse and rape. A study done by BOSCO, an organization for
street children and NIMHANS on Bangalore street children reports that 44 % of
street children experience sexual abuse, 26.6% of them are forced for oral sex by
older boys.
Sexual abuse of children is often combined with physical and emotional

abuse of children. Most likely the children, in prostitution and street children are
also physically and emotionally abused.
According to the National Crime Records Bureau, Ministry of Home Affairs,

Govt. of India (2005) between 2002 and 2005 there was a steep rise in the total
number of crimes against children. In 2002, 5972 cases were registered as against
14975 cases registered in 2005. Incidence of kidnapping and abduction of children
were around 2322 in 2002 and 2571 in 2003, which rose to 3196 and 3518 in 2004
and 2005 respectively.

Impact of abuse on children
The impact of abuse on children is manifold. All the spheres of life of children
get significantly affected due to the exposure to the different forms of abuse. They
experience social repercussions, psychological or mental health problems as well as
sexual development issues.
Social consequences
1. Becoming run away: Pagelow (1984) noted that "many runaway children are
not running toward something, but rather running away from something - a
home life in which they were subject to abuse, particularly sexual abuse."
2. Drug abuse: Researchers have hypothesized that for abused children, drug
abuse may serve a number of possible functions: (1) to provide psychological
escape from an abusive and aversive environment (2) to serve as a form of self
medication in which the child tries to gain control over his or her negative life
experiences; (3) to act as a form of self- enhancement to improve the child's
self-esteem (4) to reduce feelings of isolation and loneliness.
3. Violence: Curtis (1963) suggested that abused children would become
"tomorrow's perpetrators of other crimes of violence, if they survive". Later
several studies have explored relationship between abuse and violent behaviour
in delinquents. Some studies provide strong support for the cycle of violence
(Geller and ForSomma, 1984; Lewis et al, 1979, Straus et al, 1980, Vissing et
al, 1991).
4. Some other social consequences children face are teenage pregnancies,
institutionalization, crime and delinquencies, separation from family, and so
on.
Psychological and mental health problems
Children who have been abused often show elevated rates of depression and
anxiety problems. Dissociative disorders are very common among them as they can't
cope up with the abuse and at the same time can not disclose about it. Hence they use
defense mechanisms to cover their trauma and have dissociation. Suicide rate is
again very high among the children who have experience of abuse. Other disorders
such as conduct disorder, Post Traumatic Stress Disorder, eating and sleeping
disorders, specific learning disabilities and emotional disorders are also prominent
among the abused children. Children who have experienced different forms of abuse
often show poor self esteem, poor self concept, poor interpersonal relationships,
poor mental mastery and poor life skills, feeling of powerlessness, feeling of betrayal,
lack of self control and so on.
.
Sexuality related problems
Maltz and Holman (1987) discussed some of the sexual repercussions of

Child Sexual Abuse, which are manifested in three areas: pattern of sexual behaviour,
sexual orientation and preference, and sexual arousal, response and satisfaction.
I Pattern of sexual behaviour: Maltz and Holman found that "survivors often
gravitate towards two extreme sexual lifestyles, choosing either social and
sexual withdrawal and isolation from peers, or promiscuous and even self
destructive sexual activity. Many clinicians and researchers have described a
relationship between childhood sexual abuse and sexually promiscuous or
dysfunctional behaviour (e.g. sexual offences, prostitution) in adolescence.
I Sexual orientation and preference: Maltz and Holman (1987) and Johnson
and Shrier (1985) indicate that childhood sexual abuse may influence adult
sexual preference and orientation in both women and men. Johnson and Shrier
found that a high percentage of boys who are sexually abused by men do
indicate a homosexual preference as adults. Maltz and Holman speculate that
there are two groups of formerly abused women who exhibit homosexual
orientation: those who are lesbians who are also incest survivors, and those
who may be heterosexual or bisexual but have chosen a lesbian lifestyle as
part of their healings.
I Sexual arousal, response, and satisfaction: Maltz and Holman (1987) indicate
that females who are sexually abused in childhood tend to experience more
sexual problems than do women who are not abused, especially in the areas of
sexual desire and sexual pleasure.
Interventions offered for abused children
The literature on children and adolescents who have been abused has not
been adequate. Indeed it is sadly lacking in the areas concerning psychosocial
interventions with the abused children, adolescents and adult survivors. Children
and adolescents have far fewer resources for becoming aware of and expressing
what has happened to them. They cannot take them to therapy and do not have skills
to explain what they have experienced. Hence it is very important for the mental
health professionals to be skilled in identifying the victims and providing appropriate
psychosocial interventions.
Some of the data available on the various agencies in India that deal with
children and the state of therapeutic interventions shows that there is dearth of
counseling and therapeutic services. A study done on child care institutions in
Karnataka in 2001 shows that there is a lacunae in providing counseling and
therapeutic services. The situation is worse in Government institutions where there
is even absence of counselors. V. B. Khandekar in his paper on "Integration Counseling
Services In Destitute Homes And Correctional Institutions" says that counseling and
guidance services are not given the importance they should have been in these
institutions.
Child Guidance Centers in India is yet another source of providing therapeutic

services to the children. But considering the population of children in the country,
the number of CGCs is grossly inadequate. These services are also conspicuous by
their absence in the rural areas. School counselors are the other set of professionals
who can provide effective counseling services but very few schools have provision
of counselors.
To conclude most of the counseling and therapeutic services are centered in

urban areas and targeting middle and upper class population and the staff involved in
child care in different government non- government institutions is not adequately
trained to deal with the sensitive issues such as CSA.
Childline Foundation India offers services to the children who are trapped in
many difficult circumstances such as abuse and neglect. Childline rescues children
and adolescents from abusive circumstances and takes the steps towards children's
rehabilitation. Childline works closely with Child Welfare Committee and Childline
is successful in bringing about thousands of cases of abuse and violence against
children in front of Child Welfare Committee. They have the most sensitive and
committed child care staff who understands the needs of children in difficult
circumstances. But it often becomes difficult to provide psychosocial care to such
children, as there is dearth of counselors and mental health professionals who are
working with such legal or quasi-legal organizations. As a result, many children are
just placed in various residential organizations for the rehabilitation and protection
purpose and legal help is provided to them. At the tertiary level that is mental hospitals
or general hospital settings, a child is brought only when there is serious injury to the
child or child is seriously psychologically or mentally disturbed. Otherwise children
fear to disclose about their abuse experience and many children live with traumatic
life and experience various consequences later in life.
Interventions of psychiatric social workers with abused and neglected children
Multidisciplinary team approach

The primary goal of all agencies and institutions involved in the management
of offences against children and adolescents is to ensure their safety and well-being.
A multidisciplinary team approach allows for a coordinated response to child/
adolescent victims and creates a system of investigation and prosecution of child
abuse that causes the least possible trauma to the children/adolescents and families.
Successful community coordination of child abuse cases requires the

development of interagency agreements and guidelines. Such agreements provide a
framework to coordinate the handling of cases through formalizing collaboration
among agencies. Interagency agreements should delineate specific tasks in the
intervention process and clarify the role and responsibilities of the participating
agencies. Guidelines should explain how the agencies work together to investigate,
prosecute, and provide support to the child/adolescent victim and family. In addition,
you should develop a clear and explicit understanding and agreement with other
professionals and agencies regarding the investigative process. Without such
understanding, further trauma, duplication of effort, and omissions of necessary
evaluations are likely to occur. Although reporting requirements differ depending
upon the relationship of the perpetrator to the child/adolescent, the care afforded the
child/adolescent remains the same.
Psychiatric social worker's role in multidisciplinary team
Whether working in clinical set up or legal set up such as Child Welfare

Committee, Psychiatric social workers can facilitate the psychological healing of
the child/adolescent and provide support to the family. A Psychiatric social worker
can be requested to conduct an extended assessment of a child/adolescent when the
disclosure is not clear or when there are complicating developmental or psychological
issues. Psychiatric social workers may also be asked to conduct the investigative
interview with the child/adolescent while other members of the multidisciplinary
team observe. The same person should not act as both investigator and therapist.
Psychiatric social worker that is providing therapeutic intervention to a child/
adolescent and his/her family should maintain communication with the
multidisciplinary team because the status of the investigation will have an impact on
the child/adolescent's psychological health.
Psychiatric social workers provide

l Support to the child/adolescent and family
l Expertise in child development, family systems, and clinical intervention for
the psychological needs of children and adolescents
l Assistance in the psychological recovery of the child/adolescent and supportive
assistance to the family
l Evaluation of the emotional condition of the child/adolescent, his/her ability
to testify, and how testifying might affect his/her mental status
l Expert testimony on the psychological impact of child sexual abuse
l Information regarding state-of-the-art research and literature on psychological
effects and therapeutic issues
l If not involved in a therapeutic relationship with the child/adolescent, assistance
with the investigative interview when requested by the investigative team
Interventions at promotive level
Promotive interventions are spoken mainly in terms of health promotion,

which is defined as "the process of enabling people to increase control over and to
improve health". In the area of child abuse and neglect, there is a need for creating
competency among different stakeholders to voice against child abuse. Promotive
programmes are more about creating awareness among people and sensitizing them
about offences against children in society.
Social workers in schools

At school setting social workers have a good scope of preventive as well as
promotive interventions with children, teachers as well as with the parents. The Mental
Health Programmes designed by social workers should be aimed at creating awareness
among parents, teachers and other caretakers of the child and developing positive
competence in the children so that they will be able to voice their abuse. The content
of the programme can consist of personal safety workshop, abuse prevention
workshops, life skill training and sex and sexuality education.
Social worker in advocacy

Social workers should be actively involved in advocacy on child abuse issues,
which is another aspect of promotive interventions. The main aim of advocacy would
be sensitizing society and making them aware that child abuse exists in all classes,
castes and strata of society. The advocacy on child abuse issues should also aim at
influencing the legal system and establishing effective penal policies for children.
Interventions at preventive level
WHO (1979) defined goals of preventive interventions as identification of

causation, identification of risk factors and risk groups, availability of early detection
measures and treatment. The same principles can be adopted for the interventions in
the area of child abuse where we attempt to eliminate the causes of child abuse.
Social workers in community

Social workers working in the community can identify the vulnerable groups
such as street children, destitute children, children of commercial sex workers and
orphans who are at the high risk of experiencing various forms of abuse and
harassments. On identifying the vulnerable children, the social workers need to be
able to coordinate an array of community services in order to secure children from
exploitation and violence as well as other forms of abuses.
Social worker as a resource person

Social workers can be an important resource person to the childcare agencies
(Non-Govt or Govt) and welfare institutions. As a resource person, social workers
can directly work with the children as well as childcare personnel. Social workers
can impart training to the personnel on issues related to child abuse such as identifying
victims, primary interventions, promotive and preventive interventions, and so on.

Social workers and research
The goal of designing appropriate treatment measures could be achieved
through conducting research in the area of psychosocial treatment modalities for
victims and survivors. Existing literature shows dearth of literature in the area of
efficacy of intervention strategies. Research work on efficacies of intervention will
help in developing appropriate and culturally sensitive interventions for the victims
and survivors of sexual abuse.
Skills for psychiatric social workers to deal with abused children
Psychiatric Social Workers get well equipped with their training as psychiatric
social worker in psychiatric diagnosis, psychiatric treatment, family assessments,
child mental health, case work, social diagnosis and therapeutic interventions. But
to deal with abused children there are some special skills which needs to be inculcated
in the training of the psychiatric social work. It has been noted that interventions by
PSWs in various settings such as clinical set up, correctional settings, counseling
services would bring about a definite change in the quality of psychosocial support
available to victims and if interventions handled poorly, can be as traumatic and
sexualizing as the primary abuse itself and a relatively less traumatized child would
be made to feel traumatized because of interventions. Therefore getting well equipped
in dealing with these children is extremely important.
Knowledge and attitude
The psychiatric social workers should first acknowledge that the large number
of children get abused and exploited and violence against children exists. The
psychiatric social workers should be equipped with knowledge on various forms of
child abuse and neglect, consequences of such abuse and violence on children, law
and rights related to children and appropriate therapeutic interventions for such
children. No matter, in which setting social worker is working, the attitude of the
social worker should be empathetic and understanding towards the abused children.
Interviewing and assessment skills
It becomes necessary for social workers to make a habit of child abuse enquiry
and skill themselves in sensitive questioning. The skill of social worker lies in
questioning sensitively and enquiring carefully about abuse to the child and on
disclosure, social worker should be able to provide wide range of interventions not
restricting to the child but extending to the family also. There are various guidelines
available for assessment and interviewing of abused children. Psychiatric social
workers should have some knowledge in Forensic Interviewing of children as these
testimonies would be used in legal procedures also. Firstly, the social worker has to
be sensitive in dealing with children coming from different age groups and gender as
it would be different from interviewing a preschooler from interviewing an adolescent
and interviewing a male child from interviewing a girl child. Secondly protocol about
the questioning and the assessment of child's mental health and other psychosocial
aspects. Thirdly, social workers should be careful in recording and documenting the
assessment information and proceedings with child. These recordings and documents
may be used in legal proceedings.
Therapeutic interventions
The psychiatric social workers should get trained in various therapeutic

interventions with abused children such as group work, play therapy, behaviour
therapy, abused focused or trauma focused therapy and so on. They should be able to
assess the different needs of children and help them accordingly. For example group
work has been found to be effective with adolescents (Webb and Leehan, 1996),
whereas individual work and play therapy has been found to be very effective with
preschoolers. Psychiatric social workers should be able to focus on more of child
centered or oriented interventions.
Legal interventions
Psychiatric social workers should possess adequate knowledge about the

rights and laws related to children and how to make use of them. Psychiatric social
workers can educate the families of abused children and empower them to take proper
legal action. For this, psychiatric social worker can refer the families or the children
to the law enforcement agencies for the legal action. When psychiatric social worker
is dealing with children who are facing legal proceedings, one important work
psychiatric social workers can do is to prepare such children for legal proceedings
whether it is medical examination or a court trial. Psychiatric social workers should
stand as a constant support to such children.
CASE STUDIES
Case study 1:
Asha, 15 years old girl from lower socio economic status, studying in 9th
std. She was raped by he own father continuously for 2 days. She was also beaten up
by her father. Somehow she contacted child line and one organization rescued her.
When she came to organization, her condition was very bad. She was disturbed,
fearful and depressed. Psychiatric consultation was sought for her. But after few
days, she attempted suicide by taking overdose of the psychiatric medicine. Somehow,
due to timely action, the girl's life was saved. But following this, she was more
disturbed and disoriented. She was laughing to her self, crying loudly, could not look
after herself and was asking every visitor to rape her. She used to say "my own father
raped me, now anyone can come and rape me…." Saying this she was tearing up her
cloths. It was very difficult to handle her behaviours. She was admitted in psychiatric
ward for almost a month. After the stay in psychiatric ward, she was better but she
continued to feel depressed. Following her rescue from the home, her father was
arrested by the police. Knowing this, her only elder brother and mother refused to
support her. Now Asha feels more sad that she does not have any support and no one
to look after her.
Interventions
1. Crisis intervention: As soon as abuse is disclosed by the victim, there would
be emotional turmoil on the part of the victim. At that time, crisis intervention
is very important rather than the assessment. Victim has to be supported and
helped to ventilate their feelings. Many times victims try deliberate self harm
or attempt suicide. In such occasions immediate hospitalization is required in
order to keep the victim under observation.
2. Assessment and evaluation of abuse: Using the guidelines and protocols for
assessment and evaluation, an appropriate and accurate assessment and
interviewing is done. The report is subsequently discussed with the other
concerned treating members in the clinical set up. This report will be kept in
the hospital record as well as submitted to CWC.
3. Correspondence between hospital and Child welfare committee (CWC):
Constant correspondence between the therapist belonging to clinical set up
and the child welfare committee in order to explain the victim's condition and
treatment in the hospital set up and also to produce relevant documents and
testimonies to CWC.
4. Abuse focused work with the victim: When victim is able to disclose and able
to understand the circumstances taking place around them, it is important to
start the abuse-focused work with the victim. Abuse focused work consists of
helping the victims to understand the feelings and emotions related to abuse
and how they could resolve these feelings effectively. It also involves
empowering victims to achieve mastery over circumstances and their self-
esteem. Abuse focused work involves future oriented work also in which victims
are helped to plan for their future life.
5. Preparing victim for legal proceedings: explaining to the victim about what
the legal procedure will be like. What it involves? What steps would be taken?
Who are the professionals involved in the proceedings and so on. This is very
crucial intervention as it will help victim to understand the circumstances and
it will be less traumatizing for the victim to go through the court trials again
and again.
6. Regular follow-up and support to the victim: During the rehabilitation process
and the court trials which generally take a long time, the therapist maintains
the regular follow up and provides support to the victim. It has been noted that
more than the abuse, the subsequent life events becomes more traumatizing
for the victim. Therefore, instability in victim's circumstances as well as
reactions of the victim is always expected. Hence continuous support has to
be provided to the victim.
Case study
Rani, 16 years old girl was working as a domestic servant in one reputed
family. She had joined just few days before. They had promised that they will look
after her education. In fact both the employer couple owned their own school in
Bangalore city. After few days, the employer started showing sexual advances towards
her. Few days, Rani did not disclose about it to anyone. One day the employer, tried
molesting her in the bathroom. Somehow she pushed the employer outside the
bathroom and locked herself inside the bathroom. She remained there for whole day
due to the fear of employer. Evening as soon as the employer's wife came, Rani came
out of the bathroom and informed his wife. In the night Rani Ran away from their
home and came into the contact with police who brought her to CWC. The case was
filed against the employer and the girl was sent to Government home for girls.
Interventions:
1. Crisis intervention 2. Evaluation and assessment of the abuse
3. Support to the victim 4. Abuse focused work with victim
5. Preparing victim for the legal proceedings
6. Placement and rehabilitation
Case study
Rubina and Salma, two sisters aged about 10 and 12 years old were working
in one rich family as domestic servants. They were working there almost for last 6
years. Due to poverty, their own father has left them in this house for work. Their
money was given to their father. The girls were asked to do each and every work
such as cleaning house, washing cloths, washing vehicles, taking care of employer's
children, helping in cooking and so on. In return, girls got only the torture by the
employer lady. She used beat them up, pinch them, brand them with hot knives and
much more. Some of the neighbours complained about this practice and they reported
about it to child line. Child line rescued these two sisters and kept them in a secure
organization. The girls were brought for psychiatric and physical examination in the
Government hospital. Both the girls were malnourished and were having scars of
pinching and branding on all over the body. It was difficult to understand how they
tolerated this much of torture for so many years. One sister even had a fracture of leg
and hand. She reported that she was beaten up by the employer lady by a stick and
that is how she got the fracture. There was not a single place left on the body without
scars. Rubina being the older, was bold and reported everything and she could come
out of it very well, but the younger one Salma was the most affected. She always
used to think that she will contract cancer or some serious illness and she would die
soon. She often spoke about vague body complaints and insisted that we do a physical
check up or some surgery for her. She was always very depressed and on some occasion
even spoke of her wish of dying soon.

Interventions:
1. Assessment and evaluation of the abuse along with psychiatrists
2. Placement in the residential care organization
3. Abuse focused work with the victims
4. Correspondence with the Child welfare committee
5. Future oriented work with the victims
6. Continuous follow-up and support to victims

Chapter 4
LIFE SKILLS EDUCATION
M. N. Vranda,1 & M. L. Chandrashekar Rao,2
Ramu is a 13 years old boy studying in 9th standard. His father drinks a lot
and hits his mother and him when he comes home. He does not give money to family.
His mother works as household servant earns Rs 500 per month, which is not sufficient
to run the family. Ramu is very good in studies and wants to become a teacher.
Recently his mother suggested him to discontinue his studies and join some job in
order to help family and other siblings. Ramu is confused about what decision to
take and whom to approach for help.
Anad is 14 years old boy. He has lot of friends. Some of his friends smoke
cigarettes. Few occasions his friends offered to smoke cigarettes. But he refused to
smoke. He knew that smoking damages health and at the same time he thinks that his
friends will reject him if he refuses to smoke with them. He is totally confused.
Sujataha is 8 years old girl staying with parents, 2 brothers and uncle. She is
very much close to her uncle and likes him very much. They play games together.
Her uncle always touches her private parts which makes her very uncomfortable.
She does not like his behavior and does not know how to stop him. She is afraid to
tell this to her parents.
Chandrakala is 16 year old girl studying in college. Her parents have decided
to get her married to their own relative. Sheenjoys studying and wants to complete
college and try to get a job. She is upset about her parent's decision. She does not
know what to do? What decision to take? She does not know what to think or how
she should act?
The above scenarios illustrate real life situations where children and
adolescents find themselves oppressed by circumstances when they feel unable to
control or cope with. Children and adolescents often feel powerless and believe that
they lack the ABILITY TO ACT, including - skills to communicate their needs, to
solve their problems and make proper decisions. They need "SKILLS" to handle the
situations effectively. Enhancement of Psychosocial Competency to handle above
situations is MUST. In 21st century life is undergoing significant transition and change
and among the most affected are young children and adolescents.
Change in life styles, breaking of joint family system, easy access to

information, exposure to new way of life styles and habits, competition, conflicting
values, clash between traditional and modern cultures, created some kind confusion
1. Psychiatric Social Worker, Department 2. Additional Professor Department

and challenges for young children and adolescents. These changes interfere with
their physical, psychological and social health resulting into high-risk behaviors such
as drug abuse, smoking, early sexual experimentation, teenage pregnancy, HIV/AIDS,
delinquency, school dropout, crime, suicides, violence, abuse and neglect.
The young adolescents of today have less chance for reaching successful
adulthood. The Indian youth represents a significant proportion of worldwide
population. It was estimated that young people who are less than 20 years of age
accounted for 40% of the world's population while 80% of them are living in the
developing countries (WHO-SEARO, 2000). Empowerment of adolescents
Psychosocial Competence and Life Skills is relevant to Indian context.
Life skills
Life skills are abilities for adaptive and positive behavior that enable
individuals to deal effectively with the demands and challenges of every day life.
Life skills are designed to facilitate the practice and reinforcement of psychosocial
skills in a developmentally appropriate way. Life skills contribute to the promotion
of personal and social development, the protection of human rights, and the prevention
of health and social problems (WHO, 1993).
Life skills are innumerable. Some are specific to certain situations while
others are of a generic in nature. Based on the theoretical perspectives as well as
intervention and training in this area across the cultures and globe, a core set of ten
generic life skills are identified. These life skills are basic to every culture can be
used for promotion of psychosocial health in children and adolescents. These skills
are as follows,
1. Critical thinking skills

It is an ability to analyze information and experiences in an objective manner.
Critical thinking can contribute to health by helping to recognize and assess the factors
that influence attitudes and behavior, such as values, peer pressure, and the media.
2. Creative thinking skills

Creative thinking contributes to both decision making and problem solving
by enabling us to explore the available alternatives and various consequences of out
actions or non- actions. It helps us to look beyond our direct experience and even if
no problem is identified or no decision is to be made, creative thinking can help us to
respond adaptively and with flexibility to the situations of our daily lives.
3. Decision making
The process of assessing an issue by considering all possible/available options
and the effects that different decision might have on them. Decision making helps us
to deal with constructively with decisions about our lives.
4. Problem solving
Having made decisions about each of the options, choosing the one, which
suits best, following it through even in the face of impediments and going through
the process again till a positive outcome is achieved.
5. Effective communication
It is an ability to express ourselves both verbally and non-verbally, in a
appropriate manner. This means being able to express opinions and desires, but also
needs and fears. And it may mean being able to ask for advice and help in a time of
need.
6. Interpersonal relationship
Interpersonal Relationship skills help us to relate in positive ways with the
people we interact with. This may mean being able to make and keep friendly
relationships, which can be of great importance to our mental and social wellbeing.
It may mean keeping good relations with family members, which are an important
source of social support. It may also mean being able to end relationships
constructively.
7. Self awareness
Self awareness includes our recognition of ourselves, our character, our
strengths, and weakness, desires, and dislikes. It is also often a prerequisite for
effective communication and interpersonal relations, as well as for developing
empathy for others.
8. Empathy
Empathy is the ability to imagine what life is like for other person, even in a
situation that we may not be familiar with. Empathy can help us to understand and
accept others who may be very different from ourselves, which can improve social
interactions. Empathy can also help to encourage nurturing behavior towards people
in need of care and assistance or tolerance, as is the case with AIDS suffers, or
people with metal disorders, who may be stigmatized and ostracized by the very
people they depend upon for support.
9. Coping with stress

Coping with stress is about recognizing the sources of stress in our lives,
recognizing how this affects us, and acting in ways that help to control our levels of
stress. This may mean that we take action to reduce the sources of stress, for examples,
by making changes to our physical environment or life style. Or it may mean learning
how to relax, so that tensions created by unavailable stress do not give rise to health
problems.

10. Coping with emotions
Coping with emotions involves recognizing emotions in ourselves and others,
being aware of how emotions influence behavior and being able to respond to emotions
appropriately. Intense emotions, like anger or sorrow can have negative effects on
our health if we do not react appropriately.
Teaching above mentioned life skills every day form the foundation of life
skills education for the promotion of mental well being and positive health behavior
among children and adolescents. To make each of these skills suitable to a given
environment the program must be 'need based'. The needs of the group must be
assessed and then skills imparted accordingly. The program developer needs to keep
in mind age and cultural context of group while teaching life skills. For example
making eye contact may be encouraged in boys for effective communication, but not
for girls in some societies, so gender issues will arise in identifying the nature of life
skills. The exact content of life skills education must therefore determined at country
level or more local context.
The acquisition of knowledge and skills from life skills programs influences
attitudes and values of person leading to positive behavior which in turn helps in
prevention of high risk behaviors (for example, right knowledge and values regarding
drugs could inturn decrease the risk taking behavior in young people). Life skills
training thus enables in skills acquisition and influences health and behavior in the
social context. Though a person's behavior may partly be determined by environmental
and social factors, it essentially stems from the individual himself. The behavioral
preparedness is essential to face environmental and social changes, pressure and
demands. The following is a diagrammatic representation of a model of how life
skills equips individual in pro-social ways, through the promotion of mental wellbeing
and behavioral preparedness (Fig-1).
Figure - 1 Model of Effect of Life Skills on Health
Life Skills Behavior Positive Prevention

+ +
Knowledge acquisition reinforce
acquisition health of health
including ment or behavior problems
practice change
Life Skills Education
Life skills education programs are conceptually based on learning theory of

Bandura (1997). In social learning theory, learning is considered to be active
acquisition, processing and structuring of experiences. In life skills education children
and adolescents are actively involved in dynamic teaching and learning process.
Active participatory learning in groups is central part to the life skills education. The
acquisition of skills is based on learning through active participation.
In any life skills programs the effective learning is likely to depend more on
the methods used than the information component of the program. The role of the
life skills educator or facilitator is to facilitate participatory learning of the participants
rather than Lecture in a Didactic Style. Facilitation, groupwork/activities, experiential
learning and continuity are the main components of life skills education. The
systematic representation of these components is shown in figure - 2. Method used
includes working in small groups, brainstorming, role-play, games and debates.
Figure - 2 Components of Life Skills Education
Facilitation
Experiential
Learning
Groupwork
Continuity or
Learning
Facilitation is nothing but an approach used in life skills education. Creating

safe learning environment for practice of skills is important role of the facilitator.
The role of the facilitator comprises the following:
1. Introduce the topic and set the scene for the session
2. Define the objectives of the activity
3. Divide the students into groups and involve them in an activity around the
theme of the session.
4. Ensure that the discussions starts on time and ends at prearranged time

5. Allow students to verbalize the learning that was generated in the group
discussions or activities. The facilitator can also provide some input, share
feelings; challenge learners to think further, consider alternative viewpoints
and make them aware that there are many different solutions.
6. Encourage everyone to participate in the activity.
7. Create atmosphere of active learning
8. Be neutral and do not take the side of some students
9. Note down important points of discussions on the blackboard or flip chart.
10. Always summarize the activity covering all points at the end of each session
Who Require Life Skills Training and Why?

The focus of life skills programs are usually young children and adolescents,
since they are in their formative years and can be helped to develop Positive, Healthy
ways of Living and Behaving. The acquisition of life skills is linked to the
development of values. Enhancement of life skills promotes Self-esteem, Self control
and Personal Responsibility. Essential life skills need to be taught to young people to
cope with realities of their world. Life skills are required
- to acquire a sense of self-worth and self-efficacy
- to promote healthy living
- to build supportive relationships with friends and family
- to cope successfully with stress and pressures of daily life
- to deal with conflicting values and norms for behavior
All of these conditions are essentials for mental and physical
health. Life skills education should therefore be seen as an entitlement for all young
people. At the same time, life skills are also important to prevent specific problems,
to avoid risky behaviors and overcome particular barriers to healthy development.
The problems areas are,
- smoking
- drug and alcohol abuse
- Bullying and violence
- delinquency
- gender discrimination
- HIV/AIDS
- Child abuse
- Suicidal behavior
- school dropout
- adolescent pregnancy
Apart from children and adolescents, the others specific groups that can also
be involved in life skills education are,
l Non-formal school students
l Out of school youth groups
l Children in preschool education
l Street children
l Working children
l Refugee children

l Children who are at risk
l Primary and secondary school students
l Institutionalized children and adolescents
l Teenage parents
l Unemployed youths
l Youth in correctional institution
l Victims of abuse
l Disaster and war affected victims - children and adolescents
Life skills education: Impact and implementation
Life skills education should be imparted over an extended period of time. It

has been found that such continuity has been able to create better impact. Studies
have shown benefits of life skills programs in terms of reducing smoking, alcohol
and drug abuse, promotion of intelligence, improved academic performance, improved
school attendance and improved student teacher relationship, improvement in self-
esteem, self-image, self-confidence, self-efficacy and better social and emotional
adjustment.
Life skills education can be easily integrated in the school curriculum. The
schools, colleges have moral/ethics classes and that can be utilized to impart life
skills education. The teachers can be trained to impart life skills education effectively.
Other professionals who are directly working with children and adolescents can be
trained in imparting this novel program. The successful implementation of program
in any setting either in schools or organization always depends on the support of
agency, and well designed cultural relevant training materials.

Chapter 5
PSYCHOSOCIAL CARE FOR MARITAL AND FAMILY LIFE
G.S.Udaya Kumar,1 MJane Henry,2 & Bino Thomas,3
In India, the family is a means through which society has been extending
itself and ensuring its own existence. Here the institution of marriage provides
legitimacy and ensures the smooth functioning of a family. The Indian family plays
an influential role as the primary social regulator of its members. Young Indian adults
tend to remain with their families of origin long after they have completed their
education and have taken up employment. Older family members, both first degree
and second degree relatives, have a large part to play in the approval of marriage
partners and in the settlement of family disputes; be they minor spats between spouses
or arguments related to property.
The Family Life Cycle Stages
Every family evolves from its inception as a young couple to the parenting
phase and then old age and death. The Family Psychiatry Center follows Ellis Duvall's
(Duvall & Miller 1985) classification of the family into 8 stages of the Life Cycle
namely:
Stage I: Married couple without children

Stage II: Child bearing Families (1st Child 0-30 months)
Stage III: Family with pre-school children (30 mths-6 yrs)
Stage IV: Family with school age children (6 yrs- 13yrs)
Stage V: Family with teenagers (13 yrs -20 yrs)
Stage VI: Family with launching young adults
Stage VII: Family with middle age parents (empty nest to retirement)
Stage VII: Ageing family (Retirement to death of both spouse)
Through these stages, as families expand, contract and dissolve, members

are expected to perform certain tasks. Roles and responsibilities increase, diminish
or change through these stages and families members are bound to experience
difficulties. Sometimes families may experience chronic mental illness, death, loss,
infertility, infidelity or other such situations which puts a certain degree of strain on
its members.
Unresolved issues in the early stages of family formation may sometimes be

carried over to later stages where they may create tension among members. A healthy
family learns to negotiate and compromise through dialogue, coping and adjustment
1. Associate. professor 2. Psychiatric Social Worker, 3. PhD Scholar

as to how to overcome these difficulties. Dysfunctional families however may require
some help from therapy.
The Family Psychiatric Center
The Family Psychiatric Center at National Institute of Mental Health and

Neuro-Sciences (NIMHANS), Bangalore, India was set up in 1977. However family
work was going on at the Institute since the 1960's. It is a referral center where
patients from six adult psychiatry units, the child guidance center, neurological
services and outside agencies are sent (Bhatti & Varghese 1995). Patients are seen
both as out-patients and inpatients. There are 14 rooms for families to stay in as well
as kitchen facilities. The center handles a little over 200 referrals in a year. The
center follows a Family Systems approach in the treatment of dysfunctional families
with or without psychiatrically ill members. The emphasis is placed on the interaction
patterns of family members as precipitants or aides to family discord. Resistance and
non-compliance is also understood from the perspective of existing communication
patterns and primary or secondary gains.
The treatment process
At the Family Psychiatric Center, the first point of contact between a family
and the therapist is the Intake. This session may last anywhere between 20 to 45
minutes. During this phase the therapist tries to understand the reason for the family
being referred to family therapy and their availability for regular therapy. The therapist
also explains the course of therapy and the time that would be required for the same
as well as charges. The therapist then draws a contract with regard to the approximate
number of sessions or weeks involved.
The next phase of treatment is Assessment and Formulation, wherein the

therapist takes around 2 to 3 sessions in order to understand the family's evolution
through the various lifecycle stages and the kind of dynamics that exist within each
family. Therapists use the Family Assessment Schedule which is a semi-structured
interview tool. It was devised by the team working at the Center to assess families in
the following area namely family structure including boundaries and sub-systems,
leadership patterns which includes decision-making, role structure and functioning,
communication, reinforcement, cohesiveness, adaptive patterns which include the
social support system. The therapist also tries to understand multigenerational
transmissions through the use of a three-generational genogram. All through this
phase the therapist who is usually a trainee of psychiatry, psychiatric social work,
psychiatric nursing or clinical psychology, receives individual supervision for each
case from the faculty.
The case is then discussed among the family therapy consultants and case
supervisor and a hypothesis is formulated in order to better understand the
dysfunctions existing within the family. Therapeutic intervention for the family is
planned accordingly. Intervention may vary from 6-15 sessions or more depending
on the degree of dysfunction in the family, members' willingness for therapy as well
as affordability of money and time.
Family therapy
Family therapy is based on the belief that problems in individuals are related
to the current interactions taking place between the individuals in the family and
sometimes between these individuals and other social systems. Family therapy also
takes into account multigenerational and extended family factors (Barker 1992).
Family therapy usually includes the involvement of as many of the significant

family members as are willing for therapy or are able to come. In other cases however
a systemic perspective also allows for the use of family therapy approaches with
individuals. An integrated model of family therapy is used with families at NIMHANS.
The basis of all therapeutic measures used is the Systems Theory. The most commonly
used modules are Structural Family Therapy, Cognitive-Behavioral Family Therapy,
Strategic Family Therapy and Psychodynamic Family Therapy.
The systems approach

This can be basically summed up as an approach which uses the idea that the
problem lays within the family as a whole, and not just within a single person.
For example, if a child is wetting the bed, although recognizing that it is the
child that is actually the one who is wetting the bed, systemic family therapy, will
look at the whole family and the relationships between all the people involved
(sometimes past and present) and try to locate how those relationships are contributing
to, and keeping the problem going. The therapist(s) may want to explore issues such
as how everyone sees everyone else, what expectations about the problem are in the
family, and what function the problem serves for the family. For example, if a child
is wetting the bed, it may be that the child is doing it (although they don't know
themselves why) because they are sensing that their parents aren't getting on very
well. Thus, in wetting the bed the child is saying that the problem lies with him or
her. The parents may use this problem, again often for only the best reasons in their
own minds, to focus their attention on the child and not their own relationship
difficulties. This may serve the function of keeping the whole family together, instead
of risking the break-up of the parents' relationship and hence the family (Becvar &
Becvar 1995).
Couples/Marital therapy
Couples therapy focuses on the problems existing in the relationship between
two partners. The term couples therapy is often interchangeably used with marital
therapy. In couples therapy the most popular frameworks for conceptualizing and
treating marital distress include structural, strategic, behavioural, experiential,
cognitively oriented, communication, systems, and psychodynamic or insight-oriented
approaches (Sholevar 1981; Baucom & Hoffman 1986). At NIMHANS an eclectic
or specific approach may be followed based on the needs of the couple.
Couples therapy may include the following themes:

1. Individuation from families of origin
2. Creating healthy boundaries with families of origin
3. Building trust
4. Separation of spousal and parental roles
5. Identifying common life goals
6. Building emotional and sexual intimacy
7. Negotiation and Compromise
8. Effective Communication
9. Active Listening
10. Sharing responsibilities
11. Financial management
12. Gender sensitivity
13. Conflict Resolution
14. Amicable separation in case of divorce
15. Dealing with sexual, emotional, verbal and physical violence
Sex therapy
Sexual difficulties may exist as a part of wider marital problems. They are
sometimes found to be a central feature of a marital problem but may also be secondary
to physiological conditions (Barker 1981, Hawton 1985)
Sex therapy is the treatment of sexual dysfunction, such as non-

consummation, premature ejaculation or erectile dysfunction, problems commonly
caused by stress, tiredness and other environmental and relationship factors. Sex
therapists assist those experiencing problems to overcome them and thus possibly
regaining an active sex life. Sex therapy sometimes may occur conjointly with marital/
couples therapy when marital conflicts have resulted in sexual dysfunctions.
Other family interventions
Family member of patients who are admitted in Adult Psychiatry, Neurology,

Neuro-Surgery and Child and Adolescent Center as well as the Family Psychiatry
Center require some degree of intervention
Psycho-education
Because of improved medication treatment in the past 40 years, more patients

can be treated today in an outpatient setting and the majority of the patients stay with
their families (Schooler et al. 1995).Many families develop methods of dealing with
positive (psychotic) and negative (functional and cognitive deficits, such as flattened
affect, loss of energy and apathy) symptoms, functional disabilities, and the
frustrations of living with a mentally ill member through trials and errors. There is a
dire need for families to establish healthy coping strategies that are closely tailored
to the illness (Adamec, 1996; Cochrane, Goering, & Rogers, 1997; Leff, 1994)
Family psychoeducation has emerged as a treatment of choice for

schizophrenia, bipolar disorder major depression, and other disorders. More than 30
randomized clinical trials have demonstrated reduced relapse rates, improved recovery
of patients, and improved family wellbeing among participants. Psycho-education
as a family intervention also ensures a better quality of life for patients in the context
of their homes. (McFarlane 2003, Pitschel et al 2001 ). Psychoedication may occur
with caregivers, and significant family member either individually or in groups.
Mental illness brings with it a number of psychosocial implications at the
Individual level
1. Frequent relapse
2. High-risk sexual behaviour
3. Treatment resistant symptoms
4. Poor Functioning with regard to activities of daily living
5. Substance Use
6. Lack of Sexual Desire or Excessive Sexual Drive
7. Incompetence in employment
8. Retarded Self Care
9. Poor Communication
10. Inadequate Social Interaction
Family level
1. Lack of understanding about patient's residual symptoms

2. Problems related to marriage and rehabilitation
3. Long term care
4. Handling own emotions, emergencies, relapses
5. Caregiver Burden
6. High Expressed Emotions
7. Marital Discord
Community level
1. Handling stigma and isolation

2. Long term tertiary care
3. Unemployment
4. Lack of awareness about the welfare benefits
Psycho-education may have the following themes depending on the needs of
the patient:
1. Diagnosis, Prognosis
2. Psychosocial and Pharmacological interventions
3. Side-effects of pharmacological interventions
4. Precautions to be taken by family members
5. Identification of possible signs of a relapse
6. Drug Compliance
7. Supervision of Medication
8. Influence of Expressed Emotions on Relapse
9. Social support system
10. Regularity of follow-ups
11. Dealing with caregiver burden
12. Dealing with denial
13. Dealing with stigma
14. Discussion of issues related to marriage, sexuality
15. Long term plans: financial, residential, care giving
16. Welfare measures available to the family from government and private sources
Psycho education also allows an opportunity for families to voice their

concerns, frustrations and worries. It facilitates the learning of new healthier coping
mechanisms and provides a platform for ventilation. Group psycho education also
allows for the development of strong friendships alliances and support groups among
family members of the mentally ill.
Parent management training
Parenting can often be a challenge for new parents or those who have not
had healthy role models to learn from. Behavioral family interventions that are
based on the principles of social learning have been known to be among the most
effective and well-evaluated techniques accepted world-wide ((Brestan & Eyberg,
1998; Lochman. 1990; McMahon, 1999).
Parents are taught
1. to increase positive interactions with children

2. to reduce coercive parenting practices
3. to reduce inconsistent parenting practices
4. to increase consensus in parenting practices
5. age appropriate parenting practices
The method of administration of these programs (Sanders et al 2000) has been
as follows:
1. Group programs
2. Individually administered face-to-face programs
3. Telephone-assisted programs
4. Self-help programs
At NIMHANS, parenting programs have most often been in the form of face
to face interventions and group programs. The department also provides intellectual
resources to parent self-help groups that are run by external agencies.
Parent management training (PMT) at NIMHANS refers to programs that

train parents to manage their child's behavioral problems in the home and at school.
Treatment sessions include
1. Instruction in social learning principles and techniques.
2. Coaching parents using the techniques.
3. Procedures practiced in the sessions are encouraged to be used at home.
4. Reinforcement and punishment techniques contingent on the child's behavior
5. Parents are taught to provide consequences consistently
6. Attend to appropriate behaviors and to ignore inappropriate behaviors
7. Apply skills in prompting, shaping, and fading
8. Use techniques to manage future problems
Many children with early onset conduct problems may have parents with
significant personal problems including low income, single parenthood status, marital
conflict, parental mood disturbance, and high level stressful life events. These kinds
of families are least likely to benefit from purely behavior focused family interventions
(Webster-Stratton & Hammond, 1990). In these cases parents may undergo marital
or family therapy while simultaneously learning how to manage their child's behavioral
problems.
Supportive therapy
Winston et al states that 'a supportive relationship is the necessary cement

for any therapeutic work'. Supportive therapy with families may focus (Misch 2000)
on the following:
1. The management and resolution of current difficulties

2. Taking life decisions using the family's strengths and available resources
3. Ventilation
4. Reassurance
5. Enhancement of the affected family's social support network
6. Increasing the family members or patients self-esteem
7. Maximizing adaptive coping strategies of the family members

Grief counseling
This involves taking families through the process of grieving for a terminally
ill, chronically ill, psychologically disintegrating or dead family member.
Communication Training
Communication Training involves teaching family members to connect with

each other in healthy ways through direct, clear and positive, verbal and non-verbal
methods. It also involves teaching family members new and simple ways of
communicating with mentally ill or mentally challenged members in order to prevent
relapses and better the quality of life of the affected member as well as the rest of the
family.
Coping skills training
This involves teaching families healthy ways to deal with crises such as
supporting each other, use of problem solving technique, seeking help and maintaining
close, confiding relationships.
Psychosocial rehabilitation
Psychosocial rehabilitation is the universally accepted term which refers to

social rehabilitation involving cognitive and functional gains as well as the
development of social skills that can be achieved for patients. Family members are
treated as partners in the rehabilitative process as they are the primary caregivers of
the patient.
Recent reviews on the role of psychosocial rehabilitation (Mueser et al 2002)

reveal that while psycho education has been shown to bring down relapse rates and
improve drug compliance, cognitive and behavioral strategies for social skills,
vocational retraining may actually remove the ambiguity from the minds of family
members and encourage a more systematic focus on the long term plans for the
patient.
At NIMHANS Psychosocial Rehabilitation process begins with a baseline

assessment of the family and the patient's abilities, resources and social support
networks. After this the family may be encouraged to support the patient to undergo
vocational retraining, cognitive retraining and placement. Discussions may also be
held with the family with regard to residential and non- residential care options in
order to provide respite to family members or to decrease the degree of expressed
emotions. Residential options may include half way homes, long stay homes or respite
care homes. Non residential facilities may include day care facilities, sheltered
employment and foster homes. Psychiatric social workers also assist families to
identify resources in the community or help to develop self help groups for mutual
support and networking among families. Often environmental manipulation may be
used in order to enable a smoother transition for patients back into their community
and workplace. This could include:
1. Taking the help of a halfway home, day care center or vocational training
center
2. Respite Care
3. Activity Scheduling
4. Social Skills Training
5. Monitoring activities of daily living
6. Skills Retraining
7. Networking with a prior employer to seek a reassignment
8. Long-term residential care
Geriatric group services
The National Policy on Older Persons confers the status of senior citizen to
a person who has attained the age of 60 years (Ministry of Social Justice website).
An estimated 77 million people or 7.7 per cent of the population are senior citizens
(HelpAge India website). Many of our aged senior citizens live with their families.
Hence any physiological and psychiatric changes affect these family members.
The Geriatric Clinic conducted every Saturday afternoon at the NIMHANS

OPD also provides regular group services to the caregivers of the patients who attend
the geriatric clinic. These groups are managed by the psychiatric social workers and
the programme consists of three sessions spread over a span of three months. Each
session would be conducted for four weeks at a stretch followed by the next session.
So every three months the facilitator would restart with Session One. Session contents
are as follows are:
1. Session One: Psycho-education on Health Problems related to Old Age

2. Session Two: Psychosocial Management of the Aged Person
3. Session Three: Welfare Measures available for the Aged in India
Sessions takes place every Saturday of the month. They are conducted by
the Adult Unit Psychiatric Social Workers. As of May 2006, more than 30 group
sessions have been conducted over the last one year. On an average 8 to 10 family
members attend the group with a minimum of 4 and a maximum of 22 participants to
date.
Some of the commonly asked questions that are dealt with in the group include
the following:
1. How should we respond to hallucinatory behavior (hand gestures, talking/
laughing to self/scolding)?
2. Should we give meals as many times as the patient demands it when he/she
has forgotten that he/she has had a meal already?
3. Should we respond or clarify accusations made by the patient?
4. Will they ever be cured?
5. Are the hearing of voices and forgetful behavior connected?
6. How do I stop their hoarding behavior?
7. What do I do if he/she refuses to get out of his/her clothes when going for a
bath?
8. How frequently can we use sleep medication to control patient's insomnia?
9. Can we force-feed medications?
10. How can we prevent patient from wandering away from home?
11. Can they be allowed to do work around the house?
12. How much sleep is ideal for an older person?
13. Should we confront the patient's suspiciousness towards other family members?
14. Can we beat them and keep them tied up if they get violent?
15. Are there any side-effects of the medication?
16. Will I also get this illness?
17. I also have memory deficits. Does this mean that I too am likely to develop
dementia?
18. Can I leave the patient alone with my children?
19. Why do I need to bring the patient along for follow-ups as this is extremely
difficult for me?
20. How do I go about getting old age pension?
21. Is there a free ambulance service I can avail of for the patients in case of an
emergency?
22. My parent has not left a will for us before he developed dementia and is
currently not in a position to even understand the idea. What should I do?
23. Is this illness hereditary?
24. Are there any old age homes for the aged mentally ill in Bangalore or
Karnataka?
25. What is the use of the Old Age Helpline?
Preventive and promotive Services
Family life education

The concept of Family Life Education evolved from the discussions of a
group of young middle class mothers in New York City (Roberta H.W. 1977). In the
early 80's Dr. Felix Adler formed an organization to study the nature of child
development. This small group of mothers began to study the leading theories of
psychiatrists and social scientists of the time in order to be better parents. From this
early beginning Family Life Education has progressed from a mere focus on parenting
to encompass all family relationships and special problems such as single parenting,
mixed families, special children, premarital preparedness, adolescent sexuality etc .

In India family related issues have not so much been teenage pregnancies
and divorce as much as issues of a burgeoning population, lack of proper hygiene,
malnutrition, inadequate mother and child care, the lack of knowledge and
misconceptions about sexual functioning. The focus of most family life education
programs in India has been on sexually transmitted diseases (Godbole & Mehendale
2005), nutrition and hygiene (Shetty & Kowli 2001), reproductive health and
contraception (Tiwari & Kumar 2004). It is only now that relationship focused
programs are coming into play where mental health professionals are educating
children, adolescents, young adults, young couples, young parents and the aged
about enhancing the quality of their family life. Under the purview of Family Life
Education there have been numerous programs that the Department of Psychiatric
Social Work, NIMHANS has been involved with. These include:
Premarital counseling program

Premarital Counseling and/or education is a therapeutic couples intervention
that occurs with couples who plan to marry (Murray & Murray 2004). Premarital
education is a 'skills training procedure which aims at providing information on ways
to improve their relationship once they are married' (Senediak 1990)
NIMHANS in collaboration with the Central Social Welfare Board has prepared a
Premarital Counseling Program for young men and women. The topics included
under this program were:
1. Adolescence as a Life Cycle Stage

2. Common sources of stress
3. Reproductive health education
4. Sexually transmitted diseases
5. Marriage as an institution
6. Types and functions of families
7. Gender and power structure
8. Communication skills
9. Coping skills
10. Interpersonal skills
11. Decision making skills
12. Parenting
13. Financial management
14. Time management
15. Sleep and food hygiene
16. Positive health
Parent training programs

On a preventative note preparing expectant or young parents with the skills
required to ensure a healthy and safe environment for their children becomes a part
of training. It also involves helping young couples make the transition from being
just spouses to taking on the additional role of parenthood.
Family intervention workshops
This involves training other professionals such as school teachers, lay
counselors, NGO staff, personnel officers in the industry and medical officers. Basic
skills in family assessment and counseling are taught to these lay people for the
purpose of early detection and resolution/referral of familial problems.
Conclusion
Family intervention is an essential part of psychiatric social work.
Dysfunctional family contexts have been strongly linked to marital discord, conduct
disorders and the evolution of personality disorders. Preventative and promotive
family intervention may perhaps enable the formation of healthy families with
members who are able to cope and problem solve adequately within the context of
their homes. Curative family intervention at tertiary agencies like NIMHANS Family
Psyhciatry Center, Family Counseling Centers and Family Courts may provide much
needed care to burdened families.

Chapter 6
PARENTING: A PSYCHIATRIC SOCIAL WORK PERSPECTIVE
Bino Thomas,1 & G. S. Udayakumar,2
Parenting is one of the highly valued social roles in all human localities and
cultures. It is a two way process of interaction between the child, and the parent.
Parenting is characterized by warmth, sensitivity, support, responsiveness, conflict,
hostility, methods and degree of monitoring and controlling the children's behavior
and contingency. The quality of parent child relationship, the level of cohesiveness,
or togetherness, and the quality of marital relationship influence parenting The parents
play a great role in the socialization, emotional development, disciplining, academic
achievement and cognitive development of the children. Despite significant changes
particularly in western societies the motivation to have children remains strong. This
is because raising children serves many purposes like; producing children healthy
and well adapted children and thus perpetuating the society, enduring support fir
parents as they grow older, sustaining wealth, or providing new stimulation to and an
extension of the life of parents, many of whom find meaning fir their own existence
through having and bringing up children (Hoghughi, 2004).
Recognition of widespread child abuse and deficiencies in biological parents

in the latter half of the 20th century gave particular thrust to the codification of
specific child jurisprudence (Houlgate, 1980), coinciding with the later spread of
powerful political philosophy that ' individuals own themselves'. The subtle and
indirect impact of this has bred the concept that parents have their children 'in trust'
(Alston et al, 1992). This means that they do not 'own' their children and cannot do
with them what they want. Most national laws, certainly in the West, recognize, that
children should receive at lest a culturally assigned minimum level of care and positive
developmental opportunities and freedom from abuse. Parents are regarded as the
main agents of delivery f these rights, with the state in a policing and supportive
back up role. There is a gradual cultural shift in most developed countries towards
recognizing qualities of parenting as the major shaper of children's state and prospects
(Hoghughi, and Speight, 1998).
Concept of parenting
'Parenting' may be defined as purposive activities aimed at ensuring the survival and
development of children'. It derives from the Latin verb; parere;-'to bring forth, develop
or educate'. The use of the verb 'parenting' is as recent as the noun 'parent' is old. The
word 'parenting' from its root, is more concerned with the activity of developing and
educating than who does it.
1. PhD Scholar 2. Associated professor

In modern parlance, however, 'parent' denotes the biological relationship of a
mother or father to a child. On the other hand, the verb 'to parent' ( or more commonly
parenting) denotes a process , an activity and an interaction , usually by grown ups
with children, but not necessarily or exclusively their own. Of course parenting is
practiced by nurses, teachers, friends, relatives, and other care givers (Clarke-Stewart,
1995). The connotation of the word is that parenting is a positive, nurturing activity.
As parents get older, the age and power differential with the children which
defined their status, becomes less stark. Care giving roles are gradually equalized
and then reversed, with most children adopting an increasingly parental role, ensuring
the safety and welfare of their elders. The concept has now been extended to the
wide ranging social construct of 'corporate parenting'. Given that even people who
have no children of their own are somebody's child, brother or sister, aunt or uncle,
almost everyone engages in 'parenting' activities. As we shall see, given the core
elements of the process, the whole structure of social control -formal and informal-
can be construed as being an aspect of a parenting society. Thus when we look at its
reach and significance, parenting emerges as probably the most fundamental and
universal concern of society (Hoghughi, 2004).
Dimensions of parenting
Just as theories of parenting differed in their emphasis on control and

nurturance, so did the dimensions used to describe parenting style in early empirical
research on socialization. The dimensions included acceptance, rejection and
dominance, submission, involvement, love/hostility/ and autonomy/ control, warmth
and permissiveness / strictness. Baumrind distinguished three qualitatively different
types of parental control: authoritative, authoritarian, and permissive. She found
that parents who differ in the way they use authority also tended to differ along other
dimensions.
Authoritative parents are not intrusive and permit their children considerable
freedom. At the same time they also impose restrictions in areas in which they have
greater knowledge or insight. They are firm in resisting children's efforts to get them
acquiesce to their demands. Parents seem being responsive and attentive to their
children's needs but also being able to set limits. In contrast, Authoritarian parents
were rigid, power assertive, harsh and unresponsive to their children's needs. The
children used to be irritable, fearful, moody and vulnerable to stressors. The Permissive
parents used to be excessively lax and inconsistent discipline. It develops uncontrolled,
non compliant and aggressive behavior in children. The Uninvolved parents were
indifferent to or actively neglected their children and were motivated to do whatever
is necessary to minimize the costs in time and effort of interaction with the child.
These parents are parent centered rather than child centered. Particularly when a
child is older, these parent fail to monitor the child's activity or to know where he/
she is what he/ she is doing or who his/ her companions are.
A consensus also emerged about the association between child outcomes
and parenting. Model children as described by Symonds (1939) are socialized ,
cooperative, friendly, loyal, emotionally stable, and cheerful, honest, straightforward,
and dependable, good citizens, and good scholars and whom Baumrind called '
competent' were the products of homes where parents were warm, rational, allowing
the child autonomy within boundaries.
The conceptual contributions
There are some key theoretical contributions which are now indispensable
aid to understanding parenting process. The pride of place must go to John Bowlby
(1951, 1980) and his formulation of the concepts of maternal deprivation and
attachment. Subsequently modified and much elaborated by others. It is now evident
that early maternal deprivation by itself does not have the disastrous consequences
Bowlby suggested (Clarke and Clarke, 1976). Rather damage is done by circumstances
associated with maternal deprivation, such as distress and inconsistency of care.
Effects of separation from biological parents can be moderated by the child's age and
the quality of substitute care, but some disruptions of attachment appear to have
adverse long term consequences. Winnicot (1958) introduced the humane and
necessary concept of good enough parenting as a desirable goal of what parents do.
Realistically, the most and the best parents can do for their children is to five tem a
core of unconditional love and reliable care, providing a safe setting for children's
own resilience and developmental potential to unfold- as demonstrated by the larger
part of humanity. Ainsworth et al (1998) established the secure attachment as a crucial
outcome of good parenting.
Parental needs
Parents need, want or desire finances, psychological and social competencies

above all the core resources include qualities, social network, skills and materials to
deploy in raising their children. The main qualities highlighted in parenting include
warmth, intelligence, stability, and communicative ability as well as freedom from
serious physical and mental health problems. Supportive people surrounding the
parents are a significant source of empowerment. The more networks the parents
have the better child outcomes (Hoghughi, 2004). Material resources may be
interpreted as the money, goods, and services necessary for raising children. They
include food, clothing, housing, medicines, toys, educational materials, and a
multitude of services dictated by the prevailing standards of society. Parents need
time to do their parenting. In the western cultures, it has been an issue nowadays.
Traditionally mothers have been responsible for the care and control of their children
in the early years and fathers provided material support for the sustenance. With
rapidly changing economic circumstances, increasing numbers of women have entered
the labor market to work, full or part time. The time they spend at work cannot be
spent with their children (Hoghughi, 2004).
Parenting as a skill
The ability to parent effectively is not inborn, as is evident in much parental

incompetence across ages, cultures and psychosocial conditions. There are no
universal inborn response patterns or competencies readily available to parents of
new children. These therefore need to be acquired and that is called in this context as
skills. They are acquired both formally and informally through parent's own
experiences, trial and error with their children, observing other parents or through
media. The skills are required to meet the physical emotional and social care needs
of the child, to set and enforce behavioral boundaries, and to communicate with the
child; persuasive ability is needed to gain resources, and management skills to make
best use of them. The most obvious, long term contribution form research to the
social context of parenting has been through numerous books and manuals offering
advice to new parents. These exemplify the ways that guidance made available to
parents tends to mingle research messages with a strong dash of personal experience,
theory, and sometimes, pure prejudice.
Parenting across various life spans
Parenting practices vary across the various life cycles. The attachment as a
parent begins with the unborn child and it goes on in different modes throughout the
child development. The parenting journey moves well for some parents and not so
well for the other. The parents along with preparing themselves for becoming a father
or mother they also learn to adjust in their marital life with an entry of a new member.
As the child is born, mothering and fathering begins and they try to provide the best
for the child.
Whether one adopts, conceives naturally or conceives through some assisted

means, the decision to raise a child is a lifelong decision. The child's schedule and
needs will rake priority. The decision to change job, move to a new city, go on vocation,
and so forth will not be made without first thinking about what is best for the child.
Even after the children are grown, their influence remains. The father and mother
takes the role of provider, of the different needs and wants of the child. They discipline,
guide, love, teach them socially appropriate behaviors and once the child become
adolescent, parents guide them in making decisions, solving problems, being
responsible for their actions etc. As the child grows old, the intensive parenting
reduces and the control of parents on children decreases. But in Indian set up, the
children continue to be with the parents even when they are old and parents take
decision for their child despite the fact that the child is capable of taking decision.
Parents should be skillful, should understand and be flexible for change according to
the different life cycles needs of the children.

Psychiatric social work and parenting
Psychiatric social work has been the chosen field of many generations of
social workers and a major source of services in mental health facilities. Psychiatric
Social Work professionals use the therapeutic methods for prevention, promotion,
curing and development needs of individuals. The profession of social work lies in
the underlying needs, wants and problems of individuals when they become parents.
Increasing attention is given to the importance of better preparation for parents to
undertake their role in raising children. Parents generally receive little preparation
beyond the experience of having been parented themselves, with most learning 'on
the job' through trail and error. The changing social ecology of parenthood is also
complicating the task of raising children. The already demanding role of parenthood
is further complicated when parents do not have access to extended family support
networks (such as grandparents, trusted family friends) for advice on child rearing,
or when they experience the stress of separation, divorce or re- partnering. The rational
for parent training stems from evidence linking dysfunctional parenting practices
with an increased risk of children developing behavioral and emotional problems.
Epidemiological studies indicate that family risk factors such as poor parenting, family
conflict, and marriage breakdown, strongly influence children's development. The
major risk factors in parenting practice are; lack of a warm positive relationship with
parents, insecure attachment, harsh, inflexible, rigid or inconsistent discipline
practices, marital conflict and breakdown, parental psychopathology, especially
maternal depression and parental criminality. The above said reasons constitute the
rationale for the involvement of social work professionals in the area.
The social workers find them in the role of a therapist, trainer, educator,
collaborator, coordinator, and facilitator. They are involved in giving support to
parents in areas like Family Life Education, Family Therapy, Parent Management
Training, and Parenting Skills Programmes for the parents of different age group or
based on the different needs of parents. They work in collaboration with different
mental health professionals like, psychologists, child psychiatrists, counselors in
settings like, schools, hospitals, community centers etc.
The social worker as a therapist focuses on the deep parental issues and
helps the couple to live together, in understanding and affection and helps them to
take their role as parents. The focus of parent management training is to teach the
parents specific skills and techniques to handle their children having emotional or
any psychological disturbances. The parenting skill programmes are conducted in
various settings like, hospital, schools and community centers where the focus is
given on training the parents on skills which are appropriate on the different life
stages needs of the children. These programmes help in preventing the behavioral
and emotional problems in children. The skills may include play and disciplining
skills, adult interpersonal relationship skills, effective communication skills, anger
management, problem solving, decision making, academic skills, monitoring skills,
etc. The social workers also involve in research in this particular area focusing on
strengthening the relationship between the parents and children at different life stages.
The professionals need to make it aware that good parenting practices only can make
the children good, responsible and stable.

Chapter 7
GROUP WORK IN PSYCHIATRIC SOCIAL WORK

Ameer Hamza,1 D. Muralidhar,2 and Imran Khan,3
The group process contains the secret of collective life, it is the key to
democracy, it is the master lesson for every individual to learn, it is our chief hope
for the political, the social, and the international life of the future - Mary Parker
Follet. (Smith, 2002)
Introduction
Group life is basic to any human being. A group can be understood as any
collection of social beings that enter into distinctive social relationships with one
another. Group involves mutual support and reciprocal advantages to its members.
Group work is one of pillars of social work as a method. Group work like
social work had its professional beginnings in the west but its practice has now
spread far and wide to be included as a special method of social work practice.
Social group work uses the group as a stage to nourish, change and develop personality
of individuals.
Many authors have defined group work in different ways. One of the most
comprehensive definitions was given by Trecker. According to him" Social group
work is method through which individuals in groups in social agency are helped by
a worker who guides their interaction in programme activities so that they may relate
themselves to others and experience growth opportunities in accordance with their
needs and capacities to the end of the individual, group and community development."
Group work works on the following basic premise
l Group life is the most fundamental thing for a person to be called as a social
animal, because it is due to group living that the person is socialized.
l Social work believes that individuals and groups can be helped to growth and
changes in personality and attitude provided suitable conditions are created.
l Mutual acceptance is the basis of social group work which has its cost roots in
democracy.
l It is easier to change individuals formed into group than to change any one of
them separately.
1. Assistant Professor 2. Additional Professor, 3. PhD Scholar

Origin and development of group work as a method of social work
Social group work as one of the methods of social work practice is a broad
domain of direct social work practice. Just as the Charity Organization Movement is
the parent of social case work, the club and recreation movements of the nineteenth
century and early twentieth are the direct forebears of social group work. So also is
the case with group psychotherapy. Where the roots of contemporary group
psychotherapy are often traced to the group education classes of tuberculosis patients
conducted by Joseph Pratt in 1906, the exact birth of social group work can not be
easily identified. It would be worthwhile to travel through the development of social
group work as a part of social work.
Social group work evolved during the latter part of the 19th and the early
years of the 20th century. Many movements helped in the growth of group work as a
method which include the progressive education movement, the settlement movement,
the play and recreation movement, informal education, camping and youth service
organizations invested in 'character building' such as YMCA and YWCA,
Transactional Analysis groups, Alcoholics Anonymous groups.
Of the philosophical and theoretical influences on group work during its

inception, the most notable were research and practice efforts of Grace Coyle, Wilber
Newstetter and Neva Boyd who paved the way for the advancement and development
of social group work. In particular Grace Coyle presented an early theoretical
framework for group work articulating the need for a democratic value base,
identifying the role of the worker as a group builder and noting the benefits of 'esprit
de corps' or group morale. (Reid, 1981)
The period of time between the 1930s and the 1950s was one of growth and
expansion for social group work. The economic despair of and varied psychosocial
needs resultant of the Great Depression paved the way for greater affiliation between
the social work profession and the field of group work. The psychological needs of
returning war veterans who served in World War II resulted in the more frequent
application of social group work in psychiatric treatment (Konopka, 1983). During
this period, and further not only did the field of social group work debut at the National
Conference for Social Work but also made additional advances.
Many developments during the 1960's and the 1970's influenced the social
work profession including social group work. Having expanded into differing practice
settings, the purposes and goals of group work had been more broadly described at
this juncture than in previous decades. The work of Vinter and Schwartz and their
respective associates dominated the group work scene for much of this decade and
the next. (Smith, 2004)

In 1965 Bernstein and colleagues introduced another social group work
practice theory. The centerpiece of the edited collection was a developmental stage
model, known as the Boston Model, which presented a framework for understanding
how groups navigate degrees of emotional closeness over time.
In 1966 Papell and Rothman presented a typology of social group work that
included the social goals model (in the tradition of Coyle), the remedial model (as
developed by Vinter) and the reciprocal model (as articulated by Schwartz). In 1976
Roberts and Northen presented a collection of ten group work practice theories,
further illustrating the diversity of approaches to group practice. In the more recent
decades other models of group work have evolved. Contemporary group work practice
continues to be informed by the work of early pioneers and the vanguards of the
1960s and 1970s.
Principles of group work practice

Social group work is a therapeutic set up of individuals who are coordinated
in their interaction and efforts to achieve betterment in their functioning. The group
worker is not an authority in the group but does hold a central position in the group
work process and functioning as a facilitator. The group worker needs to be an expert
in handling the multiple interactions occurring in the group and also pay due attention
to the dynamics of the group. In all this the group work needs to be conscious of the
fundamental principles of group work which guide its practice and determine its
effectiveness.
Throughout the expanse of social work practice, many practitioners have

given many principles of group work practice to guide through group work practice.
One of the most widely accepted among these has been those given by Trecker.
(Trecker, 1955). They are as follow:
l Principle of Planned Group Formation

l Principle of Specific Objectives
l Principle of Purposeful Worker Group Relationship
l Principle of Continuous Individualization
l Principle of Guided group Interaction
l Principle of Democratic Group self-determination
l Principle of Flexible Functional Organization
l Principle of Progressive Programme Experiences
l Principle of Resource Utilization
l Principle of Evaluation
Irrespective of the setting or the type of groups conducted by the group worker
the principles of group work practice guide him/ her to focus and sail through the
process of group work in achieving its goals.

The basic theoretical models for group work
Models have been quite extensively used in social work literature. Kogan
(1960) described a model as 'a scheme for "making sense" out of the portion of the
real world'.
Papell and Rothman (1966) described a model as '…a conceptual design to

solve a problem that exists in reality. Most social work models are formulated from
practice experience and try to impose upon it some kind of order which can be used
to guide future practice and to teach students probable approaches to practice.
In the absence of a general theory, models are perhaps the limit to which
systematization of social work practice has been able to go. One of the first statements
which concerned more than one model of group work practice in social work was
made by Papell and Rotham (1966). They identified and described three models of
group work practice namely
1. The social goals model

2. The remedial model
3. The reciprocal model
The basic concepts of the social goals model are social consciousness, social
responsibility, and social change. The model proposes that individuals can affect
social change with their participation with the others in a group situation. Social
action is the desired outcome and the group worker is regarded as an influence person
and enabler, who personifies the values of social responsibility and acts as a stimulator
and role model without purveying any political viewpoint. Implicit in this model is
the ultimate transfer of leadership from the professional social worker to an emerging
leader within the group.
This remedial model is also known as the 'treatment' model. Basically the
remedial model focuses on the individual within the group. Papell and Rothman
(1966) see this model as a clinical one, focusing upon helping the mal-performing
individual to achieve a more desirable state of social functioning. Goals are established
for each individual, selection is of paramount importance, and the group is both 'the
means and the context for treatment. The group processes are not fully exploited in
this model and the leadership function of the group worker is definitely paternalistic,
knowing, and directive, i.e., the worker is a 'change agent' rather than an enabler.
In some ways the reciprocal model is the polar opposite of the remedial
model. The social worker here neither sets a programme nor controls the group as a
prescient leader, but the group forms by the 'engagement' and involvement of its
probable members and the causes which the group will espouse are decided in the
interaction of members. Clearly this involves shared responsibility and a level of
social maturity and group experience which is quite great. The group therefore is a
system comprising of the worker and client, contributing, influence, and being
influenced, both having a deep involvement not particularly different in kind from
others.
The role of the social group worker varies according to the model of group
work practice used. Nevertheless there is no single model which is used during group
work practice.
A few of the other social group work models include: the Process model, the
Eclectic position model, the Behavioural model, the Task-centered model, the Group-
centered model, the Personal growth model, the Maturational stage model, the Mutual
Aid Model and so on.
The remedial model is most commonly practice in various clinical conditions

in medical and psychiatric social work.
Scope and settings for group work practice

From the time of its evolution and growth, group work has diversified as a
method of direct social work practice. Its practice has necessarily spread beyond the
traditional areas. To list the entirety of practice settings of social group work will be
beyond the scope of this chapter. Provided is a list of settings in which group work is
practiced with psychiatric populations.
l Psychiatric hospitals
l Child Guidance Centers
l General hospital settings
l De-addiction centers
l Rehabilitation centers
l Palliative care centers
l Homes for the aged
In hospitals and clinics it is practice in both In-patient and Out-patient settings.

The use of groups in follow up services is dealt as a separate topic elsewhere is this
chapter. There are a range of populations that group work serves, the list provided
here is though, not the most exhaustive.
l Clientele with Mental illness

l Clientele with Mental retardation
l Clientele with various addictions
l People with Neurological disorders
l People with various disabilities
l Group work with children
l Group work with the elderly
l Group with people with personality disorders
l Clientele who are diagnosed with terminal illnesses
l Mixed clientele consisting of care takers of patients and patients themselves
l Care takers of various patient populations including parents of children with
various problems, spouses of people with mental illness or addictions,
personality disorders, care takers of the elderly.
The list is not exhaustive and may be expanded as and when a new setting
and population is identified for social work practice.
Group formation - how group members enter group work

Individuals enter group work through various means. It is worthwhile to
understand how they form groups or become part of the group. Group formation
refers to the ways in which groups come into being. Group formations can be
understood in various ways.
Ken Heap suggests three types of group formation according to the degree
of volition on the part of members. The three types of group formation include
compulsory groups, formed groups and natural groups. Those groups which are formed
by some agency, external to the group through the exercise of authority can be called
as compulsory groups. Many alcoholic and drug-treatment institutions and an
increasing number of mental hospitals require patients or inmates to attend group
treatment sessions of various kinds regardless of their wishes. These are examples of
compulsory groups. It should be noted that compulsory membership does not rule
out common purpose.
Though formed groups are also frequently formed by external initiative, the
members have more choice. In a sense they select themselves, since they may accept
or refuse the invitation of the sponsor. For example a social worker motivates a
group of parents of mentally retarded children to come together in order to help each
other to work through their problems, feelings and decisions. He writes or visits
them to offer group service. They choose to enter the group situation or not.
The natural group arises spontaneously without any external initiative or

compulsion, the members simply "come together" through circumstances which often
seem to involve a large element of chance. For example: a group of teenagers who
involve in shoplifting in order to finance amphetamine purchase or a group of street
children operating or residing in the same locality. (Ken Heap, 1979).
The kind of group formation has direct relevance to the practice of social
work with groups. According to the social work agency concerned, one of these
types of formation will be represented. Experience suggests that the conditions of
formation exert substantial influence on the members' attitudes to the group, on their
readiness to identify with its objectives and with each other and their attitudes to the
agency and the worker.
Rationale for group work - the therapeutic factors
"It is usually easier to change individuals formed into a group than to change
any of them separately." - Lewin's law of change (Smith, 2002)
What is it in a group that helps in helping the group members? Groups are
apparently as effective as they are due to certain inherent factors. A comprehensive
list of such factors was given by Yalom in his book titled "the theory and practice of
group psychotherapy". According to Yalom "I suggest that therapeutic change is an
enormously complex process and occurs through an intricate interplay of various
guided human experiences, which I shall refer to as 'therapeutic factors' " (Yalom,
1995).What we will attempt to understand in this part of the chapter is these therapeutic
factors. Though many therapeutic factors are reported to be operating in group work
practice, we will focus our attention to those provided by Yalom as these are most
widely accepted. These therapeutic factors include:
Instillation of hope
Group members are able to experience a new hope in their lives due to the
group work scenario. Each member in the group is inevitably at a different point on
the coping continuum and grows at a different rate. Watching others cope with and
overcome similar problems successfully instills hope and inspiration. For example
member 'A' who is a senior member in the group shares about his recovery from the
negative symptoms of a mental illness in the group. This instills hope in the newly
joined member 'D' who is actively dwelling in that negative symptoms state. He or
she finds it reassuring that he can overcome this condition which goes well with the
saying 'every cloud has a silver lining'.
Universality
Many members enter groups with the thought that they are unique in their
problems of life, that they alone have certain frightening or unacceptable problems,
thoughts, impulses and fantasies. The group experience helps the members to
understand that they are not alone who are going through these unique problems.
This is a great source of relief which goes well with the cliché "we are all in the same
boat"
Information giving
Group becomes a platform for the group members to learn about the illness
that they share. Providing information about for example bipolar disorders, depression,
panic disorders or neurological illnesses is an important aspect of group work
experience. So also the group experience helps the members to recognize the variations
in the illnesses. If there is an old member in the group he or she also adds on to the
information shared in the group.

Altruism
In therapy groups as Yalom pointed out members receive through giving, not
only as part of reciprocal giving-receiving but also from the intrinsic act of giving.
Most often members in groups especially patients with psychiatric illness, alcoholism
etc have probably had very less to offer others and much to take from them.
Consequently they tend to feel inadequate. The group offers the members to be of
help to other members even if it means methods discussed in the group about anger
control, money management, activity scheduling, re-adaptation issues and so on.
The process of helping others is a powerful therapeutic tool that greatly enhances
members' self-esteem and feeling of self-worth.
Corrective recapitulation of the primary family

Most group members who seek treatment would have interpersonal problems
at the family level for long periods. Group members start identifying with the group
as their family. Thus the authority figure, the leader becomes the head of the family
and other members act as members of a family. The group serves the function of a
family to these members with its own rules, coalitions, affection towards other
members in the family. This recasting of the family of origin gives members a chance
to correct dysfunctional interpersonal relationships in a way that can have a powerful
therapeutic impact.
Improved social skills

Yalom stated that social learning or development of basic social skills is a
therapeutic factor which occurs in all therapy groups. Groups act as a smaller unit of
society with a number of other members who have their own behaviours, beliefs and
attitudes. Group members learn to relate to other group members in appropriate ways
and frequently also get feedback about their interaction. While the process of feedback
by the group members can be anxiety provoking, the directness and honesty with
which it is offered can provide much-needed behavioral correction and thus improve
relationships both within and outside the group.
Imitative behavior
The group is a scenario where group members' model behaviours learnt in
the group from the therapist and other group members. Over time, members pick up
these behaviors and incorporate them. For example: in groups conducted for people
with alcohol dependence the group worker exhibits through a role play how to deal
with peer pressure. The same is repeated by the group members taking different peer
pressure situations. This helps in learning drink refusal skills through imitation.
Interpersonal learning
Human beings are social animals, born ready to connect. Our lives are
characterized by intense and persistent relationships, and much of our self-esteem is
developed via feedback and reflection from important others. Distortions in the way
we see others often damage even our most important relationships. Group work helps
the members in learning to relate with each other well. The group becomes a set
stage to learn interpersonal skills. For example: when a group member arrives with a
relapse with an exacerbation of symptoms, the group's equilibrium tends to be
disturbed. The group members need to recognize this as a challenge and take
responsibility rather than avoiding or being critical toward the relapsing member.
The group worker needs to address the triad of reality appraisal which includes realistic
appraisal of the self, realistic appraisal of the others and the realistic appraisal of the
situation to neutralize this disequilibrium in the group and the group to be therapeutic
and supportive.
Group cohesiveness
Belonging to a group whether it is a religious group or cultural group is one
of the most basic human needs. Many people who enter groups in various settings
may have emotional problems and may not have experienced success as group
members. For them, group helps in feeling truly accepted and valued for the first
time. This can be a powerful healing factor as individuals replace their feelings of
isolation and separateness with a sense of belonging. Moreover most learning happens
due to the fact that group members identify with the others in the groups as a whole.
Catharsis
Catharsis is a powerful emotional experience, the release of conscious or
unconscious feelings, followed by a feeling of great relief. It is a type of emotional
learning, as opposed to intellectual understanding, that can lead to immediate and
long-lasting change. Groups provide a fertile ground for catharsis as it evolves an
empathetic atmosphere. This is because all members of the group come from similar
backgrounds and thus they are able to identify with each other much better than
people outside the group. For example: In a group of people with OCD each group
member identifies and empathizes with the other because the others are undergoing
the same experiences which help the members to relieve their pent up emotions.
Existential factors
Existential factors are certain realities of life including loss, isolation,
freedom, meaninglessness and death. The fact that one must take ultimate
responsibility for the way one lives his or her life no matter how much guidance and
support one gets from others is an existential truth. Becoming aware of these realities
can lead to anxiety. The triad of trust, respect and interest along with the openness
that helps one to be among members in a group. However, this permits exploration
of these fundamental issues, and can help members develop an acceptance of difficult
realities.
Issues addressed in group work practice in psychiatric settings

The practice of group work in various settings involves discussions on various
issues. The agency setting where the group work is practiced and the population
determine the issues which will be addressed in the group work sessions. For example:
issues addressed in group work with the elderly will address old age issues ranging
from financial burden to illnesses in geriatric conditions.
The following is an example of the areas which are addressed in group work
with people with psychiatric morbidity (Muralidhar, 2005):
l Expectations and the needs of the patients and family members

l Psycho-education - information about the illness, signs and symptoms, course
etc.
l Treatment modalities, investigations
l Re-adaptation issues after discharge
l Future concerns such as marriage, having children when on medication.
l Relapse prevention strategies.
l Training in various skills which include social skills, assertiveness skills,
interpersonal skills, life skills etc.
Follow-up through groups

Group work practice in In-patient settings and residential settings is quite
popular and is generally seen to be practiced. An offshoot of the group work practice
in hospital settings has led to the evolution of group work in Out-patient settings.
This can also be referred to as follow up through groups. There are currently very
few such groups in practice. (Muralidhar, 2006)
Follow up groups have certain inherent advantages and disadvantages. Some

are listed below. The advantages are:
l Members of the group are coming from their homes and not institutional
settings which mean they are in real world situations, as they will be interacting with
the family members on a daily basis. The problems they will report are much more
nearer to reality than the imaginative, futuristic problems dealt with in Institutionalized
or protected settings.
l Members are able to field test the suggestions which the group provides by the
next follow up and provide feedback in the next sessions.
l The rate of follow up tends to increase because of the continuing advantage of
the therapeutic factors in group work. A follow up is not just an event for
meeting the social worker or the doctor but to meet a number of other members
who are sailing in the same boat.
l Issues such as compliance to medication, lapse and relapse, dealing with anger,
dealing with emergencies are much effectively dealt in follow up groups that
individual follow up.
l To the hospital staff, it is a time economizing activity as follow up groups
involve eight to ten follow ups happening at a time.
l Most times these groups include both the patients and the family members
which gives an opportunity to both of them to understand the others perspective.

The disadvantages of follow up groups include
l Many a times the follow up groups turn out to be bilingual or much worse
multilingual which makes communication very difficult in the group.
l Maintaining time becomes an issue as different members of the group may
come at different times for follow up.
l The group worker needs to be vigilant not to include actively psychotic or
excessively disturbing patients in the groups.
l Ensuring participation among group members becomes a difficult task
especially if there are patients who are grossly affected by negative symptoms.
l Follow up at times become battle grounds for the patient and family member
to complain against each other. Though discussion about the same can be a
significant issue to be addressed in the follow up groups if the same turns out
to be an argument it may disturb the whole group work activity.
Keeping in view the advantages and disadvantages, it is important to know

that conducting follow up groups requires considerable skill and experience because
of the dynamics occurring, the member characteristics, issues which may arise etc.
Recording in groups
Maintaining record occupies a significant place in social work practice and
its need is well documented in literature. Similarly recording is accepted as a necessary
practice in social group work. Recording in-group work means writing the description
of the individual's activities, his relationship with the group. Social group worker
writes about the individual members and their responses to one another, their
behavioral pattern, type and extent of participation, movement, growth and change
in individual and group and his own role in the group processes. The significance
and contents of a record are explained by P D Mishra as below. (Misra, 1994)
The significance of recording in group work is evident through the following:

l Records help the group worker to understand individuals in the group
l Help the worker to understand the group as whole
l Provide evidences of growth and changes in the members and in the group
worker himself
l Help the worker to do more effective job with his groups on the basis of
information in the records
l The worker can see merging and changing interests of individual members.
l Record helps the social worker to observe the development of skills and social
attitudes in the group members
l He gains knowledge of special problems in the group
l He knows the emergence of group consciousness
l He records provide content for supervisory conference
l They are the source of future planning
l They are source of information for other workers
l The records provide a permanent and continuous register of facts for the agency.
Contents of Record
1. Identify information of the group
2. Member's participation by name
3. Description of the group as a whole
4. Description of the group problems
5. The relationship and the role of the group worker
6. Special assistance given
7. Evaluation
A typical group work session

Groups are practiced in various settings. Particulars such as number of
sessions in group work, duration of each session, what will be discussed during a
session differ depending on the setting, the clientele etc. Provided below is an example
of a typical group work session which is carried out with people with alcohol
dependence.
l Start by greeting the group members for the day followed by introduction of
the group members (including family members or relative or friends of the
patients if they are a part of the group).
l Comment of the weather for the day or the dominant mood of the group which
is to make the environment of the Group lighter.
l Elicit responses about the previous session topic and discussions held. What
were the lessons learnt briefly
l Go over any assignment given for the day in the previous session.
l Introduce the topic for the day.
3 For example: What is a relapse?
3 Has any group member experienced a relapse?
3 What happens (reactions) of self and family on a relapse?
3 Why do people generally relapse?
The PSCM model of relapse states that relapse occurs due to the PSCM
factors which are Pressure, Stress and Strain, Craving and Miscellaneous factors.
This model has been evolved from the patients who were successfully abstinent for
a period of more than one year. (Ameer Hamza and Muralidhar, 2007) The same can
be understood in detail as given in Table - 1
3 Ask for a relapse story among the group members
3 What would others in the group do in case of a relapse?
3 Conclude with the ways of dealing with relapse which will include those
methods which the group members discussed.
l Give an assignment for the day
l Summarize for the day.
The above example provides the structure of a group work session. Other
components can be utilized such as a two minute refreshing activity, a role play, a
debate on the topic for the day by the group members.

PSCM Model of relapse prevention is one such model mainly derived from
the experiences of successful alcohol abstinent patients. This was evolved through
their transcriptions. This is a simple conceptual frame work Where P represents
Pressure, S represents Stress and Strain, C represents Craving and M represents
Miscellaneous. The corresponding sources, degree and strategy; the Alcoholics
Anonymous checklist of HALT as well as various issues in Miscellaneous helps the
group facilitator to carryout the therapeutic group sessions on scheduled days over a
period of 3to4 weeks of in-patient care setting. The Schedules I and II are for the
purpose of recording the group process for individual client and the family members
(refer schedule I and II ).
The PSCM Model of relapse prevention.
Sources Degree Strategy
Peer/ friend, Work, Mild Explain,Excuse,

Pressure Neighborhood, Family, Moderate Escape,Assertive,
Social network. Severe. Confrontative.
Financial stress,
Instill confidence in
Interpersonal, Domestic,
Stress and Mild others, Pay in parts,
Neighborhood,
Strain Moderate healthy alternatives,
Hard work.
Severe. Seek support.
Craving (intense urge to have substance) checklist of HALT
Hunger Substitute with immediately gratifying desirable alternatives
Withhold and control.

Anger Think positive,
Leave the situation.
Supportive people.
Loneliness Prayer. Etc
Healthy alternatives.
Tiredness Take family support
Positive events: child birth, marriage, anniversary, festivals,

Miscellaneous pay day. Bonus, promotion, opportunities abroad.Negative
events: failure in love, betrayal by others, death of loved
ones, desertion by spouse, property disputes, death rituals.

Conclusion
Social work is a global stream of education and practice. It is fast expanding
to include many more clientele than before, in its scope. Group work has had a
significant place in social work practice and will continue to be regarded so. The
adoption of group work method in various settings has expanded its scope. Studies
have shown that group work is a beneficial intervention for clients from varied
backgrounds in different settings. It is true on the other hand that group work as a
method of social work or intervention is losing its practice and has retained as a
theoretical method. The reasons for its non-use may be because it has not been
practices as a method in certain settings, lack of expertise to start group work practice
etc.
It is essential that group work is taught not only in classrooms but also in the
fieldwork with appropriate supervision and guidance than as a mere component of
the syllabus. We know that ideally patients in groups work leave with a better
understanding and acceptance of themselves, and stronger interpersonal and coping
skills. Some individuals continue in therapy even after the group disbands, either
individually or in another group setting. To recognize the efficacy of group work as
a method of social work by effectively practicing it should be the future of group
work.
As Lewin has quoted "It is usually easier to change individuals formed into
a group than to change any of them separately", we as social workers should be the
rightful successors of this legacy of change.

Chapter 8
STRENGTHS BASED APPROACH IN SOCIAL WORK PRACTICE IN
WORKING WITH FAMILIES WITH ALCOHOL PROBLEMS
D. Muralidhar,1 & Lakshmi Shankaran,2
'Inebriety is a disease that could be treated. It is not a moral failing'

(Mary Richmond, 1917)
It is widely accepted that alcohol problems especially in a parent, contributes
to the children's risk and vulnerability. Many studies reveal that children whose
biological parents especially the father engaging in substance abuse have a higher
risk of developing alcohol problems at an earlier age and male children are found to
be more vulnerable with a four-fold risk . Given the magnitude and rise of alcohol
problems in India , it is inevitable that the problem escalates in a number of families.
This throws the children to the vagaries of both genetic and family influences with
an additional risk of developing behavioural and emotional problems . Social Workers
(medical and psychiatry) including other mental health professionals often view this
as a barrier or as an issue that is difficult to change and may possibly neglect this
area. Without help such families invariably remain exposed to harm and the children
are hidden from the outside world. The needs of the family members, especially the
children's is in danger of being overlooked.
Social Work Professionals (medical and psychiatry) are ideally positioned

to identify, screen as well as prevent future problems in children and their families
facing the wrath of a parent's addiction. However, the usual focus is on the individual
who is viewed as a victim of alcohol abuse. According to Mane (1989), families may
be involved at a peripheral level at the most to engage in the addicted parent's recovery.
Wolin (1992) attributes this to the pervasive influence of the Damage Model on
treatment professionals. This is a traditional approach where children and families
are considered to be passive and without choices likely to suffer the lasting
intergenerational transmission of disease (alcohol dependence in this case) including
lasting emotional disturbances. Wolin adds that the Challenge Model provides the
'survivors' or children of troubled families a more balanced perspective about their
past and gives them the opportunity to actively infuse lasting resiliencies into their
lives.
Many studies reveal that the interplay of protective processes on the multiple
risks faced by the troubled children of alcoholics (COAs) through parental strengths,
broader family networks has mitigating effects on them (Masten et al 1991; Rutter,
1985). Despite the adverse risks, they are shielded from developing alcohol-related
problems in adolescence and early adulthood through strong family relationships
that enhances stability. An effective non-drinking parent's role, healthy family
interactions, maintaining rituals and routine activities and using strategies to manage
stressful situations have been found to have protective influences and contribute to
the COAs' resilience. The presence or absence of these factors helps some families
break the cycle or 'transmit' the similar problems to the next generation (Report to
the European Union on Alcohol Problems in the Family, 2000; Orford & Vellaman,
1995; and Nastasi & Dezolt, 1994).
1. Additional Professor 2. PhD Scholar

‘Resilient people have the capacity to be bent without breaking and the
capacity, once bent, to spring back ‘ (Vaillant, 1993)
A strengths based perspective by Social Work Professionals considers these

constructive and mediating influences of the family - there is an attempt to understand
and examine the clients' survival skills, abilities and resources to influence their
ultimate well - being (Early & GlenMaye, 2000; Saleebey, 1996). The Social Work
Code of Ethics reiterates this by recommending the involvement of families, the
inclusion of strengths and resiliencies in intervention practices and the role of alcohol
within its cultural context (NIAAA, 2005). In the Indian context, a similar need to
weave in resilient oriented methods that are strengths based and culturally appropriate
is increasingly recognized by the Social Work Profession (Sankaran et al, 2006;
Rangan & Sekhar, 2006). This paper attempts to provide a broad framework for
Social Work students (medical and psychiatry) to be included as part of their training
directed towards strengthening protective family factors that increase the resilience
of children of alcoholics from developing early onset alcohol dependence.
Scope of the problem
Impact on children: The concept of love and trust of caring adults is important
for the children's development of a healthy personality (Erikson, 2000 cited in the
Report to the European Union). Unfortunately this may be threatened for children
living in homes with an alcoholic parent. Witnessing parental conflicts, even non-
violent ones, separation, divorce, loss of a parent and ambivalent parenting appear to
increase the likelihood of COAs experiencing continuous problems (Vellaman, 1995).
Inconsistent child care and low parent-child intimacy are reported in such families
(Fisher & Harrison, 2000).
According to Black (1985), an implicit family dictat 'don't talk, don't trust,
and don't feel' reigns in the COAs' homes. Here, the children do not share or talk
freely about the chaos at home; the parents' broken promises leads to greater distrust
towards other individuals and there is also a loss of 'feeling words' to describe
emotions. If emotions are expressed, they are often met with reprimand, hostility or
rejection. The suppressed feelings of children increase their vulnerability to behaviour
and emotional problems and to the risk of using alcohol or other substances as a
coping mechanism.
The 'survival roles' donned by COAs described by Wegscheider (1981) are

as follows - the 'hero' or caretaker, 'lost child', the 'joker' or family clown and 'scapegoat'
or rebel. Further, these roles are reportedly due to inconsistent parenting and poor
emotional support during childhood pre-disposing the children as adults to relationship
problems, marry alcoholics or have alcohol problems themselves.

Indian studies report that COAs feel lonely, fearful, pre-occupied and
embarrassed due to their father's drinking (Desikan, 1981). Many face academic
problems and have poor adjustment at home and outside (Venkataraman & Beig,
1988).
The problems experienced by COAs reported in a study are summarized
below (Shah and Vasi, 2002):
l Lack of positive role models, witnessing repetitive negative behaviour
l Difficulty in forming, sustaining relationships by adult children of alcoholics
(ACOA)
l Loss of self-esteem due to dual messages, negative feedback,
l Lying to protect family dignity
l Witnessing constant fights, violence at home
l Depression, anxiety and 'pseudo maturity' having no one to share problems
l Helplessness and wish for stability or a normal family
l Stigma of being labeled as a child with an alcoholic father
l Taking up 'survival roles'
l Dropping out of school or work due to financial crisis at home
l Severed contacts, poor concern by relatives and others
Age of experimenting: According to Bandura's social learning theory (1986),

the child's drinking is shaped through imitative social learning or modeling. Parents
condoning alcohol and drug use behaviour as acceptable i.e. asking a child to light a
cigarette or get the drinks; display of tolerant drinking norms; and absence of parental
monitoring for drinking increase the risk and plays a powerful role in children who
are genetically predisposed (Mc Dermott, 1984; Zucker, 1996; Dawson, 2000). In
fact, the offspring appear to imitate the same sex parent's drinking levels (Harburg et
al, 1982). An Indian study reveals that the average age when males start drinking
lowered from 25 to 23 years (Benegal et al, 2003) - the risk was higher (of using
alcohol, drugs and tobacco) when they are exposed at a relatively young age to the
key adult with a drinking problem.
A large proportion of ACOA have negative adult adjustment, depression and

relationship difficulties revealing that there were areas that were also not necessarily
alcohol related and the inadequacies continued into adulthood (Black, 2002; Harter,
2000; Orford & Vellaman, 1995). An Indian study echoes this sense of internal
emptiness expressed by ACOA during group psychotherapy (Ramakrishnan & Shenoy,
1991).
Impact on the family: The impact of alcohol problems on the various

dimensions that comprise family functioning is revealed in an Indian study by Bhatti
& Channabasavanna (1982). The overall family functioning is unhealthy; leadership
is 'stop - gap' or highly indecisive filled by another member; reinforcement is through
coercion or punishment with no established boundaries for expected behaviour;
communication styles are confusing, contradictory often imposed by the leader;
common family goals are absent with poor concern towards each other including
inadequate support systems. The researchers recommend mental health professionals
to shift their intervention approach to include the entire family and not just the
alcoholic individual.
Roles- The non-drinking spouse is often burdened with role strain taking on
multiple roles due to the gradual dysfunction of the alcohol dependent parent- juggling
with daily chores, making rules, taking decisions and dealing with incremental
financial problems are some of the challenges (Graham et al, 1993; Wegscheider,
1981). An Indian study reports that children hailing from families with an addiction
problem blame parents for being inadequate role models (Monteiro, 1987). COAs
below fifteen years of age work to supplement income and compromise on basic
needs due to financial difficulties and loans taken by the alcoholic parent (Benegal
et al, 2000, Pandian, 1999).
Cohesion - Low emotional bonding and lesser activities (recreation, spending

time together) within the family weakens ties and lowers mutual trust amongst them
(Barry and Fleming, 1990). Poor problem solving abilities among both parents and
within the family including lack of compromise between parents and children is
reported (O'Farell & Fals - Stewart, 1999; Jacob & Leonard, 1994). Some families
are either completely helpless or there are others who make conscious attempts to
distance themselves from the alcohol problems (Orford & Vellaman, 1995).
Co-dependency - As the alcohol problem escalates and intensifies over time,

the family tries to deal with the crisis resulting in their lives becoming as dysfunctional
as the addicted family member. The addict or the 'dependent' may be protected by the
'enabler' i.e. family members who deny the problem at the same time try to control
the situation. An Indian study reiterates the presence of co-dependency among spouses
of male alcoholics (Bhowmik et al, 2001). According to Jackson (1954), such families'
have a tendency to attempt to maintain an equilibrium or balance referred to as
homeostasis - but they may never achieve full organization.
The Alcoholic Family - Changes in regulatory behaviours (such as family

rituals, daily routines and short-term problem solving strategies) may also occur as
the family becomes organized around, or is distorted by the presence of the alcoholic
behaviour- there may be periods of de-stabilization and consolidation (Steinglass et
al, 1987). Most importantly, these regulatory mechanisms determine whether or not
alcoholism is transmitted across generations.
There are other factors that contribute to problems within the family. Violence
is one such factor and children witnessing them are left with emotional scars leading
to faulty role modeling and the spouses facing its regular onslaught cope through
avoidance, discord and fearful withdrawal (Gururaj et al, 2006; Veni, 2001; Sreedevi,
2000; and Parvathy, 1989). Social stigma, another factor associated with alcohol is
so severe among Asian families that some experience unease even whilst talking to
treatment professionals (Neagle et al, 2002); families with high social isolation and
mothers having a smaller network are common (Coohey, 1996; Thompson, 1995;
Blaxter, 1990; and Bhatti et al, 1986).
The non-drinking spouse is also vulnerable to drinking problems often used

to cope with the resultant stress or as a misguided exercise to control her spouse's
drinking. The mothers are prone to neglecting the children resulting in emotional
distancing, poor school performance and early acts of deviant behaviour in COAs
(Miller et al, 1999; Flannery et al, 1999; and Vaillent & Milofsky, 1982). Children
living in such a milieu neither have the mobility or choice to change their destiny.
The older child or the only child is found to be more vulnerable to psychological
damages - they could simply detach and leave home (Vellaman, 1993).
Despite, the presence high risk of alcohol problems in COAs, there appear
to be certain factors whose presence protects the COA by preventing or delaying the
early onset of alcohol dependence. Social Work Professionals need to recognize the
positive outcome of this balance between environment and biological factors as being
important for children.
Protective factors in families

Protective factors are defined as influences that modify, ameliorate or alter
the person's response to some environmental hazard that predisposes to a maladaptive
outcome (Rutter, 1985). According to Vellaman (1995), the absence of these factors
may lead to higher risk in the 'transmission' of early alcohol - related problems to
some children in alcohol impaired families. In others, the presence of these factors
may break the cycle by the family's ability to distance itself from the alcoholic member.
The COAs' resilience from alcohol related problems and overall well-being is the
positive outcome. A combination of family factors and not just one factor is found to
help the COAs' balance risks with protective factors.
Role of family interactions:- Many studies reiterate the positive influences

of families having the ability to buffer the risk of substance abuse problems in children
viz. attention from the primary caretaker, emotional supports, clarity in goal setting,
effective disciplining and parental role modeling, monitoring and supervision, norms
about alcohol use, meaningful family involvement, consistent roles and responsibilities
and absence of parental conflict (Kumpfer et al, 2006; Hill et al, 1992; Werner,
1986; Rutter, 1985).
Factors that influence non-use among adults in an Indian study reveal that
family commitments including responsibilities, the presence of positive role models
at home and parents' disapproval (to non-use) play a role (Jayaram et al, 2003).
Similarly, the positive relationship between the individual's periods of abstinence
and harmonious family environment is reported in previous studies (Muralidhar et
al, 2006; Radhamani & Muralidhar, 2005; Pandian, 1999). The father's positive role
on the COAs is reiterated in a study conducted among African Americans especially
when they have a more authoritative style and talk to the children - the children
report more cohesion in the family and feel that they are worthy of trust (Mupeir et
al, 2002).
An effective non-drinking parent- This serves as a protective mechanism

and sons of alcoholics without substance abuse report having mothers with higher
occupational status including experiences of good life events (Springer, 1995). In
another study, the mother's relationship with the children and her supervision positively
influences youth in reduction of drug use especially among boys (Ardle et al, 1997).
The findings were similar in Bahr et al's study (1995) who report that feelings of
intimacy, joint activities and communication are negatively associated with substance
abuse among male and female adolescents.
Family rituals and routine activities - According to Wolin and Jacobs (1987),
rituals comprise of the following: Family celebrations - they are relatively standardized
rituals specific to the sub-culture and includes holidays, rites of passage and annual
religious and secular celebrations; Family traditions - which are less culture specific
and more idiosyncratic to families with special activities. Vacations, visits with
extended families, reunions and customs are some examples; Patterned routines -
these are frequently enacted but least consciously planned reinforcing a sense of
identity, defining roles and responsibilities e.g. mealtimes, and leisure time routines.
A study by Wolin et al (1980) demonstrates the important influences of family

rituals on the risk of alcohol transmission in children. Families that maintain their
important rituals despite severe parental drinking are called 'distinctive' families -
they manifest a strong collective sense of identity that is separate. This protects the
children from transmission of alcohol abuse to the next generation. Pre-existing rituals
are actively protected and the alcoholic parent's intoxicated behaviour is rejected by
confrontation and clear expression of disapproval. The researchers aver that such
families having a sense of control over parts of family life communicate important
messages to the children - they help COAs to take control of present and future life
events. Bennet et al (1988) refer to such families as 'deliberate families' with high
levels of ritual practices adding to the psychological resilience among the COAs.
Prabhugate (2002) in an Indian study reiterates this understanding where one of the
strengths of intact families is attributed to the presence of family rituals.
Managing stressful situations through problem solving - Vellaman (1995)

reports that in families with an alcoholic individual, the process of learning to tackle
problems at an early age plays a protective role and help them to distance themselves
from the adverse circumstances. There is a process of 'selective disengagement' from
disruptive elements and 're-engagement' with others outside the family. This
'deliberateness' may be evident in the decisions and choices made by the COA as
adults - they consciously plan on how to be same or different from their family of
origin determining whether the child will continue the legacy of alcohol problems or
instead choose to break the cycle.
The support systems (through internal and external resources) add to coping
efforts. According to the National Association for the Children of Alcoholics (1998),
the benefits of the adults' coping efforts on children helps them to develop autonomy,
strong social orientation, and social skills and provides them the opportunity to deal
with emotionally hazardous experiences on a day - to - day basis. Various studies
indicate that a wide range of supports (emotional and material) help the family to tide
over difficult times and enhances the protectiveness for COAs viz. the non-alcoholic
parent, the alcoholic father, siblings (especially older ones as surrogate parents)
grandparents and teachers (as role models), neighbours, friends, peers and employers
(Kittmer & Guelph, 2005; Werner & Johnson, 2000; Coombes & Anderson, 2000).
An Indian study (Sreedevi, 2000) reveals that the non-drinking spouse's

independent sources of income helps in coping efforts, provides a more stable home
and lowers the risk of alcohol problems among the COAs. Phillip's study (1991) on
the pattern of help seeking behaviour in alcoholic families reports that the attitude of
the primary network system, the use of different support systems by the family
(primary and secondary), and frequency of use plays a role. This may introduce the
COAs to a repertoire of resources. The role of support systems and its positive
influences on recovery and improved interpersonal relationships is similarly reported
in other studies (Radhamani & Muralidhar, 2005; Thirumoorthy, 1995).
It is evident that the interplay of the above factors influences the COAs and
contributes to their resilience and overall well-being in adulthood. The optimistic
learning is that growing up in adverse conditions can be an empowering and
strengthening process for some people. Translating the aforesaid research based
evidence into strengths based practices in addiction treatment lies with Social Work
Professionals' and their initiatives.
The framework
The various difficulties that children face when growing up in families with
alcohol problems have been discussed above. The relevance of a strengths based
approach to prevent future problems by building the children's resilience is an
important issue. According to Wolin and Wolin (1993), protective factors are external
to the individual i.e. circumstances or situations and these factors coalesce together
contributing to the internal strengths of individuals. Greene et al (2005) caution that
the languages used was important as it played a role in the empowerment process in
Clinical Social Work that was strengths based - they advocate avoiding the language
of disease and pathology and instead recommend viewing clients (families in this
case) as having strengths, resources and expertise and encourage efforts of
collaboration.
Some of the significant factors that comprise the strengths perspective
incorporated in the social work model are as follows (Saleebey, 1997):
l Belief that trauma can be both a challenge and opportunity
l Focus first on what is working well
l Look for strengths, possibilities in clients rather than problems;
l Mobilize strengths (talents, knowledge, capacities, resources)
l Help to expand, enhance coping strategies
l Help recognize and change negative thoughts into positive ones
The proposed framework is guided by the aforesaid precepts to develop core

competencies that are relevant to empower families seeking addiction treatment. It
also recognizes that the active engagement of families not only has immediate benefits
for the COAs - but they also have the innate potential to sustain positive changes in
the children from childhood to adulthood in the long run. Thus, the objectives are
twofold:
l To build resiliencies in COAs from early onset alcohol dependence

l To facilitate protective factors in families of COAs
1. To build resiliencies in COAs from early onset alcohol dependence
Assessment of the children's physical, emotional and behavioural problems

would precede intervention efforts. It is important to note that many COAs may not
exhibit overt problems and may also be well functioning. According to Black (2002),
re-shaping roles for COAs is a slow process and more effective when several adults
are part of the therapeutic plan (includes grandparents, extended family, neighbours
and the local school). These children learn to balance their roles better and experience
a sense of choice when responding to different situations. Thus, intervention would
be tailored to meet the individual needs of each child.
Some narratives of children’s experiences impacted by their parent’s alcohol problems:

‘…My father made many promises. ‘I will take you shopping for clothes and fire
crackers for Dipavali; We will go to the beach on Sunday; I will help you with Hindi
lessons this evening’. But he never did any of these things. When I remind him he
would say ‘Not now, I will do it later…’
‘….Our cousin Ravi called my father a ‘drunkard’ at the wedding. When I told my
mother this, she slapped me and said not to ever use this word again. I never talked
about this again, not even to my grandfather, my brother or my best friend…’
..I am scared when father returns after drinking and shouts at mother late in the
night. She gets angry with us the next day. She has started hitting me. Is there
something also wrong with my mother...?’

Strengthening self-esteem - COAs need to regain their lost sense of self due to their
negative self - concept and many may not even be aware that they don't feel too good
about themselves. They may have also a poor image about their bodies, an indicator
of low self - acceptance. Social Work Professionals should listen to the child, respect
and accept his/ her present feelings; and give specific and honest praise including
criticism. The COA would also be taught to receive positive strokes with grace being
prerequisites for maintaining strong self- esteem and emotional well-being. Similarly,
showing appreciation towards others, which help both the recipient and the giver
(COA in this case), would be encouraged. The case below illustrates how the parent
can play a role in boosting the child' self-esteem:
Sunita is nervous and anxious on her school sports day even though she has trained
for it. She does not want to lose and suddenly doubts her ability to play. After listening
carefully, her father highlights Sunita’s strengths and lists them out to her e.g. her
previous trophies, the extra coaching, and her dedication to practice sessions. The
discussion makes her feel better and more confident to face the game. She hugs her
father to express her gratitude.
Goal setting (both short and long term) and periodic review of the results is
an exercise towards boosting the children's self-confidence.
Banu finds wants to improve her marks in her science subjects. Her parents are too
busy to arrange for special coaching classes. She is not able to catch up with the rest
of the class and is wondering how to tackle this situation?
In the above illustration, the process of goal setting can be applied by the
Social Work Professionals. Defining the goal, steps to attain it, the ways to combat
ensuing hurdles and setting a deadline would be part of the learning process.
Increasing assertiveness - The COAs would be encouraged to practice

assertive methods to resist negative peer pressure. Here, role play can be used
effectively by presenting high risk situations that are culturally relevant. The
behavioural goals encompass the ability to express both negative (anger, fear, guilt)
and positive feelings (praise, love, happiness). Straightforward expression of COAs'
thoughts/ feelings resonating with his/ her value system strengthens self-esteem and
a sense of responsibility (illustrated in the case below):
The term exams are over in college. To celebrate this, Tony’s friends ask him to join
them at the local bar. ‘No thanks!’ he says. His friends are persistent and insist on his
company. ‘No, I will not join you as I don’t drink, and also don’t enjoy being in the
bar. It’s not my idea of a celebration. You go ahead’.

Facilitating healthy coping styles- COAs are at a higher risk of using unhealthy
methods (especially alcohol or drugs) to deal with difficult situations (see the next
section for problem solving methods). Sharing feelings openly and honestly, talking
to someone caring and trustworthy (teacher, relative, friend), and helping COA to
identify potential mentors is facilitated. Methods of relaxation as part of anger /
emotion management would be introduced. Healthy recreational activities and
sustainable changes in lifestyle are encouraged and structured. Self - help groups
(youth groups, Al-ateen groups) provide the children with emotional support and
external resources. They continue to offer succour to many ACOAs later in life.
Communicating the seven C's- You didn't Cause it; you can't Cure it; you can't
Control it; but you can help by taking better Care of yourself by Communicating
your feelings, making healthy Choices and Celebrating yourself (National Association
of Children of Alcoholics, cited in Wielchelt, 2006). The underlying optimism and
hope is summarized despite the risks of growing up in a family with alcohol problems.
(Methodology proposed to work with the COAs): Psycho education; group work
with COAs; play therapy; story telling, use of media, and case work
2. To facilitate protective factors in families of COAs

The indirect effect of involving families is to sustain positive changes among the
children and reduce their vulnerability to early onset alcohol problems.
Some of the past events recalled by fathers’ with alcohol problems:
‘…I cannot believe that my drinking aroused so much anxiety in my daughter Sita
that she would stay awake to open the door when I returned home after midnight.
Outwardly she does not show any such feelings and that pains me more…’
‘...I was once locked up in a room by my eldest son when I was very drunk so that my
family could celebrate Sankranthi at home with other relatives and friends in peace.
I feel sad and ashamed when I remember this…’
Providing optimism and a positive outlook - How the family views and
approaches crisis situations is important and for well - functioning families, and they
are usually transitions or milestones. This in turn helps in better coping styles and
contributes to resilience among the family members (Walsh, 2003). Social Work
Professionals could provide the families including children a chance to make meaning
out of adversity - in this case, the addiction treatment itself may be a traumatic
experience. Here, the strengths based treatment intervention infused with optimism
could play a catalytic role. Religious and cultural traditions within families can also
be tapped to yield transformation and re-order priorities.

Restoring healthy family functioning
Families also need to 'recover', independent from the addict's own recovery
given the understanding that addiction is a family disease. The change after treatment
intervention can be unsettling for both the recovering addict and the family members
(in this case, the spouse/ or significant caregiver and children). The interconnected
relationships within the family are widely recognized and the focus of intervention
is to help the family to revive positive family interaction. This ushers in the need to
provide the family with a safe and acceptable environment to discuss their own
problems. Increasing their self-worth, recognizing their psycho-social needs and
helping them overcome their self-imposed exile from the society at large would be
part of empowerment.
Two areas that need to be strengthened are promoting healthy styles of

communication and learning effective problem solving methods.
Communication processes - Open emotional expression during crisis situations

fosters mutual trust and tolerance and enable the family members to share a wide
range of feelings. This avoids ambiguity and keeping of 'family secrets' that are
usually common in families with addiction problems. Talking to each other,
maintaining eye contact, using personal statements ('I' statements), and non-verbal
cues are some of the methods of improving communication between the family
members including children.
Problem- solving that is collaborative through brainstorming, resourcefulness

and shared decision making helps in conflict resolution by family members'. They
learn to accommodate one another. Initial focus would be on small non-threatening
problems - as the families become more proficient with new skills in the course of
treatment, they would be helped to deal with large emotionally laden issues. The
Social Worker uses the therapeutic setting to help family members' list problems and
alternatives, make evaluations and empower them to make conscious and honest
choices. This family-centric process would facilitate the members to respect and
appreciate different values and perspectives which do not necessarily have to be a
source of conflict -the outcome may be negotiation and compromise.
Enhancing supports for the non-drinking parent - Depending on the situation,

the family's inner and outer resources (emotional and material) need to be evaluated
and strengthened. The spouse's external supports can be strengthened through use of
self-help groups that afford anonymity e.g. Al-Anon groups for families; arranging
vocational training / job placement / micro credit schemes (for economic
independence) may be required. Separate programmes for support persons (extended
family, friends or well wishers) would be offered as part of treatment intervention.
Improving parenting
The importance of rebuilding a trusting and healthy parent-child relationship helps
the child's own development of personality, provides healthy role models and helps
in sustaining positive changes into adulthood. Social Work Professionals need to
refresh the parents by imparting skills that would improve parenting efforts. The
areas are as follows:
l Understanding the children's feelings - Hurt, anger, fear and joy may be some
of the emotions expressed by COA. Keen listening, physical touch, eye contact,
giving feedback can reassure COAs about the parents respect and concern for
them as individuals and their feelings and foster re-bonding
l Spending quality time - Allotting time and doing activities together as a family
can be part of a daily structure viz. assisting them with studies, sport activities
and hobbies
l Encouraging participation in family activities - COAs should be appreciated
when they help in routine activities however mundane e.g. washing dishes,
folding clothes, watering the plants or shopping. The child's efforts in self-
reliance, initiative and responsibility should be acknowledged clearly and
considered as worthy and valuable by the parents
l Recognizing the children's strengths - Every effort made by the child should
be encouraged to their best of his/ her abilities. Communicating this message
to the child is important as it reaffirms the parents' sincere appreciation
l Getting to know the peer group -Interest in the COAs friends, their interests
and maintaining a warm relationship with them should be genuinely expressed
i.e. preparing simple snacks when they come home unannounced may be a
welcoming gesture. This would also facilitate in mediation of negative peer
influences through regular monitoring and supervision.
l Positive role model - Articulating clear norms about non-use of alcohol and
other substances, demonstrating values such as honesty, patience, and
punctuality in daily life are subtle influences on COAs. Setting limits with
clarity is important.
Revitalizing rituals and routines- Structured plans (both short and long term) for
the recovering parent and the family would include one daily activity that would
engage the family to participate as a unit e.g. eating at least one meal together,
watching television, and spending time at home. Family traditions that are special
can be included e.g. visiting relatives, religious places, going to the cinema, park,
shopping. Lost family celebrations such as birthdays, wedding days, and annual
religious / secular events would be revived. The activities reinforce a sense of family
identity and increase cohesiveness among the parents and children. The ritual practices
from the previous generation are adapted with the assumption that the offspring will
repeat the same.
(Methodology proposed to work with adults: Psycho education; group work with
families/ addicted members; and case work with individual members)

The outlined framework demonstrates that Social Work Professionals can
tap the innate potential of families by a perspective shift by them - from deficits to
challenges. According to Saleebey (2002), empowerment, resilience, and membership
are keys to the strengths perspective in Social Work Practice. The process of
empowerment also presents an opportunity to reduce the risks in children of alcoholics
from the early onset of alcohol problems. Integrating this understanding into Social
Work Training would go beyond routine intervention.

Chapter 9
WORKING WITH SUBSTANCE DEPENDENCE:
A SOCIAL WORK PERSPECTIVE
D. Muralidhar,1 & S.Bala Shanthi Nikketha,2
Addiction has a wide range of consequences encompassing the individual,

family community and society at large. It affects both the standard of living and
quality of life. A trained professional social worker with his/ her knowledge on
methods skills and techniques would certainly play a vital role in the specialized
field of addiction and rehabilitation.
The term substance, when discussed in the context of substance abuse and
dependence, refers to medications, drugs of abuse, and toxins. These substances
have an intoxicating effect, desired by the user, which can have either stimulating
(speeding up) or depressive/sedating (slowing down) effects on the body. Substance
abuse and dependence refer to any continued pathological use of a medication, non-
medically indicated drug (called drugs of abuse), or toxin. The concept of abuse and
dependence are often used interchangeably. But its important to understand the
difference. They normally are distinguished as follows. Substance abuse is any pattern
of substance use that results in repeated adverse social consequences related to drug-
taking-for example, interpersonal conflicts, failure to meet work obligations, family
or school obligations, economic/financial or legal problems. Substance dependence,
commonly known as addiction, is characterized by physiological and behavioral
symptoms related to substance use. These symptoms include the need for increasing
amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases,
and a great deal of time spent in activities related to substance use.
Substance abuse is more likely to be diagnosed among those who have just
begun taking drugs and is often an early symptom of substance dependence. However,
substance dependence can appear without substance abuse, and substance abuse can
persist for extended periods of time without a transition to substance dependence. In
addition to being an individual health disorder, substance abuse and dependence
may be viewed as a public health problem with far-ranging health, economic, adverse
family and social implications. Substance-related disorders are associated with the
transmission of sexually transmitted diseases (STD/ HIV/ AIDS) as well as failure in
school, unemployment, domestic violence, homelessness, and crimes such as sexual
assault, road traffic accidents, robbery and burglary.
People abuse substances such as drugs, alcohol, and tobacco for varied and
complicated reasons, but it is clear that our society pays a significant cost.
1. Additional Professor, 2. Psychiatric Social Worker

The common drugs of abuse include alcohol, nicotine, cannabis, opioids,
benzodiazepines and volatile solvents. Alcohol dependence is considered a public
health problem because it affects people's health (physical, mental and spiritual), it
is serious, it can be understood in terms of its causation and attempts can be made at
preventing it.
Alcohol and drugs cause devastating impact on ones quality of life. The
impact is felt on health, psychological and social functioning. Substance dependence
causes severe health problems. It impairs the persons psychological functioning by
causing memory deficits, difficulties in attention and concentration. It also affects a
persons family and work functioning. The chronic nature of the illness makes the
recovery process slow and painful.
Management of substance dependence has been a challenge to helping

professionals since long. Poor motivation to quit, stigma attached to the illness, role
of the family and frequent relapses have been factors mediating the efficacy of services
targeted at persons with substance use disorders. Treatment and rehabilitation facilities
are offered at various primary care settings, tertiary care hospitals, deaddiction centers
and rehabilitation centers.
Etiology of substance abuse- an overview

The nature versus nurture debate in the causation of substance use disorders
has been an integral part of the scientific study of the phenomenon. Until recently
when practitioners have altered their perception and have come to believe that both
neurobiological and behavioural science explanations are important in the
understanding of the disorder.
Behavioural conditioning
The most important element in substance use disorders is the origin and
understanding of the cues and craving. The behavioural theories explain that external
and internal cues associated with the use of the substance can later stimulate drug
related responses, even in the actual absence of the drug. These cues are important
secondary reinforcers or maintaining factors. The same principle can also be applied
to the process of 'conditioned withdrawal' in opiate dependence.
Psychodynamic factors
Karl Abraham, Sigmund Freud, Rado and Winnicott are a few among those
who have proposed a psychodynamic explanation for substance dependence.
Addiction is considered as a substitution for regressive infantile auto-eroticism. The
pleasurable and unpleasurable vicious cycle of addiction can be explained by this.
Gratification of pleasure occurs as result of substance use, but the person experiences
guilt and loss of self esteem, this in turn causes high levels of anxiety and makes the
person use the drug again. Psychodynamic theories also emphasize on the role of
drug and alcohol in reducing sexual inhibitions and specific type of depression.
Defense mechanisms play a significant role in perpetuating substance use. The
common defences employed by substance users are as follows:
l Denial: Denying the use, pattern, problems associated with use and the loss
of control over use and need for help.
l Minimization: Minimizing the magnitude and severity.
l Rationalization: provides a seemingly logical explanation for the substance
use and its pattern.
l Projection: Blames some other person for the pattern of use or the consequences
of the same.
The role of socio cultural factors

Substance use and problems associated with it are linked to social and cultural
factors including political and economic factors. These factors can cause and mediate
the course and outcome of substance use disorders. A few of these factors are
mentioned below.
l The availability of one or more substances,
l The community's drug/ alcohol policy,
l Attitude towards use,
l Cultural patterns of use,
l Social stressors.
Family dynamics
The role of family as a contributing factor for maintaining substance abuse
has been widely studied. Modeling and identification of the parents by children are
known to influence the development of the disorder. Family rituals and interaction
pattern have also been areas of research. Studies on families with substance using
members, reveals the following classification.
l Distinctive: little / no disruption of rituals

l Subsumptive: absence of all rituals
l Intermediate: few rituals continue and the others are disrupted.
Common interventions
In India, the Ministry of Social Justice and Empowerment coordinates the
treatment and rehabilitation services for persons with substance dependence. Three
hundred and ninety three treatment cum rehabilitation centers and fifty three
counselling and awareness centers are offering services in the country. A majority of
treatment centers provide residential care for a period of 21-30 days. The components
of therapy include psycho education, group therapy, individual therapy and family
interventions. Although a number of therapies have had varying degrees of success,
no single treatment has been shown effective for all individuals diagnosed with
substance abuse and dependence.

The service providers for persons with substance abuse and dependence
include health care professionals like psychiatrists, social workers, psychologists,
general physicians, nurses and volunteers and lay counselors. Services are also
provided by non governmental and religious organizations. Though medical
management is an integral part of the helping process, psychosocial interventions
have long been established as a significant component of a substance abuser's holistic
recovery. Trained social workers play a vital role in the management of persons with
substance use disorders. The approach of social workers to substance use is multifold.
This enables a dynamic perception of the issue. Psycho social interventions focus on
the preventive, curative and promotive aspects of substance use disorder.
Role of social workers in helping

Deaddiction services are one of the many specialized areas where the
application of social work practice has been long established. Many rehabilitation
and short term care facilities employ social workers and many of the services are run
by practitioners in the social work field. The following are the common interventions
provided by social workers in deaddiction settings.
Curative Interventions
Assessment and diagnosis
The first step in the management of a person with substance use disorder is
clinical assessment and diagnosis. Social workers commonly involve in this process.
The client who is dependent on one or several substances is assessed in the presence
of a reliable informant. The assessment encompasses socio demographic data, history
of substance intake, past and treatment history, family history, personal history and
information on premorbid personality. The persons current mental status and cognitive
functioning are also assessed. Significant time is spent in gauging the persons desire
to quit the substance which in other terms is his/ her motivation to stop using the
substance. The client is also assessed for locus of control which can be described as
attribution to seeking help.
Treatment plan
The plan of management would depend on the preliminary assessment.
Offshoot of assessment would be the clientele clinical diagnosis, identification of
problem areas, the treatment plan and the foundation of therapeutic alliance between
the client and the care giver.
Motivational interventions
Motivational interventions are based on principles of motivational
psychology; it is therapist mediated patient centered intervention. It is based on the
stages of change model and has provided a general and practical approach for changing
behaviors associated with substance use disorders. Studies over the past 10 years
have demonstrated that motivational interventions are moderately successful in
initiating change among a variety of individuals with alcohol-related problems (Burke
et al., 2003). Diclemente and Prochaska proposed the five different stages in the
motivational cycle. These stages are pre contemplation: the person with substance
dependence does not consider he has a problem, contemplation: the person
acknowledges he has a problem and is willing to consider the costs and benefits of it,
preparation/determination: the person makes the decision to stop, action: Takes action
to stop the drinking behaviour and maintenance: Sustains the modified behaviour of
drug free living. Relapse can occur at any stage of the clientele transition from one
stage to another.
Motivational interviewing is a therapeutic technique that is client centered

and directive it aims at enhancing motivation to change by resolving client
ambivalence. The basic principles include expressing empathy, develop discrepancy,
avoid argumentation, roll with resistance and support self efficacy. Which are strongly
embedded in the basic principles, methods and philosophy of professional social
work. The social worker uses these guiding principles to enhance the clients
motivation. The techniques or skills used for this process are open ended questioning,
reflection, affirmation and summarizing.
Relapse prevention interventions

Relapse is a state in which the individual returns to his/her previous pattern
of substance consumption after a period of abstinence. Relapse prevention is a non
directive therapist mediated strategy. This helps clients to anticipate probable
situations of relapse and cope with situations, craving management, drink refusal
skills, occupational rehabilitation, sleep hygiene and life style modification. Coping
skills are also an integral part of relapse prevention strategies. Social workers help
clients learn skills that the have lost due to their chronic dependence or those that
they have never acquired. These skills include assertiveness, problem solving, time
management, stress management, money management and effective means of
communication which would enable their effective re adaptation with their vulnerable
environment.
Cognitive behavioural interventions

This involves identification of negative cognitions related to substance use,
and replacing them with functional assumptions. Trained social workers are involved
in this process. Cognitive behavioural interventions are an inevitable part of
management of substance use disorders. Many clients have these faulty cognitions
which takes the form of their attribution to substance use. When these are not handled
adequately, there is a high probability of a relapse.
Family interventions
Alcoholism is often considered to be a family illness. Substance abuse has a
significant impact on the family. The family plays a vital role in mediating the course
and treatment response to the disorder. Families of the clients need to be involved in
both relapse prevention and motivation enhancement therapy. Social workers are
involved in conducting individual and conjoint sessions with the families of clients
with substance use disorders. Spouses, parents and children of client are often engaged
in treatment. In the absence of such relatives any primary care giver could be involved.
The common problems in families with substance users are high levels of
stress, conflict and inconsistency, faulty communication, child abuse and neglect
and emotional and physical abuse. Social workers play a vital role in working with
families of substance users. With specialized training in the area of family
interventions social workers are in a better position to work with the families. Family
interventions include facilitation of ventilation, assessment of the family discord,
setting therapeutic goals, behavioural contracting, structuring the family members
role in the recovery process, helping them engage in positive behaviour that promote
abstinence and reduce enabling behaviours by family members that trigger substance
use. Interventions to enhance the family interactions are also carried out, such as
increasing positive interactions and reducing conflict.
Group interventions
Group interventions in the form of group therapy and group work are practiced
by social workers in the deaddiction settings. Groups are more cost effective and
have a wider reach among persons with substance dependence. Both in patient and
out patient group are conducted. The role of the group therapist is of a facilitator.
Groups are conducted for the clients and their family members. There are different
types of group therapy conducted for this population of clients (Waston, 1995), (Levy,
1987), these include
a) Phase specific groups where the programme focuses on the task and goals
most relevant to the particular stage of recovery that the members belong to.
b) Mixed phase groups where the participants stay in a group as long as needed
to achieve their treatment goals and/ or as long as their participation in the
group remains productive
c) Early recovery groups which focus on issues most relevant to the beginning
stages of treatment like helping members to establish initial abstinence, to
stabilize their overall functioning, to acknowledge their problem, to work
through denial etc.
d) Relapse prevention and continuing care groups where preventing relapses is

the primary target. In addition to which coping skills training and other
strategies to deal with stressors and deficits among the group members are
also emphasized.

e) Psycho educational groups are primarily lecture-discussion format in which
selected topics about various aspects of chemical addiction and overall recovery
process from it are presented to the group members.
f) Self help groups which are modeled after the 12 step Alcoholics Anonymous
principle based on the philosophy that addiction to chemicals is a disease and
recovery is a life long process.
Follow ups and collateral contacts

Social workers play a key role in keeping the clients in treatment by ensuring their
regular follow ups. Once the active treatment is terminated, the client is regularly
followed up in the out patient settings. Quantity and frequency of substance
consumption, family interaction pattern, occupational adjustment and discussion on
other psychosocial stressors are the main focus of these follow up sessions. Home
and office visits are also undertaken by social workers in order to understand the
physical environment of the client and intervene with significant others who may
not be able to come for sessions after the patient's discharge from the inpatient facility.
Interventions in the out patient setting/ preventive and promotive interventions

The following are a few services provided by social workers out side the realm of
clinical practice.
Rural out reach program: these are out reach facilities carried out by a team of
experts offering Deaddiction services. It is based on the camp approach. Rural out
reach programs are implemented with an objective providing deaddiction care at the
door steps of the rural people who may not have access to tertiary care centers. This
encompasses identification, treatment and community participation in the management
of substance use disorders.
Urban outreach programs: these are conducted in places like urban slums where
there may be a vast number of people identified with substance use disorders. The
programs are conducted with the same objectives as the rural outreach. Frequent
follow up camps are also conducted.
Orientation and sensitization: Social workers conduct programs for vulnerable

population such as school and college students to sensitize them to substance use
disorders. These programs are focused on talking about the ill effects of alcohol and
drugs, causes of abuse and dependence and learning skills to avoid drugs and alcohol.
Work place prevention programs are also conducted.
Training and capacity building: Recording and documentation of all clinical and
non clinical work carried out by social workers are essential parts of social work
practice. Training programs are conducted for other care givers of persons with
substance use disorders along with those who come into frequent contact with the
high risk population. These include schools teachers, primary care physicians, human
resource personnel of different companies and volunteers and paraprofessionals.
Conclusion
Working with persons suffering from substance use disorders is a challenging

task. The practitioners involved in service delivery often face the problem of dealing
with a stigmatizing and self limiting illness. Frequent lapses and relapses contribute
to therapeutic nihilism, which is hard to overcome during initial phases of clinical
practice with this particular population. Therapeutic nihilism can be attributed to the
ambivalence due to outcome variables in the treatment of substance use disorders.
Expectations of the therapists and the client have undergone a radical change from
total abstinence to prolonged periods of abstinence combined with enhanced quality
of life and physical, psychological, social and spiritual functioning. Many therapists
view substance use with moralistic frame of reference. As the very act of using drugs/
alcohol is perceived to be with in the person's control, the therapist also tends to
adopt this view. On the contrary its very important to understand substance use as an
illness and this would help the therapist empathize with the basic distinguishing
symptom between substance use and dependence, which is loss of control. However
the scope of psycho social work in the field of deaddiction is wide ranging. Numerous
interventions ranging from didactic to community outreach models could be carried
out. Social workers with a specialization in the field of mental health, have an added
benefit of training in theory and practice of persons with substance use disorders.
This helps them in planning and successful implementation of various psycho social
interventions in deaddiction settings.

Chapter 10
COMMUNITY CARE FOR PERSONS WITH ALCOHOL DEPENDENCE
R. Dhanasekara Pandian,1 & E.Sinu,2
Introduction
Alcohol abuse related problem is one of the oldest universal problems. The
use and abuse of alcohol is well documented in the earliest writings in all over the
world. Today, alcohol abuse is seen as the world's highly prevalent public health
problem and therefore, is a matter of serious concern, not confined to any group,
culture or country. The disruptive influences of the problem, and its nature, cause
concern among social work professionals in general and psychiatric social work
professionals in particular both in developed as well as in the developing countries.
Persons with alcohol and drug addiction reflect the two extreme facets of
human beings. During their addiction they are often perceived as a menace, as
destructive, useless, hopeless and incapable of anything worthwhile. They are
frequently viewed with fear, disgust or pity. Yet the same persons, when they are
successfully able to give up their addiction, and readjust to their life situation, are
then epitomes of the good human being- caring about others, wanting to be useful,
always willing to help. However such a transition from one extreme to the other is
not easy to achieve. Some times there is a lack of willingness to change because of a
lack of insight, feeling of helplessness and hopelessness about their condition, or a
fear of severe withdrawal symptoms. That is why timely help, a good and conducive
environment, hope and encouragement to recover, and social and community supports
are crucial for long term recovery.
Basic theoretical concepts

Community
It refers to a group of people living in a particular geographical area, practicing
particular common profession, having common goals thereby making common efforts
to achieve their end in order to make the community as a whole.
Community care
Community care refers to care in the community by the people of the
community. It was originally the name of a program offering a preferred alternative
to institutional care. It has now also used to describe a particular response to variety
of problems (almost care by community). The term was first widely used in relation
to mental illness when de-institutionalization of mentally ill persons from mental
hospitals.
1. Asstistant Professor 2. Psychiatric Social Worker

Role of social workers in community level interventions
On a broader perspective, it refers to a process which comprises range of
activities designed by the social workers along with his team to bring about a change,
balance between community problems, community needs and community resources.
Social workers can directly or indirectly work with community. He/she can work
directly through health programmes and indirectly through formal or informal services.
Community involvement
Alcohol use is seen as individual and family disease; if it is not viewed as a
community entity then it will become a community problem and the efforts to deal
with substance use at large scale level becomes futile. The whole village / local
community need to be sensitized and importance to deal with the problem need to be
strongly emphasized. Any program in community becomes successful only when
the community itself takes "ownership" and responsibilities of the program are shared.
Community diagnosis
It may be defined as the pattern of alcohol consumption in a community
described in terms of the important risk and vulnerable factors which influence the
pattern of alcohol consumption. Community diagnosis for substance in community
would be based on the age and sex distribution of the affected population, incidence
and prevalence rate of the substance use disorders, in addition to that the interplay of
family, socio-economic and cultural factors in the disorder.
Community health action

It is sum of the steps decided upon to meet health needs of the community
taking into account of resources available and wishes of the people as revealed by
community diagnosis. It must utilize the people available in the community as man-
power resource to carry out the action, co-ordination of efforts all other agency in
the community, encourage full participation of the local community.
Community level intervention

It refers to any attempt to intervene or interrupt the usual sequence in the
development of problems, issues and illness of group of people at their place in
larger level. It aims at immediate arrest of progression, further development of
problem, reduction of the impact of it on people, protection and preparation of the
community to face and deal it effectively in future occurrence. The intervention
occurs through a process in which the community resource is identified and their
capacity is strengthened through experts in the field. Community is empowered to
deal with the issues on its own without depending upon external resource in case of
further recurrence.
Levels of community prevention:

1. Primordial prevention
Here the efforts are directed towards discouraging adults, children from
adopting harmful life styles. It aims at treating, intervening the emergence of risk
factors/ vulnerable groups. For e.g impulsivity in children, conduct disorders,
childhood maltreatment, adult - role modeling in the family are some risk factors for
development of substance use disorders. People in some of the works like painting,
carpentry, construction works, driving, heavy machinery, tourism industry, night
shift working hours, monotonous nature of work, works involves high demand,
risks, are prone to develop drug and alcohol dependence. Taking appropriate action
in this vulnerable group, addressing their cultural beliefs, attitude towards alcohol,
expectancies of alcohol through mass media would be a kind of primordial prevention
for them. Basically it focuses on individuals at specific risk.
2. Primary prevention
It refers to a set of action taken prior to the onset of drug dependence, which
removes the possibility of occurrence, development of dependence will ever occur.
It may be accomplished by measures designed to adopt healthy life style, improving
emotional well being, and improving quality of life by implementing specific
protective measures like "smoke free environment". Reduce the incidence rate by
educating youth in the community, in schools through programmes. Identification of
problems and importance of its prevention and strengthening capacity of people in
the community,
Fig: 1 Model of community care
Secondary prevention
Consumption Reduction
Prevalence Reduction
Harm Reduction Screening
Primary Prevention Case detection
Supply Reduction Early Intervention

Abstinence
Rehabilitation
Education Sector Social welfare sector
Referrals
Self-Help Groups
Health Sector
3. Secondary prevention
Here actions are taken to halt the progression of dependence at its incipient
stage and to prevent further complications. The specific interventions like case finding,
screening, referrals are some of the secondary prevention. Some industries have
employee assistance program, workplace prevention programs, there the social
workers s, social workers and labour welfare officers are trained to provide de-
addiction related services. At present some of the government and private concerns
are implementing workplace prevention programmes in India.
Community based intervention

In this context community based intervention programmes are set up within
the community as one of their basic components. They are owned by the community;
formed in response to the expressed needs of the community, and they mobilize
resources available within the community. In this process there is a need to include
various stakeholders which may include schools, hospitals, employers, workers,
groups, relevant government agencies, non-governmental organizations and
community volunteers. Linking these various groups in the treatment and rehabilitation
services would enable the community to play their roles and provide opportunities
for extending their support.
Fig: 2 Community Based Approach: Bottom -up Approach
Substance / Drug dependent person
Family
Local facilitator
Intermediary level
Referral Technical support supervision
Community level State level National level
In community based intervention, the first step is to educate the community

on issues pertaining to addiction and recovery. Social workers, programme planners
and other staff must actively participate in public awareness campaigns and
outreach programmes with a special mission to convey pro-rehabilitation messages.
A community must be convinced that the programme's ultimate objective is to
reduce prevalence of drug use in the area. Hence, the public need to understand
issues like that the prevalence of addiction, severity of addiction, alcohol/drug
dependents lifestyle, how addiction affects families, what rehabilitation
programmes are available for persons with addiction, what alcohol/drug dependents
actually experiences when returning to the community and why alcohol/drug
dependents relapse. What is most expected of them is to be able to interact more
naturally with recovering alcohol/drug dependents and their family members.
Comunity Involvement
Substance use is usually seen as an individual or family disease. It should
be viewed as a community entity. The whole village / local community need to be
sensitized and the importance to deal with the problem need to be strongly emphasized.
Any program in community becomes successful only when the community itself
takes "ownership" and responsibilities of the programs are shared.
Rationale For community care of alcohol problems

Recent research studies emerging patterns of alcohol usage are
l Men drink far more than women, but women's drinking is also rising
l The age of starting to drink is reducing
l Every third person who starts, develops problem drinking
l People with heavy use of alcohol, develop early health problems
l Early health damages are unrecognized by even physicians.
l Drinking also linked to growing social, economic and health problems in
community.
So it becomes necessary to address this issue in the community at large.
Objectives of community care

1. To improve service delivery system
2. To reach all who need services
3. To provide equal and more opportunities
4. Promotion and protection of the health in all aspects including human rights
5. To develop whole community through empowering them
6. To provide comprehensive and holistic care
Principles of community care

1) Maximum recognition of alcohol and addiction related disorders.
2) Public education of substance use related disorders: its nature, symptoms,
causes, treatment available, treatment centers, risk factors, and vulnerable
groups.
3) Through public health education, awareness can be brought among people in
prevention of substance related disorders in community thereby entry into
hospital can be minimized.
4) Focused group discussion with individuals in group in order to achieve positive
health thereby improving overall community health.
Techniques of community care

l Use what is locally available
l Building rehabilitative measures and recovery process through informal
training system
l Based on people's experience
l The approach basically involves is problem solving in nature.
l Training the family and local level community leaders for program
sustainability
l Integration of intervention measures into day-to - day activities of life
l Facilitate access to resources, information, and communication and education
materials.
l Decrease discrimination, stigma and negative attitude towards alcohol/drug
dependent persons and families.
l Create public awareness
l Initiate various capacity building activities
l Linking community needs and available community resources.
l Enhance community empowerment through people's participation
l Incorporate various income generating activities.
Advantages of community care
1. Availability 9. Possibility of continuity of care.

2. Affordability 10.Monitoring the progress of the
3. Easy accessibility individual clients
4. Networking 11.Provision of immediate crisis
5. Advocacy intervention services
6. Liaison services 12.First hand information on reason for
7. Effective referral services relapse, precipitating factors etc.
8. Collaboration various sectors 13.Provision of comprehensive holistic care
Skills required for providing community care
1. Skill in conducting focused group discussion

2. Skill in fund raising
3. Skill in event managing
4. Skill arranging logistics
5. Knowledge: Thorough knowledge on how community works, nature of the
community and its cultural beliefs, knowledge about various practices, needs
of the community and problems prevailing in the community.
6. Understanding the range of human needs
7. Acknowledge the impact of substance on individual, family and community
8. Skill in transferring the knowledge to others
9. Positive attitude
10. Awareness of various de-addiction treatment services
11. Skill in fore-seeing probable responses to possible lines of action while
addressing the substance use problems
12. Skill in initiating community activities.
13. Skill in resolving group conflicts
14. Good communication skills and interpersonal relationship with local formal
and informal leaders.
15. Being patient -friendly and community-friendly
16. Ability to lead and to work with other team members
17. Democratic leadership and administrative skills
Steps in community care

1. Conduct surveys in order to identify the major problems the community
2. Prioritization of the problems according to the severity and its magnitude
3. Planning for activities with the people to address those enlisted problems
4. To locate and assess the available man-power resources, material and non-
material resources.
5. Organizing public campaign to ensure continued community support.
6. Budgeting and staffing
Role of social worker in community care: The role of social workers in the
community is specially designed to deliver "comprehensive de-addiction service
delivery" to large group of people in the community. Major role for the professional
social workers working in the community is of more preventive, promotive, curative
and rehabilitative. In recent years people are viewed as health resource, instead of
source of pathology. The current trend in health care is deprofessionalization, de-
medicalization of illnesses and involving the community in a meaningful way to
protect their health.
1. Collaboration with various other service organizations.

2. Sensitization of non-governmental organizations (NGO’s)
3. Priority need to be given for persons with substance use disorders in the
community care programs
4. Community health camp for mass education on alcohol use and its impact.
5. Working with self-help groups and local communities
6. Use mass media to counter-act the stigma and discrimination.
7. Conducting awareness programs at schools, colleges on impact of alcohol on
health, family and career and emphasis on healthy life-style.
8. Training health educators, ANM’s, anganwadi workers, lay-volunteers on
addiction related issues.
9. Inter-sectoral coordination: Close coordination must be maintained with other
inter –sectoral organizations like health department, education department,
and law enforcing authorities.
10. As a Case manager: The role of case manager in the community is to ensure
the continuity of care and integration of other treatment services.
11. Community based meetings: Social workers can play effective role in
facilitating community based group meetings at local schools, library, and
public or community hall.
12. Working with volunteers: Volunteers from the local community can play a
significant role in recovery of a person with substance use disorders by ensuring
their regular follow-up. They should have the abilities to listen and empathize
with persons with substance use disorders. Social workers s can orient
volunteers from community on alcohol and drug dependence. Senior recovering
alcohol/drug dependents may be involved as “companions” and “mentors” to
recovering alcohol/drug dependents in the programme.
13. Working with Non Governmental Organizations: In most developing countries
the NGO’s may offer unique services that the government cannot undertake.
Since different organizations have different groups of people as their members,
linkage with them will expose the programme to a greater number of people in
the community. NGO’s can help to create opportunities for clients to participate
in a variety of healthy activities because each of them has their own strengths
and resources. Youth clubs may include clients in the recreational activities.
NGO’s working on drug and alcohol related issues may involve clients in their
public awareness campaigns, and other charitable organizations may hold some
kind of fund-raising activity for the community program.
14. Working with Government Agencies: Schools, hospitals, welfare and labour
department can be involved in community programs.
15. Enhancing Community Linkages: Alcohol and drug related rehabilitation
programmes need various community linkages to recruit clients, to gain
support of the families and the community, to reduce the public negative
attitude towards recovering alcohol/drug dependents, to help clients get
various services from other source and to get more financial and other
supports. The development and success of any community programmes to a
certain extent depends on its various linkages with in the community.
Community participation, community members’ active involvement and
community ownership are the core issues for sustainability of any community
programmes. The underlying purpose of establishing community linkage is to
help to modify the attitude of people in the community so that they can be
more accommodating the persons with alcohol problems. In that way, clients’
reintegration in to the society can be greatly facilitated. A good community
linkage enables a programme to render more comprehensive service to its
clients and ensure continuing support when they go back to the community.
Community linkage is an important component for a community based
programme. The participation of staff in outreach and public awareness
activities is an effort to establish community linkage. Volunteer service is more
meaningful if it is done on a regular basis. All community volunteers should
be selectively recruited and adequately oriented so that they can work in
harmony with all community members. The special roles of senior recovering
alcohol/drug dependents, volunteers and self-helpers should be acknowledged.
Community linkage should be geared to facilitate clients’ reintegration into
society by allowing them to practice good community living.
16. After-care services: 'Aftercare' refers to services that help recovering drug
dependent persons to adapt to day-to-day community life. Aftercare services
provide a safe environment for long term continued support.

Fig: 3 Role of social worker in community care
Team Approach
Informal service delivery Inter-sectoral coordination
system
Role of
Social worker
Intervention
Networking in Community
Strategies
care
Identification of
Creating Awareness Community Needs
Linking Needs & Resources
Aftercare should:
l Be an integral component of treatment and rehabilitation service.
l Include training to prevent relapse and other crisis
l Focus on reviewing and consolidating the gains made during treatment
(strategies of being drug free, crime free and gainfully employed.
l Impart new skills for maintaining recovery. This includes continued help in
handling everyday responsibilities, managing family and other relationships,
making new friends, adjusting to work and employment or acquiring/ re-
learning occupational skills, overcoming the stigma and shame of the past,
and developing new types of insights and pleasure and recreational activities.
Aftercare Vis-à-vis Follow-up: The term "aftercare" should not be confused

with "follow-up". While aftercare refers to client services as described above in later
phases of treatment, follow-up generally means monitoring and collecting information
about clients after they leave a programme. Whereas aftercare provides support and
guidance in crucial areas, follow-up only seeks to learn about clients after they leave
a programme. While an aftercare programme would have follow-up procedures, mere
follow-up is not aftercare.
Issues in Aftercare
It takes time and patience for new skills to be learnt, tested and re-tested, to
practice them with confidence till they become an integral part of the recovering

alcohol/drug dependents repertoire of coping and life management mechanisms and
get incorporated into the person's personality. While the recovering client becomes
more comfortable in leading a drug free life, aftercare provides the right environment
and support. The issues that need to be worked through in aftercare are:
a. Recognition, review and consolidation of treatment gains made so far.
b. Addressing the issue of drug-craving in terms of: Identification of alcohol/
drug-craving, psychological and other cues that trigger craving, track craving
urges, anticipate situations that may lead to alcohol use, handling craving
using craving reduction techniques when it occurs
c. Establishing a new social network by developing social and intimate
relationships with non drug using persons and peers, carrying out non drug
using 'fun' activities, establishing healthy social activities
d. Beginning or resuming new roles and responsibilities as an employee, worker
or student, as a family member, as a parent/ son/ daughter or homemaker, as a
friend, colleague or co-worker.
e. Bringing lifestyle changes to bring about whole person recovery and help the
client evolve into a responsible individual capable of handling work/
employment, family and relationships, finance, as well as social and recreational
activities without resorting to drug use.
Other services
Environmental modifications, working with family counseling centers,
working with children of alcoholics in the community, working with spouses of
alcoholics in the community, social action, join with women self-help group, capacity
building and recording and documentation.
Self-help groups
1. Alcoholics Anonymous was founded in 1936 at USA, by two persons
namely Bill Wilson and Dr.Bob. Bill Wilson is a stock broker and one of the founders
of Alcoholics Anonymous, 1936. The twelve steps in alcoholic ananymeus is as
follows :
12 Steps alcoholics anonymous

1. We admitted we were powerless over alcohol-that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God, as we understand
Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them
all.
9. Made direct amends to such people wherever possible, except when to do so would
injure them or others.
10. Continued to take personal inventory, and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as
we understand Him, praying only for knowledge of His will for us and the power to
carry that out.
12. Having had a spiritual experience as the result of these steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.
Self assessment questionnaire

1. Do you have a parent, close friend or relative whose drinking upsets you?
2. Do you cover up your real feelings by pretending you don't care?
3. Does it seem like every holiday is spoiled because of drinking?
4. Do you tell lies to cover up for someone else's drinking or what's happening in
your home?
5. Do you stay out of the house as much as possible because you hate it there?
6. Are you afraid to upset someone for fear it will set off a drinking bout?
7. Do you feel nobody really loves or cares what happens to you?
8. Are you afraid or embarrassed to bring your friends home?
9. Do you think the drinker's behaviour is caused by you, other members of your
family, friends, or rotten breaks in life?
10. Do you make threats such as, "If you don't stop drinking, fighting, etc., I'll run
away"?
11. Do you make promises about behaviour such as, "I'll get better school marks,
go to church or keep my room clean" in exchange for a promise that the drinking
and fighting stop?
12. Do you feel that if your Mum or Dad loved you, she or he would stop drinking?
13. Do you ever threaten or actually hurt yourself to scare your parents into saying,
"I'm sorry," or "I love you"?
14. Do you believe no one could possibly understand how you feel?
15. Do you have money problems because of someone else are drinking?
16. Are meal times frequently delayed because of the drinker?
17. Have you considered calling the police because of drinking behaviour?
18. Have you refused dates out of fear or anxiety?
19. Do you think that if the drinker stopped drinking, your other problems would
be solved?
20. Do you ever treat people (teachers, school mates, team mates, etc.) unjustly
because you are angry at someone else for drinking too much?
If you have answered YES to some of these, then you need help.
2. Al-Anon : Al-Anon offers understanding and support for families and friends of
problem drinkers, whether the alcoholic is still drinking or not. At Al-Anon group
meetings members receive comfort and understanding and learn to cope with their
problems through the exchange of experience, strength and hope. The sharing of
problems binds individuals and groups together in a bond that is protected by a
policy of anonymity; everything is confidential. Members learn that there are things
they can do to help themselves and indirectly to help the problem drinker. Changed
attitudes, which come from greater understanding of the illness, may result in the
drinker seeking help. Al-Anon is self-supporting through members' voluntary
contributions. The groups are non-professional and have no religious or other
affiliations and no opinions on outside issues. In the late 1930s in the United States,
close relatives of recovering alcoholics realized that they too needed help. They
sought solutions by the principles of Alcoholics Anonymous and formed themselves
into family groups. The first Al-Anon group in the UK was started in 1952.
3.Al-ateen: It is a part of Al-Anon fellowship, is for teenagers and young people

aged 12-20 who have been affected by someone else's drinking, usually that of a
parent. Al-ateen members share their ideas and experience in order to gain a better
understanding of alcoholism; they learn to accept it as an illness and so lessen its
impact on their lives. By removing their preoccupation with the drinker's behaviour
they are able to focus on their own development and sense of identity. The following
are some of the questions which would help to decide whether who needs ala teen
support services.
Government schemes for prevention of alcohol and drug abuse in india

The Ministry of Social Justice and Empowerment, Government of India has
been implementing the Scheme for Prevention of Alcohol and Substance (Drugs)
Abuse since 1985-86 for providing services for preventive awareness on alcoholism
and drug abuse, treatment of the alcohol/drug dependents, followed by their after
care and rehabilitation. From a holistic perspective, the primary objectives of alcohol
and drug demand reduction program are three fold:
l Preventive Awareness - Reaching out to the varied population sections with
specific focus on vulnerable population.
l Treatment - Ensuring treatment and care for dependence including treatment
for allied or concurrent medical manifestations.
l Rehabilitation - Ensuring the economic sustainability of the addict and/or his
family with focus on women and children and to bring back alcohol/drug
dependents into mainstream society.
The Ministry of Social Justice and Empowerment as the focal point for drug
demand reduction programs in the country is of the view that implementation of
programs for de-addiction and rehabilitation of drug alcohol/drug dependents require
sustained and committed/involved effort with a great degree of flexibility and
innovation, which could be delivered effectively only through the voluntary sectors
in the community. Government believes in addressing the problem of substance abuse
in its totality. This includes creating awareness, early identification, treatment and
rehabilitation and sustained follow-up care. Further, the Government is of the view
that substance abuse is a psycho social medical problem which can be best addressed
through community based interventions. Hence, special emphasis has been given for
involving and mobilizing the community. Under the Scheme for Prevention of
Alcoholism and Substance (Drugs) Abuse, implemented by the Ministry of Social
Justice and Empowerment, the non-governmental organizations have been entrusted
with the responsibility for delivery of services and the Ministry bears substantial
financial responsibility (GOI, 2001).
Scheme for prevention of alcoholism and substance abuse

1. To support activities of non-governmental organizations, working in the areas
of prevention of addiction and rehabilitation of alcohol/drug dependents.
2. To create awareness and educating the people about the ill effects of alcoholism
and substance abuse on the individual, the family and society at large.
3. To develop culture-specific models for the prevention of addiction and treatment
and rehabilitation of alcohol/drug dependents.
4. To evolve and provide a whole range of community based services for the
identification, motivation, detoxification, counselling, after care and
rehabilitation of alcohol/drug dependents.
5. To promote community participation and public cooperation in the reduction
of demand for dependence-producing substances.
6. To promote collective initiatives and self-help endeavours among individuals
and groups vulnerable to addiction and considered at risk.
7. To establish appropriate linkages between voluntary agencies working in the
field of addiction and government organizations.
The following legal entities are eligible for assistance under the Scheme
1. A society registered under the Societies' Registration Act, 1860 (XXI of 1860)
or any relevant Act of the State Governments / Union Territory or under any
State law relating to registration of charitable societies.
2. A registered public Trust.
3. A Company established under Section 25 of the Companies Act, 1956.
4. An organization / institution fully funded or managed by Government or a
local body.
5. An organization or institution, which has been approved by the Ministry of
Social Justice and Empowerment.
The eligible organizations as defined above should also have a properly

constituted managing body with its powers, duties and responsibilities, clearly defined
and laid down in writing, have resources, facilities and experience for undertaking
the program, not be run for the financial profit of any individual or a body of
individuals, have existed at least for a period of three years, be of a sound financial
position.
The quantum of assistance is not more than 90% of the grant amount. In case
of the seven North Eastern States, Sikkim and J & K, the quantum of assistance will
be 95% of the total admissible expenditure. The balance of the approved expenditure
shall have to be borne by the implementing agency out of its own resources.

The Universities, Schools of Social Work and such other institutions of higher
learning will be eligible for 100% reimbursement of approved expenditure. The
Scheme has the following components for financial support:
o Awareness and Preventive Education
o Drug Awareness and Counselling Centres
o Treatment-cum-Rehabilitation Centres
o Workplace Prevention Programmes
o De-addiction Camps
o NGO Forum for Drug Abuse Prevention
o Innovative Interventions to Strengthen Community Based Rehabilitation
o Technical Exchange & Manpower Development
o Surveys, Studies, Evaluation and Research
o Any other activity considered suitable to meet the objectives of the Scheme.
Regional resource and training centres: Demand reduction means prevention,

treatment, rehabilitation and all other efforts that help end the craving and desire for
drugs. Drug related problems cannot be tackled by use of force or prohibitive steps,
legal or otherwise but by positive life-affirming measures on force or prohibitive
measures, legal or otherwise, but must be a positive, life-affirming campaign too.
People must be led, taught, convinced and supported so that they can avoid the allure
of drugs and draw emotional nourishment from wholesome activities. To that end
many people will also require material resource and real-life opportunities they never
had before.
The best long-term strategy for reducing demand lies with:
o Creating more satisfying life conditions for as many people as possible,
especially the disadvantaged;
o Educating the young about the dangers of drugs and teaching healthy
alternatives. Providing rehabilitation for people who are dependent and helping
them to become productive citizens, positive role models, and active supporters
of demand reduction efforts.
Keeping the above in view, it is obvious that any effort in this direction
requires a sustained, committed and long-term intervention with a flexible and
innovative approach. The Government of India has been, for the last 15 years,
promoting and supporting culture-specific, need oriented and localized community
based interventions and initiatives through Non Governmental Organizations (NGOs).
However it is realized that effective and appropriate service delivery through

the NGOs, while on the one hand requires continuous and regular professional
development of the service providers in inculcating skills pertaining to newer strategies
for dealing with addiction, on the other, documentation of the implementation of the
programmes, monitoring of the changes in the profile of the drug abuse scenario and
technical support to be able to respond to the changing situations, needs to be taken
care of. In a country like India, with diverse physical, social and cultural features, it
is necessary that the adopted strategy takes into account the regional needs and local
field realities in undertaking activities related to advocacy, research, monitoring and
training. In order to meet the regional requirements and aspirations, the Ministry of
Social Justice and Empowerment, in collaboration with UNODC and ILO, has evolved
a functional structural mechanism. The Ministry has established National Centre for
Drug Abuse Prevention (NCDAP) at New Delhi, to serve as an apex body for training,
research and documentation in the field of alcohol and drug demand reduction. It
was set up in NISD in 1998 with the following objectives:
o Raising the competency standards of the functionaries/ personnel working in
De-addiction centres and other related sectors.
o Invigorating efforts for preventing or minimizing any anticipated or consequent
harm related to Drug Abuse in clients and in the community.
o Standardization of care in Drug Abuse Prevention.
o Updating information and creating a database on extent and pattern of Drug
Abuse and its various interventions at local, regional, national and international
levels.
o Developing standards of monitoring systems of various interventions.
The Regional Resource and Training Centres have been established essentially for
the devolution of the mandate of NCDAP at the regional level. They would, as
representatives their regions undertake the following activities:
o Training of service providers.
o Documentation of programmes/results.
o Advocacy, research and monitoring.
o Technical support to NGOs, CBOs and Enterprises.
o Strengthening the rehabilitation of the alcohol/drug dependents
The NGOs, all over the country, working in the field of alcohol and drug
demand reduction are expected to liaison with the National Centre of Drug Abuse
Prevention, NISD, New Delhi and the respective Regional Resource and Training
Centre for required technical assistance and manpower development.
The following are the some major schemes of Ministry of Social Justice and
Empowerment in collaboration of with voluntary and International other agencies
for prevention of alcohol and drug in the country (Arun Goswami, Vandana kumar,
2004)
1. Schemes for empowerment and rehabilitation of alcohol/drug dependents (as

physically, economically and socially disadvantaged sections of the society)
2. Schemes for empowerment and rehabilitation of women (as victims of
alcoholism and drug abuse, sexual exploitation, dependents of alcohol/drug
dependents etc.)
3. Schemes for empowerment and rehabilitation of children (as victims of alcohol/
drug dependents, destitute and orphans)
4. Schemes for empowerment and rehabilitation of Youth (through vocational
skills,
5. Entrepreneurship development and involvement in Productive activities)
6. Schemes for economic empowerment through concessional finance and micro-
credit facilities For socio-economically marginalized sections
Harm minimization: Proponents of harm reduction believe that drug policies based
on total abstinence are bound to fail and did not produced desired results because
they ignore the root cause of the problem. Harm minimization helps people to quit
autonomously. Thus the objective of Harm Minimization is overall reduction to a
minimum harm caused by substance, and to reduce adverse health, social and
economic consequences. Harm Minimization program does not legitimate or advocate
alcohol/drug use. Harm minimization strategies for alcohol users:
1. Use beverages which has low concentration of alcohol

2. Do not drink before driving, or do not drive immediately after having drink.
3. Mix fluids, soda, and water as much as possible in a drink. Do not drink raw.
4. Do not gulp the drink; have sip by sip and in between eat snacks and talk as
much as possible.
5. Limit your drink; do not have more than three consecutive drinks in a week.
6. Not to drink beyond one unit in one sitting
7. Avoid going to drinking places or have drink at home in a supervised
environment
8. Do not drink with friends who drinks more than you
9. Avoid drinking at empty stomach, holidays and early morning hours
10. Drink at late night.
Harm minimization strategies for Injecting Drug Users

1. Abstain from Drug use, If abstinence is not possible, stop injecting drugs
2. If terminating drug injection is not possible stop re-using injection equipment
3. Avoid sharing needles with other users; if drug injection syringes and needles
continue to be re-used follow proper disinfection procedures.
NIMHANS experience in providing community care
1. Model District Program

De-addiction centre, NIMHANS in collaboration with WHO started Model
District Programme for prevention of alcohol and drug related problems in 1999. The
main aim of the project was to evolve preventive strategies for drug and alcohol related
problems in the community. The objectives of the Model District Programme were early
recognition of the substance users, offering preventive counseling, Community -level
education for population at risk. The project was carried out in Mandya Distrct of Karnataka
state, India. As a preliminary step towards this model district programme NIMHANS
conducted orientation program for social workers s, education sectors, welfare and other
service organizations working in the district on identification risk drinkers, early stage
problem drinkers and medical and psychosocial intervention for them.
2. Camp Approach
Several government and international agencies recommended that substance
use has to be dealt with primarily as community problem. Community level
intervention strategies would involve community leaders and local volunteers. Thus
Community level intervention de-emphasis on medical model and focuses more on
psychosocial model. Activities in the community include prevention, education, and
health promotion and harm reduction. The camp approach basically involves
mobilization of local resources, involving the family, local community people, and
decentralization of service delivery. Deputing professional to villages, building new
hospital, opening extension clinics, special clinics in Government hospital may not
be viable. But organizing camps in villages is viable mode of intervention at community
level.
What a camp is all about?
l Ground work in the community

l Select appropriate clients
l Prepare them well
l Get the family involved
l Train staff team well
l Run camp as planned
l Regular follow up
l Documentation
In India, rural camps have produced significant effect on dealing with medical
problems such immunization, eye care, dental care and other general health care.
Many NGO's have initiated the CAMP approach to address substance related issues
in the community. In these camp approach people are expected to stay for
detoxification process and undergo other intervention programs. The advantages of
camp approach are
l Services are brought at the door step of community

l Professional are called to offer their services in the camp
l Medical and other psychosocial interventions are provided at free or at a low
cost.
l Common place of camp which accessible to all near by villages.
Before organizing the camp certain constraints have to be kept in mind;

o In some villages, moderate consumption of drinking and certain drugs may be
accepted as part of local life during marriages, local festivals, and deaths. The
substance use may not be seen as issue of concern.
o If selling alcohol/ drugs produces considerable income and many villagers are
involved, they may not support from the community.
o The community may not be aware of recent scientific advancement in treatment
of alcohol/drug dependence. So they may look at dependence / addiction as
"not treatable" or one cannot recover.
o Some of the community leaders may be themselves be using alcohol and other
substances may not encourage such type of camps exclusively for substance
related
Groups to be addressed in the community

ADDRESS ALL GROUPS IN THE COMMUNITY
Teachers
Parents Politicians
Women Police
Employers
CAT Community
groups
Churches /
Temples
Community
workers Youth
Health organisations
workers
Community action team
Adapted from WHO
Guidelines for conducting camp in the community
Phase: 1 Preparation for the camp Phase 3: Follow-up service
l Organized in the community l Offered in the community

l Short duration l For about two-three years
l Ownership by community l Self help group net work
l Visibility of addiction problems l Relapse management
l Motivation to recover l Documentation
l Community support is built
Phase 2: Conducting the camp
l Structured treatment programme

l Treatment team skilled in addiction
treatment
l With recovering drug users as part
of treatment team

An organization running a De-Addiction centre may organize De- addiction
camps in areas prone to drug abuse especially in rural / semi urban areas.
The camp approach has many benefits
- Treatment is cost effective because existing facilities available in the

community are made use of.
- The local community is involved in organizing the camp, hence, they provide
support to the addict in recovery and they also get sensitized regarding the
impact of addiction.
- Sustained involvement of the community promotes collective initiative towards
prevention of addiction.
Activities for conducting de-addiction camps

Creating awareness in the community about the problems associated with
drinking and drug addiction and the need for appropriate treatment. Prior to conducting
the camp, a local host organization has to be identified from the community. The
host organization could be any non-governmental organization, providing health care
/ education / rural upliftment / micro credit system. The host organization should
have credibility and be trusted by the community. The host organization should be
involved in providing infrastructure such as accommodation for conducting the camp,
organizing meals for the patients and treatment staff, and mobilizing local support
persons. Involving the community in identification, intervention and providing support
during recovery. Identification of persons with addictions may be done through
multiple contacts - formal / informal leaders, local physicians, community workers,
teachers etc. Treatment methods may include detoxification and psychological therapy
for the patients and therapy for family members for a period of 15 days by conducting
a camp. On completion of the camp, follow-up care must be planned at least for a
minimum period of one year. To sustain the momentum built at the time of the camp,
meaningful activities to be conducted on an ongoing basis.

Minimum standards on services (GOI, 2001)
Minimum criteria Records required

To involve the community, identification of a
Profile of Host organisation
host organisation and sensitizing them about the
to be maintained by the
impact of addiction and the need for treatment.
counsellor
.Two programmes to be organised prior to the
camp at the community.
Identification of patients through community
network - formal / informal leaders, panchayat
leaders, families of addicts, Youth Associations,
teachers, Mahila Mandal Workers, Religious
Leaders and health workers / recovering addicts.
Through personal contact or by distribution of
pamphlets, making people aware of the camp
programme.
The selection criteria to be clearly defined and Camp Manual to be
followed-up. developed and maintained by
Providing detoxification and dealing with Medical case sheet to be

addiction related illnesses. maintained by the medical
officer
Identification and creating linkages for medical Net work directory to be
services to handle emergencies during maintained by the project-in-
detoxification, during follow up and relapses charge
through local resources such as physicians,
hospitals and primary health centres.
Developing a structured programme for duration Camp Manual to be
of 15 days with the focus on medical care as maintained by the project-in-
well as providing support to improve the quality charge
of life. Providing a minimum of 8 re-educative
sessions for patients, 8 group therapy sessions
and 4 individual counselling sessions.
To provide support to the family, conducting five
sessions for families with components of re- Camp Manual to be
educative sessions, group therapy, and maintained by the project-in-
counselling. charge
To sustain the recovery, conducting one follow- Follow-up card

up meeting at the camp site every month for a
period of one year.

Activities for creating awareness in the community
Formal and informal methods that include community participation such as
dramas, competitions, street plays and folk media to be organized depending on the
target audience. Messages to be sensitively designed so as not to arouse any undue
scare, curiosity or experimentation with alcohol and drugs. The language used for
the awareness, content and style of message to be culture-specific according to the
target groups to be addressed. Public education programmes against alcohol and
drug abuse to incorporate contents of socially healthy alternative life styles.
Staff required for conducting a camp

A minimum of three counsellors, one nurse and a ward boy are required for
25 patients. Physician and other support persons from the camp site to be utilized.
Training of staff
The treatment staff to be placed in a treatment centre that already conducts
de-addiction camps to understand and observe the camp approach. Training to include
methods to mobilize and work with the community . Specific training on pantomime
shows, street plays and folk media to be included.
Involvement of community in action requires a lot of time and energy and

above all sustained commitment. It is not a one time effort. Sensitization and
Preparing the community and is the first step in conducting such camps. Involvement
of community in action requires a lot of time and energy and above all sustained
commitment. It is not a one time effort. Sensitization and preparing the community
is the first step in conducting such camps.
3. Work place prevention program

Addiction, especially addiction to alcohol is a major problem in industries.
7-10% of the work force may have problems related to alcohol / drug use. It creates
problems for the employer, managers, union office bearers and supervisors. Some
of the problems faced are unpredictable absenteeism upsetting production plans,
accidents leaving an unpleasant impact, constant worry over product quality and
deteriorating discipline in the department. A comprehensive strategy against the spread
of alcohol and drug abuse includes building awareness, training supervisors / managers
on the impact of addiction and offering treatment services. The scheme by the
government of India encourages and gives grants to non-governmental organizations
to undertake work place prevention programmes in urban areas. The programme is
focused towards promoting health, maintaining safety and improving work
performance. The scheme has listed two types of interventions:
1. A 15 or 30 bedded treatment cum rehabilitation centre to be established by the

industry / enterprise. Financial assistance upto 25% of the expenditure for
setting up such a centre shall be provided by the Ministry. Only an industry
with a minimum strength of 500 workers will be eligible for assistance.
2. A treatment cum rehabilitation centre (15 / 30 bedded) run by an NGO taking
up work place prevention programmes as part of its activities. Additional
funding of 25% to be provided to employ staff such as counsellors / community
workers / part time medical officer.
Activities related to workplace prevention programme

l To create awareness among the employees about the impact of use and abuse
of alcohol / drugs in relation to the quality of work.
l To create awareness among the families of employees about the impact of use
and abuse of alcohol / drugs in relation to health, finances and general well
being.
l To educate and change the attitude towards use of alcohol and drugs and
promote healthy leisure time activities.
l To conduct awareness programmes for the management as well as union office
bearers regarding the impact of addiction and the need to develop a policy.
l To conduct training programmes for supervisors / managers to identify early
phase addicts through poor job performance.
l To collect data regarding absenteeism, accidents, poor job performance among
the employees and relating them to use and abuse of alcohol.
l To identify, refer and treat workers with problems of addiction.
Functions of the programme

Minimum criteria Records required
To conduct one programme a month on creating Awareness programme register
awareness about the impact of addiction –
lecture, film shows and puppet show.
To conduct one programme every six months
Awareness programme register
for families of employees on the impact of
addiction
To conduct one programme every two months
to supervisors / managers on early identification Awareness programme register
of problem employees
To conduct one programme every six months
to management / union office bearers on the Awareness programme register
need to have a policy to deal with addiction.
To help the industries to collect data regarding
absenteeism and poor quality of work and the
use and abuse of alcohol.
To treat patients referred by industries as and Register for patients referred by
when needed. industries

NIMHANS in collaboration with Karnataka State Road Transport Corporation
(KSRTC), Motor Industries Company limited (MICO) and other organizations carried
out workplace alcohol / drug abuse prevention program. This included formulation of a
company policy on alcohol and drug abuse and prevention and treatment program for its
employees. The Deaddiction Centre, NIMHANS actively liaises with numerous industrial
units and the International Labour Organisation in promoting and aiding programmes for
prevention of drug and alcohol misuse in the workplace using the popular SOLVE model.
Patients are regularly referred from these centres for assessments and interventions. In
addition medical & non-medical personnel [welfare officers] are trained at the centre to
be sensitive to the presence of workers with substance abuse problems, detect, motivate
and refer.
4. Network Meetings
The social workers can initiate network meetings with various de-addiction related
service organizations working for the welfare of persons with alcohol/drug abuse. This
important activity will bring together various organizations working in the area of substance
abuse for information exchange and continuing professional training. The network can
facilitate sharing of experiences, plan for future activities and periodical meetings. Such
network also can take up many common issues related to better quality of de-addiction
service delivery. The De-addiction centre of NIMHANS has networked 26 agencies
offering de-addiction services in Bangalore city. The APEX group consists of member
organizations with widely different treatment approaches. Working together has resulted
in significant attitudinal change and improved understanding between member
organizations. The APEX network maintains a computerized database of the incidence
and prevalence of substance abuse and related information contributed by all member
organizations in order to obtain a clearer picture of the nature and extent of substance
related problems in the city.
5. Supported employment for recovering alcohol/drug dependents

Some of the recovering alcohol/drug dependents were referred to the department
of psychiatric and neurological rehabilitation at NIMHANS. Under this program they
were paid as per the minimum wages act. During the sheltered work they were taught
work conditioning, work behaviour, savings and drink refusal skills. They were encouraged
to seek employment outside after 3-6 months of sheltered employment. This program
found to be effective in improving the quality of life of persons with alcohol/drug
dependence.
6. Outreach services
Providing aftercare and more accessible services closer to the community has
been one of the major efforts of the De-Addiction Centre with a focus on developing
community responses. The centre is actively involved in running prevention programmes
in rural areas and urban slums, stressing on early identification and brief intervention.
These include a follow-up clinic at Mallavalli in Mandya District 120 km from Bangalore
and collaborating with many service organizations for providing community based
rehabilitation programmes in slums areas at Bangalore, in collaboration with the Bangalore
City Corporation and several non-governmental organizations.
7. Community based drug rehabilitation project

Under this project 50 persons with alcohol and drug abuse from Old and
New Bagalur, Lingarajapuram, Bangalore was treated. Treatment consisted of in-
patient or out-patient detoxification, intensive counseling and after care. The follow-
up was done at corporation clinic at Bagalur where out patient groups were run and
all the patients were also contacted through home-visits. The emphasis was not only
on maintaining the clients' drug free but also on ensuing that they were occupationally
employed and crime free. This community based comparative study on CBDR
program was found to be very successful.
Fig: 4 Community based drug rehabilitation model - NIMHANS
Rapid assessment survey –

Bagalur
Weekly clinic at
Establishment of centre corporation
Identification of clients No significant

Significant medical medical problems
problems
Routine Detoxification
CBDR
De-Addiction centre at NIMHANS
NIMHANS
Rehabilitation program,
Counseling, Vocational
Monitoring Training, Job Placement,
Evaluation Self –Help Groups
Recovery Groups
After care
Follow –Up
CONCLUSION
The role of social workers at community level in addressing substance use
disorders is screening, case-identification, diagnosis, referral to early treatment and
providing need based interventions is on one hand. On the other hand his prime role
is more of prevention of alcohol and drug related disorders at primary, secondary
and tertiary levels and over all health promotion of the community members at large.

Chapter 11
HIV/AIDS: ISSUES AND CONCERNS FOR PSYCHIATRIC SOCIAL WORK
D. Muralidhar,1 & Kavita Jangam,2
HIV/ AIDS is a rapidly growing medical and psychosocial problem in India,

which has influenced the field of professional social work. Professional social work,
has received an apt training and knowledge to deal with psychosocial aspect of this
problem. Some of the themes which are necessary to examine while understanding
HIV/AIDS problem are:
l Magnitude of the problem

l Vulnerable and affected groups
l Psychosocial problems encountered by these groups
l Sex and sexuality perspective
l Effective interventions
l Partnering with NGO's
HIV/AIDS: Global and Indian Scenario
AIDS is one of the extraordinary kinds of crisis of the humankind today. It can
be understood that no region of the world has been out of this danger. AIDS killed almost
three million people in a single year 2003. So far more than 20 million people died since
the first cases of AIDS were identified in 1981. Throughout the world, the number of
people living with HIV continues to grow from 35 million in 2001 to 38 million in 2003
(The UN's latest bi-annual reports on the state of the pandemic, 2004). AIDS is not only
a physical disease, but it has multidimensional consequences. As Kofi Annan, previous
UN General Secretary rightly mentions "AIDS is far more than a health crisis. It is a
threat to development itself". (The San Francisco Chronicles, 7/12/04).
In India, the Human Immuno Deficiency Virus/ Acquired Immuno Deficiency

Syndrome (HIV/AIDS) epidemic is nearly two decades old. India reported its first
known case of AIDS to the world health organization on 1986.
Since then the number has increased continuously without any interruptions.
Within a short period it has been emerged as one of the most serious social problems
of our country. The initial case of HIV/AIDS was reported among the commercial
sex workers in Mumbai and Chennai and injecting drug users in the northern states
of Manipur. The injection has since then spread rapidly in the area of adjoining
States of the country. Sharing needles causes more than 70% of the state's HIV
infections.
1. Additional Professor 2. PhD Scholar

This is in sharp contrast to the rest of India where more than 80% of the
infection is through unprotected sex. But now the HIV virus is spreading from drug
users to their sexual partners and children too. India has had a sharp increase in the
estimated number of HIV infections, from few thousands in 1990's to a working
estimate of between 3.8 millions and 4.6 million children and adults living with
HIV/AIDS in 2002. (Kumar, 2003). With a population of over one billion, the HIV
epidemics in India will have a major impact on the overall spread of HIV in Asia and
the Pacific and indeed worldwide. The spread of HIV within the country is as diverse
as the societal patterns between its different regions, states and metropolitan areas.
Hence both tracking the epidemic and implementing effective programs poses a
serious challenge to the authorities and communities in India.
It would be easy to underestimate the challenge of HIV/AIDS in India. India

has a large population and population density, low literacy levels and consequently
low levels of awareness, and HIV/AIDS is one of the most challenging public health
problems ever faced by the country (UNPAN, 2003).
There is a strong stigma attached to HIV/AIDS in our society. There is also

a fear attached to HIV testing which is necessary for any pointed measures to arrest
the spread of the dreaded infection. One needs to be very insightful to bring about
the possible delivery services to get them tested for HIV. There are multidimensional
issues involved in the detection of the HIV such as phobia of testing, respect in the
society, acceptability by the family/ spouse, employment opportunities and
despondence towards them. Currently most of the HIV interventions in India focus
on the behaviour change as the key component supported by other mechanisms.
However it is important to point out that behaviour change has been differently
understood and realized by the states. So many times, the interventions resolve
around IEC and end up into short term and sporadic change in incidences among
individuals.
Vulnerable and most affected groups for HIV/ AIDS
Although HIV/AIDS is still largely concentrated in at-risk populations,

including commercial sex workers, injecting drug users, and truck drivers, the
observation data says that the epidemic is moving beyond these groups in some
regions and into the general population. It is also moving from urban to rural district
(USAID, 2003).
The epidemic continues to shift towards women and young people also. It
has been estimated that 39% of adults living with HIV/AIDS in India as of the end of
2002 were women (Kaiser Network, 2003). In 2004, it was estimated that 22% of
HIV cases in India were housewives with a single partner (Hafferman, 2004). The
increasing HIV prevalence among women can consequently be seen in the increase
of mother to child transmission of HIV and pediatric HIV cases.
There are few highly vulnerable and at - risk groups for HIV/ AIDS which
need mention while we design intervention for these groups. This vulnerability
mapping is essential for effective and appropriate service delivery. These at-risk
groups include migrant population, truck drivers, and sex workers, injecting drug
users, adolescents and youths.
Migrants
Migration of a huge population has become one of the important causes in
spreading HIV/AIDS in the country. According to 1993 National Sample Survey
(NSS) in India, 24.7% population had migrated either within India to neighbouring
countries or to overseas. In other words, during mid - 2003 population about 264
million Indians might have been migrated (Population Reference Bureau, 2003).
"Being mobile itself is a risk factor for HIV infection. It is the situations encountered
and the behaviours possibly engaged in during mobility or migration that increase
vulnerability and risk regarding HIV/AIDS (UNAIDS, 2001). Various unsuitable
conditions such as separation from the family, unhealthy living conditions, hazardous
working conditions encourages careless sexual relationships and make them highly
at risk to STDs and HIV/AIDS. Migrants workers also tend to have very little access
to HIV/STD information, voluntary counseling, and testing and health services.
Commercial sex workers

Sex workers, both men and women, are often subject to a great deal of
stigma, exploitation and violence. The industry, although a significant economic
sector in many countries, is also generally illegal, a fact that limits sex workers
access to health and other services which might otherwise serve their health and
safety needs. There have been few times and places in which sex workers have been
free from persecution, stigma and violence. HIV is the most recent issue in the long
history of reoccurring moral and practical questions and conflicts raised around
prostitution. It is very sad to know that most of the times; sex work has been researched
only in connection with HIV/AIDS spread, undermining the basic and underground
realities. Mumbai has the country's largest brothel based sex industry, with over
15,000 sex workers (Gomare, 2002). It is estimated that in the region of 70% of the
sex workers in Mumbai are HIV positive. Mostly, madams, pimps and money lenders,
control and sex workers.Because of this, reaching to sex workers with HIV prevention
is a major challenge.
Injecting drug users (IDUs)

HIV infections among IDUs first appear in Manipur. In Manipur city, the
level of HIV infection increased from 61% in 1994 to 85 % in 1997 and in 1998 it
was 80.7%, injecting drug use is also a major problem in urban areas such as Mumbai,
Kolkata, Delhi and Chennai (Reid and Costigan, 2002). The majority of drug users
in India are male. According to a study in the capital of Manipur, the prevalence of
HIV infection in female IDUs was 57% compared to 20% among female non-IDUs
(Panda et al, 2001). In the northeast of India, there are increasing numbers of young
widows of addicts, many who are HIV positive as a result of having been infected by
their husbands (Panda et al, 2000). With the reported increase in HIV infection among
wives and children of IDUs, this is highlighting the crucial need to reach the sex
partners of IDUs with prevention, education, care and support services.
Adolescents and youths

A study on "sexuality and sexual behaviour in male adolescent school
students" was conducted among 120 male adolescents in an urban slum community
in Mumbai. This study revealed that 7.5 % of the respondents were sexually active
(Patil, Chaturvedi, and Malkar, 2002). A NARI study in Pune aimed at understanding
sexual behaviour and possible risks to AIDS/HIV among college youths (especially
in boys), reported sexual experience with those of the same and opposite gender, in
addition to having sex with commercial sex workers (ICMR, 1999). Yet another
study reports that in over 87 % of the cases, the first sexual contact was with sex
worker (Sharma, Sharma, Dave and Chauhan, 1996). Adolescence is a conflicting
age group. Exploration and experimentation are the distinct features of this age group.
There is a mixed reaction over the issue of sex education in schools for adolescents
in India. But having understood the sexual behaviours and experiences, sex and
sexuality education becomes essential intervention with this group.
Sex and sexuality issues in India

In India, significantly 88.87 percent of the reported AIDS cases occur in the
sexually active and economically productive 15 and 49 year old age groups. The
probable source of HIV infection of new cases was through unprotected heterosexual
sex, mainly among young people and adolescents. Among the AIDS cases were
recorded up to September 2004, 85.71 percent of them infected by sexual transmission.
(National AIDS control organization, 2004).
Some of the important and disturbing findings which we can relate to the
rapid spread of HIV/ AIDS in both developing and developed countries. (DEBONAIR
Anniversary, 2007)
Number of sexual partners

I Globally people have had an average number of nine sexual partners.
I Men have had more sexual partners than women - 10.2 compared with 6.2.
I In India, people have had fewest sexual partners that 3 compared with other
developed countries.
Unprotected sex
I Almost half (47%) of all adults globally have had unprotected sex without
knowing their partners sexual history.
I Almost two thirds (65%) of 45-55 year olds have risked unprotected sex,
compared to a third (33%) of 16-20 years old.

Believe in safe sex practice
I Almost a third of adults globally (32%) believe the best way of raising
awareness about safer sex is by providing free condoms in areas with a high
rate of STDs and unplanned pregnancies.
I A further 28% believe the best route is to provide teaching materials to schools
and health care professionals and 17% feel governments should be encouraged
to discuss safer sex issues.
Public awareness
I Globally the top three conditions affecting sexual health which people believe
need greater public awareness are HIV/AIDS (72%), syphilis (45%), and
hepatitis (45%).
I Worryingly, 8% of the adults have never heard of most of these conditions and
when broken down by age this lack of knowledge increased to 11% among 16-
20 years olds and 12% among those aged 55 and above.
I Globally most people think sex education should be taught at 11.7 years, with
virtually all respondents (98%) believing children under 16 should receive
sex education.
I Those in India believe the formal education process should start at 13.9.
Talking about sex and sexuality is stigmatizing and taboo subject in Indian
society, but the findings show a shocking picture. For example in a survey conducted
by The Week magazine shows that virginity is an outdated concept for most of the
youth generation and premarital sex, unwed pregnancies are on the rise. Talking
about virginity, premarital sex and having multiple partners is very important as it
makes these groups more and more vulnerable towards STI/HIV infections. Though
India has been revolutionizing over sex and sexuality issues, the social consequences
can not be ignored. Delhi based psychiatrist Dr. Samir Parikh (The Week, 2007)
explains, teens do not get an appropriate and adequate knowledge on issues pertaining
to sex and sexuality; hence they are not prepared for the consequences. Most of the
teens don't know how to balance the emotional and physical side of it. This complicates
the matter. They lose their focus and become vulnerable.
Effective interventions
HIV/ AIDS no longer affect only high-risk groups but are spreading to general
population. Since the predominant mode of HIV transmission is through heterosexual
contact, the general population has to be taught about AIDS and safe sex practices.
In designing interventions there must be a holistic approach. On one hand the
government is spending more money on creation of awareness on AIDS and its
prevention through all forms of media's programmes. The propaganda is about
stressing the prevention measures for combating AIDS, as condom usage; self
disciplined life and so on. But on the other hand there are some distinct social realities
which need to be considered while preparing any program on HIV / AIDS. For
example, while intervening with sex workers, it was emphasized that sex workers
should stress on the use of condoms but we forgot about the problems that the sex
workers face in dealing with their customers.
The interventions planed were targeted only on the sex workers and not on
the general population. In the same way, adolescents and youths are other vulnerable
groups for HIV infection, but there is always a debate over provision of sex education
in schools for this group. Yet another example is that of the interventions with truck
drivers again stressing on the use of condoms. Our experiences have shown that all
these interventions have failed to maintain the behaviour change or reducing the
rapidly increasing rate of HIV as we target few population and the interventions are
one way oriented.
Behaviour change
Since the HIV spreads mainly through unsafe and indiscriminate sex, the
order of life with respect to sexual behaviour is to be changed. Most of the
interventions till date with identified high risk population have been focusing on
behaviour change primarily. Behaviour change is possible not only when emphasis
is on safe sex practices. There is also need for moral education, life skills education
and sex and sexuality education.
Capacity building
Where there is such a large magnitude of the HIV/AIDS problem, our country
has equipped with very limited manpower who are equipped with professional
knowledge and skills to help people deal with this problem. At this juncture, it is
essential to train the large number of people in the basic knowledge and skills of
dealing with HIV/AIDS. This can be done using volunteers from the community and
giving them training in the basic professional skills such as
I Interviewing and identification skills

I Basic counseling skills
I HIV testing ( Pre and Post)
I Awareness building
I Mapping and dealing with vulnerable groups (women, children,
sex workers, etc)
I Psychosocial care and support
Research development
Though lot of research had been going on the various aspects related to
HIV/AIDS such as epidemiology, psychosocial vulnerabilities, vulnerability mapping
and so on, we need to research very specifically on intervention strategies to deal
with this problem. We need to research and develop the interventions which would
be holistic in nature, not only focusing on behaviour change but also on the
psychosocial realities of the vulnerable groups with culture sensitivity.

Understanding the psychosocial situations is of utmost important, without
which all other interventions would be failures. For example, from the beginning sex
workers have been told about the importance of condom use and so on but ground
realities are different. Sex workers are not empowered to make choice about condom
use. They have pressing economic needs because of which they have no control over
condom use. Therefore till the time economic need and empowerment issues are not
addressed, emphasize on condom use will alone not work.
Partnering with NGOs

In combating HIV/AIDS, interventions should focus on multi-sectoral
partnering. One such example is that of National AIDS control Programme
collaborating with different sectors which include non-governmental organizations,
schools, general hospital set ups, media and communication sectors and so on.
The National AIDS Control Programme aims to reduce the spread of HIV/
AIDS in India, and to strengthen our capacity to respond to HIV/AIDS on a long
term basis. Globally, NGOs have been leading country responses to HIV/AIDS at
the grassroots. Their flexibility and innovative approach enables NGOs to access
constituencies that the state apparatus sometimes finds difficult to reach. They often
represent realistically, the needs of even the most marginalized and vulnerable
populations. In this manner, the NGOs help complement and supplement the efforts
of government to put in place an integrated, holistic and comprehensive response.
The National AIDS Control Organization sees NGOs as its primary allies
and critical partners in undertaking targeted interventions among high risk groups,
disseminating the School HIV/AIDS Education programme, delivering counseling
services, in providing care and outreach services for people living with HIV/AIDS,
and in general, in evoking a community response to HIV/AIDS. There is a transparent
and viable system in place to ensure that the NGOs selected for participation and
partnership enjoy the trust of the target community besides having relevant and
appropriate skills with a credible track record. The National HIV/AIDS Control
Programme has been decentralized. The NGOs are selected at state levels through
Technical Advisory Committees set up by the State HIV/AIDS Control Societies.
These committees scrutinize candidate applications and project designs, and also
subsequently monitor and evaluate the programme within the framework of the
guidelines drawn up by NACO in respect of each intervention. The SACS provide
financial assistance and sustained technical support in project implementation.
a) Targeted interventions
Targeted interventions are globally seen to be a most effective strategy for

arresting the spread of the HIV/AIDS epidemic. Essentially, marginalized and
vulnerable populations at high risk for HIV/AIDS are informed, educated, counseled
and provided some preliminary care and support so that they move towards behaviour
change and healthy living practices. These high risk groups typically are commercial
sex workers, men who have sex with men, injecting drug users, street children, truck
drivers, migrant labour, and so on. Multi-pronged strategies such as behaviour change
communication, safe sex education, condom promotion, and treatment for sexually
transmitted infections have definitely helped in slowing down the rate of spread of
the HIV virus. Attempts are made to enable the high risk groups access services and
care by creating an enabling environment. This involves working with a range of
external stakeholders like opinion leaders, community or religious leaders as well as
with formal structures like police and local government. Peer education strategies
help to organize and strengthen these initiatives.
b) School AIDS education programme
The most widely deployed strategies to promote and protect the needs and
rights of adolescents against acquiring HIV are i) to provide young people with
knowledge and information and ii) to equip young people with life skills to put
knowledge into practice. Research and experiences have shown that information
alone is not enough to protect young people from health risks. Young people also
need skills to manage challenging situations and take charge of their own health
within supportive communities and environments.
The issues of HIV/AIDS are placed in context, within more holistic issues
of family life education. Efforts are made to integrate HIV/AIDS education in the
regular curriculum of classes IX to XI. Additionally, education is also provided through
extracurricular activities. For more effective monitoring and continuity, this
programme is implemented in a broad framework, through NGOs. Selected NGOs
work with a certain number of schools to carry out tasks like training of teachers and
peer educators and monitoring of ongoing School AIDS Education activities. All
this is done in close collaboration with the education authorities. Inputs are provided
towards building of leadership to deal with aspects like abstinence and value
education.
c) Community care and support
Care and Support services for People Living With HIV/AIDS (PLWHAs)
becomes a crucial component to any and all efforts at prevention. In those states
which have been designated as high prevalence states (Andhra Pradesh, Karnataka,
Maharashtra, Manipur, Nagaland and Tamil Nadu) the State AIDS Control Societies
support home-based and community based care, short term hospice or cost effective
common opportunistic infection interventions. Comprehensive HIV/AIDS care is a
holistic approach for meeting the needs of HIV positive individuals. These needs are
identified and met by cross-cutting disciplines ranging from medical care to social
support as one discipline alone cannot effectively meet all their needs.

The concept of comprehensive HIV/AIDS care across the continuum of
prevention and care provides HIV/AIDS care services as a range that includes
voluntary counseling and testing, clinical management of symptomatic infection,
nursing care to relieve the physical discomfort of illness, hygiene and infection control
promotion, palliative and terminal care, training of family members in home care,
preventive education and condom promotion. NACO through some of its state partners
has been especially effective in mobilizing PLWHAs to come together and form
support groups, drop-in centers and short-stay homes. These projects are locale
specific, and hence allow for diversity.
d) National AIDS tele-counseling helpline
The National AIDS Control Organisation supports NGOs at state levels, who
opt to run a tele counseling service at a dedicated toll-free number 1097, primarily
and solely for HIV/AIDS counseling. All relevant information, education and
communication activities are disseminated through this number via pre-recorded
information. Option is also provided to the users for a manual response to specific
queries. Information seeking ranges from basic information on HIV/AIDS, the diverse
and most common routes of transmission, to areas of services available for any
personal anxieties. One of the primary reasons for the popularity of this service is
that the callers are able to get quality information and still maintain anonymity.
NGOs/CBOs in the development sector have designed and implemented

innovative and community level need-based programmes. Government has been
responsive, but now needs to further expand access to these services. And slowly but
surely, the government is succeeding in forging inter-sectoral links that will
mainstream HIV/AIDS prevention and control with broader concerns.
Work place intervention program
HIV / AIDS infection is reported to be higher in those who belong to the

most active part of the life, i.e. from adolescents to middle age. The workers invariably
fall under the specified age group (15 to 35 years). The work place prevention program
aims at rescuing this group from two sides. On one hand this program will generate
awareness among the workers; on the other hand, it will motivate the management to
re-evaluate the company policies in a manner that workers are educated about the
issue.
Relatively high mobility and prolonged absence from family and social
support networks may be partly to be blamed. HIV infected people are often refused
employment and their children are denied schooling. There have been instances when
employers face discrimination on the grounds of HIV/AIDS. Workplace program

support prevention, expands access to care, and treatment and promotes non-
discrimination. Objectives of the programme could be :
I To advocate on a company policy regarding HIV / AIDS

I To give service to the positive people (psychosocial care and support)
I Mainstreaming the HIV / AIDS affected people into employment
I To change their high risk behaviour in the work places.
Conclusion
HIV/AIDS has been a growing psychosocial problem in India. The magnitude of this
problem is becoming manifold day by day. It is no more remained as a physical
problem of an individual or certain segment of the people but it has multidimensional
consequences which, include social issues, mental health issues, economic burden,
and lagging overall country's development. It is an epidemic and controlling such
epidemic has been a challenging job for all the Government and Non-Governmental
Organizations as it is a very complex problem. Therefore developing large number
of research and planning effective, eclectic and culture sensitive intervention is
extremely important at this hour. In this scenario, the trained professional and
psychiatric social workers can effectively help in researching, planning and
implementing the necessary interventions.

Chapter 12
COUNSELING SERVICES FOR SUICIDE PREVENTION
A. Thirumoorthy,1 & K. Bhavana,2
Suicide has occurred since the beginning of recorded history, with attitudes
toward it varying from condemnation to tolerance, depending on the time and culture.
The motives for suicide and its frequency have also varied. Suicide is viewed as a
way out of a problem or crisis that is invariably causing intense suffering. According
to Edwin Shneidman, suicide is associated with thwarted or unfulfilled needs, feelings
of hopelessness and helplessness, ambivalent conflicts between survival and
unbearable stress, narrowing of perceived options, and a need for escape; the suicidal
person sends out signals of distress.
Suicide is derived from the Latin word for "self murder". If successful, it is
a fatal act that represents the person's wish to die. There is a range, however, between
thinking about suicide and acting it out. Some persons have ideas of suicide that they
will never act upon; some plan for days, weeks, or even years before acting; and
others take their lives seemingly on impulse, without premeditation.
A common definition is as follows:
l An act with a fatal outcome, that is deliberately initiated and performed by the
deceased himself or herself, in the knowledge or expectation of its fatal
outcome, the outcome being considered by the actor as instrumental in bringing
about desired changes in consciousness or social conditions (Retterstol.N,
2003).
Epidemiology
In the year 2000, approximately one million people died from suicide: a
"global" mortality rate of 16 per 100,000, or one death every 40 seconds.
l In the last 45 years suicide rates have increased by 60% worldwide. Suicide is
now among the three leading causes of death among those aged 15-44 years
(both sexes); these figures do not include suicide attempts up to 20 times more
frequent than completed suicide.
l Suicide worldwide is estimated to represent 1.8% of the total global burden of
disease in 1998, and 2.4% in countries with market and former socialist
economies in 2020.
l Although traditionally suicide rates have been highest among the male elderly,
rates among young people have been increasing to such an extent that they are
now the group at highest risk in a third of countries, in both developed and
developing countries.
1. Assistant Professor 2. Psychiatric Social Worker

l Mental disorders (particularly depression and substance abuse) are associated
with more than 90% of all cases of suicide. However, suicide results from many
complex socio cultural factors and is more likely to occur particularly during periods
of socioeconomic, family and individual crisis situations (e.g. loss of a loved one,
employment, honour).
Risk factors Ameen & Nizamie 2004 Following are the variables that may increase
the risk of suicide in vulnerable persons.
Gender Male
Age Elderly
Social status Low
Educational status Low
Marital status Unmarried, separated, divorced, widowed
Residential status Living alone
Employment status Unemployed, retired, insecure employment
Economic status Weak (males)
Profession Farmer, female doctor, student, sailor
Special subpopulations Students, prisoners, immigrants, refugees, religious
sects
Special institutions Hospitals, prisons, army
Various clinical determinants of suicide are listed below :
Family history Suicidal behavior, mental disorders
Mental disorders Any disorder, specially depression, substance use

disorders, personality disorders, schizophrenia
Contact with psychiatric services Any contacts, recent contacts, post-discharge

period, psychotropic drugs
Psychiatric symptoms Hopeless, helpless, depressive, psychotic,
delirious, anxious, aggressive, introversive
Suicidal behavior Previous suicide attempts, suicidal ideations,death

wishes, indirect gestures
Physical health Severe physical illness such as cancer,

AIDS,stroke, and epilepsy; permanent sickness
Availability of suicide methods Easy access to lethal methods

Environmental risk factors
l Job or financial loss

l Relational or social loss
l Easy access to lethal means
l Local clusters of suicide that has a contagious influence
Socio cultural risk factors
l Lack of social support and sense of isolation

l Stigma associated with help-seeking behavior
l Barriers to accessing health care, especially mental health and substance abuse
treatment
l Certain cultural and religious beliefs (for instance, the belief that suicide is a
noble resolution of a personal dilemma)
l Exposure to, including through the media, and influence of others who have
died by suicide
Protective factors Protective factors buffer people from the risks associated with
suicide. A number of protective factors have been identified (DHHS 1999):
l Effective clinical care for mental, physical, and substance abuse disorders
l Easy access to a variety of clinical interventions and support for help seeking
l Family and community support
l Support from ongoing medical and mental health care relationships
l Skills in problem solving, conflict resolution, and nonviolent handling of
disputes
l Cultural and religious beliefs that discourage suicide and support self-
preservation instincts.
Etiology of suicide
Sociological theory
Durkheim's theory. The first major contribution to the study of the social and cultural
influences on suicide was made at the end of the 19th century by the French sociologist
Emile Durkheim. In an attempt to explain statistical patterns, he divided suicides
into three social categories: egoistic, altruistic, and anomic. Egoistic suicide applies
to those who are not strongly integrated into any social group. Altruistic suicide
applies to those prone to suicide stemming from their excessive integration into a
group, with suicide being the outgrowth of the integration. Anomic suicide applies
to persons whose integration into society is disturbed so that they cannot follow
customary norms of behavior.

Psychological theories
Freud's theory: In his paper, Mourning and melancholia, Freud stated his belief
that suicide represents aggression turned inward against an introjected, ambivalently
cathected love object. He doubted that there would be a suicide without an earlier
repressed desire to kill someone else.
Menninger's theory: Building on Freud's ideas, Karl Menninger, in Man against

Himself, conceived of suicide as inverted homicide because of a person's anger toward
another person. This retroflexed murder is either turned inward or used as an excuse
for punishment. He also described a self-directed death instinct plus three components
of hostility in suicide: the wish to kill, the wish to be killed, and the wish to die.
Recent theories: contemporary psychologists are not persuaded that a specific

psychodynamic or personality structure is associated with suicide. They believe that
much can be learned about the psychodynamics of suicidal patients from their fantasies
about what would happen and what the consequences would be if they commit suicide.
The suicidal patients most likely to act out suicidal fantasies, may have lost a love
object or received a narcissistic injury, may experience overwhelming effects like
rage and guilt, or may identify with a suicide victim.
Genetic factors: Suicidal behavior, like other psychiatric disorders, tends to run in
families. In psychiatric patients, a family history of suicide increases the risk of
attempted suicide and that of completed suicide in most diagnostic groups.
Types of Suicide (Simon 2006)
Thousands of books have tried to answer the question of why people kill
themselves. To summarize them in three words: to stop pain. Sometimes this pain is
physical, as in chronic or terminal illness; more often it is emotional, caused by a
myriad of problems. In any case, suicide is not a random or senseless act, but an
effective, if extreme, solution.
A slightly more elaborate list of some reasons people commit or attempt

suicide follows. The categories are arbitrary and overlap to some degree. However,
this is just an outline, and there is no lack of books that discuss suicidal motivation in
much more detail and from many different perspectives.
(1) Altruistic/Heroic suicide. This is where someone (more-or-less) voluntarily

dies for the good of the group. Examples include the Greeks at Thermopolae;
the Japanese Kamikaze pilots at the end of WWII; the Buddhist monks and
others who, starting in 1963, burned themselves to death trying to stop the
Viet-Nam war; elderly Inuit (Eskimos) killing themselves to leave more food
for their families; some Communists who confessed to invented (and often
impossible) crimes during the Purge Trials of the late 1930s and early 1950s.
Gandhi's tactic of hunger strikes, called "satyagraha" or "soul force", would
have fallen into this category, had the British authorities failed to respond to
his demands.
(2) Philosophical suicide. Various philosophical schools, such as stoics and
existentialists, have advocated suicide under some circumstances.
(3) Religious suicide. There is a long history of religious suicide, usually in the
form of martyrdom. This was widespread in the early years of Christianity
and was also commonly seen in the various "heresies" uprooted before and
during the Reformation, Counter-Reformation, and Inquisition. More recent
examples may include members of the Solar Temple in Switzerland, France,
and Canada, the San Diego Hale-Boppers in March, 1997, the Branch Davidians
in Waco, Texas, and some of the people at Jonestown, Guyana.
(4) Escape from an unbearable situation. This may be persecution, a terminal
illness, or chronic misery. Epidemics of suicide were frequent among Jews in
medieval Europe; (sometimes they were given a choice between converting to
Christianity and death). Later, both Indian and black slaves in the New World
committed mass suicide to escape brutal treatment. There were large numbers
of suicides during times of pestilence in medieval Europe. More recently, AIDS
has generated a similar response among many of its victims.
(5) Excess alcohol and other drug use. The observed high correlation between
alcohol and suicide can be explained in several ways, including: (a) Alcoholism
can cause loss of friends, family, and job, leading to social isolation,(b) Alcohol
and suicide may both be attempts to deal with depression and misery; (c)
Alcohol will increase the effects of other sedative drugs, frequently used in
suicide attempts; (d) Alcohol may increase impulsive actions.The significance
of the last two points is emphasized by findings that alcoholic suicide attempters
who used highly lethal methods scored relatively low on suicidal-intent tests.
The correlation between lethal intent and method was found only among non-
alcoholics. Thus, to claim that alcoholism "causes" suicide is simplistic; while
the association of alcohol excess with suicide is clear, a causal relationship is
not. Both alcoholism and suicide may be responses to the same pain. "A man
may drown his sorrows in alcohol for years before he decides to drown himself."
(6) Romantic suicide. "My life is not worth living without him". This is most
celebrated among the youth, as in Romeo and Juliet, but is probably most
frequent among people who have lived together for many years, when one of
them dies. Suicide pacts (dual suicide) constitute about 1% of suicides in
Western Europe. Most often, their participants are over 51 years old, except in
Japan, where 75% of dual suicides are "lovers' pacts."
(7) "Anniversary" suicide is characterized by use of the same method or date as
a dead loved one, usually a family member used. "Imitative" suicide is similar
to anniversary suicide in its focus on the dead, but uses a different date and
method.
(8) "Contagion" suicide. This is where one suicide seems to be the trigger for
others, and includes "cluster" and "copycat" suicides, most often among
adolescents.
(9) An attempt to manipulate others. "If you don't do what I want, I'll kill myself,"
is the basic theme here. However, the word "manipulative" does not "...imply
that a suicide attempt is not serious....fatal suicide attempts are often made by
people who are hoping to influence or manipulate the feelings of other people
even though they will not be around to witness the success or failure of their
efforts." Nevertheless, while people sometimes die or are maimed from their
attempts, the intention in this case is to generate guilt in the other person, and
the practitioner generally intends a non-fatal result.
(10) Seek help or send a distress signal. This is similar to "manipulative" suicide
except that there may be no specific thing being explicitly sought; it's the
expression of too much pain and misery. This may occur at any age, but it is
more frequent among the youth. However, "Parents may minimize or deny the
attempt. One study found that only 38 percent of treatment referrals after an
adolescent attempt were acted on. Another found only 41 percent of families
came for further therapy following an initial session. `It's often difficult to get
parents to acknowledge the problem because they are the problem,' says Peter
Saltzman, a child psychiatrist."
(11) "Magical thinking" and punishment. This is associated with a feeling of
power and complete control. It's a "You'll be sorry when I'm dead" fantasy. An
illustration is the old Japanese custom of killing oneself on the doorstep of
someone who has caused insult or humiliation. This is similar to "manipulative
suicide", but a fatal result is intended. It's sometimes called "aggressive suicide."
In a power struggle, if you can't win you can at least get in the last word by
killing yourself.
(12) Cultural approval. Japanese (like Roman) society has traditionally accepted
or encouraged suicide where matters of honor were concerned. Thus, the
president of a Japanese company whose food product had accidentally poisoned
some people, killed himself as an acknowledgment of responsibility for his
company's mistake.
(13) Lack of an outside source to blame for one's misery. J.F. Henry and A.F.
Short present evidence that when there is an external cause for one's
unhappiness, the extreme response is rage and homicide. In the absence of an
external source, the extreme response tends to be depression and suicide. Thus,
while marriage and children are associated with a lower suicide rate, they are
also correlated with a higher homicide rate.
Common misconceptions
The following are common misconceptions about Suicide
1. "People who talk about suicide won't really do it": Almost everyone who
commits or attempts suicide has given some clue or warning. Do not ignore
suicide threats. Statements like "you'll be sorry when I'm dead," "I can't see
any way out," -- no matter how casually or jokingly said may indicate serious
suicidal feelings.
2. "Anyone who tries to kill him/herself must be crazy": Most suicidal people
are not psychotic or insane. They must be upset, grief-stricken, depressed or
despairing, but extreme distress and emotional pain are not necessarily signs
of mental illness.
3. "If a person is determined to kill him/herself, nothing is going to stop
him/her": Even the most severely depressed person has mixed feelings about
death, wavering until the very last moment between wanting to live and wanting
to die. Most suicidal people do not want death; they want the pain to stop. The
impulse to end it all, however overpowering, does not last forever.
4. "People who commit suicide are people who were unwilling to seek help":
Studies of suicide victims have shown that more then half had sought medical
help within six month before their deaths.
5. "Talking about suicide may give someone the idea": You don't give a suicidal
person morbid ideas by talking about suicide. The opposite is true --bringing
up the subject of suicide and discussing it openly is one of the most helpful
things you can do.
6. "Suicide is hereditary": Suicidal behavior to a certain extend can also be
learnt from experience during childhood, but the behavior as such is not
inherited biologically.
Suicide in various age groups
Suicide among Youth: The majority of suicidal children and adolescents have clinical
depression alone or in conjunction with another depressive illness like anxiety
disorder, attention deficit disorder, bipolar illness (manic depression), or child-onset
schizophrenia. Each child's personality, biological makeup, and environment are
unique, and depression and suicidal ideation in children are complex issues involving
many factors. By recognizing and treating depression in children, we can improve
the chances of young person with depression can live longer, healthier, and with
more quality in life.
Warning signs of suicide in children
Verbal Clues- Saying things like:
l I shouldn't be here.
l I'm going to run away.
l I wish I were dead.
l I'm going to kill myself.
l I wish I could disappear forever.
l If a person did this or that…..would he/she die?
l The voices tell me to kill myself.
l I want to see what it feels like to die.

Behavioral clues- doing things like
l Talking or joking about suicide.

l Giving away possessions.
l Preoccupation with death/violence; TV, movies, drawings, books, at play,
music.
l Risky behavior; jumping from high places, running into traffic, self-cutting.
l Having several accidents resulting in injury; "close calls" or "brushes with
death."
l Obsession with guns and knives.
l Previous suicidal thoughts or attempts.
High risk children
l Are preoccupied with death, and don't understand its permanency.

l Believe a person goes to a better place after dying or can come alive after
dying.
l Are impulsive (act w/out realizing the consequences of their actions).
l Have no sense of fear or danger.
l Truly feel that it would be better for everyone if they were dead.
l Believe that if they could join a loved one who died, they would then be rid of
their pain and be at peace.
l Speak of death in a positive way rather than negative; think that death might
be pleasant.
l Have parents or relatives who have attempted suicide (modeling behaviors/
genetic factors involved here).
l Are hopeless; feeling that things will never get better, that they will never feel
better.
Many suicidal children believe that when others die, death is final, but that
if they die, their death is reversible. Vulnerable children and adolescents who may
be under stress (internal or external) may have a change in perceptions of and feelings
about death.
Suicide in the elderly
Reasons for suicide in the elderly
(1) Social isolation and loneliness, especially among widowers.

(2) Physical isolation: because many old people live alone, a suicide attempt
may not be discovered soon enough to survive it.
(3) The accumulation of losses, such as friends, physical and mental abilities,
social status, and health.

Warning signs of suicidal behavior in elderly
l Talk about suicide, e.g. "I have nothing left to live for." "I won't be a burden on
my family much longer." "I should just kill myself."
l Statements of hopelessness, helplessness or worthlessness.
l Suddenly happier, calmer.
l Loss of interest in things one cares about.
l Unusual visiting or calling people one cares about - saying goodbyes.
l Making arrangements; setting one's affairs in order.
l Giving things away.
l Stocking pills or obtaining a weapon.
l Refusal to follow doctor-prescribed medications and/or special diet.
Suicide prevention
The best method for preventing suicide is one that of long term approach
designed to address the major distal risk factors in an integrated manner. It includes
individual as well as his or her physical and psychosocial environment. An important
aspect of comprehensive strategies for suicide prevention is education. Education is
actually the indispensable link between suicide research and practical preventive
work within any suicide prevention strategy.
1. Increasing public awareness about suicide as a problem and challenge-

Even though suicide taboos have been reduced in many countries, taboo still
exists. Taboos tend to reduce people's access to adequate information about
suicide. There is clearly a need to provide simple and adequate information to
the public; this should be done in a flexible way through multiple information
channels.
2. Influence attitudes and counteract stigma and myths- There is a need to
help people change some of their attitudes towards suicide and counteract
myths and to reduce stigma of mental disorder. It is important to provide
decision makers with adequate information and hopefully increase their
willingness to make necessary changes in the social conditions and health
care systems that are associated with the alleviation of suicidal risk.
3. Increase knowledge and skills of key personnel in suicide prevention- It
must be well adapted to each group's specific needs.
4. Counseling
Counseling is used as one of the methods in suicide prevention programmes.
The most commonly used techniques in counseling are:
a. Ventilation, b. Explanation, c. Reassurance d. Healthy distraction
5. Crisis intervention
Crisis Intervention is a systematic process of problem resolution and it occurs
in a relationship. Within the context of the relation, the interventionist attempts
quickly to focus on and address a presenting problem, whether the patient is
presenting suicidal or other traumatic experiences.
Key tasks of crisis intervention (Rudd.et al, 2006)
The key therapeutic response during a state of suicidal crisis is to detail a specific
crisis response plan to resolve the acute emotional upset.
l Ensure the safety of the patient. Remove any available or accessible means of
suicide. This will require careful, methodical, and thorough questioning, along
with the necessary and indicated responses.
l Initiate self monitoring, particularly during periods of acute emotional upset.
Improve the patient's awareness and understanding of his or her own cognitive,
emotional, and behavioral functioning- the patient's suicidal mode.
l Target and achieve symptom remission and stabilization. It is important to
identify and target those symptoms the patient identifies as most disruptive,
symptoms which are impairing the patient's ability to function on a day to day
basis.
l Target the source of the patient's hopelessness directly. In targeting the patient's
source hopelessness, active problem solving will be necessary.
l Initiate immediate activity, regardless of its significance, to undermine the
patient's sense of helplessness. It is important to do something, but it needs to
be something strategic, specific, and consistent with the longer-term treatment
plan and directed at the patient's source hopelessness.
l Marshall support to undermine the patient's sense of isolation and detachment,
involving family, friends, or significant other as needed or indicated.
l Identify the patient's active suicidal mode, with a particular focus on the
cognitive and behavioral components.
l Provide a crisis response plan. It is important for the patient to have a clearly
articulated, specific crisis/emergency response plan, one that attributes as much
responsibility to the patient as possible
l Articulate the initial conceptual model for intervention, that is, the suicidal
cycle.
l Reinforce the patient's commitment to treatment as a preferable alternative to
suicide
l Solidify the therapeutic relationship by maintaining flexibility and availability.
Crisis intervention model (Rudd. et al, 2006)

It includes the following five steps:
1. Establish rapport
2. Explore
3. Focus
4. Develop options and a plan of action
5. Terminate
Establish rapport
Crisis intervention begins in the first encounter. The patient talks and the
interventionist listens. It requires the development of an active, non-judgmental
rapport or therapeutic alliance. The goal is to keep a person alive. The goal of treatment
is quite simple. It consists almost by definition of lowering the lethality; in practice,
this amounts to decreasing or mollifying the level of perturbation. The person's
constricted focus on suicide has to be diffused. The therapist makes the person's
temporarily unbearable problems and injustices just sufficiently better so that he/she
can stop to think and reconsider and discern alternatives to suicide.
Explore
As the therapist explores, he redefines to the individual the trauma as painful

but tolerable. The adaptive potential of the individual is developed. The following
points are relevant to the exploration phase of the model:
1. The pain of the suicidal person relates to the frustration or blocking of important
psychological needs, that is, needs deemed to be important by the person. It
should be the therapist function to help the individual in relation to those
thwarted needs.
2. The suicidal individual is ambivalent. He/she wants to die and yearns for
intervention, rescue and life. Rescue often implies improvement or change in
one of the major details in the person's world.
Focus
It is imperative for the crisis interventionist to understand how the suicidal
person defines the trauma; that is, what it is that cannot be endured. These patients
often cannot concentrate; they are too perturbed. The focusing allows not only the
patient to focus but also the interventionist so that clarity can emerge. It allows for a
good consensus and collaboration.
Develop options and a plan of action

Three things should be borne in mind when exploring options and constructive
action. (1) A key to intermediate and long-range effectiveness with the suicidal
person is to increase the options available. (2) When the patient is no longer highly
suicidal, the usual methods of psychotherapy can be usefully employed. The main
point with the suicidal patient is to increase that individual's psychological sense of
possible choices and his/her sense of being emotionally supported. It is vital to counter
the suicidal person's constriction of thought by attempting to widen the mental blinders
and increase the number of options, certainly beyond the two options of either having
some magical resolution or being dead. Active contact, letting others know about it,
encouraging the person to talk to others, getting loved ones involved, interested and
responsive and creating action around the person are all examples of active
intervention.
Termination
Before terminating the treatment, one should summarize, rehearse, develop
planning skills, identifying resources, make referrals, identify emergency procedures
and establish follow up, to identify but a few essential steps before ending contact
with the patient in crisis. Crisis intervention does not completely fix situations. Once
the lethality is lowered, once the difficulties are more bearable, one moves towards
more usual therapy- psychoanalytic, cognitive, behavioral etc.
Ensuring the patient's safety

If there is clear expressed intent, there needs to be immediate referral for
psychiatric evaluation and hospitalization. Regardless of risk category, remove access
to or availability of means of suicide.
Measures to ensure compliance to treatment

l Definite appointment for follow up should be offered after treatment
l A 24 hr back up should be available
l At risk patients not attending follow up should be pursued with telephone
calls, letters or visits
l Family members and family physician should be involved in planning and
maintenances of treatment
l Drugs with fewer side effects should be prescribed in order to enhance
compliance
l Patients should be helped to understand the illness and need for treatment
Suicide prevention strategies

There are a number of strategies for suicide prevention. This typology was
adapted from Programs for the Prevention of Suicide Among Adolescents and Young
Adults, which appeared in Morbidity and Mortality Weekly Report, April 22, 1994 /
43(RR-6);1-7
School gatekeeper training helps school staff (such as teachers, counselors, and
coaches) identify and refer students who may be at risk of suicide. Gatekeeper training
also teaches staff how to respond to suicide or other crises in the school.
Community gatekeeper training teaches community members (such as clergy,

police, merchants, and recreation program staff) and clinical healthcare providers
who see adolescent and young adult patients (such as doctors and nurses) to identify
and refer persons in this age group who are at risk for suicide.
General suicide education teaches adolescents about suicide, its warning signs,
and how to seek help for themselves or others. These programs often incorporate
activities that increase self-esteem and social competency.
Screening programs use questionnaires or other screening instruments to identify

high-risk adolescents and young adults for additional assessment and treatment.
Repeated assessments can be used to measure changes in attitudes or behaviors over

time, test the effectiveness of prevention efforts, and to detect potential suicidal
behaviors.
Peer support programs are designed to foster peer relationships and competency in
social skills among high-risk adolescents and young adults.
Crisis centers and hotlines provide telephone counseling and other services for
suicidal persons. Some programs offer "drop-in" crisis centers and referral to mental
health services.
Restriction of access to lethal means are strategies that restrict access to handguns,
drugs, and other common means of suicide.
Postvention (intervention after a suicide) target friends, family, and classmates of

persons who completed suicide. They are designed to prevent or contain suicide
clusters and to help adolescents and young adults cope effectively with the feelings
of loss that follow the sudden death or suicide of a peer.
Indian scenario
There is no separate mental health policy or national policy for suicide

prevention and not much attention is given to the preventive aspects of suicide. The
government should recognize suicide as a public health problem. There is a need for
measures to identify the correct statistics regarding the epidemiology. Suicide
prevention should focus on creating awareness about the causes and prevention of
suicide to public as well as to the health care professionals. More emphasis should
be given on public health education through mass media, identifying high risk groups,
creation of crisis intervention centers and counseling centers in vulnerable places.

Chapter 13
WELFARE AND LEGAL MEASURES FOR THE MENTALLY ILL
Mohd. Ameer Hamza,1
Introduction
One in four people in the world will be affected by mental or neurological

disorder at one point of time in their life. Around 450 million people currently suffer
from such conditions (WHO Report 2000). According to the census, 2001, there are
2.19 crore people with disabilities in India which constitute 2.13 percent of total
population.
Psychiatric illness is recognized as stigmatizing, disabling & discriminating

one among all illness. It causes impairments, disabilities and handicap in mental
disorders like schizophrenia. We have taken an account of the lack of ability to perform
daily activity, slowness, emotional bluntness and loss of contact with reality and
work. By this, their quality of life is affected. Disability due to mental illness is
though not visible, affects all spheres of life and further it is compounded by stigma,
, inequality, discrimination, lack of family support etc. Media plays a central role in
relation to a negative attitude of the society. To over come this, there is a need for
change in the public health policy. All custodial care institution is to be made acute
curative centers and the emphasis should be on individual case and rights of individual
patients. There is a need to involve the practitioner general practitioner in this
treatment. Disability is placed in disadvantaged conditions. To meet this challenge,
our efforts should be made and necessary actions should be taken to reduce the
impairment.
Variations among human beings in the physical, mental and sensory
functioning have existed since the beginning of time. Yet people with functional
limitations, disabilities, have always been excluded and marginalized. Mental health
care facilities, care and support, improvement of living conditions, exercising their
rights to freedom (realization of human rights of the disabled, Right to role, stand for
education, a right to shed before the court of law, to right to marriage and property
etc) should be implemented. A comprehensive legal and institutional structure has
already been put in place for the welfare of the persons with disabilities. The Persons
with Disability (Equal opportunities, protection of rights and full participation) 1995
Act was enacted.
Brief Historical Milestones

Initiative prior to the National Human Rights Commission (NHRC):
1946 - Bhore Committee
1948 - Declaration of Human Rights
1962 - Mudaliar committee
1. Asstistant Professor

1975 - UN adapted to rights of the disabled
1982 - Focus on mental hospitals
1991 - UN General assembly adopted the principles of rights of the mentally ill
1993 - NHRC established in India
1987 - Mental Health Act
1992 - The Rehabilitation Council of India Act
1995 - Persons with Disability Act
Involvement of the NHRC in mental health
Article 21 of the constitution (Fundamental/ Human Rights) includes the

right to live with human dignity and right to health. The Supreme Court noted that
maintenance and improvement of public health is one of the obligations in the Article
21. The rights of the mentally ill be threatened, it becomes the responsibility of the
disability commission to examine the problem and recommend appropriate remedial
measures.
Rights of the mentally ill
The fundamental rights of their fellow citizens, including the right to decent life, as
normal as possible is applicable for the persons with disability. Their rights also
include.
l Legal safeguards against abuse appeal.
l Necessary treatment as for as possible, to treat and care in the community.
l Personal autonomy, privacy, freedom of communication.
l Education, training, economic and social security
l Family and community life, employment.
l Protection against exploitation and discrimination, abuse or degrading
treatment.
Recommendation of the NHRC
l Reconstruction/ repairs of wards and buildings a phased manner.

l Abolition of cells.
l Increase in basic living Condition (space, food, water, toilets, beds, linen,
clothes, personal care)
l Professional care: Role of doctors, and other professional, nursing staff and
ward attendees
l Treatment: adequate investigative facilities, pharmacotherapy, modified ECT,
psychosocial treatment.
l High dependency care units
l Adequate rehabilitation facilities
l Follow-up of effective care
l Liaison with other specialties for medical care
Admission/ discharge procedures
l Encourage voluntary admission

l Encourage family to stay with patients.
l Encourage outpatient treatment
l Implementation of Mental Health Act 1987
Defining disability is difficult to accommodate the expectation of all disabled

persons and groups. There are hundreds of disabilities and as many causes for these
disabilities. Some born with disabilities, other disabled later on in their life, some
disabilities exhibit only periodically (seizures, others are life long). They may be
physically disabled, mentally retarded, the visually, hearing and speech impaired
and mental ill.
In the world, 600 million people are disabled out of that 400 million people
are in the developing countries. In India: According to NSSO (National Sample Survey
Organization) 18.49 millions are disabled in the year 2002. Prevalence rates from
1991 - 2002 has been increase 1.70 to 1.88. More disabled are in the age group of 15-
45. Many disabled are willing to and able to work but they are unemployed because
of disability. We assume that disabled people cannot do much work. If disabled people
are given access to education, training in employable skills, they can live on their
own, support families and contribute to the national economy.
Existing legal structure
The attitude of the society towards persons affected with mental illness has
changed considerably and it is realized that no stigma should be attached to such
illness as it is treatable, when it is diagnosed at an early stage. With the rapid advance
of medical sciences and the understanding of the nature of the malady, it has become
necessary to have fresh legislation with provisions for the treatment of mentally ill
persons in accordance with the new approach.
1. Mental Health Act, 1987

2. The Persons with Disabilities (Equal opportunities protection of rights
and Full Participation Act, 1995).
The Mental Health Act (MHA) is divided into 10 chapters with 98 sections
1. Talks about all definitions
2. Mental health authorities
3. Psychiatric hospitals and psychiatric nursing home
4. Admission procedures
5. Inspection, licensing etc
6. Judicial inquisition: Property issues
7. Liability to meet the cost of maintenance
8. Protection of human rights
9. Penalty
10. Miscellaneous
In 1995, the Persons with Disabilities (Equal opportunities, protection of

rights and full participation) Act was implemented. The main concern of the Act is
that the mentally ill persons are to be treated like any other sick persons and the
environment around them should be made as normal as possible. This is possible
when rehabilitation services which includes early identification, intervention,
education, vocational training, employment opportunities and the availability of aids
and appliances.
PWD Act is divided into 14 chapters with 74 sections.

1. Definition
2. Central co-ordination committee
3. State co-ordination committee
4. Prevention and early detection of disabilities
5. Education
6. Employment
7. Affirmation
8. Non-discrimination
9. Research and man power development
10. Recognition of Institute of persons with disabilities
11. Institution with service disabilities
12. The chief commission and commission of personality with disabilities
13. Social security
14. Miscellaneous
Initiatives in rehabilitation of persons with disabilities
1. Public awareness: Greater awareness is happening in the general public, about

disabling conditions and the needs as well as abilities of people with disabilities.
This is joint effort by Government and Non Governmental organization,
disabled people, and their families and by the media (Railways, Airlines, Hotel
and Tourism Department etc).
2. Primary prevention: Since disability, in a large number of population as is
preventable, there needs to be a strong emphasis on prevention of disabilities.
Early intervention and detecting helps in minimizing the impact of disability.
3. Secondary prevention: This is possible through identification and surveillance

of networks at risk of developmental delay and difficulty. The assessment
cum rehabilitation specialties can be started at the hospital itself. This
developmental surveillance of rehabilitation personnel is currently taking place
in about 50 Government Hospital and primary health centers in Tamil Nadu.
4. Early intervention: Rehabilitation services like counseling, psychotherapy,
occupational
therapy, strengthen the capacities of person with disabilities and their families.
The vocational training followed by special schools emphasizes on
a. The whole child outlook
b. Sensory integration and
c. Transformation of rehabilitative team from interdisciplinary to a.
multidisciplinary team. This is more helpful in community based (CBO)
rehabilitation at villages (100) (Southern Whole District).
5. Education: According to the national sample survey organization, 2002 report

on disabled persons in India, 55 percent with disabilities were illiterate. This
need involvement of persons with disability with general education system.
The Government of India had launched a specific and comprehensive
programme on Integrated Education (IED) in 1974 and in 1977 the government
initiated Primary education programme in 14 states in India (DPEP). National
open school in New Delhi (NOS) has made high school leaving certificates
more accessible to students with disabilities. The Indira Gandhi National Open
University has started centers in every state to make post high school education
accessible to persons with disabilities. Sarva Shiksha Abhiyan (SSA) launched
by the Government has the goal of eight years of elementary schooling for all
children, including children with disabilities in the age group of 6-14 years by
2010. the Act also emphasizes on promoting settings of special schools and
government and private sector for those in need of special education for
disabled children. Providing non formal education through open schools or
open universities, conducting classes through interactive electronic or other
media, providing every child with disability free of cost special books and
equipment needed for education is also the specialty of this Act.
Employment
l Identification of persons which can be reserved for disabilities. Government

shall appoint in every establishment not less than three percent each shall be
reserved persons suffering from a blindness or low vision or hearing impairment
or locomotor disability or cerebral palsy in the posts identified for each
disability. No promotions shall be denied on the ground of his/her disability.
l Special employment exchange should be established. Any person authorized
by the special employment in writing, shall access to relevant record.
l Employer should maintain record
l Schemes for ensuring employment of persons with disabilities, (a) Training
and welfare
l (b) Relaxation of upper age limit (c) regulating the employment (d) health and
safety measures.
l All the educational institutions to reserve seats for persons with disabled.
l Incentives to the employers of disabled, both in government and private sectors
to ensure
l 5% of their work force comprising persons with disability.
l Encourage self employment
Affirmative action
l Aids and appliance to persons with disability The government shall by

notification to prepare schemes to provide aids and appliances to persons with
disabilty. They should also involve NGO's within programme to provide
friendly affordable services to complement the endovor of the state. There
should be networking, exchange of information, interaction among NGO's
will encourage and facilitate within the constrains of available resources.
l Schemes for preferential allotment of land for certain persons. Land should be
allotted for concessional rates. a) House, b) Setting up business, (c) setting up
of recreational centers, (d) establishment of special schools, (e) establishment
of special research centers and f) establishment of factories by entrepreneurs
with disabilities.
l A directory NGOs working in the field of disability should be prepared.
l NGOs will be encouraged to draw and adopt minimum standards, code of
conduct, ethics
Non-Discrimination
Non-discrimination in transport: Take special measures to

a) Adopt rail compartment, buses, vessels and aircraft in such a way as to permit
easy access to such persons.
b) Adapt toilets in rail compartments and provide wheel chair
Non-discrimination on the road
a) Installation of audible signals of lights in the public roads (visual handicap)

b) Slopes to be made for easy access of wheel chair users
c) Zebra crossing for blind and low vision
d) Devising appropriate symbols of disability.
e) Waiting signals at appropriate places
Non-discrimination in the built environment
Ramps in public building, adaptation of toilets for wheel chairs.

Research and manpower development
The Government and local authorities shall promote and sponsor research of the
following areas:
a. Prevention of disability
b. Community based rehabilitation
c. Development of associative devices
d. Job identification
e. Financial assistance to universities and other institutions for conducting
research for special education rehabilitation and manpower development
Recognition of institution for persons with disabled

l Appointment of competent authority for purpose of this act.
l Institution should be recognized
l Certification of registration shall be made by the competent authority
l Time to time renewal
Institution for persons with severe disabilities
Government is obligated to provide rehabilitation to severely disabled individuals.

With over 40% of disability
The chief commissioned and commissioner for persons with disability
The central government shall appoint chief commissioner for persons with disabilities
and the person should learn the modalities related to rehabilitation.
l Chief Commissioner to look into (a) Deprivation of rights, (b) non
implementation of laws, rules, bye-laws, regulations, guidelines or any welfare
rights protected for the persons with disabilities.
l Every state has to appoint one commissioner for the purpose of this let. Annual
reports have to be prepared by the chief commissioner and commissioner
Social security
Appropriate government and local authority within their limits of their economic
capacity should rehabilitate the persons with disabilities.- Government should then
sanction financial assistance to Government or non-governmental organizations
working for the cause of persons with disabilities.
Insurance scheme for employees with disabilities
l Alternative insurance schemes for employees with disabilities

l Payment of unemployment allowances.
l Travel concession - Train (upto 50% including accompanying personal)
l Identity card: valid for 10 years
l Allotment of STD/PCO
l Income tax concession (15000 for medical treatment, 20,000 for maintenance
of Disabled dependent)
l Rebate on IT for senior citizens with psychiatric disability
Miscellaneous
Punishment for fraudulently availing benefit from disabled persons
Central Government schemes for Rehabilitation of PWD under the ministry of

social justice and empowerment
- Schemes to promote voluntary initiatives for person's disability
- Social security measures
- Disability benefit for 150 to 400/-
- Schemes for promotion of cultural and sports activities.
- Counseling and information services on job, vocational training, education
etc.
- In the District primary education program, schools are now building ramps,
providing teaching and learning materials
Financial assistance
- National Handicap Finances and Development Corporation (NHFDC)

- NHFDC - loan at low rates.
- Self-employment up to 20 lakh
- Low interest rates - for self employment
- National centre for the promotion of employment of persons with disabilities
has been setup.
- Financing allocation has been doubled from 97-98 to 106 to 180 crores in
1999-2000 by the Ministry of social justice and employment and handicapped
welfare section.
- National rehabilitation council of India - Trained 30000 medical officers in
PHC
Ministry of Social Justice and Empowerment
The Ministry of Welfare has been renamed as Social Justice and

Empowerment. The handicapped welfare section is now called as Disability Division.
The funding allocation has been doubled from Rs. 106 crores in 1997-98 and Rs. 180
crores in 1999-2000. Today, more than 1500 non government organizations receive
financial support from Government of India.

Chapter 14
COMMUNITY MENTAL HEALTH CARE PROGRAMS AT NIMHANS
Sini Mathew,1 & K. Sekar,2
Some 450 million people worldwide currently suffer from some form of
mental disease or brain condition, but almost half the countries in the world have no
explicit mental health policy and nearly a third have no program for coping with the
rising tide of brain-related disabilities (WHO, 2001). India, the second most populated
country of the world with a population of 1.027 billion, is a country of contrasts. The
population is predominantly rural, and 36% of people still live below poverty line.
The mental health services currently available in India are recent and limited in
extent. There is only 40 psychiatric hospitals and 0.4 psychiatrists per 100 000
population.
The locus of care for mental health in India has traditionally, asylum-based.
Prior to the 17th century, some cultures viewed mental illness as a moral problem
and confinements or punishment was the mode of treatment. Mentally ill' were
considered evil and described as witches. In the modern era, there was a shift from
'evil' to 'ill. Mentally ill were called as 'mad' or 'insane' and were placed in special
places called as 'asylums'. Between the 17th and 19th centuries, the idea of mental
illness as a medically treatable illness gained momentum. Through out the last century
various researches have explored the organic and psychosocial base of mental illness.
These shifts in attitude is reflected in the various treatment methods and psychosocial
care provided to the mentally ill people in the community. In our country, a modern
increase in community mental health care delivery began in the 1970s. Community
mental health is a decentralized pattern of mental health, mental health care, or other
services for people with mental illnesses. Community mental health care may be
more accessible and responsive to local needs because it is based in a variety of
community settings rather than aggregating and isolating patients and patient care in
central hospitals. It is widely acclaimed that community care is more effective as
well as more humane than in-patient stays in mental hospitals. It is, therefore, essential
to develop mental health services in the community settings as an integral part of
primary health care; to root out stigma, myths and misconceptions and discrimination
against mental disorders. The World Mental Health report 2001 advocates community
based mental health program and active involvement of families and consumers and
community in the delivery of program. This article briefly talks about the various
developments that occurred in the community mental health care programs, the
ongoing civilities and the role of psychiatric social workers in NIMHANS.
1. Psychiatric Social Worker 2. Professor and Head

The history of community mental health in India.
According to R L Kapur who is a pioneer in the field of community psychiatry

the inspiration for the community mental health movement in India comes from
three sources (Kapur, 2004). In the 1960s, American psychiatrists discussed the social
breakdown syndrome, which resulted from long term hospitalization (Gruenberg,
1967). Second source is the realization that institution based psychiatry through trained
professionals is very expensive and that country like India will not have sufficient
human resource and facilities to deliver services through conventional methods. The
third source was the discovery of capacity of the para professionals and
nonprofessionals. After undergoing a simple and innovative training, they could
deliver the mental health care to the needy (Haworth, 1969; Schmidt, 1967 &Swift,
1972). Yet another revelation of the recent years is the successful implementation of
the district mental health program in different parts of the country (Murthy 2000).
Dr.Vidya Sagar in the late 1950s began to involve family members in the
treatment of mentally ill in Amritsar hospital (Kapur, 1971). This hospital had 900
beds with inadequate staff. He has requested the patient's relatives stay back and
assist in providing nursing care. Every evening he assembled a large number of
relatives and carry out an open case conference in which he encouraged them to
understand the symptoms of the illness as well as the methods of treatment. First, it
reduced the hostility and fear of abandonment in the minds of patients and second it
helped the relatives to dispel age old myths about incurability of mental illness.
Finally, by attending the group work sessions the relatives learned the essential
principles of mental health care and were motivated towards improvement in their
own ways of life.
The next phase in deinstitutionalization was the establishment of the General

Hospital Psychiatric Units (GHPUs). The first one was set up in 1933 at the R.G.Kar
medical college at Kolkata (Wig 1978) & GMC R. J. J. group of Hospital Bombay in
1938 (Khanna et al, 1974). The number has gradually increased since then. Gradually
GHPU started the PG training centers at Delhi, Chandigarh, Lucknow, Bombay,
Madurai etc resulting in development of District Psychiatric unit. However, most of
the units started in 1960s because of the availability of antipsychotic drugs that
controlled the agitation, aggression and withdrawal tendencies of the mentally ill
patients making the treatment possible in general hospital without much difficulty.
Another major step in mental health care was to integrate mental health care
with general health services followed by the initial demonstration of projects at
Chandigrah and NIMHANS, Bangalore (Wig et al, 1981& Isaac 1980). The reasons
for this integration were: (1) the recognition of the large numbers requiring mental
health services especially those who were living in rural areas; (2) the limited numbers
of mental health professionals; (3) the emerging integration of all programs from
vertical to multipurpose model; (4) the international development of primary health
care as the approach to organized health services; (5) the awareness of the importance
of early recognition and treatment to prevent chronicity; and (6) the goal of continuity
of care and integration of the mentally ill in the community. The integration occurred
at two levels, namely the training of general practitioners and primary health care
personnel working in the rural health services (Wig &Murthy, 2004)
Community mental health care programs at NIMHANS
On the recommendation of Bhore committee (in 1946), All India Institute

Mental Health was set up in 1954, which became the National Institute of Mental
Health And Neuro Sciences in 1974 at Bangalore. An expert committee of WHO
in1974, made several important recommendations, urging its members to consider
mental disorder as a high priority problem. The recommendations included : to
undertake pilot projects to assess existing mental health care program in a defined
populations and training program for health workers and to devise a manual for the
same (Isaac 1986). Hence, first community Mental Health unit (CMHU) was started
with the Department of Psychiatry at NIMHANS in 1975 with the following
objectives,
l Organizing mental health services

l Human resource development (developing training materials and conducting
training programs for the personnel from health, welfare and community
development)
l Developing community based research
l Developing various models of care
It was at the initiative of the director, Dr.R.M Varma and that of Dr.Karan
Singh, then Minister of Health in the central government, that a crash program for
community based mental health was introduced at NIMHANS. For short-term training
of primary care personnel, a Rural Mental Health Center was inaugurated in Dec'1976
at Sakalwara, 15 km from Bangalore. Mental Health clinic opened in a General
Hospital in Bangalore to involve General Practitioners in Mental Health (Isaac 1986).
This is one of the oldest model programs of integration of mental health with general
health in India. since 32 years the CMHC is involved in providing services to mentally
and physically ill people as well as conducting training programs for Para professional
and non professionals. This unit simultaneously launched the following experimental
programs.
Primary health centre (PHC) - based rural mental health program:
The mental health-training program was carried out in Anekal primary

health centre of Bangalore rural district. Eleven multipurpose workers (MPWs), both
male and female and two medical officers were trained.

The objectives of the training for MPWs were:
l Detect all cases of severe mental illness, severe mental retardation and fits in
their respective areas of work.
l Refer these cases to the PHC doctor.
l Follow up these cases once the doctor has started them on appropriate treatment.
l Educate the family and community in taking care of these cases
l Attend the psychiatric emergencies and give them first aid.
The PHC doctors were trained to;
l Diagnose and manage typical cases of epilepsy, mental retardation with
associated problems and psychiatric emergencies referred to them by the
MPWs.
l Refer cases, which they cannot manage to the district level psychiatrist for
further management and receive these cases back, if referred back.
l Supervise the MPWs in the follow up of all detected cases.
The training was completed in 15 weekly sessions of 2 hours each, 13 of which were
for the pre training and post training assessment. For the training program, a manual
was prepared to train the multipurpose workers to recognize cases of severe mental
illness and to follow them up under the leadership of a PHC doctor. Another manual
was prepared to train the PHC doctors to diagnose cases of severe mental disorders
and to treat patients. Experiments showed that after 15 days of training, the PHC
personnel helped them to carry out the given task in a satisfactory way (Isaac et al,
1982). Followed by the successful implementation of the training program similar
training programs were carried out in different parts of the state and country. Some
of the training programs are still ongoing.
General practitioner (GP) based urban mental health program:
For this, a manual was prepared to teach the GPs methods of treating common
mental disorders. Research showed that this also could be satisfactorily accomplished
(Shamsundar et al, 1978).
Training of traditional Healers.
Large number of patients and families seek the help of traditional healers
before they visit a mental heath centre .so traditional healers were sensitized about
the various mental health problems and the need for the referral if the patients have
major mental illnesses (Isaac 1992).
Training of lay volunteers in mental health work

Training of lay volunteers in mental health work carried out in Bangalore,
which led to the starting of a counseling service, by voluntary organization (Kapur,
1986 ).This consisted of lectures on counseling and mental health and minor and
major mental heath problems. They were also trained in simple skills of interviewing,
case taking and counseling with case demonstrations.
Involvement of ICDS Personnel in Child Mental Health Care
NIMHANS has initiated training of Aganwadi workers in basic mental health

care. The objectives of training were to sensitize them on the aspects of psychological,
social and motor development of normal child and to equip them with the knowledge
to identify, refer, and follow up children with mental retardation (Varma, 1985).
There are also manuals developed on mental health for Aganwadi workers and simple
assessment schedules with vignettes that could be used by other centers. These initial
efforts at involving the ICDS personnel for mental health care of the preschool children
have raised possibilities of extending care to the vast population in a feasible manner.
School mental health program
In this program, schoolteachers were trained to diagnose children with

emotional problems and counsel them. The primary school teachers were trained in
identifying mental retardation and other childhood disorders so that they could refer
the children to the nearby mental health centre. It was evaluated with satisfactory
results (Kapur & Cariapa, 1978). The second phase aims at training the teachers in
the management of cases, which do not require referral to a specialist can be handled
effectively at the school. The model demonstrated that teachers could play the role
of counselors. NIMHANS still undertake training of teachers in counseling skills.
Community participation in mental health through village leaders
The psychiatric social workers of the community mental health unit of

NIMHANS identified the village leaders during their field visits (Isaac, 1986). Thirty
leaders from 10 villages were oriented about on scientific information on mental
health and services of NIMHANS. Along with the discussions, audiovisual aids were
also utilized and the participants were provided with materials for day today
references. Later they undertook the activities that consisted of sharing their
knowledge with other villagers, identification of the needy patients and referring
them to centre, discussion with family members, organization of health education
meetings and their continued contact with agencies for consultation.
Home-based follow-ups of psychiatric patients
Started in 1980s, multidisciplinary team make home visits and provide drugs/
counseling and crisis intervention. The home treatment gives a better clinical out
come, better social functioning of the patient and greatly reduces the burden on the
patient's families. Researches showed that relapse rate is almost nil after two years
of follow up (Pai & Kapur, 1983).

Psychiatric camps
Psychiatric camps were organized taking into account the difficulty of

reaching patients to distant hospitals, cost of travel and so on. The monthly
neuropsychiatry camps started in June 1981 in NIMHANS with the participation of
government and non-governmental organizations and local people. Along with the
services by the multidisciplinary team, training would be given to the local doctors
to enable them manage the psychiatry cases in the community. Simple case record
and casework performa were designed for quick and efficient record keeping by the
doctors. The initial camp case records were to be filled by the NIMHANS psychiatric
team and the local doctors would fill follow-up. After one-year follow-up by the
NIMHANS team gradually would withdraw with the hope that the local doctors
would be able to provide the basic mental health care to the community. If needed,
periodic refresher courses were arranged. Mental health exhibition on mental health
issues were carried out. A hand out was designed in vernacular describing different
types of mental illness, mental retardation epilepsy and treatment modalities for each.
These strategies were described to the local doctors and their consent and co-operation
was obtained. Research showed that the camps were instrumental in involving the
village leaders in the therapeutic process and helped to reduce stigma against mental
patients. When one family was willing to have its sick member treated openly, it
became easier for others to follow (Kapur et al, 1982).
Community based rehabilitation of minor mentally Ill (1999-2001)
With the aim of rehabilitating the minor mentally ill in the community ,
training was given to a group of selected patients attending Sakalwara rural mental
health centre on tailoring, broom stick making, cover making etc. The trained
personnel were later provided with appliances for income generation.
Life skill education program
Adolescent boys and girls who are the future parents need greater degree of
mental health services to develop value based learning and balanced personality.
Teachers training program for balanced development of physical, mental and social
faculties of school going children is essential for healthy life styles. Teachers along
with parents can shape balanced personality. WHO's "Life Skills" educational
curriculum which attempts learning of wide range of skills amongst school children
to improve their psycho-social competency through problem solving, critical thinking,
communication, equity, tolerance, interpersonal skills, empathy and methods to cope
with emotions can be made effective through school teachers and parents ( WHO,
2001). Health promotion using life skills approach for adolescents in schools, module
for secondary school teachers, developed by NIMHANS life skill education group
with the support of WHO-SEARO, New Delhi in the year 2002 .The program started
in a small way in 1995. Since then NIMHANS is actively involved in capacity building
of the trainers from different disciplines.

Disaster mental health programme
Majority of survivors of disaster have multiple psychosocial needs, which

continue for many months. In India, NIMHANS has studied the various psycho social
issues systematically since the Bangalore circus tragedy of 1981 (Narayanan, 2004)
right to the tsunami of 2005. NIMHANS along with Oxfam India, Action Aid and
CARE have developed community based mental health programs in affected
communities in Orissa and Gujarat (Diaz, 2004). There are also ongoing psychosocial
care programs and research in tsunami-affected areas. The other intervention includes
psychosocial assessments, capacity building, support provisions, working with NGOs,
development of models, evaluation exercises and policy implications
National mental health program 1982 (NMHP)
The National Mental Health Program (NMHP) aimed the following objectives,
l To ensure the availability and accessibility of minimum mental heath care for
all in the foreseeable future, particularly to the most vulnerable and under
privileged sections of the population
l To encourage the application of mental health knowledge in general health
care and in social development.
l To promote community participation in the mental health service development
and to stimulate efforts towards self help in the community
From the time of the formulation of NMHP, the following activities have been taken
up by NIMHANS;
l Sensitization and involvement of the state level program officers
l Workshops for voluntary agencies
l Workshops for mental health professionals namely psychiatrists, clinical
psychologists, psychiatric social workers, psychiatric nurses;
l Training program in public mental health for program managers;
l State level workshops for the health directorate personnel;
l Preparation of materials in the form of manuals, health records for different
types of health personnel;
l Training program for the teachers of undergraduate psychiatry
l Preparation of training videos and evaluation tools.(Murthy, 2000)
District Mental Health Program (DMHP)

District mental health program envisages implementing the aims and
objectives of the National Mental Health Program .The program is based on the
district mental health program of NIMHANS Bangalore in Bellary district of
Karnataka with suitable modifications. The objectives of the ongoing program are
l A decentralized training program for the existing health personnel on essentials

of mental health care at the district level
l Provision of mental health care in all general health facilities
l Involvement of all categories of health and welfare personnel in mental health
care
l Provision of essential psychiatric drugs at all health facilities
l A simple record keeping; mechanism to monitor the work of primary health
care
l A mental health team at the district level consisting of psychiatrists, psychiatric
social workers, psychologists and psychic nurses for training, referral support
and supervision of the mental health program (Murthy ,2000)
NIMHANS is the nodal agency for implementing the program in the country.
DMHP extended to of to 25 centers around the country with central funding during
the 9th Five Year Plan13. Currently, during the 10th Plan period, the goal is to cover
100 districts with about 150 million population (Khandelwal, 2004).In the 11th five
year plan it has been decided to implement district mental health program through
out the country.
Neuropsychiatry extension services

Started in 1981, currently NIMHANS has five neuropsychiatry extension
clinics in and around Bangalore. The clinics are in Gunjur (25km), Madhugiri (115km),
Maddur (75km), Kanakapura (50km) and Gowribidanur (75km ).
The following are the objectives of the neuropsychiatry extension clinics
l Availability of service
l Accessibility of Service
l Affordability of Service
l Community participation
l Integration of Mental health into Primary Health Care
The neuropsychiatry camps are conducted every Thursdays and Saturdays.

The follow up is done after one month. A team consisting of psychiatrists, psychiatric
social workers and psychiatric nurses provide mental health care to the community
people. The camps are conducted in taluk general hospitals or PHCs with community
participation. Whenever necessary the NGOs and local doctors working in the
particular community support the team. On an average 300 patients, attend the monthly
camps. Treatment is provided to both children and adults with psychosis, neurosis,
epilepsy, childhood disorders and substance abuse. All the patients have to maintain
files and medication will be given free of cost to those who are fro below poverty
line. The follow up rate and family participation is excellent and relapse rate is
minimal because of the accessibility of services.
Neuropsychiatry extension services provided by the psychiatric social workers

Psychiatric social workers along with the multi disciplinary team members provide
the following services:
l Brief intake
l Psychosocial assessment
l Psycho education
l Case work and group work intervention
l Networking with NGOs
l Supportive therapy
l Referral
l Mobilization of resources
l Marriage and Family Counseling
l Family intervention
l Making social welfare measures available
l Brief cognitive behavior therapy for depressed and neurotic patients
Rural mental health services
Rural Mental health Center at Sakalwara started in 1976. This is the first
model program for integration of mental health with primary health. Here out patient
care is given to patients with physical health as well as mental health problems.
Everyday 50 to 60 patients avail the services of the centre. Team includes trained
general duty medical officer (GDMO) in psychiatry, psychiatric social worker, Clinical
Psychologists and psychiatric nurses. The team also conducts regular home visits for
the chronic patients.
Satellite clinic
NIMHANS has one clinic at Anekal which is 22 km away from Sakalwara.

Objective of the clinic is the availability of Services. Mental health team visits the
Anekal taluk hospital on every Tuesday and provides services to 50 -70 mentally ill
per clinic .Every month last Tuesday being the epilepsy clinic, more than 500 patients
avail the services of the center
Working with homeless mentally ill people
Homelessness remains a persistent public mental health problem. India being

an under developed country, there are various reasons for homelessness. However,
the researches show a close association between homelessness and mental illness.
Lack of mental health facilities also contributes to the severity of the problem.
NIMHANS mental health team visit the government rehabilitation center for the
homeless people (relief and rehabilitation centre) twice a month and provide mental
health support to the mentally ill. NIMHANS is also involved in rehabilitation of the
inmates and training of the non-medical and medical staff of the center

Working with mentally retarded children and families
Mental retardation can cause severe impact on the life of parents and the
family members .usually parents are known to pass trough different stages of stress
reaction, which adversely affect their physical as well as mental health. Therefore,
the role of the mental health professionals in working with mentally retarded children,
parents and teachers is very important .NIMHANS community mental health team
aims to develop a mental health care model by working with such children, parents
and teachers. The weekly intervention includes assessment of mental retardation,
parental psycho education and training, supportive therapy, behavior modification
and assisting in availing the social welfare benefits. Another important intervention
is parental support group. All the parents participate in monthly group meetings,
share their concerns, and get solutions from other parents. It is found that the sharing
reduces the distress of the parents largely.
Support to voluntary organizations
Government or Public Mental Services is just one resource for mental health
services, Private sector and Non-Governmental Organizations act as diverse health
care providers. Voluntary organizations are more sensitive to the local realities and
committed to innovation and change. Voluntary organizations can play an important
role in developing suicide prevention, and crisis support, formulation of self-help
groups of families, organizing community based income generation activities, for
mentally ill persons and their families, setting up of day care centers, sheltered
employment facilities, life skill education programs and public mental health
education. The community mental health unit provides various consultation services
with the objectives of imparting professional input when necessary to NGOs working
with the mentally ill persons, mentally retarded children, homeless mentally ill
persons, disaster mental health, HIV affected persons, street children and adolescents
and children.
Teaching and training
Training is essential to impart need based and relevant training on the key
areas of mental health and related fields. The community mental health unit is actively
in the teaching and training of the following students;
l M.Phil in Psychiatric Social Work
l M Phil in Clinical Psychology
l M.Sc and Diploma in Psychiatric Nursing
l MD in Psychiatry
l Diploma in Psychological Medicine
l Placement Students of Social Work, Psychology, Psychiatry,
l Psychiatric Nursing
l Central/State Govt. Deputed Candidates
l WHO deputed Candidates
l School & College Teachers
l Lay Volunteers
l Volunteers in Disaster Management
l Primary Care Physicians/GPs
l Health Workers
The training is conducted by using manuals, flip charts video reviews

developed by the NIMHANS community mental health care unit. The methodologies
used are group discussions workshops didactic lectures field visits/agency visits and
case demonstrations.
Research activities of the unit
Indian Council of Medical Research (ICMR) has been in the forefront of

mental health research and constantly supporting the research initiatives of the
community mental health unit NIMHANS. Many of the trainees who participated in
the community mental health training programs initiated their own community mental
health projects. These initiatives demonstrated both the need for research support to
the developing NMHP (formulated in 1982) as well as the willingness of professionals
to work as teams (Murthy, 2007). The ICMR also supported research into the mental
health aspects of disasters like the Bhopal Disaster in the 1980s, the Marathwada
earthquake in the 1990s and the most recently Gujarat earthquake . It is largely the
result of these efforts that following any disaster in India, psychosocial support is
readily provided to the survivors along with other services. The unit is actively
involved in epidemiological, experimental, evaluative and service delivery research
on various community mental health related issues. All these researches demonstrated
how research support could help develop mental health services and models of care.
Role of Psychiatric Social Workers (PSWs) in community mental health settings
Socio cultural factors shape a patient's ability to cope and adjust and
biomedical model is not adequate for treating mentally ill patients. Thus, psychiatric
social workers (PSWs) have a major role in community mental health services. The
role of PSW in the multidisciplinary team in community mental health service can
be broadly classified in two levels namely, micro and macro.
The micro level interventions include working with individuals, groups and
families. The individual interventions include brief psychosocial assessment, brief
therapies and placement services. The psychosocial assessments and interventions
help to diagnose expand the management scope from the individual to family and
societal levels. There is also lot of scope for the group work methods in community
settings. The PSWs are involved in group psychotherapy and group psycho education
programs for the mentally and neurologically ill patients and families. At the family
level, PSWs provide family psycho education and family counseling and family
therapies. PSWs also provide information on disability benefits to the mentally ill
and mentally retarded people and help them to get them to get those benefits. At the
macro level, the PSWS performs the roles of trainer, consultant, case manager,
advocate, resource mobilizer organizer, administrator, collaborator, activist and
researcher. Through the provision of tangible services, resources mobilization and
psychosocial intervention at the individual family and societal level, PSWs help
mentally ill people and their families achieve optimum social functioning.

Chapter 15
REHABILITATION OF PERSONS WITH NEUROLOGICAL AND
MENTAL DISORDERS
Prakashi Rajaram,1 & K. S. Meena,2
Introduction
Mental, neurological and social health problems are an increasing part of

the heath problems the world over. The World Health Organization [WHO] has
declared 2001 as the year for mental health recognition of the burden that mental and
brain disorders pose on people and families affected by them. Neurological,
Psychiatric, and Developmental disorders-account for a significant proportion of the
global burden of disease. Growing recognition of the prevalence of brain disorders,
as well as the availability of cost-effective treatments, may now lead to the adoption
of measures designed to achieve significant reductions in the disease burden due to
these disorders. Neurological disorders encompass a wide range of disabling
conditions, including epilepsy, stroke and degenerative disorders as the most common
and severe. It is estimated that currently 1.5 billion people worldwide are affected by
the disorders of the brain- a number that is expected to grow as life expectancy
increases.
Most of the disorders result in long-term disability and many have an early
age of onset; measures of prevalence and mortality vastly understate the disability
they cause. Social isolation and stigma is often added to the medical and financial
burden borne by patients and their families.
Stroke and its associated disability are increasing in developing countries

where the disorder is projected to become the fifth leading condition contributing to
the disease burden by 2020. Because of the high risk of death, long-term disability,
and recurrence after a stroke, prevention is the key in reducing the public health
impact of Cerebro-vascular disease.Epilepsy, on the other hand, affects an estimated
40 million people in developing countries roughly 85% of the total number affected
worldwide. This disorder commonly affects young adults in the most productive
years of their lives. It is the cause frequently leading to their being unemployed.
Children are also commonly affected.
Impact of Neurological and Psychiatric disorders

Neurological and Psychiatric Disorders results in physiological,
neuropsychological, social and psychological [emotional] complications in the persons
affected. The physical, neuropsychological, and psychological/emotional problems
trigger a chain of difficulties for the persons affected in participating effectively in
their social and familial contexts.
1. Assistant Professor 2. Ph. D Scholar

The person experiences various interpersonal, familial, occupational and
social problems due to these complications.
Physical Impact
The Persons affected with neurological disorders such as stroke and spinal
cord injuries suffer from various physical/physiological complications, which include
decreased or no power in extremities, seizures, respiratory complications, balance
difficulties, abnormal sleep patterns, lethargy and giddiness as well as episodes of
disorientation, to name a few.Similarly, persons affected with psychiatric disorders
like Schizophrenia and Depression suffer from delusions, hallucinations, sadness of
mood, disorientation to time, place and person, thought disturbances, anxiety
disturbances and memory impairments and so on.
Neuropsychological impact
The neuropsychological difficulties experienced by the persons affected are

tremendous. They include a decline in capacity for attention and concentration, poor
encoding, memory retrieving, impaired judgment and perception, lack of initiation
and planning and trouble expressing thoughts and difficulties in communication.
Psychological and emotional impact
The psychological and emotional upheaval that people affected with

neurological or psychiatric disorders undergo is tremendous. While the psychological
factors associated with the particular disorder have a direct effect on the prognosis,
some people find it difficult to accept the fact that one is diagnosed with a chronic
illness that may leas to a lifelong disability. Emotional disturbances appear to increase
with duration of disability following the onset of illness. [Levin and Eisenberg, 1987]
Some people may experience fear, anxiety and nightmares, usually of life threatening
experiences, whereas lack of ambition, loss of interest in any pleasurable activities,
depression and irritability are also commonly observed reactions.
Personality change is commonly seen or observed following the onset of

illness. The personality changes observed following onset of illness are characterized
by reduced frustration tolerance, increased regression and dependence, depression,
somatization, denial, lack of initiation, and extreme withdrawal.
Impact on psychosocial functioning

Neurological and Psychiatric disorders and its consequences have an
encompassing and disabling impact on the psychosocial functioning of the persons
affected. It may range from having trouble on the job or in the school to unemployment
or underemployment. There will also be difficulty with regard to maintaining
friendships and a decrease in participation in any socio-recreational activities. This
might lead to poor social support and peer group relationships.
As a result of the illness, the person may have to face stigma and
discrimination in his work place, school as well in the society. Even family and
relatives might shun him out. Marital strains, personal loss of control/incapacity in a
productive age and life style changes are also common. Feelings of embarrassment,
shame and humiliation may keep the patient away from the ordinary activities he
was indulging in before the onset of the illness. Another important impact of a severely,
or even moderately disabling illness is the role reversals if one spouse is disabled,
and has to leave his previous job. For example, if a male member who has been the
breadwinner of the family is affected with spinal cord injury rendering him
permanently disabled, then his wife who has been a housewife and unemployed may
have to seek a job due to financial constraints.
Impact on the family
Families are an integral part of the care system for persons affected with
chronic and debilitating illnesses. The caregivers of neurological and psychiatric
disorders are exposed to high levels of burden and distress. The five components of
family structure like cohesion, family values, communication, organization and
relationships with the society [Sachs1991] change radically after the onset of illness.
The cohesiveness of the family maybe disrupted often because the needs of the person
affected will take the first priority and the common rituals and jobs that bring the
family together as a unit might be disturbed.
Families as caregivers experience a feeling of loss and grief. They are

confronted with uncertainty and emotions of shame, anger and guilt. Like the patient,
they feel stigmatized and socially isolated [Wahl and Harman, 1989]. Their lives
may be disrupted by providing more care than would normally be. The addition of
the care giving role to the already existing family roles may become stressful, both
psychologically and economically [Schene et al, 1996]. Family members experience
a loss of value or a sense of demoralization. They may withdraw from their contacts
with other people and with the society.
Disability due to Neurological and Psychiatric disorders
The World Health Organization [WHO, 1980] International Classification

of Impairments, Disabilities and Handicaps define various concepts that underlie
disability as follows: Disease-Impairment-Disability-Handicap.
Impairment is defined as any loss or abnormality of physiological,

psychological or anatomical structure or function.
Disability (resulting from an impairment) is defined as any restriction or

lack of ability to perform an activity in a manner or within the range considered
normal for a human being. Disability reduction primarily depends on the qualitative
intervention of medication and allied therapeutic interventions as well as psychosocial
therapeutic inputs.
Disability is a limitation in performing socially defined roles and tasks

expected of an individual within a socio-cultural and physical environment of the
person affected. These roles and tasks are organized in spheres of life activities such
as those of the family or other interpersonal relations; work, employment, and other
economic pursuits; and education, recreation, and self-care. Not all impairments or
functional limitations precipitate disability, and similar patterns of disability may
result from different types of impairments and limitations in function.
The nature of the illness and its course and prognosis, and the time at which
the intervention has been sought explains the disability levels of the person affected.
A person affected with stroke, with acute onset, who is brought immediately to the
hospital and treatment has been initiated will have physical complications in spite of
this, because of the nature of the illness and may have high disability levels.
Same with a Person affected with Schizophrenia, who has had a insidious
onset, and the family has not been aware of it, will bring the patient to the hospital
when he is symptomatic and owing to the nature and course of the illness will have
high levels of disability. Disability affects 75% of neurological and psychiatric
survivors. They can affect patients physically, mentally, emotionally, or a combination
of the three. [Anderson.R,1987].
Some of the most commonly applied dimensions affected in Neurological and

Psychiatric disorders are:
Activities of daily living (ADL)--including behaviors such as basic mobility and

personal care
Instrumental activities of daily living (IADL)--including activities such as preparing

meals, doing housework, managing finances, using the telephone, and shopping.
Paid and unpaid role activities--including performing one's occupation, parenting,

grand parenting, and being a student.
Social activities--including attending religious rituals and other group activities and
socializing with friends and relatives.
Leisure activities--including participating in sport and physical recreation, reading,

or taking distant trips.

A handicap is a disadvantage for a given individual, resulting from impairment
or a disability that limits or prevents the fulfillment of a role that is normal (depending
on age, sex, and social and cultural factors) for that individual. (WHO, 1980]. The
focus of handicap is the person in the society in which he or she lives and reflects
cultural norms and expectations for performance. Unemployment will be a handicap
for a person suffering from Schizophrenia owing to Social stigma and Isolation.The
clinical diagnosis has paved way to formulate rehabilitation plans, primarily based
on disabilities that are left with the client, which are enforced, on them by the disease
process.
What is rehabilitation?
Rehabilitation is initiated when the person affected with Neurological and

psychiatric disorders are not able to fully recover from the treatment process, and the
person had high levels of disability owing to the nature of the illness. Some persons
affected may have resistant to treatment and then the professionals will have to try to
array of other treatment options for helping the person to recover to his maximum
potentials.
Rehabilitation is defined as the process of helping a physically or

psychiatrically disabled person to make the best use of his residual abilities in order
to function at an optimum level in as normal a social context as possible. [Wig 1963].
Recent advances in diagnosis and therapeutics have resulted in better survival and
coping among patients with Neurological and psychiatric disorders
The rehabilitation process:
l Identifying the clients abilities

l Identifying the issues and limitations
l Describing the problems in terms of impairment, disability, handicap and
dependency, and
l Describing the problem, i.e. the functional domains. The rehabilitation process
should include rehabilitation planning with aims, goals, and contracts. This
includes short-term goals and goal-directed therapy. During the rehabilitation
process, regular progress of the clients should be monitored with follow-up
and standardized outcome
Multidisciplinary team approach
It is important to improve the communication between individuals involved

in management. Sharing knowledge between individuals of different disciplines would
improve the efficiency of treatment of patient, and, thus a more consistent goal-
oriented approach and better continuity of care for patients can be achieved.

The medical rehab team consists of the rehabilitative neurologist/psychiatrist,
psychiatric and medical social worker, clinical psychologist, speech therapist,
occupational therapist, dietician, and a nursing professional. The multidisciplinary
team consisting of professionals from different disciplines meets regularly. There is
allocation, by each member, of a significant proportion of his/her time, to the pursuit
of a team's objective. There is also agreement on explicit objectives for the team,
which determine the team's structure and function.
NIMHANS is the first institute in the country to introduce the

multidisciplinary team approach for optimal recovery of the persons affected with
neurological and psychiatric disorders by involving professionals from other
disciplines. The multidisciplinary team at Department of Psychiatric and Neurological
Rehabilitation, NIMHANS follow the Medical model as well as the psychosocial
model in treating persons affected with neurological, neurosurgical and psychiatric
disorders.
Role of Psychiatric Social Worker
The psychiatric social work practice aims at psychosocial management of

human problems and the improvement of psychosocial functioning of the individual.
A number of activities are geared towards the achievement of this aim. The main aim
of a Psychiatric Social Worker is restoration of impaired capacities, provision of
individual and social resources, and prevention of social dysfunction. A detail
assessment is important for gathering vital information about the person affected
and their caregivers for providing total rehabilitation by using eclectic approach.
Assessment carried out by the Psychiatric Social Worker
A socio-demographic profile of the person affected and of their caregivers
Brief clinical history that focuses on onset of illness, symptoms, severity, causal
factors and diagnosis, course of the illness and prognosis;
Family assessment that comprises of knowing about the person affected and his
interactions and relationship with other member of the family;
The focus will be on gathering information on interaction patterns,

understanding or exploring family dynamics like boundaries, subsystems,
developmental stages, role functioning, communication styles, cohesiveness, support
systems. Rating Scales are used to understand the disability levels of the persons
affected with the illness [WHO-DAS], Needs [Camberwells Assessment of Needs],
and Burden [Family Burden Schedule]

Once the assessment is done, interventions for psychosocial rehabilitation are planned
and are implemented at individual, family and community levels.
Psycho-education
The goal is to establish a collaborative partnership with families who suffer

from mental and neurological disorders, providing them with the kind of information
and skills most needed. It includes an eclectic mix of intervention derived from
individual and family therapy that have particular relevance to the particular syndrome,
as well as psychopharmacological interventions. It aims to impart information,
increase the sense of social support, and reverse the negative interaction. Expresses
emotions, behavioral skills training and crisis management aspects area also dealt.
Families are considered as partners in care.
Social Skills training and Independent living skills training
Social skills may be viewed as the coping process by which social competence
is achieved. In order to be highly effective, social skills training is designed to carry
out in the following fashion:
l The therapist translates the patient's obvious presenting symptoms and problems
into deficits of socially appropriate behavior.
l After the evaluation of the patient, the therapist notes down the strengths and
capabilities in social relations; e.g. does the person know how to meet people?
l The therapist then will engage the patient and the caregivers in a warm, mutually
respectful relationship. A therapeutic alliance is earned.
Social skills training involves the following:
Goal setting: Setting up specific and concrete interpersonal goals is the challenging
step in the procedure.
Behavioral rehearsal: Much of the training of social skills takes place in simulated
situations, through role-playing, the patient's real life experiences. Scenes related to
the patient's goals are practiced or rehearsed.
Positive reinforcement: All steps along the way, from showing interest in
participating in social skills training to completing homework assignments are met
with positive feedback by the therapist.
Shaping: Shaping involves building complex sequences and chains of social behavior
and successively reinforcing small steps along the way. The therapist breaks down
long term goals into small steps and helps the client accomplish them.

Prompting: Prompting requires the therapist to use elements of speech or phrases
and to employ effective non-verbal behaviors in teaching social skills.
Modeling: The therapist will have to demonstrate a particular skill for the client to
improve.
Vocational training for psychological preparedness and skills required to acquire

employment is an important area in rehabilitation.
l The psychiatric social worker will have to do a work skills assessment of the
client, which includes evaluation of both the premorbid and the current
vocational skills available to the client.
l The therapist will then assess the client's adjustment to work, handle equipment.
Or get along with co-workers.
l The therapist then trains the client in a specific job or skill, and gradually in a
systematic manner, the client is placed in a agency by informing the agency
about the client's needs, his illness and his caregivers.
Models in Psychosocial Rehabilitation
The models, used at Department of Psychiatric and Neurological

Rehabilitation, NIMHANS are:
1.Intensive case management approach

This approach offers an interdisciplinary model that integrates
pharmacotherapy, social skills training, and family involvement. This evidence-based
plan of care is cost-effective and offers opportunities to facilitate symptom
management, facilitate self-efficacy, and improve communication and social skills.
2. Psycho-educational model
Studies have established the value of the psycho-educational model in the
prevention of relapse. So, this model is used to elicit the cooperation and collaboration
of the family by teaching them to understand the illness better and to respond to its
manifestations more appropriately.
Case Vignette 1
Ms. Y was a 26 year old female, educated up to BA, married for the past one
year, and separated, from middle socio economic status, semi rural background was
referred to Psychiatric rehabilitation unit rehabilitation unit, NIMHANS for
appropriate psychosocial intervention by the parent unit. The parent unit made a
diagnosis of Paranoid Schizophrenia, with one-year onset.

As mentioned earlier, a psychosocial assessment at individual and family
level was elicited in detail with regard to the onset of illness, causal factors, burden
of care, and family dynamics after the onset of illness and needs of the client and
caregivers were looked into. Individual assessment revealed that the client was dull,
withdrawn, and was found laughing and talking to self, for the past one and half
years. She was shown to a consultation psychiatrist, and was diagnosed as having
Paranoid schizophrenia. Her marriage was arranged, but after the marriage, her spouse
and family came to know that the client was unwell, and they have been separated
and applied for divorce. Her illness worsened after the initiation of divorce
proceedings. Premorbidly, the client was shy and introvert in nature, had few friends,
and was basically a loner by nature.
Family assessment revealed that client's father was very dominating and
authoritative by nature, and mother was submissive. Marital discord among the parents
was present. Burden was present among the parents, as they had to take care of the
client's siblings who were mentally retarded. Looking at the above issues, the
psychiatric social worker planned a detail intervention at the individual and family
level.
Individual therapy with the client

The psychiatric social worker established rapport with the client who was
an inpatient at the hospital, and explained the need for therapy sessions regularly.
The client's strengths were explored and based on that, specific interventions were
planned.
1. It was noticed that client tend to be withdrawn and was withdrawn most of the
time, and did not initiate any conversation. She was a graduate and was not
working. The psychiatric social worker planned a detail activity scheduling
and allotted small tasks for the client. The client through social skills training
was thought to talk to people, made to rehearse periodically, answer phone
calls and take down notes and messages. Initially, it was difficult for the client
as she was introvert by nature, buts she slowly started developing interest in
the work, as her main interest laid in working as a receptionist or office staff.
Slowly, the work was graded and the client was made to do complex work like
accounting and writing down topics. She enjoyed the work, and was very regular
and committed.
2. Along with activity scheduling, the client was given homework assignments
to carry back to the ward, and bring it back next day. Specific time was allotted
for her reading to develop the habit, and the ADL was guided..
3. Along with the activity scheduling, it was also planned by psychiatric social
worker to have therapy sessions for the client. The client was educated about
schizophrenia, symptoms, regularity of taking medications and course of illness.
The client developed a fairly good insight about her illness, and was motivated
to adhere to the medication.
4. The psychiatric social worker kept regular touch with the parent unit and briefed
them in regular intervals about the sessions. As client and her parents were
from a different place, the therapist contacted the school of social work in that
place, networked with the faculty there, and client was placed in the library
section for training and job placement.
Family therapy with the caregivers
The family plays a crucial role in rehabilitation of clients with severe mental
illness, and it was no less in client's family too. Client's parents were asked to come
for sessions as it was felt by the psychiatric social worker that there was a need for
the overall development of the client. In individual sessions, it was seen that client
was very fearful of her father like her mother, and would not initiate any conversation
with him.
Sessions focusing on the marital discord among client's parents were looked
into. It was seen through sessions that marital bonding was very weak from the time
of marriage. The parents were overtly not interested in communicating with each
other, but had minimal conversation with regard to the children's needs. The parents
were explained about the nature of the illness to the caregivers and need for parents
to function as a unit. The father's hostile and overprotective behavior was discussed
with him and need for client and other siblings to take their own decisions, and he
playing partial part was explained to him. The parents were ready to undergo changes
for the client's behalf and took up initiatives. Need for regular medications, family
functioning as a single unit was explained by the psychiatric social worker. The
psychiatric social worker counselled the family to follow up regularly and was satisfied
with the progress the family had made. The family was slowly becoming one unit,
and the client was enjoying the work at the library and her sessions with the therapist
there.
Case Vignette 2
Mr. X a 32 year old male, educated up to 4th standard, married with two
children, from low socio economic status, semi rural background presented to Neuro-
rehabilitation unit, NIMHANS, with loss of weakness in the lower limbs, urinary
incontinence, fever after sustaining a fall from a coconut tree, 3 months back. A
diagnosis of Traumatic paraplegia with Permanent Disability was made. Client was
referred to Psychiatric social worker for psychosocial intervention.
A psychosocial assessment was elicited in detail with regard to the onset of

illness, causal factors, burden of care, perceived social support from family members
and friends after the onset of illness and needs of the client and caregivers were
looked into. The client was evaluated on the WHO-DAS, Family Burden and
Camberwell's Assessment of Needs.The client was found to have 40% and above
disability, high family burden, in terms of financial and psychological burden, poor
social support and need for financial assistance and supportive therapy after the
onset of illness.
Family details revealed that the patient's spouse was working as a domestic
laborer in the village and was making two ends meet, but after her husband's illness,
had stopped working and was taking care of him.The medical team revealed that as
patient had sustained a fall from a height of 20 feet and above, the chances of regaining
power in the legs were bleak and mobility doubtful, and reported permanent disability
and need for wheelchair for mobility.
Need for psychiatric social work interventions
The client and caregivers were in a:

Helpless state of intense insecurity and confusion leading to non-acceptance of illness
Fear of rejection and desertion by spouse
Anxiety on the recovery process
Marital and family life adjustment
Concerns over unemployable status and financial strains
Social security benefits
Interventions carried out by the psychiatric social worker
Through detailed sessions, the psychiatric social worker elicited illness

history, degree of disabilities; support systems, family dynamics and needs of the
patients, and the need for the following therapeutic interventions were derived at:
1.Psychoeducation at individual level
In discussion with the treatment team, it was assessed looking at the severity
of the trauma, that client was going to be permanently disabled. The client was
undergoing a lot of distress and anxiety. Looking at the personality profile of the
patient, and identifying his hardiness as a positive outlook, the therapist broke the
bad news stage by stage and session by session, about the client being permanently
disabled and the reasons for it. Initially, the client went into stages of denial and non-
acceptance of illness, but with continued education and support, and explaining about
the nature of illness, causal factors and the need to use wheelchair for mobility, the
client gradually accepted his condition over 5-6 sessions. The client was followed
up frequently and supportive therapy extended to him.
2.Family intervention
The spouse of the client was the main caregiver. After the onset of illness,
the couple had noticed poor support from other family members and friends. The
therapist found the spouse to be very accommodating, adjusting and a willingness to
be partner in care for her husband's treatment. The therapist gradually prepared the
spouse in accepting her husband's physical condition and permanent disability over
a few sessions as the spouse was devastated on hearing that. The severity of the
accident and the after effects were explained to her in detail. As the sessions
progressed, the spouse was able to come into terms with the reality and face them
effectively.
The therapist had to offer individual therapy to the spouse as she reported
certain problem behaviors like irritability, demanding behavior, ill temper, depressive
features and confusion on the client's part. Through conjoint sessions and using the
technique of education, the therapist was able to decrease the problem behaviors.
E.g. it was explained to the client's spouse that Fatigue combined with cognitive or
sensory deficits might contribute to irritability and other causes like toxicity due to
drugs or electrolyte.
Sex education is a sensitive area in the context of Persons with Disabilities.

Many hesitate to seek professional help on this intimate aspect, when one spouse is
disabled. The same was noticed in this couple, as they were in the young adult age
group. The role of the therapist was mainly to avoid being non judgmental or
disrespectful, be aware of and sensitive to cultural and social values. The therapist
had to talk about sexual matters, dysfunctions, positioning using words that the client
and his spouse realized the alternatives. The therapist held marital sessions with the
client and spouse. Though the couple did not have problems amounting to marital
discord, the illness of the client and the frustration in not able to overcome led to
irritability and anger outbursts by the client towards the spouse which led to the
spouse having a feeling of depression about it. The couple was made to understand
the reason for the strains occurring between them, and identifying the resilient factors
like mutual trust, support, hardiness between them, the therapist could minimize the
strains occurring to a large extent.
The therapist in discussion with local women groups and donors could garner
financial support to the client and his spouse. The spouse was given financial aid by
the Women's group in staring a petty shop like a teashop in their village and a donor
came forward in providing financial aid by donating a quality wheelchair to the
client for enhancing his mobility and quality of life. The client and his spouse
participated in the group therapy sessions, with other clients suffering from similar
disorders. The therapist facilitated the group members by talking about their problems
pertaining to the disorders, and its effects on their body [problems with various parts
of the body, sensations],mind[fear, sadness, dissatisfaction with present life and
situation, a feeling of isolation, guilt among family members], occupation[ losing
the job, inability to perform the same job, alternate employment], financial conditions[
loans taken for treatment, ongoing expenses], family life[not being able to reach out
to the expectations of the life partner, marital strains, separation, irritability and
anger outbursts leading to friction] and interpersonal relationships among other
members[loosing friends and other support systems, non acceptance]
Evaluating the group sessions and the problems faced by the clients and
their caregivers, the following remedies were offered to the group:
l Discussing the illness/disorders faced by the clients, and providing information

and practical help.
l Giving support and reassurance.
l Evaluating and emphasizing on the positive coping strategies, like taking other's
help when unable to solve by yourself, acknowledge, accept, and compromise
with what has happened, rationally find out the cause of the problems and take
positive actions based on the understanding of the problems.
l Anger management techniques like engaging in alternative activities like
drinking water, taking a stroll, telling the reason for getting angry, distraction
techniques like reading aloud or hearing music, mental counting and then
analyzing themselves of the feelings.
l As client had 40% and above disability, need for disability benefits were
explained to the family, and the means of procuring the disability benefits was
initiated for the client, in need for monthly pension, bus and railway
concessions, loan facilities etc.
l Vocational assessment was carried out, and vocational counseling was provided
for the client. Employment opportunities like starting a STD booth or helping
the wife at the petty shop was suggested
At the termination of the sessions, the couple opined that the nature of
interventions carried out by the PSW had minimized the severity of the impact of
the illness to a large extent, and had strengthened the couple in facing the challenges
ahead with determination.
Future of rehabilitation
Rehabilitation by its very nature is multidisciplinary because of the many
competencies required for its implementation in promoting optimal levels of recovery
from neurological and other disabling mental disorders. Teams must combine the
expert contributions of professionals and paraprofessionals who can individualize a
comprehensive array of evidence-based services with competency, consistency,
continuity, coordination and collaboration. The overarching goal of rehabilitation is
to promote the highest possible levels of social and vocational functioning and well
being for individuals with severe and persistent neurological and mental disorders,
so that they may enjoy optimal levels of independence from professional supervision
and the least interference from symptoms, social problems and neuro-cognitive
impairments.

As advances accrue in our understanding of the potential for recovery from
severe mental illness and neurological disorders, rehabilitation practitioners and their
teams will have to obtain a broader array of competencies. New modalities are in
various stages of development. They include cognitive-behavioral therapy for
refractory psychotic symptoms; naturalistic augmentation of skills training; neuro-
cognitive, psychopharmacology, cognitive adaptive training and errorless learning,
which are aimed at compensating for neuro-cognitive deficits that interfere with
rehabilitation; precision teaching, computerized instruction, and use of the Internet
for skills training; greater use of telecommunications and electronic communication
for prompting, reinforcing, and problem solving; cognitive remediation combined
skills training and supported employment; and integrated service agencies. These
innovations will challenge mental health disciplines and allied disciplines to broaden
their professional training, roles, and repertoires or face displacement or even
extinction. Novel rehabilitation technologies, combined with medications, will also
require reconfiguration of multidisciplinary teams in ways that we can hardly
anticipate.
Through the development of evidence-based, comprehensive, coordinated,

and integrated services, most clients with severe and persistent mental illness now
have the opportunity to lead independent, satisfying, and functional lives. Judicious
use of anti-psychotic, mood-stabilizing, anticonvulsants and antidepressant drugs,
combined with social skills training, family psycho-education, and supported
employment, can result in optimal outcomes. These services can be effectively
delivered through systems of care and multidisciplinary teams.
A key element in achieving favorable outcomes is the active involvement of

clients, together with their families and other natural supporters, in the process of
treatment planning, intervention, and evaluation of progress. To motivate clients to
engage in treatment and adhere to comprehensive treatment regimens, the
multidisciplinary team must help them identify personally meaningful goals and
demonstrate that collaborating with treatment providers can help them attain their
goals.
Because treatment and rehabilitation must be individualized, evidence-based

interventions cannot be taken directly from controlled clinical trials and applied to
all clients in the same way. Standardized treatments, both psychosocial and
pharmacological, not only must be tailored to the individual client but also must be
integrated with other services into a coherent package that changes as necessary
with the phase of the disorder and the client's goals as treatment proceeds.

Chapter 16
PSYCHIATRIC SOCIAL WORK INTERVENTION WITH EPILEPSY
Prakashi Rajaram,1 & A. U. Shreedevi,2
Introduction
Neurological disorders are recognized as the disorders of the brain and

nervous system. These disorders are of different origin, e.g., toxic, genetic, metabolic,
vascular, infectious, immunologic or traumatic (Leonard & Ustun, 1997). Most of
the neurological disorders result in long-term disability as many have an early age of
onset, and often measures of prevalence and mortality vastly understate the disability
they cause. The socioeconomic demands of care and treatment put a strain on entire
families, seriously diminishing their productivity and overall quality of life. Social
isolation and stigma often add to the medical and financial burden borne by the
patient and the families. This is more so with a disorder like 'Epilepsy' wherein its
negative psychosocial implications are equal or more than the medical or neurological
complications.
Epilepsy is the most common serious neurological disorder and is one of the
world's most prevalent non-communicable diseases with unique characteristics. The
World Health Organization has defined epilepsy as "a chronic brain disorder of various
etiologies due to excessive discharge of cerebral neurons"(WHO, 1990). Adams
(1993) elaborates this further as "an intermittent derangement of the nervous system
due presumably to a sudden, excessive, disordering discharge of cerebral neurons.
The discharge results in an almost instantaneous disturbance of sensation, loss of
consciousness, impairment of psychic function, convulsive movements or some
combination thereof." An ancient Indian medical system Ayurveda also elaborately
mentions about epilepsy, its nature, cause and treatment. Epilepsy in Ayurveda is
referred to as 'Apasmara'; the prefix 'apa' means negation or loss of, and 'smara'
means consciousness or memory. The definition, etiology of the disease, state of
aura (apasmara poorva roopa), symptoms and treatment of epilepsy in Ayurveda is
more or less similar to the theories of modern medical system. The term epilepsy
does not refer to a specific disease but rather a group of symptom complexes that
have many causes, of which some are static and some are progressive.
Types
In 1969 International League Against Epilepsy has recommended major types
of seizures based on the clinical features of fits and differences in their
pathophysiology as partial seizures, generalized seizures and unclassified epileptic
seizures. In partial seizures a focal or localized onset can be discerned and in
1. Assistant Professor 2. Ph. D Scholar

generalized, the seizures appear to begin bilaterally (Adams & Victor, 1993). However,
commonly seen subtypes in a clinical setting are general tonic clonic seizure, absence
seizures, myoclonic and juvenile myoclonic epilepsy, partial seizures, hot water
epilepsy, refractory epilepsy, reflex seizure, status epilepticus and so on.
The period during which the seizure actually occurs is called the ictus or
ictal period. The time immediately after the seizure is referred to as the post ictal
period. The interval between seizures is the interictal period. The 'aura' is the earliest
portion of a seizure recognized and the only part remembered by the person; it may
act as warning sign. Some signs of aura may appear in the form of flashlight, giddiness,
tingling sensation or headache.
Etiology
Epilepsy is a complex symptom caused by a variety of pathologic process in

the brain. In considering the etiology it is possible to divide cases of epilepsy into
two broad groups namely, idiopathic and symptomatic. Idiopathic epilepsy is not
associated with an identifiable structural cause and there is no evidence of any organic
brain lesion, which is responsible for the attacks. In symptomatic epilepsy, the attacks
are precipitated by organic disease of the brain; whether it is effects of fever (febrile
convulsion), diffuse degenerative brain disease, an infarct, brain infections,
encephalitis or abscess, a cerebral tumor, anoxia, hypoglycemia, stroke, alcohol and
drug abuse or even any drug withdrawal (Walton, 1982). About two third of all causes
of epilepsy are idiopathic, that is, no structural or metabolic cause can be determined
(WHO, 1998).
Epidemiology
Epidemiological studies have assessed the prevalence of epilepsy in numerous

populations throughout the world. Most studies in the United States, Europe and
Asia have reported overall prevalence of 5-9 cases per 1000 persons (Annegers,
2001). Global Burden of Disease 2000 estimates more than 50 million individuals
have epilepsy. It is estimated that more than 80% individuals with epilepsy live in
developing countries (WHO, 1998).
A recent meta-analysis obtained from community-based studies in India puts

the overall prevalence rate of epilepsy at 5.33 per 1000 population. The study further
dissects the prevalence rates for urban/semi urban areas as 5.11 and rural areas 5.47
and in terms of gender distribution, the prevalence rates for men were 5.88 and
women were 5.51 (Sridharan & Murthy, 1999). The community based surveys
representing north, central and south India, have shown prevalence rates per 1000
population as 9.9 for Tamilnadu, 4.6 for Karnataka, 3.6 for the Parsi in Bombay and
2.5 for Kashmir (Mani, et al, 1998). Gourie-Devi et al (1987) found prevalence of
epilepsy to be 248 and 558 per 1 lakh population in semi-urban and rural areas
respectively. The Bangalore Urban-Rural Neuro-epidemiological (BURN) Survey
supported by Indian Council for Medical Research reports a prevalence rate of 8 per
1000 population of active epilepsy constituting one fifth of the global epilepsy
problem. Prevalence of active epilepsy seems to be 2 to 2.5 times higher in the rural
compared to urban population (Sathishchandra, 1999). Among neuro-epidemiological
studies in the country, epilepsy has been identified as the first or second major
condition as per the rank order of individual neurological disorders contributing to
nearly 25% of all neurological disorders (Gururaj, 1999).
Many studies from both developing and developed world show an incidence
of epilepsy in the order of 20-70 per 1,00,000 persons per year (Shorvon, et al, 1991).
The incidence rates of epilepsy are slightly higher about 15% in men than in women
at all ages and for most seizure types (Annegers, 2001). The studies from developing
countries are few in numbers, and they show rates ranging from 49.3-190 per 1,00,000
population. Higher incidence rate in developing countries thought to be attributable
to parasitosis such as neurocysticercosis, HIV and other infections, trauma, perinatal
morbidity and consanguinity. The incidence is slightly higher in males than females,
which may be related to the greater frequency of head injuries in men due to the
work they are involved or due to motor driving. Denial of epilepsy in women
especially those in younger age groups who fear social stigma may be another factor
causing variation in prevalence and incidence between men and women (Sridharan
& Murthy, 1999).
Prognosis
There are certain features, which offer a more favourable prognosis in regard
to remission of seizures. The probability of a spontaneous or therapeutically induced
remission is good if there have been only a few seizures, if the seizures have their
onset after childhood or if there is no gross brain injury (Merritt, 1960). Once a
pattern of epileptic seizures has been established for a number of years, the chances
of complete remission are poor. Marked mental retardation and severe cerebral damage
make the outcome worse. The sooner the treatment can be begun after the first attack,
the better the outcome. (Brain,1960). In persons with epilepsy who had spontaneous
remission, it is not unusual if seizures return after an interval of ten to twenty years.
Similarly, if treatment is withdrawn there may be a seizure occurrence after three to
five years of gap in those who had therapeutically induced remission.
Diagnosis and Treatment
Epilepsy is essentially a clinical diagnosis hence the diagnosis is usually

made on the basis of the clinical history. A clear eyewitness account is therefore
imperative and obtained in the first place. Indeed, investigations are necessary to
confirm or support clinical diagnosis, classify epileptic syndrome and establish a
cause. Modern diagnostic technology makes it possible to identify the cause of these
epileptic seizures easily in most patients. Electroencephalography (EEG) is most
sensitive tool to elucidate the diagnosis of epilepsy in terms of its type and location
but it is not the tool used to confirm the diagnosis (Betts, 2005). Computerized
neuroimaging, particularly computerised tomography (CT) scan or magnetic
resonance imaging (MRI) are other tools used for this purpose.
The treatment of persons with epilepsy can be divided into many facets.
Firstly, eliminating the factors of importance in the causation of seizures. It requires
discovering all those underlying physiologic or structural abnormalities by the treating
team while examining the patient. If the cause is identified as infections, then treatment
is provided accordingly and if cause is tumor in the brain, the surgery helps in the
removal of the operable tumors or evacuation of brain abscess. The surgery also
favours some of the chronic epilepsies either to stop the attacks completely or in
controlling the attacks to a great extent.
Secondly, if epileptic seizures occur with no underlying cause, the 'anti-

epileptic drugs' (AEDs) are the choice of treatment. The decision regarding the
selection of drug/s to be given depends mainly on the diagnosis and also on nature
and type of the attacks. In general, careful outpatient follow up is required to establish
the minimum effective dosage and monitor for the side effects. Sixty to 80% of
persons with epilepsy would be completely, or adequately controlled by AEDs. If
satisfactory results are not obtained with one drug, the others should be tried. In
some persons with epilepsy a combination of two or more of the drugs will yield
much better results than the use of one alone (Merritt, 1960). Predominantly used
drugs are Phenobarbitones, Carbamazepine, Sodium Valproate, Phenytoin,
Lamotrigine, Clonazepam, Topiramate and so on (Ginsberg, 2005).
A few anticonvulsant drugs, if given in excess produce toxic effects on the

nervous system leading to drowsiness, gastric discomfort, weight gain, anaemia,
hyperplasia of the gums, less frequently rashes. The minor toxic symptoms are
frequently transient and may disappear with continuation of the drug therapy and if
they persist for long, the individual may have to bring to the notice of treating team
who may regulate the dosage or change the medicine. Perseverance in treatment is
essential and if a relapse is to be avoided the patient must continue to take the effective
drug for at least two to three years after the attacks cease depending on the type of
the seizure. Insufficient dosage, non-compliance, missing the dosage, non-affordability
of the expensive drugs etc may have great impact in slow recovery or turning illness
into chronic one. The long-term prognosis of epilepsy is good; most attaining five
year remission and many successfully stopping the treatment. However the decision
to tapering off the dosage and stopping the medicines will be determined by the
treating team based on the type of epilepsy, duration of remission, side effects of
treatment and some specific management issues like pregnancy, driving, employment
etc (Ginsberg, 2005).

Thirdly, in a large number of patients, control of the attacks requires, in
addition to drugs, regulation of physical and mental hygiene. People must be
encouraged to use all of their resources to overcome their feelings of inferiority and
self-consciousness resulting from the attacks. People should be assisted in obtaining
productive work. Physical activity of the patient should be regulated so that there is
a set time for eating, sleeping, work and exercise everyday. Person should have a set
time for sleep arising routine, as adequate sleep is required but not over sleeping.
Although it is a neurological disorder, the associated significant physical,
psychological and social consequences affect not only the patient but also the patient's
family. It may require either regular or timely counseling sessions to patient and
education to the other members of the family to avoid excessive attention and over
solicitousness or complete negligence and provide proper care to these people. Equally
important is that the patient, family members, friends, teachers, employers and all
others who might be affected, directly or indirectly, by the epilepsy understand that
it is a treatable neurologic symptom of specific abnormality in the brain, and not a
mental condition, or a contagious disease, or a supernatural affliction of some sort.
Epilepsy and psychosocial issues
Epilepsy is the most common serious brain disorder and a global problem
affecting all ages, sex, races, social classes and in all geographical areas. So far we
have understood that epilepsy is a brain disorder; in most cases the etiology is
unknown, regular medication helps in controlling the illness successfully, however
the unpredictable nature imposes enormous physical, psychological, vocational, social
and disease specific burdens on individuals, families and society at large.
Physical issues
One of the major issues observed in the physical aspect is injury due to
unpredictable falls. It may be an injury to the body or head and any other casualty
like drowning, burn, accident etc. Although accidents and injuries are slightly more
frequent among people with epilepsy than in the general population, the majority of
the accidents are trivial and occur at home. The most frequent injuries among patients
with epilepsy are contusions, wounds, fractures, abrasions and brain concussions. In
addition to these physical injuries, consumption of antiepileptic drugs sometime brings
unwanted side effects and physical discomfort particularly when medication dose is
maximized in order to control seizures.
It is desirable that a person with epilepsy should as far as possible lead a

normal life. Minor attacks unless very frequent in adult should allow them to carry
on their activities of daily living and occupation, though certain activities will
necessarily be ruled out. Daily routine activities for women like cooking near the
fire, fetching water from well or pond requires monitoring those activities. For both
men and women the occupations including working at heights, water sources, near
moving machinery or driving vehicles are obviously unsuitable if they are suffering
from frequent attacks. Some of the leisure activities like swimming, rock climbing,
tree climbing should be restricted to situations where there is adequate supervision
and support to avoid physical injuries that are dangerous to life.
Psychological issues
A person's own attitudes towards having seizures can very much influence
their emotional state. By not accepting the reality of having seizures, the anxiety of
possibly being noticed by the people around may reinforce the desire to socially
isolate them. Afraid of having a seizure in public and the very real possibility of
injury also leads to psychological distress. For people with epilepsy, a range of factors
like this can combine to produce a low self-esteem, feelings of isolation, heightened
sense of anxiety, depression, or adjustment disorders. A history of depression is
significantly more frequent in persons with epilepsy than in nonepilepsy controls
(Beghi, et al, 2004). Again, negative responses of people around may considerably
add to the stress of the person with epilepsy and may lead them to choose isolation
and avoid social interaction.
While most people with epilepsy learn how to deal with these feelings, some
may respond to such pressures by reacting in an overly aggressive verbal or physical
behaviour or in an irritable manner. Difficulty with attention and concentration, motor
hyperactivity, impulsiveness, lack of motivation and energy, mood swings, inability
to plan and organize behavior are some of the changes people with epilepsy exhibit
as a result of their psychological distress.
Due to epilepsy several seizure-related characteristics like symptomatic

etiology, early epilepsy onset, non-controllable seizures or high seizure frequency,
long duration and severe seizures, and factors related to AED treatment have been
reported to be associated with impaired cognitive performance. In some individuals
cognitive impairment may be more debilitating than seizure themselves.
Employment and social functioning
Another important factor for a person with epilepsy which can greatly increase
stress and thereby emotional strain, is economic hardship. Undoubtedly employment
is a main source of economic support for most of them, but many of the crucial jobs
are denied based on this health condition. Also, high rates of unemployment and
underemployment among more than 50% for persons with epilepsy severely restrict
their income. There are no specific rules barring people with epilepsy to be employed
as white-collar workers, executives etc., yet in practice, people are deprived of jobs
just because they are honest enough to declare they have epilepsy. This well-researched
area consistently reports in countries around the world higher rates of unemployment
in them compared with those of the general populations. Thus many of them may
face difficulty in sustaining a household, which is exacerbated due to added expenses
of anti-convulsant medications. Lack of economic self-sufficiency among people
with epilepsy increases their feeling of burden to the family, low-self esteem and
sometime leading to depression.
In addition to the direct effects epilepsy can have on the daily functioning,
the social function is also often impaired with the diagnosis of epilepsy. Social
functioning posits a set of causal influence factors on social adjustment process
(Suurmeijer, 2001). The impairment in social functioning can be loss in personal,
social and economic resources, general adjustment difficulties with people or
circumstances, restricted recreational activities and the like. Some people may
experience social skill deficits like money management, adequate socialization or
independent living skills which cannot be always related to the illness; rather it is an
outcome of personal, familial or social perception towards the illness.
Treatment issues
The physical and psychosocial problems of persons with epilepsy are

universal but are greatest in the developing countries. Besides this, in the developing
world where 85% of the 50 million people with epilepsy live and as many as three
fourth receive no diagnosis and treatment. Relatively few people today can afford to
take advantage of the advanced diagnostic facilities, purchase the new AEDs or obtain
appropriate referrals to specialists. Of course this large percentage of people without
treatment greatly increases the burden and reflects a higher disability weight. In
most of the cases the condition is unreported for several reasons. The patient may be
unaware of the nature of the attack hence not able to seek medical help. In some
countries, different types of non-medical beliefs about the nature and cause of epileptic
seizures are prevailing and thus people have a tendency to visit the traditional healers
or priests to seek alternative treatment than medical one. We get to hear many incidents
related to alternative treatments such as branding, keeping individuals in temples
without proper food for many days, consumption of various herbal medicines, chaining
the individuals, various types of rituals during full moon or new moon day. In majority
of such cases, the person and family members come to specialists after they realize
the failure in alternate treatment and in others, they come only when the illness
becomes chronic. The 'doctor shopping' is another common trend in treating this
illness. This gap in treatment due to misconception towards illness and treatment
warrants in depth psychosocial intervention.
Stigma
Epilepsy is well understood and accepted in many societies, yet in many

others, particularly in developing countries, it is considered contagious or the sign of
a curse or possession, with blame for the condition attached to the family as well as
to the patient. For 4,000 years and more people with epilepsy have lived their lives in
a world dominated by fear and ignorance about their condition. Although the scenario
is changed, the tag of stigma associated to this disorder is still unchanged to a great
extent. Whether it be in New York or Nairobi, Canberra or Calcutta, the fact is that
people with epilepsy and their families all over the world experience prejudice and
discrimination, isolation and exclusion. They and the whole condition of epilepsy
are in short, stigmatized (Lee, 2002).
The direct and indirect discriminatory behaviour and factual choices by others
cause substantial reduction in societal opportunities such as education, marriage or
work, or may result in being excluded from community activities. The problems that
persons with epilepsy go through vary from interpersonal and emotional adjustment,
family coping, adjustment within marital relationship, issues surrounding employment,
economic burden to stigma that exists in society around epilepsy (Prakashi et al.,
2004).
The social prejudice and discrimination of stigma is in action in all spheres

of ones life. For instance, parents prevent their children from playing with children
with epilepsy from fear that they will pass on their condition. Some schools deny
opportunity to participate in various activities or some others even deny admissions
or discourage continuing education. Practical routine things like making friends,
having a family, driving or traveling alone can be traumatic experiences for the persons
with epilepsy. The unpredictability of the nature and course of epilepsy is a key
factor in the psychosocial handicaps it engenders for people in whom it develops.
Because modern science has not succeeded in completely dispelling negative
misconceptions about epilepsy in the minds of the general public, the stigma associated
with this diagnosis tends to create additional unnecessary disability. Whether it is
employment, marriage or even treatment for epilepsy, many a times the stigma acts
as a barricade in conducting these functions normally. Many of these problems are
perpetuated needlessly because of widespread ignorance of the facts about epilepsy.
It is not surprising therefore that faced with this scenario, many of the people with
epilepsy lack self-confidence in them, have low self esteem and even come to
stigmatize themselves. Thus the personal stigma bounded by society's stigma seriously
affects the quality of life of a large number of people with epilepsy.
Marriage and family issues
Marriage is a major concern for the person and families of persons with
epilepsy. Large number of instances quoted on broken marriages, as the status of
illness had not been revealed before the marriage, more so if found in girls. The
common reason behind this is either not getting any alliance or not getting suitable
alliance if the truth is exposed. There have been instances of marriages broken despite
the fact is known which might be related to the ignorance people have towards this
illness. Due to the presence of active symptoms, many people do not prefer to marry
until their late adulthood. Factors like lack of productiveness, motivation or economic
instability also causes marital disharmony. However, the scenario is not always
pessimistic; there are examples of marriages occurring specifically because of the
illness being present, which is either on humanitarian grounds or in consanguinity.
Sustained marriages over many years with full support from the spouse and quite
healthy relationship maintained between the couple or the family members makes
people with epilepsy to have better quality of life, although the instances are few in
number.
The family plays a crucial role in reducing the effects of epilepsy but the
same family becomes a source of exacerbation of symptoms at times. The lack of
knowledge on the nature, cause, course and treatment processes makes some families
to either over protect the person or express complete negligence and show high
expressed emotions. Lack of family and social support means a diminished self-
value and less instrumental, cognitive and emotional aid from the family and
surroundings which in turn lowers the evaluation of the individual regarding his/her
ability to cope with disease. In the case of persons with epilepsy, social support is
often related and seen as mirror image of social stigma. Hence the quality of the
social network becomes the evidence of the acceptance or social rejection for the
individual (Amir et al., 1999).
Epilepsy and driving
Probably the most socially disabling aspect of having epilepsy is the possible
bar to driving. The reason for persons with epilepsy being subject to various driving
restrictions lies in a perceived danger to themselves and other road users consequent
to a person having a seizure whilst driving a vehicle. Driving regulations around the
world are inconsistent and vary from extreme restriction to highly liberal. In countries
like India, Greece, Guatemala, persons with a history of epilepsy can never drive
where as Japan has one year, Europian countris have 2 years of seizure free period
before aquiring a license. Driving is a luxury for most in India. However in some
cities it can become a basic necessity. As per current law i.e., Motor Vehicle Act
2000, all driving license applicants have to fill in a form that specifically asks 'Do
you have epilepsy?' If a person answers in the affirmative, he/she is denied a license
irrespective of any medically fit certificate he/she may produce. Most people
diagnosed with epilepsy are forbidden by their local laws from operating vehicles.
The issue is further intensified when a person is denied an employment, or removed
from existing job as driver but in turn do not provide an alternative job arrangements.
Those few whose seizures do not cause impairment of consciousness, or whose
seizures only arise from sleep, may be exempt from such restrictions, depending on
local laws, unfortunately it is not prevailing in practise.

Issues related to children
Epilepsy can begin at any time of life but it is most common in children
under five years. Children are most prone to developing epilepsy in early childhood
or at adolescence. Nearly one-third of people newly diagnosed each year with epilepsy
are children. Most commonly seen type is febrile convulsions which are caused by
a rapid rise in temperature. The common causes for occurrence of epilepsy in children
are birth trauma, infectious illnesses and head injuries. Fortunately, most children
grow out of them by the time they start school. Although epilepsy varies from person
to person, children with epilepsy generally have seizures that respond well to
medication and they enjoy a normal and active childhood. For some, it will be a
temporary problem, easily controlled with medication, outgrown after a few years.
For others, it may be a lifelong challenge affecting many areas of life.
Social impact in childhood is often severe, producing isolation and loss of

self-esteem. If a child has epilepsy, families and caregivers understandably worry
about seizure-related injuries. Such concerns frequently limit the child's activities
and result in restrictions that may lead to undesirable behavioral and psychological
consequences with major adverse effects on the child's quality of life and psychosocial
well being. As mentioned earlier, over protection, over involvement and high
expressed emotions along with imposing 'don't' norms by the family members
exacerbates psychosocial problems of children with epilepsy.
Issues related to women and Epilepsy
It is now accepted that women's health status has an important impact on the
health of the children, the family, the community and the environment. For centuries
and across countries epilepsy has been a condition with extremely negative
connotations. It has been considered both as medical diagnosis and a social label
(Jacoby, 1992). Although the fundamentals of epilepsy are similar for both males
and females, epilepsy in women has more consideration in variety of factors including
medical, social and cultural issues (Tettenborn et al., 2002). As epilepsy is a chronic
and often life-long disease it is interlinked with many aspects of women's life. The
complications in each phase of their life cycles like menstruation, pregnancy, child
bearing, lactation, menopause not only concerns of the medical professionals, but
for social scientist, as it has been looked from psychosocial perspective as well because
of the additional burden women undergo during each of these phases. Though
consumption of anti-epileptic drugs are the choice of treatment, it has some negative
implications to women on their fertility, pregnancy, lactation or while using
contraception. Other than medical complications, the social stigma, misconception
and belief of the public towards this illness play the contrary to a woman's normal
effective functioning. Both men and women may develop a similar emotional turmoil
as an individual per se, but the societal attitude may not be always similar. The
literature across the world and professional experiences do tell us the disadvantages
women face having a stigmatizing illness like epilepsy. Financial barriers, dependency
on family, difficulty in carrying day-to-day work often adds to the psychosocial burden.
Epilepsy and the law in India
The Hindu Marriage Act of 1955 and the Special Marriage Act of 1954
specifically stated that a marriage under these acts can be solemnized "if at the time
of marriage neither party suffers from recurrent attacks of insanity or epilepsy".
Repeated letters and petitions to successive Prime Ministers, their cabinet colleagues
and members of parliament by the late Dr. K.S. Mani from 1987 - 1996 brought forth
nothing except vague assurances and empty promises. It was then decided to approach
the judiciary. Accordingly, a civil writ petition was filed before the Supreme Court
on in November 1996. A week after the first hearing the union cabinet decided to
introduce a bill delinking epilepsy from marriage and divorce. The government did
keep its word and the bill was introduced in the Rajya Sabha and then the Lok Sabha
followed suit on December 1999. After a struggle for over 12 years the legal shackles
have been wrenched and persons with epilepsy are legally free to marry (Indian
Epilepsy Association).
The divorce was allowed by the Indian Insane Act of 1976 because it defined
epilepsy as insanity, or as leading to insanity. The IEA put in great efforts to dispel
such prejudices and false beliefs nationwide and, in December of 1999, epilepsy was
no longer considered as grounds for divorce (Indian Epilepsy Association).
As the life expectancy in a large number of persons with epilepsy is not

reduced it is understandable that people with epilepsy should have the same premium,
benefits and coverage in the life insurance policies. However the reality is The Life
Insurance Company of India issues life insurance policies at a slightly increased
premium rate of 10-15%. However personal accident, health insurance and travel
insurance is available with a provision that the insurance does not cover illness/
accident related to epilepsy. Enquiry with these private insurance companies showed
that Life Insurance is issued with or without extra premium depending on the
recommendation of the medical board. No clear cut guidelines are available. India's
Medical Insurance Act did not include epilepsy in its range of services until 1983,
after the IEA took action to fight such discriminatory policies. Yet, epilepsy is still
excluded from Mediclaim, one of the government's more recently established health
insurance systems. The Bangalore Chapter of the IEA had filed a writ petition (3208
of 1996) before the Division Bench of the Karnataka High Court regarding health
insurance to persons with epilepsy. This was later squashed and no progress has
been made in this regard. In India epilepsy is not included in the welfare for
handicapped and therefore persons with epilepsy do not get any special aid/benefits.
(Indian Epilepsy Association).

These legal and government policies throw a light on the deprivation persons with
epilepsy facing in all spheres of their life.
NIMHANS experience
It is a well known fact that, NIMHANS is considered as one of the best

hospitals when it comes to the management of patients with different types of
psychiatric and neurological disorders. Its multi-disciplinary team approach is well
recognized and been followed in other hospitals as well. The same is applicable in
the treatment and management of epilepsy as this illness attaches a tag of social
stigma along with its medical complications. Psychiatric Social Work discipline is
actively involved in the process of management, be it psycho-education or
rehabilitation of the patient. The role is played in different phases from the time of
referral.
Epilepsy education
Majority of the cases are referred for providing required information about
epilepsy. The education about epilepsy to persons with epilepsy takes a prime role
due to two aspects; firstly, this disorder is well controlled when the treatment regime
is followed strictly as suggested by the doctor and secondly, there is a large amount
of misconception towards the illness in general and towards intake of medicine for
long duration in particular. Irrespective of their education background, persons with
epilepsy tend to become non-compliant. So the information about epilepsy, its nature,
cause, prognosis and need for the regular treatment had to be imparted to those who
have been referred. Many individuals express their queries regarding marriage,
misconceptions regarding menstrual period and seizure, child bearing which are aptly
dealt during these sessions.
Education to the family

Generally, epilepsy education is given to the persons with epilepsy if they
are adults because their involvement in treatment and management of the condition
is vital in bringing a better outcome. However, family members are equally worried
about the condition and are concerned caregivers who would contribute considerably
in adhering to treatment strictly and in attending follow up regularly. Apart from
these issues, over protection or over negligence are also part of education to all the
families who are referred. When a child is affected by epilepsy the parents take up
more responsible roles requiring professional support to deal with their emotional
difficulties effectively.
Supportive counseling
The goals of supportive counseling are to provide guidance for persons with
epilepsy in making informed choices, to promote self-management practices that
will decrease health risks, and to provide comprehensive answers / understanding
about relevant issues. Counseling also includes access to care, personal care and
safety, and maintaining healthy social and community relationships. Supportive
counseling works as an apt method in an out patient setup as the persons and families
are seen briefly. Reassurance with brief psycho-education is found to be the most
beneficial intervention for them to get rid of their distress.
Intervention through groups

Family support groups were formed to provide supportive counseling to deal
with many common issues occurring while having a person with epilepsy. Workshops
conducted to provide epilepsy education in schools and in family support groups
were found effecting in dispelling the myths and misconceptions and created a better
understanding of the illness (Prakashi & Parthasarathy, 1988). Short-term group
interaction sessions to the patients who come for treatment at out patient units were
also found therapeutically effective.
Preventive, promotive and rehabilitative measures

As preventive measure psychiatric social work consultants visit schools,
colleges and organizations to conduct awareness programs and provide epilepsy
education. Discussion with employers about person's illness provided it helps the
person to receive fair treatment and perform better in the work place when they face
some problems while working. The people with epilepsy who lost their job because
of epilepsy, psychiatric social work consultants involve in liaison work with the
employers to provide alternative jobs for them. Networking for jobs, home visits,
identifying residential homes (after proper analysis of the case, if necessary this
service is extended), fund raising, temporary accommodations are some efforts
consultant involve as part promotive and rehabilitative interventions. Frequency of
seizures, duration of epilepsy and age were significant variables in relation to demands
for rehabilitation resources, however focusing on individuals' ability rather than their
incapacity and limitations, bearing health and safety standards in mind is important
in the process of rehabilitation (Prakashi & Gourie-Devi, 1988).
Resource mobilization
Generally hospitals cannot cater to the needs of all the persons with epilepsy,
especially when costs of the drugs are too high. At the same time, it becomes
unaffordable to people from lower socioeconomic background despite it being the
choice of drug in controlling the symptoms. In such cases, identifying donors becomes
inevitable. A few donors provide support for buying medication, some philanthropist
help for investigations and some help by providing temporary employment. The efforts
of identifying donors are though not meeting the enormous needs we have, there is a
significant change in the lives of those who receive the help.
What to do during a seizure:

Do's..
l Remain calm
l Clear a space around the person, prevent others from crowding around
l Loosen tight clothing / neckwear
l Remove spectacles
l Cushion the head to prevent injury
l Put person into shock recovery position (i.e. roll person into his / her side, top
leg bent, bottom arm slightly extended)
l Wipe away excess saliva to facilitate breathing
l Reassure and assist until person has recovered or become re-orientated
l Allow the person to rest / sleep is necessary
l Note the duration of the seizure and the time it took place. Provide this
information to the person who had the seizure after the person has recovered
fully, in order for him / her to record the information in his / her seizure diary.
Don'ts..
l Restrict or restrain the person's movements
l Move the person unless the person might hurt him / herself or is in immediate
danger (i.e. in a busy road)
l Put anything between the person's teeth or in the person's mouth
l Give anything to eat or drink during the seizure
l Give any fluids immediately after the attack
l Give extra anti-convulsants, unless stipulated to do so by the neurologists
l Call a doctor or an ambulance unless the person has injured him / herself
badly or the seizure lasts longer than 6 minutes, or the person has repeated
seizures without recovering
Brief overview of epilepsy
l Epilepsy is purely a brain disorder. It does not occur because of the influence
of the black magic or evil spirits.
l Epilepsy is a treatable disorder and can be controlled well with the medicines.
l Epilepsy is not a contagious disorder.
l People with epilepsy can marry provided the status of illness is revealed to the
prospective family well in advance. The prospective bride, bridegroom or the
family can clarify their doubts if any from the treatment team.
l The person with epilepsy can have children provided proper guidance is taken
from the doctors well in advance in terms consuming safer drugs, other
precautionary measures before conception
l The medicine needs to be continued minimum for the period of two to three
years without missing the prescribed dosage and would be later tapered off
depending on the type of epilepsy
l The medicine has to be stopped only under the guidance of treating team and
person has to bring to the notice of treating team before discontinuing the
medicine on his/ her own in extreme situations like severe side effects,
pregnancy or any other
l Persons with epilepsy can perform activities of daily living absolutely
independently
l They can take up any employment, but employment like working in heights,
near moving machinery, deep water, deep slops and work which involves
handling sharp objects could be done only with adequate supervision
l The persons who have active symptoms which come without any warning
signs need supervision in activities like driving vehicles, moving in heavy
traffic, swimming or climbing. They need to be careful while taking bath,
preferably keep bathroom unlatched
l They have to maintain a seizure dairy, which includes date, time and duration
of seizure occurrence. If person is not in a position to record them, the family
members, friends and relatives should record the same
l When people with epilepsy move independently it is safe to carry the address
and phone numbers of family members, immediate relatives, friends or
employer
l Habits like alcohol, drug abuse and excessive smoking are contraindications
for persons with epilepsy. Rather positive frame of mind and healthy habits
always help effective control of seizures, there by fast recovery
l If the person is keen to explore alternative treatment modalities, it can be done
with a condition that anti epileptic drugs are not discontinued. Treatments like
yoga, meditation, pranic healing supports fast recovery but they may not
successfully control the illness
Case study
G is 21 years unmarried lady hailing from a lower socio economic background

from urban Bangalore. She is suffering from Complex Partial Seizure for the past six
years.
G's family consists of father, mother and a married brother. Father is a coolie
who does not attend any work due to alcohol dependence. Mother works as housemaid
in 2-3 houses and is the earning member of the family. G's brother got separated after
the marriage, and he neither supports the family financially nor emotionally. Sister
in law provides emotional support to some extent.
G also works as a servant maid in a few houses. Due to the nature of her
attack she often had to loose the job for days together. She was found visiting the
hospital on odd days (not on her follow up day) and at odd hours with bruises on her
face and body due to falls following the attack. When the incidents were very frequent,
the treating team referred the case for detailed psychosocial assessment and
management.
Highlights of psychosocial assessment
G's uncontrolled attacks were major concern which was associated with
various psychosocial issues. G's low socio-economic condition and poor family
support force her to be independent at a crucial phase of her life stage where as her
clinical condition warrants regular Anti-Epileptic Drugs (AEDs), good emotional
support with clear understanding of her illness and its management. Her family
atmosphere has worsened due to her father's alcohol dependence, inadequate support
from her brother's family and non-availability of mother who spends most of her
time outside on work. Due to such a background, she couldn't raise enough money
for her AEDs; as a result her drug compliance was poor, which lead to continued
attacks and falls. Being unable to give up working, despite attacks, she continues
work however irregular it might be. Trapped between her keenness to improve and
the pathological background she lives in, she is unable to attend clinical follow up
on appropriate day and time, which doesn't get her even the adequate clinical attention
that she desperately requires. These issues compounded by her personal limitations
such as poor personal hygiene, sudden anger outbursts, low self-esteem and self-
confidence. Poor housing and environmental condition was another concern as this
physical infrastructure was causing injuries while suddenly falling from seizures at
home.
Focus of psychiatric social work intervention
l Measures to control her frequent attacks

l Making AED available
l G's understanding on illness and its effective management
l Family's understanding on the above
l Building the family as a supportive caregiver
o Attention on father's alcohol dependence
o Ensuring brother's involvement
o Improving family involvement and relationship
l Strengthening G's resilience
l Feedback and regular discussion with the treating team
l Identifying donors for supporting G in her treatment
l Efforts to motivate her to gain employment
l Reintegration into the family and community
Interventions are carried on
l Controlling the attacks with the help of treating team

l Regularizing AEDs after modifying by the neurologists (considering their
economic condition)
l Psycho-education on epilepsy and management to G and her family
l Individual therapy with G in terms of supportive counseling and reassurance
for improving self confidence and self esteem, self-help skills for improving
personal hygiene, communication skills and time management
l Behavioural modification techniques such as setting the goals, positive and
negative reinforcements, task and environmental stimulation, anger
management
l Crisis interventions during the time of uncontrolled seizures
l Family Therapy was initiated
l Raising resources for free drugs through collateral contacts and sensitizing
the donors for regular financial assistance for the medication
l Home visit was conducted to provide awareness, involve family in treatment
process
l Initiating de-addiction intervention for G's father
l Individual counseling to G's brother
The treating team consultant was involved throughout the management process and
supportive for the cause.
Outcome
l Unanticipated attacks were controlled from daily 6 times to 2 attacks per month
l Mother accompanies G and discusses the interval history and management of
issues like seizure and behaviour
l Identified a women organization to sponsor her medication cost on a continuous
basis
l G was made accountable to buy the medicines and regular in intake of the
same
l Communication skill was improved in a clear and un-manipulated manner
l Regaining the work by informing the status of illness to the employer which
helped in attending follow up regularly without loosing her wage
l Psychological needs of the G and her mother were handled as and when crisis
arise
Challenges
l Intervention on father's alcohol consumption

l Environmental manipulation to avoid injuries from falling at home
l Brother's involvement in treatment
Future plans
l Further monitor of seizure in a day care rehabilitation setting

l Identifying her skills to train in higher graded employment
l Family life education and premarital counseling

Conclusion
As mentioned earlier in this chapter though epilepsy is a neurological disorder,

it is considered as psychosocial disorder too. Hence, psychosocial intervention is
undoubtedly an essential component in the treatment process. As the magnitude of
persons diagnosed with epilepsy, compared to other neurological disorders is very
high, it is essential to train various disciplines like psychologists, social workers,
medical practitioners, counselors and health workers about the psychosocial aspect
of the illness. More research studies on overall psychosocial factors affected by
epilepsy are required.

Chapter 17
WORKING WITH THE NEUROLOGICALLY ILL -
A GROUP WORK APPROACH
Prakashi Rajaram,1 Priya Treesa Thomas,2 & Chandramukhi,3
Introduction
Group work is one of the most important, and primary methods of social
work. Group work offers considerable scope for addressing problems in social
functioning and unmet needs as well as safeguarding rights, enhancing quality of life
and promoting empowerment in persons with disabilities. Social group workers are
essentially interventionists. In pursuit of the general aims of social work and backed
by the values of the profession, the social group worker establishes, creates or takes
over a group with the direct intent of influencing the lifestyles of the members of the
group. Technically, the worker accepts that whatever is perceived to be 'wrong' in the
client's situation is susceptible to the ameliorative influence of a particularly informed
group approach. The influence may range all the way from support and information
giving through to attempts to modify areas of behaviour and patterns of attitudes.
But the basic assumptions are that human beings are able to receive support to accept
change, i.e., capacity to be sustained or to achieve growth and that direct intervention
to tap this capacity / potential can be successfully attempted by the use of a particularly
informed group approach.
In the group situation, experience of others is made available, so that the

members learn mutually. Group creates a set of therapeutic factors that include:
instillation of hope, a sense of universality, providing guidance, developing a sense
of altruism among the members, learning from interpersonal interaction, self
disclosure as well as emotional catharsis. Social group work is concerned to cover
the whole gamut of human social behaviour wherein people may not be functioning
as well as they might. Though a Herculean task, it has to be attempted for people
whose own coping behaviour needs strengthening, redirecting, changing and for whom
the normal social institutions, e.g. friends, neighbors and family have not been able
to help for some reason.
Working with groups of neurologically ill
Chronic disorders often result in deficits in multidimensional areas, which

range from physical to neuropsychological and social. It has a tremendous impact on
the concerned individuals and families that often leaves them bewildered as to how
to tackle them.
1. Assistant Professor 2. Ph. D Scholar 3. Psychiatric social worker

There is also the undefined and hidden economic and social burden for the
individuals and the families. This is especially true in neurological illness because of
the impairment in the psychosocial functioning for the individual and family, which
greatly diminishes the individual's social roles and productivity. Again the prolonged
and continued nature of the neurological disorders has long drawn out social and
emotional implications for the patient and the family. Hidden burden refers to the
burden due to with the stigma and human rights violations associated with the illness.
The stigma associated with the neurological illness, especially disorders such as
Epilepsy leads to negative consequences for the patient and family, which include
humiliation and isolation.
Unlike the patient with an acute but transient illness, the patient with a
progressive and chronic neurological illness is faced with an incurable, debilitating
disease that may eventually lead to total physical dependency and a shortened life
span. The long, slow course of the disease causes overpowering anxiety in both the
patient and his family, especially in those instances where the patient knows other
persons with the same diagnosis whose condition is more advanced than his. The
physical limitations of a progressive neurological disease invariably interfere with
the patient's performance of his previous role responsibilities. In our culture the
husband carries primary responsibility for providing the family income. When he is
the patient, the family is threatened with a loss or reduction of income and frequently
a lower standard of living. Patient who is a wife and mother may find it increasingly
difficult to handle responsibilities attached to these roles.
A disorder such as stroke entails various degrees of impairment in physical

and mental functioning. Deterioration in function can occur in a variety of areas, and
depending on severity, they greatly influence the recovery and adjustment. The
repercussions of stroke are there in families also as they are forced to face an
unanticipated crisis, which could lead to total breakdown of the entire family function,
causing great stress. Social work services for neurologically are relatively new field
in India, where as it has been widely practiced in Western countries for patients
suffering from neurological disorders and their family members. In India, major
hospitals have social workers attached to their Departments of Neurology and provide
services focusing on specific disorders such as Epilepsy, Stroke and Neuromuscular
disorders, as well as general services. Working with the patients and their families in
groups forms a cost effective as well as valuable method in social work. Groups for
persons with chronic diseases or disabilities are usually formed on a community
basis, in hospitals or in rehabilitation centers. Such groups are especially important
in the light of stress generated by the onset of a disability or long-term or terminal
illness. Clients are often uncertain of the course or prognosis of their condition.
Given the uncertainty of medical factors, the need for emotional support,
and the struggle of working through the lifestyle changes, different kinds of groups
with this population can be quite beneficial. Groups can provide education and
information on health related issues and help clients deal with psychological issues
such as loss of identity, anger, and the grieving process. Groups can also provide
support and help with problems solving. The type of group that is followed is usually
a support group, which consists of members with something in common, and meets
on a regular basis. In this type of group, members share thoughts and feelings and
help one another examine issues and concerns. The group enables the members to
learn that other people struggle with the same problems, feel similar emotions and
think similar thoughts.
Working with the neurologically ill patients in groups is important for the
persons with chronic illness or disability to
l Learn to understand other people in similar situation and their view points
l Develop a deeper respect for other people, particularly those who are different
in many ways from oneself, and those who cope in a different way with similar
problems,
l Gain greater social skills in dealing with peers,
l Learn to share with other people a sense of belonging by participating in group
activities,
l Clarify one's own concerns, problems, values and ideas through discussion
with others having similar problems in like areas.
An initial explanation of the purpose of group and its interaction to the group
members, and a brief formal introduction of all the members enable healthy interaction
among them. When the focus of the group is education, the facilitator mainly focuses
on the misconceptions & doubts the members have on their disease and disability,
and scientific suggestions given by the members are encouraged. Unhealthy behavior
is discouraged and alternative management patterns are suggested. When the focus
is counseling, the psychosocial problems are discussed in the group. It serves as a
platform for the members to share their individual problems, and helps them to see
that there are many more individuals with similar problems & thus offering a source
of relief. Sharing their problems with the guidance of the social worker bring forth
many solutions to the problems associated to their illness, and is facilitated by the
peer support that is made available through the group process. The group provides
an alternate socialization experiences to the persons with epilepsy, whereby the
members can receive honest feedback and develop relationships. The group also
becomes a learning platform in which the members begin to discuss issues such as
the social stigma they are likely to face, and how it can be tackled.
Group level education regarding specific neurological disorders includes

education in which the following contents are discussed - structural aspects of brain,
functions of brain, types of neurological disorders, possible causes, risk factors, and
early recognition of disorders, investigations, treatment, rehabilitation including
coping with care giving as well as government benefits.

Regular group interactions are used to reduce the feelings of isolation, and
of being the only one who has to cope with the problems of a neurologically ill
patient. The group is guided to provide the members with peer support in attempting
new solutions for the purpose of day-to-day management and rehabilitation. The
group also serves as an effective medium for dispelling wrong notions and
misconceptions regarding neurological disorders. For example, thinking that marriage
can cure epilepsy, many parents want to have their child with epilepsy get married.
These kinds of issues require a thorough discussion with the family members, (Gupta
1980) which can be dealt with effectively in a group situation.
The worker aims at helping the client achieve self-integration, self-direction

and responsibility, an accepting, permissive climate for the clients to participate freely
so that their defenses are reduced. In working with the patient in group setting, it is
essential that the worker provide opportunity for him to express and clarify feelings
about the client's condition as well as adjustments. Smith (1983) observed that for
the Multiple Sclerosis victims, the group offers several advantages over individual
treatment. First, the group was designed to emphasize vicarious learning through the
provisions of extensive group discussion. Secondly, benefits of peer understanding
and support, characteristic of many treatment groups, are particularly valuable to
individuals engaged in comprehensive change and concomitant self doubt that are
typical of one in the process of adjusting to Multiple Sclerosis. Thirdly, the group
served to motivate individual participants towards productive and regenerative change.
As participants report successful resolution of problems, motivation for individual
change was enhanced. Finally, the group also facilitated the development of a viable
social/ interpersonal network for the participants.
The intermediation effect of combined group process, cognitive restructuring,

and modeling, behavior rehearsal and homework assignments in an attempt to assist
Multiple Sclerosis victims helped them to reconcile themselves to their illness and
learn, to cope with its numerous and varied effects. (Welch & Steven, 1979)Clients
are often uncertain of the course or prognosis of their condition. They must deal with
a change in lifestyle, the feelings of loss of control, role changes and burden. The
focus of their lives for some time shifts from the day-to-day business of making a
living, socializing, and being involved with the family and friend to medical
examinations, treatments, and waiting with some degree of uncertainty. (Jacobs et
al, 2002)
In support groups, the worker wants to cerate a safe environment where the
members can share. Again, for a support group to work, the members must feel a
common bond. It is usually best to form homogenous groups based on one particular
illness or disability because illness or disability is the common denominator about
which patients have concerns. At times, this may not be possible, or it may be found
that it sis beneficial to involve members with different neurological conditions. While
forming the group, the worker must be especially sensitive to the intense anxiety,
depression and anger that the people may experience following the diagnosis of a
long-term disabling illness. Many begin a grieving process that go through the phases
of 1. Denial, 2. Anger, 3. Bargaining, 4. Depression and finally, 5. Acceptance. (Kubler-
Ross, 1969). In the group, members who are dealing effectively with their diagnosis
and problems and provide information support as well as serve as role models for
those who are still in the initial stages.
The beginning stages of a group may last one to three sessions, where the
sharing may not be as personal as in the middle stage. It is in the middle stage that the
sharing is more intimate and caring is greater because the members now know each
other better. The closing of the group can be an emotional experience for the members.
Groups with members who have a chronic disease or disability may be either open or
closed group. Usually in hospital setting, we need to have an open group, so as to
accommodate new people arriving in the unit who are suffering from the same or
similar illness, or disability. Another important area where group work is being
successfully practiced in this connection is that working with family members, as
well as other caregivers of patients with a chronic illness or disability.
While dealing with a group of people who have chronic disease, or disability,
the worker needs to be prepared to deal with the powerful feelings often felt by
them. The strong sense of injustice the members might feel as a response to a newly
diagnosed chronic condition might manifest as anger outbursts, or resentment that
might be displaced to the worker. It is important for the worker to accept this anger
as a part of the grieving process and help the members to work through it. The
members also become intensely preoccupied with their medical condition, at times
neglecting all other aspects of their life. Effective cutting off skills are important
here, because the members need to be encouraged to look beyond the condition, to
the possibility of getting on with their life, in terms of future employment, socialization
with friends and so on. Often, the members with dealing with a chronic disease or
disability are quite knowledgeable about their condition. They should be treated as
experts in the group. It follows that having as much knowledge as possible about the
disease, or disability is often helpful. The worker will need to have, or make available
through medical staff sound information on disability and its after effects. Another
consideration while working with group members with specific problems in the
hospital setting is the effect being in the hospital would have on their emotional
well-being. The worker needs to work with the members in countering this effect
and the apathy hospitalization may produce.
The patients who visit the outpatient and in patient departments of Neurology
Department in NIMHANS are widely dispersed, in terms of socioeconomic status,
educational and cultural backgrounds and various diagnosis. Common illnesses that
are encountered include Epilepsy, Cerebro Vascular Accidents, Degenerative
disorders, infectious disorders, headache and some rare disorders. In the case of
outpatient department, the rate of follow up in many cases is quite good, and hence
working with them in groups has proven to be a feasible and effective method. In
many instances, homogenous groups have been used in the Outpatient Clinics. In the
wards, the groups are predominantly heterogeneous in nature, yet the psychosocial
issues dealt with are more or less similar.
Information is given about he welfare benefits provided by the government

organizations that cater to the needs of persons with similar problems. Psychosocial
rehabilitation services to help the patients to cope effectively with their limitations,
as well as vocational guidance in terms of suitability for training and job placement
are also discussed in the groups.Group work helps the members, apart from being a
vehicle for information dissemination, to identify and focus on the strengths and to
accept the reality of illness and related disabilities. It also provides for ventilation of
frustration, as well as for understanding the guilt associated, leading to mature ways
of coping. (Rajaram et al 2006)
Conclusion
Working with the neurologically ill in groups provide a platform for exploring
new support systems, reassurance, education, legal discussions, advice and guidance
as well as other context based psychosocial interventions. While groups prove to be
an effective and comprehensive method of dealing with the psychosocial problems
of an individual with a chronic illness or disability, it calls for certain skills from the
worker, as well as an insight into the problems faced by the person in that situation.

Chapter 18
PSYCHOSOCIAL ASPECTS OF HEAD INJURY
N. Krishna Reddy,1 A.Durai Pandi,2 & Atiq Ahmed,3
Introduction
Head injury can alter the life of a healthy individual in the blink of an eye,
and affect the lives of the individual's loved ones, as well. It is incredible when one
thinks about how, in a split second, the life of a previously healthy individual could
be tragically and permanently altered. Head injuries can have a devastating impact
on the injured individual, the family and the community as well. The brain controls
the actions of our body and allows us to think, learn, feel and remember. It is protected
by our hair, skin and skull. Head Injury is a traumatic condition of nervous system.
This term is used to refer an injury to skull, the brain or both structures that is sufficient
to get the attention of medical consultation and which will interfere with the person's
normal activity. Although the symptoms of minor head injuries often resolve on
their own, more than 500,000 head injuries (world wide) each year are severe enough
to require hospitalization; 200,000 are fatal; and 200,000 require institutionalization
or other close supervision, the remaining live their lives with post concussion sequelae.
The psychosocial determinants of recovery among the victims of head injury depend
on severity and type of head injury, personality make up of individual before brain
injury, body images related issues, person's previous satisfaction with selected
activities, presence or absence of therapeutic interventions, familial and social
relations, religion and philosophy of life, life stage of the person, ability to live with
uncertainty and ambiguity, and specific location of the brain injury or lesion in addition
to social support network.
World studies
In most developed countries, a realization of the gravity of the problem has

over time led to a series of coordinated and integrated measures aimed at reduction
of driving under the influence of alcohol. A series of these measures have successfully
reduced alcohol related fatalities by 40% in Europe, 35% in U.S and 40% in Australia.
Reducing the number of drinking drivers through legislation, enforcement and public
education have played the crucial role in reducing a major cause of mortality and
morbidity in the last few years.
1. Associate Professor 2. Psychiotric Social Worker 3. Ph. D Scholar

Bangalore city
The city of Bangalore has been progressing at a significant pace during the
last one to two decades. The city has witnessed increasing motorization, urbanization,
migration and changing values of people. The rapid change in the life style of people
has been a noticeable phenomenon in all urban areas of India, more so in the city of
Bangalore. The city has nearly 16,00,000 registered vehicles and another 2,00,000
enter the city every day from outside. An accompanying effect of these changes has
been an increase in road accidents in the city of Bangalore. As per official reports,
nearly 700 people are killed and 7000 injured every year on the roads of Bangalore
The NIMHANS Experience
With increasing road accidents in the city of Bangalore, systematic efforts

towards reduction have been far from satisfactory. NIMHANS has undertaken series
of research activities to unravel the various dimensions of alcohol related problems
in the city. NIMHANS has also been a key partner along with several other agencies
in addressing this growing problem. The international literature reveals that nearly
40% to 60% night time crashes are linked to alcohol consumption. An earlier study
by NIMHANS identified that nearly 16% of brain injured individuals were under the
influence of alcohol at the time of injury. The severity, duration of hospital stay,
death and disability were higher among individuals with alcohol. Gururaj & Benegal
(2000) of NIMHANS organized a project study in collaboration with the Bangalore
City Police and two other NGO, aimed at identifying alcohol related road traffic
injuries. Series of studies completed by NIMHANS estimates that nearly 800 deaths
and 14000 persons are injured every year. This could be related to variations in data
collection practices in different agencies. It is known that road accidents are multi-
factorial in nature. The various factors related to human, vehicle, environmental and
system related issues contribute to increasing road accidents. Among the various
human factors, consumption of alcohol and subsequent driving on the roads has
been found to be a major risk factor. The relationship of alcohol with injuries in
general and road accidents in particular has been documented by numerous reports.
During the study period of one month a total of 1605 persons were registered in
various hospitals of Bangalore city. This included accidents occurring both within
the city limits of Bangalore and also those occurring outside the city (including patients
referred from outside hospitals). Among the total cases, 778 (49%) and 827 (51%)
had occurred in daytime and nighttime, respectively.

Table 1: distribution of injured persons as per Age (in years)
Agegroup Day time Night time Night time Night time Total
RTA RTA RTA RTA
(Alcohol (Alcohol ( Alcohol
taken) not Taken) status
not
known)
0 to 14 54 0 51 0 105
6.9% 0.0% 8.4% 0.0% 7.0%
15 to 19 32 6 44 0 82
4.1% 3.3% 7.2% 0.0% 5.0%
20 to 24 130 32 119 9 290
16.7% 17.4% 19.5% 26.5% 18.0%
25 to 29 135 45 98 10 288
17.4% 24.5% 16.1% 29.4% 18.0%
30 to 34 96 35 73 2 206
12.3% 19.0% 12.0% 5.9% 13.0%
35 to 39 72 14 54 4 144
9.3% 7.6% 8.9% 11.8% 9.0%
40 to 44 68 19 43 2 132
8.7% 10.3% 7.1% 5.9% 8.0%
45 to 49 65 15 45 2 127
8.4% 8.2% 7.4% 5.9% 8.0%
50 to 54 48 6 14 2 70
6.2% 3.3% 2.3% 5.9% 4.0%
55 to 59 25 6 26 1 58
3.2% 3.3% 4.3% 2.9% 4.0%
60 + 53 6 42 2 103
6.8% 3.3% 6.9% 5.9% 6.0%
Total 778 184 609 34 1605
48.5% 11.5% 37.9% 2.1% 100%
(Gururaj & Benegal, 2000)

Among nighttime injuries (n=827), 184(22%) persons were under the
influence of alcohol at hospital entry time. 73% were not under the influence of
alcohol and status was not known in 5% of cases. In the total sample, a selective
examination of men above 15 years and less than 60 years (n-1397), revealed that
11% were injured while driving under the influence of alcohol. The mean age of
injured persons was 32.6 +/- 14.1 years. However, among nighttime crashes and in
men of 15-59 years, the proportion of road traffic injuries related to driving under
the influence of alcohol was 28%. The mean age of persons under the influence of
alcohol and involved in road traffic injury was 33.0 +/- 10.4 years. This indicates
that one fourth of nighttime hospital registrations in this age group are directly linked
to driving under the influence of alcohol (table 1.1). Among those injured persons
under intoxication highest age of occurrence was in 20 - 34 years to the extent of
60% (20-24 years - 17%; 25-29 years - 25%; 30-34 years - 19% and 40-44 years -
10%).
The role of alcohol was re-examined using data from the Neuro-trauma
Registry at NIMHANS (March 2000 - March 2001) from a sample of nearly 7,000
patients registered at NIMHANS. It was observed that nearly 60% of hospital
registered brain injuries were due to road accidents. 58% were men aged 16+ years.
21% of individuals were under the influence of alcohol (physician confirmed
diagnosis) at the time of injury. 90% had consumed alcohol within 3 hours prior to
injury. The highest proportion of road accidents and brain injuries were in 20 - 30
years age group (40%). The 15 - 20 years group and the 30 - 35 years group constituted
11% and 13%, respectively. Thus, the age group of 15 - 40 years represents 70 % of
the total subjects with alcohol consumption, recorded in 22% of brain injured persons.
Also in another study of alcohol and injuries undertaken by NIMHANS in

collaboration with World Health Organization (WHO), it was observed that 16% of
emergency room attendance at Victoria hospital was due to road accidents. Within
this group nearly 59% were injured either due to self-consumption of alcohol or as a
result of alcohol intoxication of others on the road. These observations over a period
of time have revealed that alcohol consumption among drivers is a significant risk
factor for fatal and nonfatal injuries. The above findings have been shared with
responsible agencies and individuals in the city of Bangalore. It is envisaged that a
program combining education, enforcement and legislation needs to be developed to
contain the problem.
Severity of head injuries

A retrospective survey of statistics was done on cases registered with head
injury at NIMHANS from January 01, 2004 to December 31, 2006. The authors
visited the medical records and casualty & emergency services block of NIMHANS
to calculate the incident rate of head injuries registered at NIMHANS. It was found
that there has been a steady increase in the head injury patients of all categories.

Figure. 1. Head injuries registered at NIMHANS (year wise, 2004-2006)
H E A D I N J U R Y R E G I S T E R E D A T N IM H A N S ( 2 0 0 4 - 2 0 0 6 )
1200
NUMBER OF INDIVIDUALS
1000
800
M a le
600 F e m a le
M a l e C h ild r e n
400 F e m a le
C h ild r e n
Total
200
0
2004 2005 2006
YEAR
Gururaj and Benegal (2000) estimated the outcome of road traffic accidents at
emergency room level, in the study conducted with respect to alcohol and road traffic
accidents. The results showed that out of the total 1351 people injured only 38% of
the individuals showed good recovery. 33% showed moderate recovery; 26% showed
severe disability; 3% died and 1% had PVS. (Table: 2)
Table 2: Outcome at ER level among road traffic injuries
STATUS Day Time Night Time Night Time Night Time Total
RTA RTA RTA RTA
(Alcohol (Alcohol (Alcohol
Taken) Not Taken) Status
AGEGROUP Not
Known)
Good recovery 241 71 186 11 509
43.1% 40.1% 31.6% 40.7% 38.0%
Moderate 194 52 197 6 449
Disability 34.7% 29.4% 33.5% 22.2% 33.0%
Severe 104 48 189 4 345
Disability 18.6% 27.1% 32.1% 14.8% 26.0%
Death 17 4 8 6 35
3.0% 2.3% 1.4% 22.2% 3.0%
PVS 3 2 8 0 13
0.5% 1.1% 1.4% 0.0% 1.0%
Total 559 177 588 27 1351
41.4% 13.1% 43.5% 2.0% 100%

Physiological aspect of head injury
Head injury may be direct injury, indirect injury, open head injury, closed head injury,
coup injury, counter coup injury, missile injury
Classification of head injury

Based on the type of Injury, it can be classified into
l Primary : Primary head injury is the result of the dynamic mechanism that
caused the direct tissue disturbances. The injury can be focal or diffused.
l Secondary : Secondary Head injury arose from the inefficient treated primary
head injury, which may led to death if not handled in time.
Based on the part of the head injured it can be classified as

l Scalp Injury: Contusion, Abrasion, Laceration
l Skull Injury: Linear Fracture, Communicated fracture, Depressed fracture,
Cranial fracture, Facial Fracture, Meningeal tears, Logorrhea, Rhinorrhea,
Postnatal drip
l Cerebral injuries: Concussion, Contusion, Laceration, Brain stem injury
l Intra-cranial Hemorrhage: Epidural Hemorrhage, Subarachnoid Hemorrhage,
Subdural Hemorrhage, Intracerebral Hemorrhage.
Various causes of head injury

l Accidents, especially motor vehicle accidents
l At least half of all Traumatic Brain Injuries (TBI) are associated with alcohol
use
l Sports injuries cause about 3% of Head Injury,
l Falls at home and at work place
l Violence or clashes, implicated in about 20% of Head Injury,
l Firearm assaults are involved in most violent causes of TBI in young adults,
whereas
l Child abuse is the most common violent cause in infants and toddlers.
l Occupation Hazards
l Shaken baby syndrome, a baby is shaken with enough force to cause severe
counter-coup injury
Symptoms of head injury:
Symptoms of head injury may occur immediately or they may develop slowly
over several hours. Depending on the cause, mechanism, and extent of injury; the
severity of immediate symptoms of TBI can be mild, moderate or severe. Following
are the commonest symptoms and few symptoms may exit in clusters.
l Experience a brief or transient loss of consciousness,
l Fainting or passing out, or merely an alteration in consciousness,
l Headache, nausea, dizziness, lightheadedness,
l Changes in vision such as blurred vision or tired eyes, Ringing in the ears,
l Bad taste in the mouth, altered sense of smell, loss of the sense of taste,
l Coma
l Immediate numbness or weakness of one or more limbs,
l Blindness, deafness, inability to speak or understand speech, slurred speech,
l Lethargy with difficulty staying awake,
l Persistent vomiting, loss of coordination, disorientation, or agitation,
l Personality changes, depression, irritability, other emotional and behavioral
problems
l Seizures
l Confusion, fatigue or lethargy, altered sleep patterns,
l Trouble with memory, concentration, attention,
l Post-concussion syndrome including headache, dizziness or a sensation of
spinning (vertigo), memory problems, trouble concentrating, sleep disturbances,
restlessness, irritability, depression, and anxiety.
Impact of head injury
Head Injury may cause intellectual, emotional, social, behavioral, vocational,

cognitive, visual, vestibular speech and physical disabilities. These difficulties may
often affect present care, future life style and personality behaviors of the brain injured
or head injured recovery and recovered individuals in most instances, the person you
knew no longer exists. A new person reemerged, a person who is unknown to you
and even to them.
The major three areas of impact of head injury on the individual are
l Cognitive impact: may be very mild to exceedingly severe. They include
memory deficits difficulties in concentration, slowness, thinking, attention,
perception, communication, reading and writing skills, planning, sequencing
and judgments.
l Physical impact: Speech, hearing, and sensory impairment, head ache,
dizziness, vertigo lack of co - ordination spastically of muscles, paralysis and
seizure disorders are often seen.
l Psycho social impact: includes fatigues, mood swings, denial, self
centeredness, anxiety, depression and lower self esteem, sexual dysfunction,
restlessness, lack of motivation, difficulty with emotional control with,
inability to cope, agitation, excessive laughing or crying and difficult in relating
to others.
Impact of head injury on the family
The head injury in the family challenges the core value and resources of the
family system.
l Shock
l Family Dynamic Changes (Role, communication, social support, structure,
Adaptive Pattern and rituals)
l Adjustments
l Financial crisis
l Emotional turmoil
l Guilt
l Anxiety, depression and Post Traumatic Stress Disorder
l Denial of the implication of the trauma,
l Grieving over perceived loss,
l Social isolation,
l Coping styles (Displacement, regression, intellectualization),
Bio-Psycho social interventions
l Although no specific treatment may be needed for a mild head injury, it is

crucial to watch the person closely for any developing symptoms over the
next 24 hours.
l If the person is sleeping, he should be awakened every two to three hours to
determine alertness and orientation to name, time, and place.
l Immediate medical help is needed if the person becomes unusually drowsy or
disoriented, develops a severe headache or stiff neck, vomits, loses
consciousness, or behaves abnormally.
l Stabilizing the head and neck by placing the hands on both sides of the person's
head to keep the head in line with the spine and prevent movement, which
could worsen spinal cord injury.
l Bleeding should be controlled by firmly pressing a clean cloth over the wound
unless a skull fracture is suspected, in which case it should be covered with
sterile gauze dressing without applying pressure.
l If the person is vomiting, the head, neck, and body should be rolled to the side
as one unit to prevent choking without further injuring the spine.
l Although the initial brain damage caused by trauma is often irreversible, the
goal is to stabilize the patient and prevent further injury.
l Some patients need medication for psychiatric and physical problems resulting
from the Traumatic Brain Injury (TBI), prescribing drugs may be problematic
because TBI patients are more sensitive to side effects.
l Both in the immediate and later stages of TBI, rehabilitation is vital to optimal
recovery of ability to function at home and in society.
l Problems with orientation, thinking, and communication should be addressed
early, often during the hospital stay. The focus is typically on improving
alertness, attention, orientation, speech understanding, and swallowing
problems.
l As the patient improves, rehabilitation should be modified accordingly, like,
physical therapy, occupational therapy, speech/language therapy, physiatry
(physical medicine) etc.,.
l Psychological treatment and social support should all play a role in TBI
rehabilitation.
l Appropriate settings for rehabilitation may include the home, hospital outpatient
department, inpatient rehabilitation centers, comprehensive day programs,
supportive living programs, independent living centers, and school-based
programs.
l Families should be involved in rehabilitation, in modifying the home
environment if needed, and in psychotherapy or counseling as indicated.
Management of head injury
Preventive measures
l Unlike most other devastating neurological diseases, head injury can be

prevented.
l Practical measures to decrease risk include wearing seatbelts, using child safety
seats, wearing helmets for biking and other sports,
l Safely storing firearms and bullets; using step-stools, grab bars, handrails,
window guards, and other safety devices; making playground surfaces from
shock-absorbing material; and not drinking and driving.
Rehabilitation
In rehabilitation setting, therapeutic treatment may include:
l Sensory-motor stimulation - to increase the level of arousal of a comatose

patient by introducing various stimuli to them.
l Therapeutic positioning - to prevent pressure sores and contractures from
developing or getting worse.
l General strengthening and conditioning exercises.
l Bed mobility and transfer training.
l Balance and coordination training.
l Ambulation, gait, and stair negotiation training with or without an appropriate
assistive device.
l Speech and swallow training.
l Community re-entry training -. to help re-introduce society to the patient and
vice-versa.
l Training in activities of daily living, such as dressing, homemaking, and
hygiene, with or without appropriate assistive devices.
l Experienced psychologists, cognitive therapists, and vocational therapists -
work with the patients to educate and orient them, improve their reading and
writing skills, and help restore and ensure their mental and psychological well
being.
l Therapeutic recreation - to help patients enjoy leisure activities, explore their
emotional needs, and learn to interact with others.

Family intervention
The Family Caregiver: Integral & Formal Member of the Rehabilitation Process
In our society more and more responsibility is placed on the family to provide care.
Due to lack of government resources and appropriate assistance upon discharge, it is
important that during the rehabilitation process the psychiatric social worker and the
rehabilitation team can provide the family with as much information and training as
possible.
The family-care-giver is that significant person in the family of head injured

person, who looks after the basic needs of the patient through out the day. The care
for the caregiver is of immense importance as this population suffers more
psychological effect than the patient himself. Timothy & Shewchuk (1997) brought
out an article in which they discussed how more responsibility has shifted to the
family of people with disabilities and the problems that these caregivers encounter
and touched on five different aspects of care giving.
1) The personal costs of care giving.

2) Care-giving and adjustment to physical disability
3) Ethnic and minority issues in care-giving
4) Integrating the caregiver in the rehabilitation process.
It is discussed how, with the onset of a disability, the family is forced to take
on new roles and greater responsibility. This causes high levels of stress in an already
stressful situation. Caregivers are sometimes forced to give up their own needs in
order to care for a loved one. The caring for someone and constantly giving up ones
own personal interests can affect the caregiver both physically and emotionally which,
in turn affects the patient. The caregivers need to be aware of their own feelings,
judgments, and different ways of reacting to the patients' behavior. A trained
professional can facilitate this with active counseling and psychological interventions.
The caregivers must also take care of their own physical and emotional health in
order to provide care to their loved one.
Ethnicity and cultural issues also play a greater role in care giving. In society
today, we have many different types of families. Some cultures tend to have extended
and blended families, which can offer more support to the caregiver. Some cultures
also view care-giving as an expected family function that can put added pressure and
stress on the family. The importance of having the family involved in the rehabilitation
process is the best approach and the only approach. Not just having the family involved
at the time of discharge but integrating the family and the treatment team throughout
the rehabilitation process. It is important for the treatment team to understand the
patients' needs, but it is also important that they understand the families' (caregivers)
needs.

Stress and caregiver burden following head injury
The negative phenomena associated with caring for victims of illness and
injury is defined as caregiver burden. Caregiver burden may be further categorized
into objective burden and subjective burden. Objective burden includes changes in
the patient's personality and behavior which are seen by the caregiver as well as
financial strain, changes in the daily routine, changes in living conditions, and changes
in social activities. Subjective burden is defined as the caregiver's negative reaction
in response to the presence of objective burden.
Many studies have looked at objective burden to predict subjective burden

and outcome in caregivers of head injury patients. Interestingly, there was no simple
relationship found between the severity of head injury, cognitive impairment, or
physical impairment and the caregiver's experience. Emotional impairments associated
with brain dysfunction however, was consistently associated with subjective burden
and negative physical and mental health outcomes for the caregiver. Mood disorders,
particularly depression and anxiety, have been reported consistently, and one study
showed that 60% of spouse caregivers of head-injured patients experienced distress
significant enough to warrant psychotropic medications. Many caregivers feel trapped
by their role, isolated from social, or abandoned by other family members. 25% of
relatives of patients with closed head injuries reported an illness such as migraine
headaches or asthma within the first year following injury.
There is a series of common emotional reactions reported by caregivers; of

head injury patients which progress from happiness (to have the family member
home) to bewilderment to grief and eventually to emotional disengagement from the
situation. Stress tends to result from an individual's reaction to environmental events
and that individual's appraisal of the situation. The stress reaction occurs in situations
where the demands of the environment exceed an individual's resources. The critical
component in the caregiver burden process is whether or not the caregiver perceives
the effects of the injury to exceed the caregiver's resources to manage the situation.
Perceived stress has consistently predicted negative outcomes for the caregiver.
Coping and social support are extremely important in helping caregivers

deal with stressful encounters. Coping refers to cognitive and behavioral efforts to
reduce or tolerated the demands created by a stressful transaction. People who use
more effective coping strategies experience less negative outcomes. Since caring for
head-injury persons is a situation with which few individuals have had previous
experience, the presence of coping strategies during the initial encounter may be
critical to perceived stress and successful coping with the situation. Ineffective coping
has been associated with anxiety, sleeplessness, and other negative outcomes.
Unsuccessful coping may result in perceiving the situation as more stressful, and
coping resources become scarcer over time. Interpersonal relationships (social
supports) also protect individuals against stressful encounters. However, many spouses
of head-injured patients have a decreased social support system, because they no
longer have a partner with whom to participate in social activities, and many feel
their partners to be more of a social handicap than spouses of non-head-injured
patients.
Age of the caregiver has also been associated with burden. Younger spouses
tend to be unhappy, perhaps due to "role overload". Women also report more subjective
burden and depression, and tend to use more avoidant coping strategies. The previous
mental and health history of the caregiver and perceptions of the patient's impairment
have not been consistently associated with subjective burden.
Work with families after head injury: A family centered approach
The families react to crisis in different ways. Some systems are able to support
and communicate with each other to find strength in dealing with the crisis. Other
family systems react by feeling unsupported and fall apart at the time of a traumatic
event. Several factors are listed that can have an impact on the family's ability to
respond to traumatic brain injuries. The need for family centered counseling and
support groups were stressed as an essential part of the rehabilitation process by
DePompei and Williams (1994). They also suggest that in understanding the family
and response to Traumatic Brain Injury, we need to look at the actual family system,
which makes up that system and what roles, rules, and communication patterns are
specific to that system. In our society, the family system can also consist of various
types of families and the cultural and ethnic concerns of the family have to be kept in
mind all the time. Responses such as grief, death and dying stages, episodic loss
through the life cycle, acceptance versus adjustment issues, and the employment of
the defense mechanism of denial are to be identified and worked with. Explanation
of the use of denial in both a functional (positive) and dysfunctional (negative)
perspective and the possible coping behaviors are to be explored. The broad categories
of work with families can be discussed as follows.
1. The family system's previous ability to function during crisis and the other
stress factors that may already be present at the time of injury.
2. The family's communication style
3. Ethnic and cultural background
4. The family's ability to access community resource.
5. The age of the TBI patient.
However, the importance of involving the family in all aspects of the

rehabilitation process (assessment, planning, and interventions) is of immense
importance. The treatment teams should provide appropriate teaching and educational
materials to assist the patient and family. Traumatic Brain Injury can be a life altering
experience. Understanding the specific family system can help carry out family
centered interventions. These include how the system reacts to a crisis and what that
systems needs are, we as professionals can begin to work more effectively with
patient and family members throughout the rehabilitation process.
Family involvement in brain injury rehabilitation
Families and professionals generally agree that families should become

involved in the rehabilitation process of traumatic brain injury patients. Unfortunately,
family involvement tends to be limited by logistic, attitudinal, and other barriers,
and both families and professionals often become frustrated, confused, and angry at
the discrepancy between what is considered ideal involvement versus the reality of
their involvement.
Shaw et al. (1997) developed a Family Involvement Questionnaire to examine

which specific kinds of involvement were perceived as being desirable by families
and professionals. The items evaluated 6 general categories: opportunities for family
input; availability of information and education regarding TBI; opportunities for
family involvement in treatment; opportunities for family advocacy; opportunities
for family contact with TBI patients; and availability of counseling and support
services for family members.
In the study, rehabilitation professionals and family members agreed on the

importance of sharing general information about head injured patients. However,
although the two groups generally agreed that families should be involved in patient
care, family members felt more strongly than rehabilitation professionals about the
need to participate directly in the treatment planning and ongoing rehabilitation of
the TBI patients, and about their rights to advocate for, and have frequent contacts
with, the patient. Conversely, rehabilitation professionals perceived family and
personal counseling as a more appropriate involvement than did family members.
In addition, family members desired immediate notification of changes in

the patient's status and therapy schedules (including minor health and behavioral
problems). They also felt entitled to routine copies of progress notes, copies of all
test results, and to be active participants in every meeting at which the patient's
progress is discussed. Professionals overwhelmingly felt that it was inappropriate
for families to receive copies of daily notes, and that they would feel constrained
about what they included in a written note if the family expected copies of every
note written. They also felt that reviewing the results of every specific test was time-
consuming, unnecessary, or logistically impossible, and that is was unreasonable for
families to hold them to rigid therapy schedules.
Finally, families generally felt strongly about the ability to have unrestricted
access to the patient, while professionals felt strongly that some restrictions were
appropriate, especially if the visit was unannounced. Professionals also placed much
more importance on the provision of counseling and support for family members,
including on marital and sexual issues. It is suggested that the next step would be to
develop strategies to maximize opportunities for family involvement while minimizing
conflict between the two groups.
Overview of family interventions

l Educating the family is very important, with regard to the current condition
and the prognosis of the patient.
l While communicating the breaking the bad news only the significant and
psychologically sound minded people must be selected to impart the
information.
l Severity of the injury, age, at the time of onset, academic issues and the family
environment can influence how a young person will adapt to the effects of
TBI
l Family with head injured members, also emerges with new problems, following
interventions are suggested to manage the problems, such as…
Creating a stable family situation, Improving Parent - child relationship,

Workable relationship with the family and professionals, utilization of social support
systems including the practice of networking, educational planning during the early
stage of re - entry into the family, and realistic expectation of the patient by the
family members, handling the reactions of the individual and family to TBI (Shock -
Denial - Grief - Gradual realization - Reorientation < Success, Survival and
Submission >).
Educational and vocational needs of individuals with brain injury
Return to work or school for individuals who have experienced a traumatic

brain injury could be a difficult process, but not a futile endeavor. There are many
stereotypes and prejudices that surround individuals with brain injuries and which
impact negatively upon their ability to perform within an educational or vocational
setting. Educating employers, employees, teachers, and students about the nature of
a brain injury and also about specific details relative to the individual's injury are
critical factors in ensuring effective services for both the individual with a brain
injury and the employers/teachers.
Individuals with brain injuries face numerous challenges when re-entering

educational and vocational settings. Physical, emotional, behavioral and cognitive
issues impact a great deal on performances and subsequent reintegration into society.
The results from a Support Person Model and its relationship to maintaining education
and employment (Neuropsychological Rehabilitation: Visions for the Future) stressed
the need for continuous rehabilitation after a brain injury. Their findings indicated
that individuals with brain injuries are better able to manage everyday successes and
failures when they are able to develop the necessary skills and learn strategies to
compensate for their limitations or deficits.
Developing a realistic individualized vocational/educational plan, providing
ongoing support and follow-up could help maximize independent functioning and
reintegration into society.
Family aspects of returning to work after brain injury
Returning to work after a traumatic brain injury is a prominent concern for

most survivors. Research and experience from professionals and family members
suggests that many individuals can make a transition back into work if they receive
support from employers, colleagues, and family members. Supportive efforts, patience
and persistence are extremely valuable in helping survivors of TBI obtain success in
their work. Various steps typically take place in the successful transition from the
hospital to home and the work place, the psychiatric social worker recognizes these
steps and facilitates the onward journey of productivity.
Recognizing the effects of traumatic brain injury
The person with a brain injury may experience various changes that can
significantly alter their lifestyle. These changes do not only affect the person with
the injury but the entire family and anyone who is emotionally involved with the
person who has been injured. Families most often have to come to grips with the
significant cognitive, physical, personality, and emotional changes exhibited by a
family member who has been injured. With these changes comes a greater
responsibility in dealing with new challenges that arise due to a traumatic brain
injury.
The family must be able to prepare themselves in dealing with the significant
emotional and physical demands over a period of time. Some of these demands include
recognizing that a brain injury survivor may never be the same, taking on additional
financial and household chores, and dealing with the healthcare system on a regular
basis. Recognizing the affects and changes on the survivor and family members is
the first step towards coping and dealing with a brain injury.
Survivors of brain injury typically experience rapid improvement in the first

three to six months following injury. After this period many individuals become
frustrated when they continue to deal with cognitive and behavioral symptoms.
Kreutzer, J.S. and Kolakowsky-Hayner (2001) report that individuals who sustained
a brain injury and adjusted well possessed easy irritability, frustration, short
temperedness, confusion and memory loss.

Role of psychiatric social worker
In hospital
The following are the identified areas in which the psychiatric social worker
in hospital can contribute the services
l Psycho education to the family member and Patient regarding nature of Head
of injury and need for the treatments as well as further follow up.
l Clarification of the doubts of the patient and family.
l Pre and post operative counseling to alleviate the fear and anxiety,
l Group Therapy for the patient and the family to ventilate their feelings and
emotions and also facilitate interaction among the group.
l Trauma Counseling
l Supportive Therapy for the patient and the needed family members
l Creating a support group
l Resource identification and resource utililization
l Family counseling to make the family to accept the patient with his limitations
and to make the family adjust with the new demands of the role change.
l Breaking the bad news - if the condition is severe or deteriorating
l Addressing the disability benefits and facilitate availing these benefits.
l Collaboration with NGO, Police, Media etc. for unknown patient services.
l Rehabilitation of patients in coordination with available resources
l Pre discharge counseling
In community
l Create awareness among the people about head injury, causes, nature, and
symptoms, first aid and treatment availability, through coordinating with NGOs,
Youth Clubs, Women Support groups, Govt. Welfare agencies.
l Contributing to the Policy framing
l Community based Rehabilitation
Conclusion:
Personality and emotional disruption have decided impact on the life of adjustment
of those with brain injury. The disruptive behaviors may persist for several years,
only contributing to adaptive difficulties. With the understanding of both family and
the professional are better to approach the brain injury from a perspective based on
hope tempered by reality. From this frame of reference, effective intervention can be
designed that may help the person and his family to live more adaptively with the
realities of brain injury and the other challenges of life and living.

Chapter 19
PSYCHOSOCIAL INTERVENTIONS IN NEUROSURGICAL SETTING
N. Krishna Reddy,1 A.Durai Pandi,2 & Atiq Ahmed,3
Introduction
In the wake of the nineteenth century very little was known and understood
about the nervous system and much less about brain. It is science and technological
advancement which has drastically changed the medical profession and one among
the advancing field of super specialty is neurosurgery. There has been a drastic
improvement in treatment procedures and a very deeper understanding of the nervous
system and brain, however, the other dimension viz., psychosocial is understood
very poorly. A holistic approach towards treatment needs psychosocial interventions,
which are yet to be explored, understood and to be found. This article tries to present
a brief outline of neurosurgical complications and associated psychosocial
consequences; an endeavor is made to introduce to the reader the basic psychosocial
interventions which are in use.
Understanding Neurosurgery
Neurosurgery is the surgical discipline focused on treating those central,
peripheral nervous system and spinal column diseases amenable to mechanical
intervention. Neurosurgical Interventions aims to alleviate Pain and Suffering arising
from the Disorders/ illness of Nervous System. Neurosurgical conditions include
primarily brain, spinal cord, vertebral column and peripheral nerve disorders.
Brain and Spinal Cord are Susceptible to

l Tumors
l Infection
l Vascular Lesions
l Trauma Or Injury
l Congenital Disorders
Common Neurosurgical Complications

The following conditions are identified by advanced neurosciences as more
common than others affecting the human being.
Brain Tumors
Any mass or growth of abnormal cells occurring in the brain tissue, skull,
supportive tissue around the brain, cranial nerves, or the pituitary or pineal gland can
be a brain tumor.
1. Associate Professor 2. Psychiatric Social Worker 3. Ph. D Scholar

Primary tumors are those that develop in the brain; secondary brain tumors
originate somewhere else in the body and spread to the brain. Malignant, or high-
grade, tumors contain cancer cells.Cancerous cells in the brain grow rapidly and
involve the healthy tissue around them. Eventually, a malignant tumor destroys the
normal cells and interferes with their functions. Tumors can cause severe neurological
impairment, such as seizures, behavioral changes and memory loss, and can interfere
with normal, vital brain functions and is also life threatening. Common Symptoms
of the brain tumors include recurrent headaches, loss of sensation in parts of body,
nausea, giddiness and sometimes loss of vision or hearing capacity.
Head injury
Head Injury is a traumatic condition of nervous system resulting from an
injury to skull, the brain or both structures that is sufficient to get the attention of
medical consultation and which interferes the person's normal activity. Various
causes of head injury include, accidents, especially motor vehicle accidents, Sports
injuries, Falls at home and at work place, violence or clashes, shaken baby syndrome
( a baby is shaken with enough force to cause severe counter-coup injury)
Symptoms of head injury may occur immediately or they may develop slowly
over several hours. Depending on the cause, mechanism, and extent of injury; the
severity of head injury is assessed by the help of symptoms displayed. The commonest
symptoms which can appear separately and or in clusters, include brief or transient
loss of consciousness, fainting or passing out, headache, nausea, dizziness, changes
in vision such as blurred vision or tired eyes, ringing in the ears, seizures, confusion,
fatigue or lethargy, trouble with memory, concentration, attention, altered sensorium
etc.
Cerebral Aneurysm
A cerebral aneurysm (also known as an intracranial or intra cerebral
aneurysm) is a weak or thin spot on a blood vessel in the brain that balloons out and
fills with blood. The bulging aneurysm can put pressure on a nerve or surrounding
brain tissue. It may also leak or rupture, spilling blood into the surrounding tissue
(called a hemorrhage). Some cerebral aneurysms, particularly those that are very
small, do not bleed or cause other problems. Cerebral aneurysms can occur anywhere
in the brain, but most are located along a loop of arteries that run between the underside
of the brain and the base of the skull. Most cerebral aneurysms are congenital, resulting
from an inborn abnormality in an artery wall. Cerebral aneurysms are also more
common in people with certain genetic diseases, such as connective tissue disorders
and polycystic kidney disease, and certain circulatory disorders, such as arteriovenous
malformations
Other causes include trauma or injury to the head, high blood pressure,
infection, tumors, atherosclerosis (a blood vessel disease in which fats build up on
the inside of artery walls) and other diseases of the vascular system, cigarette smoking,
and drug abuse. Some investigators have speculated that oral contraceptives may
increase the risk of developing aneurysms.Aneurysms may burst and bleed into the
brain, causing serious complications including hemorrhagic stroke, permanent nerve
damage, or death. Once it has burst, the aneurysm may burst again and rebelled into
the brain, and additional aneurysms may also occur. More commonly, rupture may
cause a subarachnoid hemorrhage-bleeding into the space between the skull bone
and the brain.
A delayed but serious complication of subarachnoid hemorrhage is

hydrocephalus, in which the excessive buildup of cerebrospinal fluid in the skull
dilates fluid pathways called ventricles that can swell and press on the brain tissue.
Another delayed post rupture complication is vasospasm, in which other blood vessels
in the brain contract and limit blood flow to vital areas of the brain. This reduced
blood flow can cause stroke or tissue damage.
The symptoms vary depending on the location of the aneurysm. Swelling

with a throbbing mass at the site of an aneurysm is often seen if it occurs near the
body surface. Aneurysms within the body or brain often have no symptoms In the
case of rupture, low blood pressure, high heart rate, and lightheadedness may occur.
The risk of death after a rupture is high.Many of the complex issues associated with
the treatment of aneurysms remain controversial. Towgood, Ogden and Mee (2004)
reviewed neurological, neuropsychological, and psychosocial outcome following
treatment of unruptured intracranial aneurysms and found that most of the studies
reviewed address outcome in terms of mortality and neurological morbidity. Very
few studies exist which include measures of outcome such as cognitive status,
psychosocial functioning and quality of life. They suggest that it is important to take
into account the long-term consequences of Aneurysm and its treatment.
Hydrocephalus
Hydrocephalus is a term derived from the Greek words "hydro" meaning water,
and "cephalus" meaning head, and this condition is sometimes known as "water on the
brain". Hydrocephalus is usually due to blockage of cerebrospinal fluid (CSF) outflow in
the ventricles or in the subarachnoid space over the brain. In a normal healthy person,
CSF continuously circulates through the brain and its ventricles and the spinal cord and is
continuously drained away into the circulatory system. In a hydrocephalic situation, the
fluid accumulates in the ventricles, and the brain and skull may become enlarged because
of the great volume of fluid pressing against them.
This may cause increased intracranial pressure inside the skull and progressive
enlargement of the head, convulsion, and mental retardation in children. It is also a
comorbid condition in various central nervours system complications. Alternatively,
the condition may result from an overproduction of the CSF fluid, from a congenital
malformation blocking normal drainage of the fluid, or from complications of head
injuries or infections.
Moilanen et al. (1985) had looked into the psychosomatic symptoms and
family characteristics of children with hydrocephaly and noted that the children
frequently showed behaviour disorders of the MBD-type, e.g. concentration
difficulties, aggressiveness, fastidious eating and nervousness. The hydrocephalic
childrens' families showed very significantly more cohesion and less rigidity, and
significantly less authoritarianism. When examining the parents' attitudes to their
sick child, one third of the children were seen to be in a healthy role, with parental
expectations realistically related to the child's abilities. One third of the children
were seen as "babies", with unnecessarily over-protective attitudes on the part of
their parents, and one third as "scapegoats", with accusatory attitudes from their
mother and father. Those in the role of "scapegoats" had the poorest perceptual skills,
the highest frequencies of behaviour disorders and the poorest self-concept.
Prolapsed intervertebral disc (PIVD)
Prolapsed literally means "To fall out of place." A spinal disc herniation is
also sometimes called disc prolapse. It is a condition affecting the spine, in which a
tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc allows the
soft, central portion (nucleus pulposus) to bulge out. Some of the terms commonly
used to describe the condition include herniated disc, prolapsed disc, ruptured disc,
and the misleading expression "slipped disc." Other terms that are closely related
include disc protrusion, bulging disc, pinched nerve, sciatica, disc disease, disc
degeneration, degenerative disc disease, and black disc.
Disc herniation can occur in any disc in the spine, but the two most common
forms are the cervical disc herniation and the lumbar disc herniation. The latter is the
most common, causing lower back pain (lumbago) and often leg pain as well, in
which case it is commonly referred to as sciatica. Lumbar disc herniation occurs 15
times more often than cervical (neck) disc herniation, and it is one of the most common
causes of lower back pain. The cervical discs are affected 8% of the time and the
upper-to-mid-back (thoracic) discs only 1 - 2% of the time.
Causes of a disc herniation can include general wear and tear on the disc
over time, repetitive movements, and stress on the disc that occurs while twisting
and lifting, genomic susceptibility, or other injuries.
The chief complaint for spinal disc herniation is leg pain greater than lower
back pain, symptoms of a herniated disc can vary depending on the location of the
herniation and the types of soft tissue that become involved. They can range from
little or no pain if the disc is the only tissue injured to severe and unrelenting neck or
low back pain that will radiate into the regions served by an affected nerve root when
it is irritated or impinged by the herniated material. Other symptoms may include
sensory changes such as numbness, tingling, muscular weakness, paralysis,
paresthesia, and affection of reflexes. If the herniated disk is of the Lumbar region
the patient may also experience sciatica due to irritation of the sciatic nerve. Unlike
a pulsating pain or pain that comes and goes, which can be caused by muscle spasm,
pain from a herniated disc is usually continuous.
Spina bifida
Spina bifida (Latin: "split spine") is a developmental birth defect involving
the neural tube: incomplete closure of the embryonic neural tube results in an
incompletely formed spinal cord. In addition, the bones of the spine (vertebrae)
overlying the open portion of the spinal cord do not fully form and remain unfused
and open. This allows the abnormal portion of the spinal cord to protrude through
the opening in the bones. There may or may not be a fluid filled sac surrounding the
open spinal cord. Spina bifida can be surgically closed after birth, but this does not
restore normal function to the affected part of the spinal cord and an individual with
this condition will have dysfunction of the spinal cord and associated nerves from
the point of the open defect and below.
Symptoms and complications vary with the extent of the spinal defect. The
most common location of the malformations is the lumbar and sacral areas of the
spinal cord. The lumbar nerves control the muscles in the hip, leg, knee and foot, and
help to keep the body erect. The sacral nerves control some of the muscles in the
feet, bowel and urinary bladder, and the ability to have an erection. Some degree of
impairment can be expected in these areas, resulting in varying degrees of paralysis,
absence of skin sensation, and poor or absent bowel and/or bladder control, curvature
of the spine (scoliosis), depending on the severity and location of the lesion damage
on the spine. Although these individuals are rarely mentally retarded, in most cases
there are cognitive problems.
Other conditions treated by Neurosurgeons include:

v Spinal disc herniation
v Spinal stenosis
v Hydrocephalus
v Head trauma (brain hemorrhages, skull fractures, etc.)
v Spinal cord trauma
v Traumatic injuries of peripheral nerves
v Brain tumors
v Infections and infestations
v Tumors of the spine, spinal cord and peripheral nerves
v Cerebral aneurysms
v Some forms of hemorrhagic stroke, such as subarachnoid hemorrhages, as
well as intraparenchymal and intraventricular hemorrhages
v Some forms of pharmacologically resistant epilepsy
v Some forms of movement disorders (advanced Parkinson's disease, chorea,
hemiballism) - this involves the use of specially developed minimally invasive
stereotactic techniques (functional, stereotactic neurosurgery)
v Intractable pain of cancer or trauma patients and cranial/peripheral nerve pain
v Some forms of intractable psychiatric disorders
v Malformations of the nervous system
v Carotid artery stenosis
v Vascular malformations (i.e., arteriovenous malformations, venous angiomas,
cavernous angiomas, capillary telangectasias) of the brain and spinal cord
v Peripheral neuropathies such as Carpal Tunnel Syndrome and ulnar neuropathy
v Moyamoya disease
v Congenital malformations of the nervous system, including spina bifida and
craniosynostosis
Major symptoms of neurosurgical complications
These are various symptoms which patients with neurosurgical complications

would undergo. Some of the symptoms could be seen independently or may arise in
clusters and, in varying intensity and frequency. Any of the following symptoms
which may be on and off or present mildly and or increasing in intensity should be
consulted to rule out any physiological pathology.
v Brief or transient loss of consciousness

v Fainting or passing out
v Headache, nausea, dizziness, lightheadedness,
v Changes in vision, Ringing in the ears,
v Bad taste in the mouth, altered sense of smell,
v Numbness or weakness in any part of body
v Blindness, deafness, speech related problems,
v Persistent vomiting,
v Personality changes or altered sensorium
v Seizures
v Fatigue or lethargy,
v Altered sleep patterns,
v Loss of Muscle coordination,
v Disorientation, Confusion,
v Trouble with memory,
v Emotional and behavioral problems
v Trouble with concentration, attention,
v Restlessness, irritability, depression, etc.
Impact of neurosurgical problems

Despite many common psychosocial features, the differences between the
various neurosurgical conditions is mainly psychological rather than physiological,
because of greater 'post-traumatic-stress-reaction' and it stresses the need for
appropriate psychosocial care immediately after neurosurgery to reduce unnecessary
distress and costs to patients, carers, and community. Pritchard et al. (2004) compared
cohorts of elective and emergency neurosurgical patients: and psychosocial outcomes
of acoustic neuroma and aneurysmal sub arachnoid hemorrhage patients and carers.
It was found that both cohorts were generally satisfied with neurosurgical in-patient
care but both suffered high-economic costs and were predominately very dissatisfied
with community care. There were significant psychosocial differences between
elective and emergency patients, and despite greater relative physical disability among
elective patients, it was the emergency cohort who had worse psychosocial outcomes.
Buchanan, Elias and Goplen (2000) concluded with their study that despite
the neurosurgeon's classification of patients as having a "good recovery" or "moderate
disability," the majority of patients surgically treated reported psychosocial and
neurobehavioral changes that were disabling for them and burdensome to their family.
Patients and relatives who are interviewed separately by an experienced clinician
may provide differing perspectives on neurosurgical illness and its outcome which
are not necessarily good.
Between surgery and radiotherapy patients with a malignant brain tumor

may encounter a number of psychosocial issues that could invoke an anxious or
depressive response. Kilbride, Smith and Grant (2007) found that heightened level
of anxiety was present in patients of pre radiotherapy. This anxiety is more prevalent
in younger patients and is not related to the patients change in functional state and
anxiety was more common in younger patients. Anxiety was slightly more frequent
pre-radiotherapy. A past medical history of depression is a predictor of significant
depression in the post-operative period.
Psychiatric social work interventions

Patient education
Patient Education to the patient as well as to the family members about the
nature of the illness, symptoms, causes, diagnosis, prognosis, treatment and possible
side effects of treatments has to be explained. Patient and the family need to be given
proper orientation about the illness. This would alleviate significant distress and
help in preparing the patient and family to face the crisis in a better way. Patient
education can prevent certain reactions like helplessness, hopelessness and doctor
shopping.
Supportive therapy
Supportive Therapy needs to be provided to the patient and family members
who are significantly distressed out of the illness. Ventilation and reassurance is a
techniques used to alleviate the distress.
Group intervention
Group intervention aimed to form a net work for the patient and the family
to share their experience, ventilate their feelings, discuss about handling the practical
difficulties etc.
Behaviour modification
It's aims to modify the undesirable behaviour and the behaviour changes
happened due to damage in the brain.
Breaking the bad news

It is one of the daunting tasks for the social worker. bad news can be at any
form. It may be telling about the diagnosis, prognosis, treatments and possible side
effects of treatments even telling about the treatment cast. all the family members
including the patients (if conscious) has to be properly assessed in terms of their
level of knowledge about the illness, their confidence , ability to receive the bad
news and handle the feature demands etc,. after assessing the family ,appropriate
members has to be selected and gradually bad news has to be disclosed.
Family interventions
Family counseling need to provided to the family to adapting to the effects
of Illness, Creating a stable family situation, Realistic expectations of the pt, Handling
the reactions of the family, accepting the lose , adopting to the behaviour and
personality changes , handling the illness behavior and negative expressed emotions.
Apart from the psychosocial interventions by a psychiatric social worker the

interdisciplinary neuroscience team, along with colleagues from neuroradiology,
ophthalmology, and endocrinology, can join together to care of patient their family
to meet their complex health and psychosocial needs. Dusik (2004) highlighted this
issue with the help of an example of Ms.Kerry, a case of recurrent craniopharyngioma.
And they learnt about perseverance, strength, and the power of an unconquerable
human spirit.
Pre operative counseling

Studies conducted in various parts on world regarding pre operative concerns
reveals patients and family members have shown significant preoperative distress
before the operation which is characterized by anxiety, depression, postponing the
Surgery, uncooperative to surgery, etc., conducting ex-patients group meeting ,real
live examples, bibliotherapy, supportive therapy, patient education and simple
relaxation techniques can alleviate the anxiety associate with surgery.
Block et al. (2001) in a study found that Medical and psychological risk
levels were significantly related to outcome, with the poorest results obtained by
patients having both high psychological and medical risk and concluded that
presurgical psychological screening should be routinely applied on patients in whom
spine surgery is being considered. It can be generalized to other neurosurgical
conditions too, which highlights that presurgical psychological evaluation and
counseling is an essential part of psychosocial interventions.

Post operative counseling
Post operative counseling will help the patient and family to handle the body
image concerns, possible functional impairments and future demands, etc., Hermann,
Wyler and Somes (1992) with an extensive study have tried to explain that
postoperative psychosocial adjustment is the adequacy of their preoperative
psychosocial adjustment, among the patients with brain surgery.
Community re-entry training

Community re-entry training focuses training in activities of daily living,
Cognitive and vocational training, Restore & ensure Psychological Well-being,
Therapeutic recreation , Utilization of social support systems for the effective
functioning in the community after the hospitalization.
Trauma counseling
It helps the patients and family members to handle traumatic reactions.
Resource identification and utilization

Identify the material and non material recourses which is present in the person
himself family themselves and the community itself and asses whether those resources
have been utilized for the betterment of the patients if not
Addressing the disability benefits

Most of the neurosurgical conditions are significantly disability inducing.
Most of the disability benefits applicable for the physically disabled can be applicable
to the person with neurological disability also. Facilitating patients to avail disability
benefits is one of the major role of social worker.
Unknown patients services

Psychiatric social worker may need to collaborate with NGO, Police, Media
in order to trace the family members of unknown patients who are victims of road
traffic accidents and are admitted in casualty by the public or police.
Pre discharge counseling

It focuses on preparing the family and the patient to adapt to a new lifestyle
as well as handle the practical difficulties likely to arise. It also helps to emphasize
the importance of follow up and further medical management.
Research
Conducting research in the area of neurosurgery in terms of psychosocial problems
associated with neurosurgical conditions and the effectiveness of psychiatric social
work interventions to alleviate those psychosocial problems. This will give mental
health professionals information on the psychosocial experiences of patients and
families with neurosurgical complications and the possible psychosocial methods to
solve those problems.
Rehabilitation
This is the ultimate goal for a functionally impaired individual with a
neurosurgical condition. The social worker has to formulate appropriate rehabilitation
measures within the functional ability of the patient to improve his/her quality of life
as well as to enable them to lead an independent and satisfactory life.
Psychosocial determinants of recovery

The recovery of an individual would depend on a number of factors such as
the severity and type of illness, personality make up of the individual, person's previous
satisfaction with selected activities, presence or absence of therapeutic interventions,
familial and social relations of patients, religion and philosophy of life, life stages of
the person, family integration and ability to face challenges, social support and his
ability to live with uncertainty and ambiguity.
Conclusion
Every medical problem has its own psychosocial impact on the individual,
family and the one who are near and dear to the individual. Most neurosurgical
conditions are life threatening and significant disability inducing. Both patients and
family members would face various bio-psycho-social problems. The provision of
essential psychosocial support to patients and family is essential in order to prevent
personal and family disorganization.

Chapter 20
PSYCHOSOCIAL CARE IN DISASTER MANAGEMENT
K. Sekar,1 & Aravind Raj,2
Introduction
Disasters, natural or human made, causes huge loss of life, economic loss
and makes the community function with less effectiveness. Countries including
developed, developing and underdeveloped countries, faced disaster, either natural
or manmade, and has come across a huge loss in terms of human and economic loss
(CRED, 2005). The term disaster is defined in many ways by different organisations.
For instance, Centre for Research on the Epidemiology of Disasters (CRED) defines
disaster as a situation or event which overwhelms local capacity, necessitating a
request to national and international level for external assistance, an unforeseen and
often sudden event that causes great damage, destruction and human suffering.
Disaster Management Act (2005) of India, defines disaster as a catastrophe, mishap,
calamity or grave occurrence affecting any area, arising from natural or human made
causes or by accident or negligence which results in substantial loss of life or human
suffering or damage to and destruction of, property, or damage to, or degradation of
environment, and is of such a nature or magnitude as beyond the coping capacity of
the community of the affected area.
In any disaster, the psychosocial impact is one of the major impacts that
arise due to different types of losses faced by the survivors. World Health Organisation
(WHO) adds the psychosocial dimension in a disaster by defining disaster as a severe
disruption of ecological and psycho social aspects which greatly exceeds the coping
capacity of affected community (WHO, 1992). This definition gives a broader
understanding of the need to address psychosocial issues in disaster management.
Disasters in India
India supports one sixth of the world's population on just 2% of its land
mass. It suffers heavily from natural disasters of every shade and description that
hits the poorest of the poor. In India, 12% of land is vulnerable to floods, 8% of land
is vulnerable to Cyclones, 59% of land is vulnerable to earthquakes and 28% of land
is vulnerable to Drought (Bhandari, 2006). Of the 35 states and union territories, as
many as 27 are prone to disasters which very well explains the disaster profile and
the extent of impact of disasters in India.
1. Professor and Head 2. Ph. D Scholar

Thus India could be called as "theatre of disasters" as almost all types of
disaster that includes natural disasters like earthquake, cyclone, Tsunami, drought
etc. and man made disasters like gas tragedy, communal riots and terrorist activities
has hit India at different point of time which was in increase in the last one decade.
Table: 1- Major disasters in India (1984-2004)
No Type of disaster State Year

1 Bhopal Gas leak Disaster Madhya Pradesh December , 1984
2 Marathwada Earthquake Maharashtra September , 1993
3 Orissa super cyclone Orissa October , 1999
4 Earthquake Gujarat January , 2001
5 Communal riots Gujarat February , 2002
6 Tsunami South India -

Tamil Nadu, Andhra
Pradesh, Kerala &
Pandicherry, Andaman
& Nicobar islands December , 2004
7 Earthquake Jammu & Kashmir October , 2005
Impact of disaster
The impact of disaster varies from physical, psychological, social and

economic impact where these impacts are interlinked and one such impact leads to
the other. The various social issues that arise in the aftermath of disaster are
displacement, changes in marital status and family structures featuring widows, single
parent families or orphans, there is a disruption in the social fabric and a breakdown
in the traditional forms of social support in the affected communities. There is a high
rate of unemployment due to the loss of primary livelihood and secondary livelihood
sources related to the loss of infrastructure and alternative occupational availability
to revitalize the economic conditions. These social issues in the disaster situation
produce a large amount of psychological distress in the survivors which results in
the decreased functionality of the individual and the community.
Psychological reactions to disaster
Any disaster is followed by different kinds of emotional reactions at different

points of time after disaster due to the various psychosocial issues that affects the
individual and the community. The immediate emotional reactions (in rescue and
rehabilitation phase) are tension, panic, anxiety, shock and numbness, flashbacks
and nightmares, relief, elation, euphoria among the survivors, sadness, anger, blame,
survivor's guilt. In the later stages the emotional reactions varies from prolonged
grief, inability to adjust, post traumatic stress disorder, depression, dissociative
reactions, dependence on substance, Somatisation (Sekar, 2005).
Psychosocial care
Psychosocial care is a process that deals with a broad range of psychosocial

problems and promotes the restoration of the social cohesion and infrastructure as
well as the independence and dignity of individual and groups. It serves to prevent
pathologic developments and further social dislocations (Aarts, 2001)
From the international disaster literature the following broad principles of Mental
Health care has been identified. (SAMHSA, 1999)
l No one who experiences the event or witnesses the event is untouched by the
event.
l Disasters result in two types of trauma, namely the individual and the collective
trauma.
l Most people pull together and function during and after a disaster but their
effectiveness is diminished.
l Disaster stress and grief reactions are normal responses to an abnormal
situation.
l Many emotional reactions of disaster survivors stem from problems of living
caused by the disaster.
l Disaster mental health services must be uniquely tailored to the community
they serve.
l Survivors respond to active interest and concern.
l Interventions must be appropriate to the phase of the disaster.
l Support systems are crucial for recovery.
Psychosocial care should be provided to facilitate the normalization of the

emotional reactions after the disaster. International organisations like WHO (1992,
2003), Red Cross (2001, 2003) have also identified this component of care as essential
in their activities. It is a scholastic approach to rehabilitation with the objective of
making individual and communities more resilient.
The analogy of a person with an injury would help in understanding the

need for psychosocial care. An injury to any part of the body will heal over a period
of time because the body has the ability to repair the damage. The natural healing
process takes some time. However, if the person gets immediate first aid for his
injury, the healing will be hastened, thereby gradually reducing the pain and
discomfort. But on the other hand, imagine if these helps are not available and the
wound is unattended. The wound is likely to get infected and healing will be delayed
leaving a bad scar. This might even cause some disability in the normal functioning
of that part of the body. It is important to note that in both instances the scar remains.
However in the former, the scar is light and does not produce limitation. In the latter,
the scar is deep and produces disability.
Similarly any emotional reaction like grief and pain due to loss and death
will require help to facilitate ventilation or relieving. This would work like the sterile
cloth preventing infection, and allowing the body to work and heal. It also helps the
individual to gain mastery over their emotions and resume normal life. Unavailability
of such help to release or share these emotions will leave a scare in the mind. Therefore,
it is very important for people to share the pain, feelings and thoughts about personal
losses.
Psychosocial care at different phases of disaster
Rescue Relief Rehabilitation and Rebuilding or Reconstruction phases are

different phases of disaster. The psychosocial care is a process and it has to be initiated
right from the rescue phase and should go on till the reconstruction phase which is
essential part of the overall interventions. The form of care varies with each phase
and the local situation. During the time of disaster, the people are forced towards
basic survival and are left to fend for themselves. In the rescue phase, volunteers and
others at the disaster scene can provide essential emotional first aid and form the
base for further intensive psychosocial care and rehabilitation by trained community
workers and the professionals in the relief and rehabilitation phases.
The emotional first aid during the initial rescue phase includes, meeting the
immediate needs of the disaster, listening to the survivor, Linking with family and
community members, helping them to get relief materials etc.
During the relief phase, psychosocial support helps to build up the primary
support by mobilizing the individual strength, ensuring family unity and building the
community resources. These support systems are crucial for recovery. The rebuilding
of the support systems through psychosocial intervention at individual, group, and
community level is of utmost importance.
The emotional reactions reported by the people are the normal responses to
an abnormal situation. It is estimated that nearly 90% of survivors of any disaster do
undergo these emotional reactions immediately after the disaster. However it reduces
to 30% over a period of time with psychological reactions of stress leading to change
in behaviour, relationship, physical or psychological symptoms. The psychosocial
rehabilitation helps in providing basic mental health care and the referral needs for
higher order mental health care.
The psychosocial care in reconstruction phase aims at the competence
building activities like life skills approach, disaster preparedness activities that enables
the survivors to be better prepared to deal with the challenges of every day life. The
final stages of rebuilding of the support system should be directed towards developing
a caring community for the survivors and thus making the community independent.
Need for spectrum of psychosocial care intervention
The main techniques of psychosocial care are helping the individual and
community to ventilate their emotions, active listening, showing empathy, helping
them to externalize their interests, building the social support, main streaming the
survivors in to relaxation and recreational activities and involving them in spiritual
activities in the process of helping them to get back to their normal life. But the care
should not be limited to the relief and psychological support. The care should be
holistic because psychosocial care, not only means emotional support but also practical
help, suggestions, guidance, providing information and education.
So under the spectrum of psychosocial care the focus should be identification

of needs and attention to specific problems related to areas like medical facility,
legal aid, livelihood, housing, compensation along with providing the basic
psychosocial care. Referrals would be made as and when required and there would
be a commitment of long term work.
In the process of providing spectrum of psychosocial care, one should keep

in mind that the social support system of the individual and the community is totally
disrupted due to disaster. Therefore, along with providing emotional support and
care to the survivors, it becomes important to attempt to rebuild the pre existing
support system that the individual had previously. At the initial phase of disaster,
support would come from the external sources, but gradually efforts should be made
to strengthen the affected community to such an extent that it is capable of rebuilding
and providing the required support to its members. Support and care needs to be
built not only at the individual and family level but also at the community level, so
that every individual gets the care and support during the times of distress. There is
a need to build up a caring community where in each and every member in the
community would be supportive and involved in each other's well being. This also
would make the individual, family and the community as self reliant and independent
in the process of providing psychosocial care.
Thus the role of psychosocial care intervention is to focus on the normalization

of the individuals through various ways as mentioned above and the effort is to move
the agenda from deviancy to normalcy and give no labels to the affected people to
stigmatize them. There is an effort not to talk of 'mental cases' and 'people going
mad' which give a derogatory connotation to essential normal reactions to an abnormal
experience.
Psychosocial care services
The capacity building of the community level workers is one of the important
means of providing psychosocial care services to the affected population for a broader
reach in a short period of time. The main objective of capacity building in the context
of psychosocial care for the community level workers is to provide essential
knowledge and develop necessary skills for providing psychosocial care by ensuring
individual initiatives family unity and mobilizing community resources, capacity
building also involves self care initiatives for a disaster worker in the form of stress
management programs for the workers. There are different modules in which the
workers could be trained on psychosocial care for disaster survivors.
After testing in for so many years in different disaster affected areas, the
standardized training modules currently available are:
No. Days Training modules Hours

1 7 days Holistic module 49
2 4 days Holistic basic module. 32
3 3 days Medium basic module. 24
4 2 days Short basic module. 16
5 1 day Sensitization module. 8
The training content of the basic module comprises of the understanding on

disaster, importance of psychosocial care during disaster, sharing of experiences of
Tsunami, needs of the survivors, social support during disaster, different reactions
due to stress, normal & abnormal reactions, principles and techniques of psychosocial
care, spectrum of care for the survivors. The above sessions gives a general
understanding for the trainees on psychosocial care for the survivors.
The session on women covers the discussion on the issues of women in

disaster, the various factors that make women vulnerable during disaster, general
principles to work with women, session on body mapping (only for women) that
empowers the trainees to look in to the internal resources of women for effective
coping strategies during disaster, need for change in the attitude towards women for
empowering women in disaster situation. Simultaneously the issues of men during
disaster are also discussed by the men and both the sessions would be shared between
the two groups.
The children issues covers the need for special care for children, the
psychosocial problems related to children of various groups, the qualities to work
with children, the various mediums to work with children and the various children

problems for which the referral is required. The session gives an insight to the
participants on the problems of children during disaster in different dimensions and
the effectiveness of the mediums to work with the affected children.
The stress induced in Personal, Professional and Familial life for those who
are involved in working for the survivors of the disaster would be handled through
the session on stress management. This helps the participants to internalize the fact
that stress is an inseparable part in every one's life and it could be better handled
only with one's own effort through following positive life styles, relaxation, recreation,
pleasurable activities and having a strong social support.
The session on implementation and documentation in psychosocial care

includes the introduction of tools on the psychosocial indicators and also a group
discussion by various sectors on the action plan of each sector after the workshop.
The qualitative and quantitative documentation and the process documentation of
the psychosocial work would be emphasized through the sessions.
The training program also includes the review of the manuals on psychosocial
care for the survivors of Tsunami, orientation visit to the various clinical departments
of NIMHANS, visit to a counseling centre. The training sessions ends with the post
assessment of the participants on their knowledge level on psychosocial care using
the same tools administered for the pre assessment. The content of the training program
varies depending on the number of days of training program.
The various tools available for the training programs are:
l Natural disaster information manual 1: Psychosocial care for individuals/

families
l Natural disaster information manual 2: Psychosocial care by community level
workers
l Natural disaster information manual 3: Psychosocial care for children
l Natural disaster information manual 4: Psychosocial care for women
l Psychosocial care in disaster management- My Work book
l Facilitation manual for Trainers of Trainees in Natural Disasters
l Stress management work book
The above mentioned training materials are available in different languages

like English, Tamil, Malayalam, Telugu, Hindi, Kannada and Urdu. These materials
are very useful as reference materials for the trainees who attend the training program
and get back to the community to implement psychosocial care services.
Indicators of Psychosocial care
The basic indicators of psychosocial care are the level of psychological

distress, impact of the disaster, disability due to distress, quality of life and quality of
community life. A study was taken up during Gujarat Riots in 2002, to find out the
effectiveness of psychosocial care in the affected areas. For this study, an area where
the psychosocial care interventions were provided along with other services were
selected as experimental group (Intervened) and the other area where the services
except psychosocial care services were provided was selected as the control group
(Non Intervened). The diagram given below shows that the distress, disability, impact
and burden are less and at the same time the quality of life is high among the intervened
group when compared to the non intervened group.
70
60
50
40
30
20
10
0
Disability Burden Impact Distress QOL
Intervened Non intervened
Figure 1 - impact of psychosocial care interventions
35
30
25
20 BASE LINE
6 MONTHS
15 1 YEAR
10
0
IES SRQ DISABILITY
Figure 2- follow up study on the impact of psychosocial intervention

for survivors of Tsunami in Tamil Nadu
Figure 2 represents the effectiveness of psychosocial care interventions over
a period of time in terms of impact of the disaster, psychological distress and the
disability of the Tsunami affected population in Nagapatinam, Kanniyakumari and
Cuddalore Districts by averaging the mean scores of all these three districts.
The impact of the disaster in Tamil Nadu shows the average impact as 28.4
during the base line data which is similar to all the individual district scores and it
has gradually come down to the 22.5 and 13.3 in the first follow up and the second
follow up study which varies from the individual district scores in the respective
periods. This could be because of the various disasters like flood, high tides in different
places at different parts of time.
The distress level on a average for all the three districts comes to 8.6 during
the base line study and the distress level has gradually come down to 3.8 and 2.9
during the first follow up and the second follow up study . The disability level,
similar to that of the distress level, has gradually decreased from 30 during the base
line study to 14.8 and 11.3 during the first and the second follow up study.
Role of social workers in providing psychosocial care
Social workers play a major role in providing psychosocial care for the
survivors of disaster. The various techniques and methods of social work can be
used in psychosocial care interventions at different phases. The basic principles of
social work, believing in the inherent dignity and worth of all people, acceptance,
working with rather than for people, a non judgmental attitude etc. lend themselves
to an effective outlook towards working the aftermath of a disaster. Social Workers
reach out in a manner where the relationship formed with people is healing and
therapeutic in itself apart from the practical interventions being made (Dave, 2004).
Drawing on the resource base of subjects, such as sociology, psychology, research,
political science, economics etc. help social workers make holistic interventions.
They gain a certain fluidity that helps them to look at needs in a multifaceted manner.
Capacity building
Training of the community level workers in providing psychosocial care for

the survivors of disaster is one of the major roles of the social workers. Training
helps in building the social capital in disaster situation. Capacity building helps to
bridge the gap between theoretical and field realities and help trainees gain skills
required to work in the field. The other types of training would focus on getting
information about survivor experience, recovery and rehabilitation processes. Another
area of training includes managing field program, documentation, monitoring and
researches depending upon the requirements of the trainees.

Services
i. Rescue and Relief phase
The major role played by social workers is to reduce the distress of survivors.
Listening to the survivors and meet their basic needs helps them to deal with the
emotions of grief, anger, loneliness, sadness etc. and helps to form a close bond with
the survivors as well as healing them as they shared their experiences. Helping the
community in taking up initiatives, for example, involving women in cooking and
cleaning, young men in organizing and storing of relief materials, men in putting up
the temporary shelters enable the people to start relying on their own capacities.
Social workers play a crucial role in making effective linkages between the survivors
and the available resources.
ii. Rehabilitation & Reconstruction phase
Interventions at this stage focus on making people own the process and
become equal partners in the entire rebuilding process from planning to
implementation. The simultaneous need assessment of the people helps in providing
right intervention at the right time and to meet their needs at all fronts. The assessment
of physical, psychological, economic and social needs forms the major part of the
need assessment. This ensures that the options chosen are viable, sustainable, and
owned by the people. Providing spectrum of care, by supplementing the roles of
other professionals and aid workers to meet the needs of the people is an important
role of a Social Worker.
Research, Documentation and Monitoring
The skills of social worker in research, documentation and monitoring helps

in influencing public opinion, evaluating interventions and redefining future
interventions. Research and documentation is one area that has to be really
strengthened in the field of psychosocial care because that is the only evidence to
show its effectiveness. Also the documented materials as well as field experiences
and research can be used to educate the general public, policy makers, planners and
professionals in bringing about social change.
Conclusion
Psychosocial care is not mere counseling services for the survivors of disaster,
rather it covers spectrum of care to enhance the coping capacity of the survivors as
well as the whole community and change it to a caring community. To achieve this
goal, the deprofessionalization of psychosocial care services is essential. Though
there are some policy level initiatives such as the national health policy (2002)
recognizes the need for an adequately robust disaster management plan to be in
place to effectively cope with situations arising from natural and man made calamities,
only the effective implementation of such plans makes the difference. Social workers
play a vital role in making this difference both in policy as well as implementation of
psychosocial care interventions as an integral part of disaster management.

Chapter 21
COMMUNITY BASED DISASTER PREPAREDNESS
E. Aravind Raj,1 & K. Sekar,2
Introduction
Disaster management is one of the prime focuses of the Government of India

considering the frequencies of occurrence of natural and man made disasters in the
country. Disaster management in recent years has had a paradigm shift in its approach.
The center of gravity stands visibly shifted from relief and rehabilitation to
preparedness, prevention, mitigation and planning. Disaster Management Act (2005),
National Disaster Management Authority (NDMA) and inclusion of crisis
management in the second Administrative Reforms Commission (2005) are some of
the recent developments in the last three years which paved way for effective
management of disasters in India.
Disaster preparedness
Disaster preparedness is a set of activities that you can undertake to reduce
the monumental loss and damage that the disaster can cause, to organize and facilitate
timely and effective rescue, relief and rehabilitation measures that would further
facilitate in rebuilding the disaster affected community.
The message emanating from the International Decade for Natural Disaster
Reduction in May, 1994 underlined the need for an emphatic shift in the strategy for
disaster mitigation. It was stressed that disaster prevention, mitigation, preparedness
and relief are four elements which contribute to and gain from the implementation of
the sustainable development policies. These elements along with environmental
protection and sustainable development, are closely inter related, and it was therefore,
recommended that Nations should incorporate them in their development plans and
ensure efficient follow up measures at the community, sub-regional, regional, national
and international levels. The disaster prevention, mitigation and preparedness are
better than disaster response in achieving the goals and objectives of vulnerability
reduction. Disaster response alone is not sufficient as it yields only temporary results
at a very high cost. Prevention and mitigation contribute to lasting improvement in
safety and are essential to integrated Disaster Management. (Ministry of Home Affairs,
2004)
Community based disaster preparedness

Communities are at the frontline of disasters. Over the last two decades it
has become apparent that top-down approaches alone to disaster risk management
fail to address the specific local needs of vulnerable communities, often ignoring the
local capacities and resources. At times this approach further increases the
vulnerability of the community.
1. Ph. D Scholar 2. Professor and Head

In response to the limitations of this top-down methodology, the Community-
Based Disaster Management emerged as an alternative approach, during the decades
of 1980s and 1990s (ADPC, 2007).
Approaches in community based disaster preparedness
Community-Based Disaster Preparedness (CBDP) approaches are

increasingly important elements of vulnerability reduction and Disaster Management
strategies. They are associated with a policy trend that values the knowledge and
capacities of local people and builds on local resources, including social capital.
CBDP may be instrumental not only in formulating local coping and adaptation
strategies, but also in situating them within wider development planning and debates.
In theory, local people can be mobilized to resist unsustainable (vulnerability
increasing) forms of development or livelihood practices and to raise local concerns
more effectively with political representatives (Allen, 2006).
The underlying objective of CBDP activities is to reduce vulnerability and

increase the capacity. Working in a cooperative and participatory manner with
communities, if done properly, can reduce the impact that disasters have on the lives
of the people. Community work or community based approach encourages maximum
work, high participation, leads to action on the part of community members, moves
away from dependency on outside resources/ experts to the use of community
resources and attempts to maximize citizen control of decision making (IFRC, 2005).
Rather than providing only services which deal with the effects of problems,
community work involves having members address the causes of problems.
Service delivery Vs. Capacity building of community (Community based

approach)
Service Delivery Community based approach

Reactive Proactive
Needs driven Core problem driven
Minimum participation High Participation
Top down approach Bottom up approach
One approach Constantly reinventing approaches
Creates dependency Power shifts to community
Static Adaptive as situation changes
Low training needs High training needs

Models of Community Based Disaster Preparedness
OXFAM model
OXFAM in its CBDP model explains about the contingency plan and the
formation of different groups. The village contingency plan (OXFAM, 2001) includes
five stages that include discussing what happened in the village during the last disaster,
situational analysis - making the description of the village, hazard mapping, risk
mapping and opportunity mapping. This contingency plan has to be made involving
the community people with the support of the GO and NGO sectors. Once this is
discussed, task force groups would be formed. The different task force groups are,
Early Warning Groups, Shelter Management Groups, Evacuation and Rescue Group,
First aid and Medical Group, Sanitation Group, Relief Group, Patrolling Groups,
Liasoning Group, Carcass and Corpse Disposal Groups, Counselling Group, Damage
Assessment Group and Rehabilitation and Reconstruction Group
UNDP (2002) responses to CBDP in India
Disaster Management Teams (DMT) are formed at different levels to carry

out the activities during emergency for sustainable recovery from disaster such as
State, District, Municipality, Block, Gram Panchayat, Community and Ward. DMT
at village/ward level would comprise of a group of 10-12 people in task-based groups
such as Early Warning (EW), Search and Rescue Operation (SRO), First Aid & Water
& Sanitation (FAWS), Shelter Management (SM), Trauma Counseling (TC) and
Damage Assessment (DA) groups. Similarly, DMT at Gram Panchayat, Municipal
and Block level may be formed with the involvement of people representatives,
members from local administrative system like local Police, Medical Officer, Junior
Engineer from Rural Water Supply and Sanitation, Veterinary Assistance Surgeon /
Inspectors, Revenue Inspector, Block Development Officers (BDO) etc. BDO would
be the convener of the team at the Block level.
Functioning of the task force group
Training would be a continuous process on Disaster Risk Management

Programme. The trained cadre of the Block will facilitate the process of Disaster
Preparedness and Response Plan development at different levels. Selected village
volunteers will be provided with three modular training programmes to develop the
village disaster management plans. One or two volunteers will be selected by the
PRIs/ CBOs/NGOs from their own locality, based on their past experiences on relief
and rehabilitation activities for facilitating the process at village and GP levels. More
emphasis will be given to women volunteers in the development of village disaster
management activities. Specialized training will be organized at different levels for
the Disaster Management Team members for enhancement of skills to effectively
carry out their responsibilities such as warning dissemination, search and rescue
operation, shelter management, fist aid, trauma counseling and damage assessment
etc. The DMT members will be provided a specific type of apron or jacket for easy
identification after the training. Adequate training will be provided to the women
DMTs to carry out activities during emergency situation. UNDP in coordination
with Government of India had implemented the CBDP program in 169 districts in
the country.
Limitations of CBDP in India
The existing literature as discussed above talks about the Disaster

Preparedness. Training modules at village level for teachers, panchayat members,
village leaders etc., formation of village contingency plan, the government initiatives
on Disaster Risk Management etc. But the inclusion of psychosocial aspects in Disaster
Preparedness is very less and even in the village task group that are formed as a
Disaster Preparedness activity, the counseling group is mentioned whose activities
would be just restricted to counseling the survivors of disaster and does not cover
the spectrum of psychosocial care.
Psychosocial consequences of disaster
Life after disaster changes drastically. Daily routines and lifestyles are
disrupted completely for the people who come to stay in relief camps. People find it
difficult to perform even the simple everyday routines that were an integral part of
their lives. This often hurts them deeply. The constant intrusion into their privacy is
a source of tension for them. This has different psychosocial consequences for different
people.
For women it would be a shock because many would see them without proper
clothing, they have great difficulty maintaining their personal hygiene, especially
during menstruation. Several women experience disturbances in their menstrual
cycles. Pregnant women and those with new born babies would be at risk for infections
and would not receive pre and post natal care.
Due to loss of employment and curtailed freedom of movement the men in

the relief camps usually would spend their time sitting idle, without any productive
output. There would be no work to keep them occupied, instead, they would brood
over their conditions and thus bring upon greater distress to themselves. The adolescent
boys are at a stage of sexual awareness, and the camps give them plenty of proximity
to girls of their age, something they were not accustomed in their earlier life styles.
Adolescent girls would be at greater risk of sexual misbehaviour and lack of privacy.
Children would have little space to play. They would not be interested to
attend schools because of the fear of the disasters. There would be constant worries
and doubts about the disaster for the children. Several children would witness the
deaths and injuries and they would not be able to comprehend the tragedy and would
not be in a position to express their feelings and fear about the disaster.
Psychosocial care in Community Based Disaster Preparedness
The psychosocial consequences on different vulnerable groups could be

prevented and it makes their life more productive rather than providing curative
services. It is very imperative to include the psychosocial care as one of the important
components of Disaster Preparedness. The Disaster Management Team (DMT) should
be strengthened in providing training program on psychosocial care to the community
as an integrated service. The emotional reactions can be prevented from becoming
more severe if services such as information, psychological education, and support
groups are provided.
Basic principles for psychological support in disaster preparedness (IFRC, 2003)
l A community based approach should be adopted.

l The community volunteer technicians and specialists should be used and
involved.
l The program should be technically appropriate and sensitive to the cultural
and linguistic diversity of the country.
l Identifying and strengthening problem solving resources in the community.
The major components of psychosocial care in Disaster Preparedness include

the assessment of the vulnerable groups like children, women, aged and disabled in
the community, need for creating the social support system and the network in the
community, understanding the different emotional reactions due to the various
psychosocial consequences after the disaster, understanding that the reactions are
normal reactions in an abnormal situation, identification of various resources available
inside and outside the community for the vulnerable groups, awareness and education
on provision of psychological first aid, psychosocial care and psychosocial
rehabilitation. The Psychosocial Disaster Preparedness Program focus on three phases
namely psychosocial care before, during and after disaster.
Psychosocial care before disaster
l The counseling group of Disaster Management Teams should be given training

on psychosocial care for the survivors.
l The importance of psychosocial care and different techniques of providing
psychosocial care needs to be emphasized.
l The inputs on psychosocial care for the other teams of Disaster Management
Teams should be provided through the counselling groups so as to integrate
psychosocial care services by all the teams of DMT.
l The identification of vulnerable and risk groups in the disaster
l Identification of internal and external support systems available for the
individuals and families in the communities.
l Capacity building for the CLWs on psychosocial care in Disaster Preparedness
for the survivors of disaster
Psychosocial care during disaster
I Meeting the immediate needs of the disaster survivors that include food, water,
clothing, shelter and medications
I Helping the family members of the deceased to carry out the death ceremonies
that would enable them to accept the loss.
I Listening to the survivor about his/her personal experiences of the disaster
I Linking with family and community members
I Attending to the medical needs of the disaster survivors
I Helping them to get relief materials
Psychosocial care after disaster
I Providing quicker support for the vulnerable groups with the help of the
identified support systems inside and outside the community.
I Provide correct information on disaster and discourage the rumors in the
community.
I Ensure integration of psychosocial care services in the community through
the DMT teams and CLWs.
I Continuous psychosocial need assessment and provision of psychosocial care
services according to the need at different phases after the disaster.
I Strengthen mental health centers and rehabilitation centers in a long run.
I Institutionalize the psychosocial care services in the community with the use
of social infrastructure already in existence.
Thus psychosocial component in CBDP explains about the various stages of

Psychosocial Disaster Preparedness and the integration of psychosocial disaster
preparedness in CBDP through the DMTs.
Role of Schools of Social Work in CBDP
Schools of social work play a major role in Community Based Disaster

Preparedness (CBDP) program and the integration of psychosocial care component
in CBDP. In any disaster, students and faculty from different schools of social work
jump in to the relief services as early as possible. They lend their services in terms of
rescue, relief and need assessment. The role of schools of social work in the
rehabilitation and reconstruction phase is limited due to unavailability of adequate
syllabus on Disaster Management and lack knowledge on the role of social workers
in long term care for the survivors of disaster. In terms of role of Schools of Social
Work in Disaster Preparedness, there are two steps in preparedness, i.e., preparing
Schools of Social Work and Social Workers in providing psychosocial care services
for the survivors of disaster and secondly they in turn preparing the community to
face the disaster effectively.
Networking on disaster management
To overcome the limitation, networking workshops on disaster management

by schools of social work in different parts of the country has been initiated with the
technical support from the Department of Psychiatric Social Work, NIMHANS. The
first nodal hub was formed in North East India which will be coordinated by the
Department of Psychiatric Social Work, LGB Regional Institute of Mental Health,
Tezpur, Assam. In Karnataka, Roshini Nilaya School of Social Work, Mangalore
coordinated the Networking Workshop in which nine schools of social work
participated. In Tamil Nadu, 12 Schools of Social Work participated in the networking
meeting coordinated by the Department of Social Work, Karpagam College,
Coimbatore and in Kerala three hubs were formed. Department of Social Work, St.
Joseph's College, Calicut would coordinate with seven schools of social work and
Department of Social Work, Bharat Matha College, Ernakulam would coordinate
with 11 Schools of Social Work and Department of Social Work, Marian College,
Kuttikkanam would coordinate with ten Schools of Social Work in Kerala.
Through these networks various training programs, workshops and field

activities could be carried out by the different schools of social work. This would
enable the social workers to learn from the on hand experience as well as from
other's experience. This networking through out India would help the social workers
to be more prepared and equipped to work in a disaster situation.
Followed by the training program and the workshops, the Concurrent Field
Placement and Block Placement as part of the Social Work Curriculum in disaster
affected areas in association with organisations working in disaster and emergency
situations would enable the students to practice psychosocial care services more
effectively. This is also a formidable platform to initiate CBDP programs as a
preventive measure in the community. Social Workers in general and Psychiatric
Social Workers in specific should emphasize on integration of psychosocial component
in CBDP which helps the survivors to receive a holistic Community Based Disaster
Preparedness program.

Conclusion
Community participation, including socially excluded and vulnerable groups, must

be an integral part of Disaster Preparedness interventions. It is also important to
involve the professional social workers to integrate the psychosocial component of
preparedness in Community Based Disaster Programs. It is the responsibility of
social worker to emphasize on psychosocial issues and psychosocial care in the
Disaster Preparedness programs or Disaster Management programs.

Chapter 22
PSYCHIATRIC SOCIAL WORK SERVICES IN IN-PATIENT CARE
SETTINGS
D. Muralidhar,1 & E.Sinu,2
Introduction
Psychiatric social workers are integral part of the Multi-disciplinary health
care team at NIMHANS. They work mainly with psychiatric, neurological and
neurosurgical patients. They play a crucial role in hospital settings by helping patients
and families in addressing the impact of the illness on the individuals and the family
members. Tremendous stress often stems from the hospitalizations that are sudden
and at times related to catastrophic nature of illness or injury. Stressors such as
decreased personal control, change in functional ability, information overload and
reduced financial resources can lead to a range of emotional responses such as anger,
anxiety and depression in family members.
Psychiatric Social Workers as a part of the health care team provide

assessment and appropriate interventions. They commonly provide individual, group
and family intervention, crisis intervention at the time of crisis, patient /family
education, resource mobilization, Advocacy and referral services both in-patient
setting and out-patient setting. Psychiatric social workers render psychosocial care
and other services to the patients and the families. Psychiatric Social Workers often
have specific expertise in the areas of Adult psychiatry, Child Psychiatry, Family
psychiatry, De-addiction, Neurology, Neurosurgery, Casualty and emergency set up
and palliative care and community care.
Guidelines for Working with Individuals

1. Every patient is evaluated in terms of psychological and social aspects of
functioning. There should be minimum understanding of the patient's social
milieu and current psychosocial situation and how it relates to patient's visit to
the facility.
2. Informed consent is obtained prior to starting a planned treatment program.
This need to be done at out-patient department (OPD) for patient requiring IP
care under Pre-admission counseling. In case patient get admitted under
emergency care/mid week admission, it can be done as and when necessary
before patient starts getting formal planned treatment. Content of pre-admission
counseling consist of information on goals, approximate during of treatment
and stay, types of treatment like pharmacological and psychosocial
intervention, types of investigations, as well as risks involved, anticipated side-
effects of medicine, hospital rules and regulations, approximately estimated
hospital charges for treatment should be clearly explained and discussed with
each patient in a language he/she can understand. When the patient is not in
condition of understanding the information or giving informed consent, this
should be obtained with his/ her significant caregiver or personal representative.
1. Additional Professor 2. Psychiatric Social Worker

No treatment procedure except for emergency ones should be started before
these steps have been taken.
3. Psychosocial treatment plans need to be written down for each patient and
followed by social workers. Psychosocial management plan should be
appropriate for the patient's clinical conditions, age and socio-economic status.
4. There should be clear cut written guidelines on the indications, rationale for
use of particular psychosocial intervention strategies.
5. Patients need to be kept informed about their progress in each area of bio-
psycho-social conditions.
6. Social worker should always speak to patients in a friendly, courteous, positive,
purposeful and professional manner.
7. Social workers need to see the new patients at least 45 minutes till the
psychosocial assessments gets over.
8. Social workers need to spend daily at least 20 minutes to see the patients for
psychosocial interventions in the ward,
9. Meetings are held regularly with supervisor of the social worker to discuss the
individual patient care plan and progress during ward rounds /review meetings.
10. Trainees at least need to spend 10 % of their work time with their supervisor,
for supervision, guidance, and discussion of the cases in a week during weekly
reviews. Progress of the intervention can be updated as and when required.
Guidelines for psychiatric social workers to work with families
1. Involvement of family members in the patient's treatment program is essential.

2. Families need to be thoroughly orientated towards various mental illnesses,
impact on health, family, occupational, psychological, and social functioning.
3. Complete family assessments need to be carried out in first few days of
admission so that intervention can be planned according to family environment,
family socio-economic status, living arrangements, interaction patterns and
quality of relationships, family burden, family adjustment, family expectations
and social support network,
4. Family members / caregivers who are not staying with the patient are
encouraged to participate in family support groups / and other intervention
programmes for family members. Identification of unsupportive family
members is also important.
5. They are encouraged to visit the patient on regular basis minimum of thrice in
a week.
6. Family members need to be informed about patient's health progress and
condition.
7. Home visit can be made if the patients' houses are within 50-60 km range from
hospital for improving caring skills, coping skills of families of some selected
patients' house and when their family members do not visit the health care
facility frequently, Office visit and visits to other agencies like workplace,
government organizations and non-government organization for the purpose

of collateral contacts, resource mobilization and rehabilitation.
8. Family members are needed to be thoroughly oriented to the scope of service,
facilities and provisions available for patients and family members in the
hospital.
9. Discharge plans are discussed with patient and the concerned family members.
10. Family members need to be educated on prodromal conditions, early warning
signs of relapse, exacerbations, reappearance of symptoms, in terms of acute
care management, managing crisis / emergencies and the need for re-
hospitalization.
11. Upon discharge, a standard information form on discharge plans need to be
enclosed in the file. The same information at least on maintenance medication;
social, occupational and family needs; special areas of attention and specific
risks should be in two sheets - eventually with a carbon copy: one to be given
to the patient and the other one to be attached in the case file.
12. Upon discharge, a standard information form is given to the patient. The patient
and / his/her family are to be requested to bring this form during the first
follow-up.
Role of psychiatric social worker in in-patient care
Psycho social assessment (pre-assessment)

a) Self-introduction and Gathering information on socio-demographic profile of
the hospitalized patients Assessment of help seeking behaviour and expectations
of the hospitalized patients, family members and significant others.
b) Assessment of family /social burden and Impact of psychiatric disorders,
neurological, and neurosurgical disorders on patient and family members.
c) Assessment of patients, family members' knowledge and attitude towards
psychiatric disorders, neurological, and neurosurgical disorders.
d) Assessment of impact of hospitalization on patient and family members.
e) Assessment of needs of the hospitalized patients and family members.
f) Assessment of social support system of the patients and family members and
financial resources.
g) Assessment of family interactions and relationships and dynamics.
h) Assessment of disability level at the time of admission.
i) Assessment of functioning level of the patients at the time of admission.
j) Any other assessments
k) Psychosocial analysis and social diagnosis for formulation of appropriate
psychosocial intervention.
Psycho social intervention in inpatient setting

a) Intervention to address the negative impacts of hospitalization (Hospital anxiety
and depression and realistic expectations.
b) To ease the Burden of the family members and significant others in view of
the nature of the illness.
c) To strengthen, to improve the coping strategies, abilities of the patients and
family members and to prepare them to continue maintenance treatment, and
to live with chronic illness/disability in order to promote better adjustments
in role performance, house hold responsibilities and personal, family,
occupational and social and interpersonal personal relationships according to
their needs and expectations.
d) Education to patients and family members regarding illness, treatment,
medication management and psychosocial rehabilitation services.
e) To strengthen social support network in existing primary, secondary and tertiary
support system of persons with neurological, neurosurgical and psychiatric
disorders who have moderate to severe disability.
f) Income re-assessment and Psycho-education.
g) Correspondence with hospital administration for waiving off hospital charges
in case of patients from lower socioeconomic strata.
h) Offering group intervention programmes for patients and family members.
i) Family intervention for relationship problems and post discharge care, after
care service.
j) Preparation of patients and family members for Blood test, Liver Function
test, LP, CT, MRI- SCAN, ECT, EEG, ECG, other investigative, invasive and
operative procedures.
k) Pre and Post operative counseling.
l) Helping patients and family members to make their own decisions and their
own discharge plan.
m) Addressing the felt needs of patients and family members, pre-admission
counseling.
n) Disability intervention (arranging disability certificate, rehabilitation)
o) Resource mobilization (like arranging medicines, funds for operation. Linkage
to available community resources and services)
p) Collateral contact and liaison work with community agencies for placement.
q) Referrals to appropriate after care services like half-way home. (Living
arrangement)
r) Counseling for preparing the patient for discharge to avoid abrupt discharges
(Pre-discharge Counseling).
s) Working with families and counseling them in case of discharge against medical
advice.
t) Arrangement of transport for needy patients and family members to facilitate
(easy discharge) smooth transition from hospital to alternate level of care like
half-way homes, day care centers and other agencies. .
u) Assisting patients and family members in procuring medicines to facilitate
discharge.
v) Assisting patients and family members in obtaining necessary documents.
w) Grief counseling services, Bereavement therapy for family members if patient
expires during the course of hospitalization due to illness severity, and
unexpected operation failures.
x) Intervention during discharge and crisis periods.
Assessment during post discharge (post- assessment)
l Assessment of level of understanding information on illness and treatment
l Assessment of disability level at the time of discharge
l Assessment of global level of personal, family and occupational functioning
l Assessment of met needs and unmet needs after discharge
l Assessment of family burden after discharge
Documentation
1) Documentation of detailed psychosocial assessment and interventions process
2) Recording the notes and issues discussed during Multi-disciplinary team
consultant's rounds/reviews.
3) Recording the patients and family members discharge plan and
multidisciplinary team members' suggestions and inputs regarding the index
patient's discharge plan.
4) Recording the progress of implementation of Discharge Plan.
5) Recording the psychiatric social worker's discussions with psychiatric social
work consultant regarding Discharge Plan of patients.
Specific roles
1) Pre-admission counseling
2) Psychosocial assessment through case history taking and detailed work up
3) Mental status examination
4) History clarification
5) Individual and group intervention
6) Pre-discharge counseling
Psycho-education
The reasons why psychiatric patients need information about their diagnosis are
that:
1. It is the right of every individual to know his/her diagnosis.

2. It is good professional practice to tell the patients about their diagnosis
3. It helps in leading to an open discussion of the ramifications of the disorder
4. It helps to know more about the possibility of recovery
5. Enables families to decide on the best mode of treatment
6. Discuss the fears about illness
7. Discussing medications for the patient.
J how it is expected to work, what are the possible side effects
J What would happen if they reduce/stop medicines/discontinue medications in
between?
J Counseling regarding precipitating factors, psychosocial factors in early
warning signs of relapse / exacerbations.
J Measures to be taken to avoid relapse

8. Remove the guilt feelings of family and provide support to cope with illness
9. Psycho-education can be given to de-stigmatize the illness.
Psychiatric social workers need to take necessary steps before revealing, while
revealing and after revealing the diagnosis. Social workers should not keep any secret
about the diagnosis to patients. While revealing the diagnosis, acknowledge their
feelings and give them time for acceptance before proceeding. Do not overload the
family with too much information at a time. Listen actively; give adequate time to
clarify doubts about the illness. Express empathy, and explain the reasons for
prognosis, the etiology, as well as prevalence rate.
Activity Scheduling
Most of the psychiatric patients who get admitted in in-patient care do not
use their time productively. Families as a result often complain that the affected
member is 'lazy'. This can be overcome by constructing a schedule of activities for
the affected member to do. It is important for the affected member to follow an
activity schedule for the following reasons:
l To keep the affected member engaged in useful tasks
l Helping the affected member to learn punctuality
l To improve his memory, attention, concentration and judgmental abilities
l To distract the affected member from becoming engrossed in the hallucinations
and delusions
l To help him to develop problem-solving abilities
l To improve his initiation and independence
l To improve his self-confidence
An activity is specific goal oriented behaviour. Activities like doing puzzles,

telling stories, playing games, singing, dancing, creative writing are non-productive.
Productive activities could be tasks like making a collage, stitching, making baskets,
etc.
When selecting an activity, it should meet the following criteria ; a) Be goal

directed b) Have meaning to the affected member-meet his individual needs c) Involve
mental and physical participation d) Be related to his interest and leisure activities e)
Be adaptable, gradable and age-appropriate .
An activity schedule involves the affected member 'doing' something i.e.

being participative, involved and productive. It should be a combination of work,
rest, leisure, self-care and sleep. Tasks should be attained in a graded manner. The
affected member should begin from a lower level of difficulty and then move to
higher levels. For example, initially an affected member can hang the clothes and
fold them when they dry. Later he/she could wash clothes, hang them to dry, fold
them and replace in the wardrobe. Tasks should not be time consuming. When
negotiating the activities that the affected member should do, psychiatric social worker
should:
1. Offer a wide variety of choice from which the affected member should choose
2. Give careful instructions on how to do the task
3. Ensure that the affected member has the capacity to do the task
4. Ensure that there is a high probability of success
5. Correct the errors
6. Encourage and compliment the affected member when he does it right
7. Advance the affected member to higher levels as he becomes competent in a
task
8. Encourage the affected member to have a sense of responsibility for
advancement in tasks
The family members may be required to supervise the affected member in

certain tasks. They should not pressurize the affected member to complete the activity
schedule in any form. They can occasionally remind the affected member when he
forgets to follow the schedule. A copy of the schedule is generally affixed in the
psychiatric ward/ affected member's room.
Group intervention
"Social group work is a method of social work which helps individuals to
enhance their social functioning through purposeful group experiences and cope
more effectively with their personal and group problems"(Konopka, 1963). The
objectives of Group intervention in IP care is to relieve tensions and anxieties in the
family members of patient, to help patients to resolve some of their problems, and to
assist patients in arriving at a clear understanding of some of the reasons of their
trouble, to enable patients to re-adaptation and rehabilitation.
Case management
Case management includes the functions of: psychosocial needs assessment;
individual care planning; referral and linking to appropriate services or supports;
ongoing monitoring of the care plan; advocacy; monitoring the client's mental state;
compliance with medication and possible side-effects; the establishment and
maintenance of a therapeutic relationship; and supportive counseling after-care,
continuity of care and follow-up.
Family intervention
In the early years families of people with chronic mental illness were often
considered as toxic and mental health professionals identified the family as the cause
of the illness. Soon however family members were regarded as cause of relapse due
to expressed emotions in the family. Off late families of mentally ill are being
increasing seen as the primary caretakers and researchers have begun to focus on the
family as a partners in care. Family intervention is an essential adjunct to
pharmacotherapy in decreasing the risk of relapse and hospitalization frequently
associated with mental illness. It is a strategy, designed to help and empower families
to cope with the mental illness through provision of support, education, skills training,
family consultation, support, advocacy groups, and other forms of assistance to
families. Psychiatric social worker can teach family members skills that will help
them to become more effective caretakers and cope more effectively with the bizarre
behavior of the ill family member. For example, by reducing the amount of expressed
emotion (defined as critical comments directed toward the patient and over
involvement in the patient's affairs) in the family environment, caregivers can reduce
the risk of the patient's relapse (Leff, Kuipers, 1982).
Psychiatric social workers can provide support for patients' family members,
teaching them skills for coping with stress and for expanding their social network.
Family therapy may help the family cope with the grief, guilt and anger of having a
mentally ill family member and deal with any other problems that may make care
giving more difficult. Over all Family intervention is effective in addressing the
mental health concerns of the families and patients in terms of reducing relapse,
expressed emotion, re-hospitalization, burden, increasing the awareness, and
increasing realistic expectations of treatment.
Role of psychiatric social worker in emergency care set up
Psychosocial problems are common among emergency care visitors, and

can remain undetected if not focused upon. The emergency care services provide
care for persons with urgent predominantly life threatening problems. Emergency
care has been regarded as a crisis not only on the patient but also on the family and
taxes the capacity of the family to cope with highly stressful situations. At the same
time, the psychosocial issues pertaining to the emergency have been grossly neglected
by the health care professionals due to the medicalization of the whole health care
delivery system. The social workers role in emergency care services have been
acknowledged but not fully implemented. The social work methods and philosophies
such as casework, group work, administration, crisis intervention, community work
etc have been well studied and researched in the area of emergency services and
found to be most effective and successful too. In order to provide "holistic care" it
has become significantly necessary to assess the psychosocial problems faced by the
patients and their family members and provide appropriate and immediate intervention
to them. The psychiatric social work interventions in the emergency care set up are
crisis intervention, supportive interventions, psycho-education, admission planning,
discharge planning, resource mobilization, information gathering, mediator between
professionals and patients and family. (Jangam, Rao 2004).
Psychiatric social worker in multidisciplinary mental health team
Historically, the practice of psychiatric in-patient care has been characterized

by unidisciplinary thinking, and individualistic. However, care of mentally ill persons
with complex and interactive health, social, and functional needs is best achieved
when the knowledge and skills of various mental health disciplines are shared and
integrated. Multidisciplinary, collaborative mental health care practice is an effective
means to plan, coordinate, and implement care of psychiatric in-patient.
Delivery of mental health services is the concept of working with a

multidisciplinary team. The literature related to working with a multidisciplinary
team in mental health reveals a widespread belief that collaboration among health
care professionals is desirable and results in therapeutic benefits for client outcomes.
Furthermore, it is perceived to enhance work satisfaction for health care professionals
(Freeman, & Miller, 1998). Psychiatric social work services in in-patient care offer
the opportunity to work closely in a multidisciplinary team with other mental
healthcare professionals such as psychiatrist, clinical psychologist, psychiatric nurses,
and occupational therapists. The skills and knowledge of mental health professionals
are needed to conduct a comprehensive multidimensional assessment of the physical,
psychological, social, emotional, functional, and social status of a mentally ill person.
Family members and caregivers should be participants in this process. Their
contribution to the assessment process, to problem solving, and to identifying and
selecting appropriate goals and acceptable outcomes is vital.
Fig: 1 Multidisciplinary Team
Psychiatric Social
Occupational Worker Psychiatrist
Therapist
In-patient
Support staff Care Clinical Psychologist
Family as partners
of care Psychiatric Nurse
Volunteers

Multidisciplinary team approaches utilize the skills and experience of
individuals from mental health disciplines (psychiatry, psychology, social work, and
nursing) with each discipline approaching the patient from their own perspective.
Most often, this approach involves separate individual consultations. This occurs in
a "one-stop-shop" fashion with all consultations occurring as part of weekly ward
rounds by unit head on a single day. Multidisciplinary teams to meet regularly, in
"case conference" to discuss about patient care in all aspect. Multidisciplinary team
provides psychiatric social worker more knowledge and experience to work with
patients. Psychiatric in-patient care by its very nature is multidisciplinary because
of the many competencies required for promoting optimal levels of recovery from
disabling mental disorders. The experts' contribution from professionals and
paraprofessionals is every essential who can individualize a comprehensive array of
evidence-based services with competency, consistency, continuity, coordination,
collaboration, and fidelity.
Issues in working in a multidisciplinary team

The following are the issues which arises commonly among new trainees
when they come to work in a mulitdisciplinary team for first time. However this may
not appilcable to well defined multidisciplinary teams.
l Definition problems: The term "multidisciplinary" is not well defined and

widely understood.
l Lack of clarity about the nature and over all functions of each discipline.
l Multidisciplinary/interdisciplinary tensions like professional conflict, lack of
respect or knowledge, attitudes of other staff.
l Supervision issues: lack of support and direction.
l Work pressure like insufficient time, deadlines, paperwork, demand on time,
late evening work hours)
l Communication issues ( between staff and staff, staff and patients)
l Knowledge of how to work as part of a team is taken for granted within the
realm of professional training.
l Research on working with a multidisciplinary team in inpatient mental health
care is underdeveloped
Conclusion
Social work as a profession forms an integral part of a bio-psychosocial
approach which has evolved as consequence of striving towards an enhanced holistic
patient care. In the process of continuous care for the patient in a more intensive
care environment, arises a need for addressing the emotional concerns of the patient
and his/her family. The helping profession comes into play with its humanistic
empathetic and non-judgmental skills to undertake the allied treatment essentials
and improves the standards of treatment experiences for the patient.

Apart from patient care, psychiatric social worker in in-patient care sensitizes
the other related professionals, regarding the need for empathy towards patients which
in turn improves the quality of care. Hospitalization related issues like role
replacement, role transformation, re-adaptation issues and rehabilitation programs
are the main concerns apart from clinical skills and theoretical understanding. The
assets of the psychiatric social worker is his intensive training in social work,
psychiatry, psychology and sociology. He is well trained and well equipped in these
above mentioned areas of specialties that are essential for multidisciplinary team to
provide holistic care for patient from all angles.

Chapter 23
SOCIAL WORK SERVICES FOR ADULT PSYCHIATRIC OUT PATIENTS
M. Chandrasekhar-Rao,1 & K. P. Soundarapandian,2
Introduction
In every hospital setting the patients are first registered at Out Patient
Department. Subsequently depending upon the need and severity of their illnesses
some of the patients are admitted in the hospital for in-patient care and the remaining,
a majority of the patients are treated at the out patient department. The in-patients
discharged from hospital are regularly followed up at the out patient department.
Thus, the out patients constitute a major bulk of the patient load in the hospital that
needs special attention from the service providers.
Out Patient Psychiatric services in mental hospitals and General Hospital

Psychiatry Departments have emerged as a need in the expanding mental health
field. Firstly, a large proportion of persons with diagnosable mental disorders are not
receiving services from mental hospitals (Key, and Jasman, 2006). The social stigma
attached to mental Illness is pernicious and it continues to grow and has terrible
effect on patients and their families. The origin of stigma is partly due to the mental
health services system (Sartorius, and Schulze, 2005) that failed to integrate it self
into the existing health and social care systems. Secondly, it is also known that mental
hospitalization leads to social breakdown and institutionalization syndromes and
increases chances for relapse in patient's illness. Lastly, a majority of the persons
with mental health problems do not require hospitalization. Moreover, the nature of
mental health interventions does not warrant the patients to get admitted to the mental
hospitals. The Common Mental Disorders such as depression constitute a large
proportion of the attendees in the psychiatric extension centers (Gururaj, and Isaac,
2004) and out patient departments. Management of these cases through out patient
services may be considered as a stigma reduction effort of modern mental health
field.
In the Psychiatric Out Patient Department, all the new patients are screened
by the medical officers and then referred to the multidisciplinary team consisting of
Psychiatrists, Psychiatric Social Workers (PSW), Clinical and Psychologists for brief
or detailed assessment and intervention. The old cases are directly seen by the same
team during the follow up visits.
Psychiatric social work services

Unlike their counterparts in other fields of social work, the Psychiatric Social
Workers are directly involved in most of the clinical and non clinical services provided
at Psychiatric Out Patient Department.
1. Additional Professor 2. Psychiatric Social Worker

The out patient services rendered by the Psychiatric Social Workers are a
meaningful blend of case history taking, independent psychosocial assessments and
therapeutic activities at individual, family and group levels( Parthasarathy and
Ranganathan, 2004) and using referrals for services available at other centers.
Detailed Case History Taking: The psychiatric social worker's involvement

in the detailed case history taking is mostly governed by the psychosocial nature of
mental health problems and the management strategies, their knowledge in dynamics
of human behaviour, and skills in communication and social relationships ( Sheafor,
et al. 2000). During the first contact with the patient and their family members the
Psychiatric Social Workers uses their engaging and relationship skills to explore the
psychosocial events and problems of the patients proceeding to their psychiatric
conditions. This requires collection of all the psychosocial issues surrounding the
psychiatric illnesses through detailed case history taking.
Detailed case history of psychiatric patients has several benefits to different

people. A part of the information is used by the psychiatrists to make psychiatric
diagnosis of the case. Such details include the origin and development of abnormal
feelings, thoughts and behaviours, changes in their severity along with duration of
time period, associated medical illnesses, and current mental status of the patient.
The remaining information is useful to social workers for formulating the social
diagnosis, an essential component of the mental health care of the patients. These
include socio-cultural and economic details, family constellation, family atmosphere
and dynamics, social resources, problems and functions, social network map, details
of childhood, education and occupation, pre and post marital functioning and
interactions and personality profile etc. This information is also useful to design
appropriate psychosocial interventions for different patients having different problems.
Case history taking process is also useful to patients and their care givers as
they get clear understanding of the psychosocial linkages to their psychiatric
conditions and means of bringing positive change, rather than labeling themselves
as mentally ill and mentally disabled. The information giving process would also
facilitate the therapeutic effects of exploration, ventilation, clarification, and insight
orientation to the patients and their care givers. Indeed much of the psychosocial
management of the cases would have occurred during this phase of information
exchange between the care providers and care receivers (Chandrasekhar - Rao, 1994).
Lastly, the case histories of the patients are also useful as secondary source information
in the Psychiatric and Social Work Research.
Social work interventions

There has been a long history of alliance between the social work profession
and mental health field that resulted into the birth of psychiatric social work. The
methodologies of social work, particularly the Social Casework and Social Group
Work have been applied to various types of clients in the mental health field and
experimented for their effectiveness ( Videka-Sherman, 1988). Similar studies
conducted in India have also endorsed the effectiveness of social work practice with
psychiatric patients. (Shariff, 1979 and Chandrasekhar-Rao, 1994). These studies
have reported that the Social Work Interventions used either alone or in combination
with the routine psychiatric services were more effective than the routine services or
no intervention at all. Some of these interventions include, the social work theory
based models of practice such as Psychosocial, Problem Solving, Behavioural
Modification, Family Therapeutic, Crisis Intervention and Task Centered Casework,
and remedial and interaction models of group work ( Turner, 1979).Some of the
important evidence based social work interventions include, Major Role therapy
with Schizophrenia, ( Hogarty, et al., 1973) Social work Intervention with Depressed
patients ( Corney, 1984 and Chandrasekhar-Rao, 1994). Other forms of Psychiatric
Social Work Services include Psycho Education at individual and group level, material
and non material assistance to the patients and the care givers and guidance to identify
and utilize the community resources for the rehabilitation of the patients. Replication
of these intervention strategies by the Psychiatric Social Workers would benefit many
patients in the Psychiatric Out Patient Department.
Referral services
Referral is an important activity of social workers in the Psychiatric Out
Patient Departments. The purpose of referral is to link the patients to the community
resources (Weissman, 1976) for the management of psychiatric condition, or
psychosocial problem or for the psychosocial rehabilitation. These linkages include
Marriage and Family Counselling centers, Rehabilitation centers (Half way homes,
long stay homes),Centers for Occupational Therapy and Vocational Guidance,
Agencies for income generation and employment assistance, Governmental and non
governmental agencies for social welfare etc The referral is not as simple as one
often thinks. Many referrals may end up in failure, because either the referral is not
essential or it is not appropriate. In order to make effective referral, it is necessary to
review the need for referral, availability and accessibility of appropriate facility or
resource for referral and the affordability and suitability of the patients to the resource.
The referral note must indicate the details of the patient and purpose of referral. A
simple referral note without educating the patients about the contents of it will not
give positive result.
Follow-up services
All the cases seen by the psychiatric team are regularly followed up at
periodical intervals, usually once in a month or two months. The purpose of the
psychiatric follow up is to monitor the effect of the interventions used in the preceding
time period or to review the sustainability of outcome after the interventions are
modified or withheld or terminated. During the follow up sessions the patients are
interviewed about their day to day activities and functions. Brief mental status
examination is conducted and regularity of medication and psychosocial inputs is
emphasized. The new problems or dysfunctions or impairments are assessed and if
necessary additional inputs are initiated immediately. The follow up services offered
by the psychiatric social workers of much useful to the patients and their care givers.
The patients will develop confidence and high self esteem by monitoring the positive
change in their feeling and behaviours which in turn prevents the onset of social
disability. The care givers will get the first hand information about the changes in the
behaviours of their patients that result in reduction of their burden
Conclusion
With the advent of modern psychiatry the social workers are increasingly
involved in the various activities of the mental health care system. The psychosocial
knowledge and skills of psychiatric social workers are extensively used in the care
of psychiatric patients and assisting their care givers. The benefits of the non-
pharmacological interventions to the psychiatric patients are being materialized
through active collaboration between the social workers and other mental health
professionals. The effective collaboration is achieved only through proper case
discussion and planning, utilization of case materials, collective decisions about the
case management and monitoring of outcome systematic termination and case closing.
Ineffective collaboration can arise when the social workers end up with routine case
history taking while other mental health professional practice their interventions in
isolation.
The terminologies such as Out Patient and In-patient services are often used
in the medical system of care. Indeed, follow up service is part of quality assurance
activity of the health care system. The psychiatric social workers with a social care
orientation and appropriate training profile need to overcome the hurdles in their
integration into the health care system of practice. This is possible only through their
profound knowledge in psychosocial aspects of mental illness, skills in engaging all
types of psychiatric patients, use of quick screening procedure for exploration of
social issues, systematic application of psychosocial assessments and interventions
and monitoring of the outcome. The psychiatric social workers need to perform their
functions in more scientific manner rather than using their personal prophecies.
Effective implementation of all the services of the psychiatric social workers

is further affected by their disproportionate numbers. Increasing the social work
manpower in mental health settings would go a long way for their services to 'Reach
the Un-reached.

Chapter 24
STRESS EXPERIENCED BY STAFF WORKING IN AN ORGANISATION
B. P. Nirmala,1 & Atiq Ahmed,2
Introduction
Stress is becoming an indispensable part of life. Recent life style changes

growing demands on people to find jobs, rising cost of living, fierce competition in
the workplace all contribute to increased stress. Stress has been found to have both
positive and negative influence on the human mind and body. Our bodies are designed
to feel stress and react to it. It keeps us alert and ready to avoid longer, sustained or
pervasive stress which tends to have an illness producing effect on the individual.
He may feel trapped and unable to cope especially if the person has a genetic
predisposition or genetic vulnerability to stress. Stress can be good (called eustress),
when it helps us to perform better or it can be bad (distress), when it causes upset or
makes us sick.
Dr. Jams Selye, the father of stress theory defined stress as "the non - specific
response of the body to any demand made upon it, another commonly accepted
definition of stress attributed to Richard S. Lazurus (1984) is that a person perceives
conditions that demand exceed the personal and social resources the individual is
able to mobilize.
Most investigators in India have made use of the Social Readjustment Rating
Scale (SRRS) developed by Holmes and Rahe (1967). Singh et al., attempted to
construct stressful life events, commonly experienced by normal Indian adult
population.
Stress and its management is of paramount importance in organizational

Practice, Rescue and Rehabilitation Work of stress management programme are
incorporated in the health care profession, people, who are working at various levels
will be able to recognize the stress factors inherent in their work place, and learn to
develop the preventive methods for mitigation of these stresses this in turn could
help to arrest the decline in Job - Performance burnout high turn over and family
related problems.
What is Stress?
Stress is an internal state which can by caused by physical demands on the

body or by environmental and Social Situations which are evaluated as potentially
harmful, uncontrollable, or exceeding our resources for coping.
1. Assistant Professor , Dept Of PSW 2. Ph. D Scholar, Dept Of PSW

What Causes Stress?
Stress can be caused by anything that requires you to adjust to a change in

your environment. Your body reacts to these changes with physical, mental and
emotional responses. We all have our own ways of coping with change, so the causes
of stress can be different for each person. There are external and internal causes of
stress.
External stressors include:

l Physical environment: noise, bright lights, heat, confined spaces.
l Social (interaction with people): rudeness, bossiness or aggressiveness on
the part of someone else.
l Organisational: rules, regulations, "red tape," deadlines.
l Major life events: death of a relative, lost job, promotion, new baby.
l Daily hassles: commuting, misplacing keys, mechanical breakdowns.
Staff stress
Staff stress is of particular concern in the caring profession: Some of the common
causes of the stress are:
1) Personal
2) Work
3) Role
1. Person
An individual's personality style may play a part in determining whether
one is attracted to his work and stays on or leaves it. Persons may be attracted to the
job due to excessive drive, financial benefits, to gain self esteem among peers to
achieve maximum in a minimum period of time. They have urgency in their work.
These types of persons are more prone to stress. There are others who prefers to
work in a slow pace, adopt to the changes, find work experience more interesting,
and stimulating. These kind of persons are committed to the organizations who employ
them. They do not quit on flimsy grounds. They are called as 'Hardy Personalities'.
Motivation to join Health Care profession may also be due to person's personal
emotional needs, missionary zeal to help others. These kinds of persons have difficulty
in working with authority figures, they are particularly vulnerable to stress as after
the job will cease to fulfill their demands.
Social support: The social relationships not only provide us a social support,
they may also prove to be a significant stressor, of due to some person, this support
is not available at the appropriate time. This system includes relatives, friends,
neighbors, fellow employees and professionals. During the early period of one's career,
there is a tendency to use his or her family primarily as "professional support system"
the complexities faced at work may be beyond family's understanding, they may

develop a "detached concern", leaving the professionals as open to psychological
problems and even suicide.
Stressful life event. A stressful life event may be seen as growths enhancing
eg, marriage, birth of child, as well are potentially destructive. Stress generating.
This is particularly true of chronic intermittent stressors like problems with marriage
personal problems including health problems, concerns regarding infertility,
pregnancy divorce/ separation. Family problems including problems with children,
in - laws, patients single parents, unemployed spouse etc, are some of them.
2. Stressors in the work environment

Team Communication problems: There are problems in the leader, who has
the right to take decision. Members do not know one another, they do not acknowledge
and recognize each others area of expertise. There is constant comparison between
the new entrant and person who has left. These communication distortion, and
breakdowns have frozen some competent health care professionals.
3. Role Ambiguity, Role Conflict and Role Overload

Roles are not clearly defined. There is uncertainty about what is expected,
being assertive, is felt as being aggressive. There are frequent power struggle and
rivalry in delegating roles. Since there are mutual accusation and blows when mistakes
occurs. People tend to avoid taking multiple roles.
Career Path concern: Sometimes jobs become routine, there may not be future
prospects but there are no options left either, hence professionals stick on to their
career without any involvement.
Manifestation of stress
Stress may be manifested as physical, psychological and behavioral problems.
Physical manifestations include constant fatigue, stomach ache, gastro

intestinal problems, head ache, appetite disturbance involving weight loss/gain,
menstrual irregularities, back ache, muscular problems, urinary tract infection etc.
Psychological feelings of depression, grief, low - self esteem, guilt may be present.
Behavioral problems including irritability, temper tantrums, self - injurious behaviors.
Burn out: Burn out has been defined as "Progressive loss of idealism, energy
and purpose experienced by people in the helping the profession as a result of the
conditions of their work. Job is stressful when the situation places inordinate demands
on the individual which he cannot cope.

Different ways of alleviating stress:
1. Develop wide social network nurture your friendship and relationship with
others outside your job.
2. Develop a range of interest away from work. Sports, drawing, painting, music,
etc.
3. Vary your work as much as possible consider your education, training needs
and plan ahead.
4. Take care of physical health, practice medication, and attend spiritual retreat
programmes.
5. Attend refresher workshops to update your knowledge base.
6. Leave the work situation, plan a mental health day, by having a long week end
vacation, mini sabbatical is an effective coping strategy.
7. Decrease Caffeine (Coffee, tea, Cola and Chocolate).
Visualization
Sometimes we are not to change our environment to manage stress this may
be the case where we do not have the power to change a situation or where we are
about to give an important performance. Visualisation is a useful skill for relaxing in
these situations. Imagery is a potent method of stress reduction, especially when
combined with physical relaxation methods such as deep breathing. One common
use no visualization in relaxation is to imagine a scene or event that you remember
as safe, peaceful, restful and happy like sound of running water and birds, listening
to rain on a tin roof while struggling in bed, one the imagined place as a retreat from
stress and pressure. Do not structure your leisure times. Seek humor in your life.
Eat, well balanced meals. Take adequate rest and sleep, because your body needs
time to recover from stressful events. Don't rely on alcohol or drugs to reduce stress.
Cognitive-Behavioural Techniques (CBT)
Cognitive-behavioural methods are the most effective ways to reduce stress

which has resulted in an anxiety related disorder or a depressive disorder. They include
identifying sources of stress, restructuring priorities, changing one's response to stress,
and finding methods for managing and reducing stress. Individuals who are suffering
from these disorders will be most often be treated by psychologists or doctors. Some
of the CBT techniques that are prescribed for anxiety and depression include:
relaxation training, goal setting, problem solving, flooding, systematic desensitization
and cognitive restructuring. Sometimes CBT techniques are not effective enough on
their own to treat the depressive or anxiety disorder. That is when an individual may
require antidepressant medications. The use of medication is then combined with
psychological treatment methods such as CBT and proves more efficacious than the
use of either treatments on their own.

Conclusion
In the years to come stress would find more place in our lives. One has to
adopt specific skills to combat stress. Stress management is of paramount importance
in organizational practice, rescue and rehabilitation work. If stress management
programmes are incorporated in the health care profession, people who are working
at various levels will be able to recognize the stress factors inherent in their work
place and learn to develop the preventive methods for mitigation of these stressors
this in turn would help to arrest the decline in Job-Performance, burnout and family
related problems.

Chapter 25
PSYCHIATRIC SOCIAL WORK RESEARCH
R. Parthasarathy,1
"Research helps build knowledge for practice. It can generate and refine concepts,
determine the evidence for generalizations and theories and ascertain the effectiveness
of practice methods.
William Reid
The last six decades of Psychiatric Social Work have witnessed many changes
and developments in India. Consequently, Psychiatric Social Work Educations and
Researchers have been seriously involved with making suitable attempts to change
the curricular frame work to suit the needs of the persons with mental health problems
and their distressed families.
As early as in 1961, Gauri Rani Banarjee observed that Psychiatric Social

Work in India should be the practice of Social Work and not just case work in a
psychiatric setting. In the practice of Psychiatric Social Work, other methods such as
Group work, Community organization, Administration, Social Action and Social Work
Research are also made use of. The emphasis on each method will depend on the
nature of psychiatric setting in which Psychiatric Social Worker is going to practice
promotion of mental health and presentation of mental health problems, psychosocial
interventions, and treatment and rehabilitation services.
The scope of Psychiatric Social Work is expanding in tandem with the

progress and development in the field of mental health. Psychiatric Social Worker
play a vital role in the following areas:-
1. In patient / out patient psychiatric services

2. Child and Adolescent mental health services
3. Family Psychiatric centers
4. Psychiatric / Neurological Rehabilitation centers
5. Neurological and Neurosurgical units
6. Community mental health programme
7. Alcohol / Drug Deaddication programme
In all the above mental health related settings, the psychiatric Social Workers offer
the following services:
l Psychosocial study of the patients and families
l Home visits / Collateral contacts for diagnostic and therapeutic services
l Contacting Community agencies for resource mobilization
1. Professor

l Educating the patients / families members about illness, treatment and
rehabilitation
l Marital counseling/ therapy / intervention
l Family counseling / therapy / intervention services
l Group intervention / intervention services for patients and their family members
l Liaison services with the families, schools and communities.
l Training the paraprofessionals and non professionals in mental health services
l Community participation, Voluntary agencies involvement, mental health
campus and out reach programmes
l Psychosocial Care in Disaster situations.
These services are offered in various permutations and combination

depending on the nature of problems, felt needs of the patient, families and
communities. In addition to therapeutic services, certain promotive/ preventive
services are also undertaken by professionals in collaboration with voluntary agencies,
industries, and educational institutions. Some of the programmes are orientation to
teachers, student enrichment programmes, Counseling skills orientation to teachers,
Participation in parent - teacher association meetings, Pre marital counseling, Family
life education, Adolescent Education, Effective parenting, Life skills Education for
children and adolescents, Pre retirement counseling etc.
There is a trend to employ Psychiatric Social Workers in industrial settings

to work as Social Counselors, especially to take care of various psychosocial problem,
family related issues and psychiatric problems including alcohol and drug dependence
among industrial workers.
Likewise, a considerable number of educational institutions in big cities like

Mumbai, Delhi, Chennai and Bangalore make use of the services of Psychiatric Social
Workers for students counseling and guidance programmes. Psychiatric Social
Workers are employed in deaddiction counseling centers for psychosocial therapies.
In family courts, counseling services extended by psychiatric social workers

are highly recognized. Many Psychiatric Social Workers provide their services to
Juvenile service, Bureau, Family counseling centers, HIV / AIDS Counseling
integrated child development schemes and to correctional institutions.
In addition to the above clinical and psychosocial services, psychiatric social

workers have been actively involved with a wide variety of capacity building activities
related to Psychosocial Care in disaster situations.
Research activities
Slesinger and Stephenson in the Encyclopedia of Social Services (as cited in

Wilkinson and Bhandarkar 1999), proposed a very comprehensive definition of
research: " The manipulation of things, concepts, or symbols for the purpose of
generalizing to extend, correct or verify knowledge, whether that knowledge aids in
construction of theory or in the practice of an art". Applying this definition to
psychiatric social work research, it focuses on:
1. Problems encountered by clients and their families in various settings related

to mental health
2. Problem solving strategies adopted and their efficacy in alleviating the
psychosocial problem
3. Socio cultural aspects of application of methods of social work helping the
patients and their families to help themselves
4. Feasibility and effectiveness of social work related promotion / prevention
programmes in various settings of mental health
5. Stress and strain faced by psychiatric social workers in extending the services
to clients challenging situations.
6. Indigenous methods of helping the mentally disorder persons to get integrated
into family and community life.
Thus, we see Research activities from indivisible components of psychiatric

social work interventions. Research projects are undertaken in the areas related to
social and mental illness. They undertake either independent or collaborative research
projects sponsored by Government of India, the Ministry of Social Justice and
Empowerment, Ministry of Health, ICMR, WHO and Council for the Advancement
of People's Action and Rural Technology (CAPART).
In many Schools of Social Work, the students submit their research

dissertations as part of their MSW, MPhil and PhD programmes. These researches
usually focus on areas like:
l Marital and family systems as perceived by clients

l Efficacy of family counseling, family therapy group intervention etc
l School Mental Health - students, teachers and parents
l Community mental health related activities
l Social Work aspects of child and adolescent problems
l Life Skills Education - Construction of tools, formulation of training packages,
efficacy of programmes etc
l Impact of psychiatric social work intervention on stress, coping, and social
supports in different strata of the society.
l Resource mobilization for psychosocial rehabilitation
l Psychosocial Care in disaster mental health professionals, careers, victims
and other allied aspects
l Training of volunteers to work with disabled in the counting
l Psychosocial aspects of deaddiction / mental retardation
l Psychiatric social work in Neurology and neurosurgery settings
l Other issues related to welfare, development education and health
General observations on the psychiatric social work researchers conducted
1. More exploratory and Descriptive studies have been carried out.

2. Less experimental / action oriented researches are attempted at by psychiatric
social workers
3. No attempts are made at meta analysis of research studies in psychiatric social
work
4. Very few properly designed randomized controlled trials have been undertaken.
5. Improper or no documentation of such research activities is witnessed.
6. Duplication of research studies is profusely seen.
7. Very few studies applied advanced statistical analysis - multivariate analysis -
factor analysis cluster analysis, discriminant analysis, regression analysis etc.
8. Recent studies have made use of internet and computers for review of literature
and analysis of data.
9. Long term follow up studies are not attempted.
10. Cost - effectiveness of psychiatric social workers attempts has not been
assessed.
Evidence based psychiatric social work practice
Currently, "evidence - based practices" have become a priority in the delivery

of health care including care to those psychiatric disorders. In 1999, the report of the
Surgeon General on Mental Health (US DHHS: 1999) emphasized the great gap that
existed between the kinds of mental health care that research found to be most effective
and the kind of care most Americans receive. Research shows that most mental health
programmes do not provide evidence based practices for most patients with psychiatric
disorders. Thus increasing national attention has been focused on evidence based
treatments. In psychiatric social work, these treatments include the following:
l Specialized psychosocial interventions

l Self help and poor supports
l Family psychoedcuation
l Psychosocial rehabilitation and supported employment
l Case management based on the principles of assertive community treatment
l Substance abuse treatment that is integrated with mental health treatment
l Multi systemic therapy for children and adolescents
l Therapeutic foster care
Accountability for patient care outcome is a basic responsibility of psychiatric

social workers. Central to this accountability is the ability to examine psychiatric
social work practice palterns, evaluate the nature of data supporting them and
demonstrate sound clinical decision making in a way that can be empirically supported.
This approach is the essence of evidence based practice.
In the current health care environment, psychiatric social workers can no

longer rely on opinion - based processes or unproven theories. They need to question
their current practices and find better alternatives to improve patient care. To do so
psychiatric social workers must learn to search the research literature, critically
synthesize research findings and apply relevant evidence to practice. Evidence based
practice in the Conscientious, explicit and judicious use of the best evidence gained
from systematic research for the purpose of making informed decisions about the
care of individual patients. (Sackett, 1996)
Implicit in the process of evaluating the evidence in the idea that there is
hierarchy tn the quality of research evidence. A Commonly used hierarchy (with 1
indicating the best) for research designs is presented below:
1. A systematic review (Meta analysis) of all relevant randomized controlled

trials.
2. At least one properly defined randomized controlled trial
3. Well designed controlled trials introit randomization
4. Well designed cohort, case-controlled or other quasi experimental study
5. Non experimental descriptive studies such as comparative studies
6. Expert committee reports and opinions of respected authorities based on clinical
experience.
Tips on conducting small research projects
The following ten steps will help any social worker get started on his/her way to
becoming a professional who utilizes research in a meaningful way in any of
psychiatric social work practice.
1. Define a topic that you want to find out more about your interest level which
will help spur you on to explore the topic further. Note two things-the types of
articles you tend to read when you look through professional journals and the
aspects of Psychiatric social work that you think about a lot.
2. Find several studies that have been published on this general topic or ones that
are closely related to it. Remember, in your search that you may find a related
study discipline such as Psychologists or Psychiatrists. Summarize the main
points of the study or make a copy that you can put in your folder for later
reference. The more you know about a particular topic, the better
3. Pick out one aspect of one of the studies in your folder and draw up a plan to
reconstruct this in a limited fashion. Talk with other Psychiatric social worker
to find out their views and experiences
4. Try to locate some one with some research experience with whom you can
consult and discuses ideas.
5. Write out a simple study plan. Define what you intend to study and outline the
steps you plan to take to complete your project. Keep it simple and straight
forward,
6. Polish your proposal outline with advice from some expert source - some one
who has previously conducted research project. Make a time frame realistically.
7. Identify the steps you need to follow in gaining permission to conduct your
study.
8. Watch for advertisements of workshops, conferences, seminars etc in research
related topics. Make use of them.
9. Keep a record of all you study activities in case you want to write about the
study at a later time
10. You can communicate your precedence's through reports published in journals
or presented in conferences/ seminars.
Future trends
Extrapolating the present development, it is realistic that Psychiatric social work

research in future would focus on the following aspects;
a. Nature, processes, extent and efficacy of psychosocial intervention services

children, adolescents, adults and the elderly, offered in the mental health
institutions. De addiction centers, rehabilitation centers, family counseling
centre. Child and adolescent mental health centers, neurology, neurosurgery
and allied services.
b. Identification and assessment of Psychiatric social work services associated
with community based mental health programmes in rural, urban and slum
areas based on the guidelines of National Mental Health Programme and District
mental health programme.
c. Evaluation of involvement of Psychiatric social workers in training of
paraprofessionals, non professionals and personnel from voluntary agencies
to extend their services to the needy in their areas
d. Exploratory, Descriptive and Experimental studies related to Psychosocial
aspects of crisis intervention and disaster mental health care (Suicide
prevention, Disaster preparedness etc)
e. Patterns of utilization of social security measures by mentally disabled persons
and their families and factors associated with non utilization.
f. Scope of Psychiatric social workers in the agencies related to general health,
mental health, development, education, industry and welfare especially
quantification of such activities
g. Objective analysis of contents of Psychiatric social work in BSW.MSW and
M Phil courses including field work activities.
h. Content analysis of Indian literature- ancient and modern - to cull out the
essential elements of mental health and Psychiatric social work for the purpose
of education, training and there any activities.
i. Documentation and development of existing researches in schools of social
work, national and international social welfare/ development agencies.
j. Feasibility of incorporating the developments in information Technology into
Psychiatric social work Research - Internet, usage of computers for analysis,
networking for research communication etc.
k. Formulation and evaluation of promotional/ preventive activities like Stress
Management Programmes, School Mental Health Programmes, effective
parenting, marital and family enrichment, and community based rehabilitation
services.
l. Differential impact of various strategies at micro and macro levels to counteract
the stigma attached to mental ill ness mainly dealing with materials, methods
and time frame.
m. Researches on the felt needs of the public, and improvement of quality of
services at individual family and community levels- Self Help Groups/Peer
support
n. Gather newer areas related to Hospice care, HIV/AIDS care, community based
rehabilitation, implementation of policies and legislation related to mental
health, issues related to team work/ interdisciplinary approach, spirituality in
Psychiatric social work and standardization of instruments for Psychiatric social
work Research.
If psychiatric social workers get involved in priority research activities in

institutional, semi-institutional and non-Institutional settings, using scientific methods,
it will go a long way in improving the quality of services provided to persons affected
with Psychiatric disabilities as well as in introducing culturally relevant preventive
or promotive activities applicable to all age groups and thus contributing towards
healthy and effective social action for mental health pen poses.

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Chapter 1

PSYCHIATRIC SOCIAL WORK IN CHILD AND ADOLESCENT

In today's world a vulnerable group needing recognition beyond generic

l The right be protected against neglect, cruelty, abuse, and exploitation;

The Universal Declaration of Human Rights and other UN documents echo

Handbook of Psychiatric Social Work 1

The concept of mental health

The White house conference, preliminary Reports (1930) quote "mental

Concept of positive mental health

Children and mental health

l Children need to be healthy and happy to become productive and contented

Providing stimulation to learn

Social / Cultural exposure

Style of parent-child interaction

Structure and routine

'Parenting' may be defined as purposive activities aimed at ensuring the

Knowledge and understanding are concerned with parents' abilities to

Some theories of parenting focus primarily on the emotional context of parent-

Origin and historical aspects of psychiatric social work

Handbook of Psychiatric Social Work 7

Child guidance methods originated in the pioneering work of Haley in USA.

Work of Healay and Bronner in C.G.C. influenced the multidisciplinary

The first psychiatric social worker to be appointed in a psychiatric setting in

Gradually psychiatric social workers were appointed in mental hospitals in

The fundamental objective of child guidance is to aid socially and emotionally

Handbook of Psychiatric Social Work 9

Pervasive development disorders

Attention deficit hyperactivity disorder

Specific learning disabilities

Emotional and conduct disorders

l A family history of bed-wetting in parents or sibs

Handbook of Psychiatric Social Work 11

Fear and anxiety

Conversion / dissociative disorders

Obsessive compulsive disorder

Major mental illnesses / Psychosis

Bipolar affective disorders

Specific issues in adolescence

Psychosocial interventions with children

Behavior modification is a system of treatment for changing behaviors. The

Case work with children

Group work with children and adolescents

Working with parents

Individual/ marital work with parents

Psychiatric Social Work Practice in Child Care Institutions

In addition to government run institutions, there are institutions run by the

Circumstances that cause children to live in institutional care

Psychiatric social work with children in need of protection

Functions of the psychiatric social worker

Multidisciplinary team work

Training the personnel of child care organization

School Mental Health Program

Schools play a crucial and a formative role in the spheres of cognitive,

The mental health programs implemented by the CGC's can be both

School related problems in children and adolescents

Mental Health Programmes in Schools

Life skills education

Sex and sexuality education

Mental health orientation programs for teachers in schools

Teachers as trainers for life skills

School social work services

II. Group work services

III. Parent teacher association meeting

Research in the area of child and adolescent psychiatric social work