Future of Psychotherapy in India

INTRODUCTION I am privileged today on September 28, 2024 to give the presidential address on this 49th Annual Conference of Indian Psychiatric Society (IPS)-North Zone at Bikaner. I bow my head to almighty who bestowed his blessings upon me to enable me to reach this post. I am very grateful to you for electing me to this highest office post. It is indeed a great honor and I am surprised whether I really deserve it. It is a humbling experience and opportunity for a ground level worker to speak before my beloved teachers and stalwarts. I have decided to share my thoughts on an important area in current clinical practice. I am very much influenced by the work of Prof. NN Wig, Dr. Gurmeet Singh, Dr. V.K. Verma, Dr. J.S. Neki who has done immense work in this area. WHAT IS PSYCHOTHERAPY? Psychotherapy, defined as the treatment of emotional problems through psychological means, involves a trained professional establishing a relationship with the patient to address symptoms, mediate disturbed behaviors, and promote positive personality growth.[1] However, the landscape of medicine is becoming increasingly fragmented and super specialized, with patients often viewed as customers seeking services rather than individuals in need of secure, sensitive, and continuous care. This shift has contributed to a plague of overdiagnosis and overtreatment, while preventive measures and health promotion are often downgraded. The rise of chronic illnesses has outpaced the development of appropriate theories and practices to address them, and psychiatry has not been immune to these changes.[2] In this context, psychotherapy services have become marginalized within the psychiatric field, often perceived as “soft” and lacking a robust evidence base, despite the fact that the individual life history remains paramount. Research indicates that the evidence supporting psychotherapy is as strong, if not stronger, than that for pharmacotherapy, with notable sleeper effects that extend the benefits of therapy well beyond its completion. Moreover, psychotherapy plays a critical role in helping individuals with personality disorders and contributes to the broader spectrum of psychiatric disorders. Unfortunately, the field has been slow to engage in research and academic discourse, with psychoanalytic psychotherapists often ambivalent about collaborating with colleagues from cognitive-behavioral and systemic approaches.[2] This reluctance has led to a neglect of free and respectful communication among psychiatric professionals, further isolating psychotherapy from its rightful place within comprehensive mental health care. BROAD CATEGORIES Psychotherapy can be broadly categorized into several types, including psychoanalysis and psychodynamic therapies, behavior therapy, cognitive therapy, humanistic therapy, and integrative or holistic therapy.[2] Both directive and nondirective talk therapies have been utilized for centuries to address mental health issues in the Indian context. It is common for psychiatrists to dedicate a portion of their working time to some form of psychotherapy, reflecting its integral role in mental health care. However, many mental health professionals have primarily learned these therapeutic techniques through self-directed methods and trial and error, highlighting a need for more structured training in the field. INDIAN PSYCHOTHERAPY MODELS Indian psychotherapy is deeply enriched by the lessons derived from various religions, with Indian psychotherapists drawing upon these teachings to inform their practices.[3] Supportive psychotherapy, known for its eclectic and practical approach, is one of the most commonly used modalities by psychiatrists and mental health practitioners worldwide. Buddhism, for instance, offers insights into psychological development through meditation, reflecting Gautam Buddha’s teachings. Similarly, the Bhagavad Gita illustrates Lord Krishna’s role as a therapist and psychoanalyst for Arjuna, emphasizing the therapeutic nature of dialogue.[3–7] Sikhism contributes significantly to well-being by focusing on interdependence with family, community, and religion, while promoting community service and social justice through the concept of “Chardi Kala,” which embodies a spirit of optimism and resilience. In the Muslim community, individuals often seek guidance from Imams for counseling on social and mental health issues, particularly regarding marital and family problems, proving effective in improving marital adjustments among incompatible couples. Over the past 75 years, India has seen the emergence of numerous pioneers in psychotherapy training, with figures like Girindrashekar Bose, the founder of the Indian Psycho-Analytic Society, making significant contributions. Bose’s thesis on repression in 1921 laid the groundwork for a unique Indian perspective on psychoanalysis, integrating social and biological factors emphasized by Freud with his own insights into the psychological opposition of infantile wishes. The legacy of Indian psychotherapists includes notable figures such as Dr. Jaswant Singh Neki, known for his exploration of the guru-chela relationship; Dr. N.N. Wig, who introduced the concept of the Hanuman complex; and Dr. Gurmeet Singh, recognized for his work in grief therapy and emotional distress syndrome. Other influential practitioners include Dr. Malvika Kapur, Dr. V.K. Varma, and Dr. Shamsundhar, who have made significant contributions to the various aspects of psychotherapy.[7–14] The awakening of cultural sensitivity in psychotherapy is evidenced by the discontent expressed by Surya and Jayaram in 1964 regarding the reliance on the Western models.[8] It highlighted the need for Indian psychotherapy to draw from the nation’s spiritual heritage. As noted by Prof. Varma, psychotherapy in India has experienced a transformation, with nonmedical mental health professionals increasingly taking the lead.[7] This shift has raised concerns about the rising trends of treatment with medications by psychiatrist and perception among caregivers about the early remission of symptoms with medications. The pharmacological treatment is only choice for treating psychiatric disorders. The guru-chela relationship, as articulated by Dr. J.S. Neki, presented a therapeutic paradigm where the guru assumes an active role, guiding the chela (student) through responsible decision-making and insights.[10] Neki documented that Indian patients often employ mechanisms such as dissociation, conversion, denial, and regression, indicating the need for a method of inquiry that reflects the therapeutic relationship and techniques unique to Indian psychotherapy.[2] Ultimately, Indian psychotherapy possesses a rich heritage, with centuries of introspection yielding profound psychological insights that continue to shape its practice today. THE SHIFTING TRENDS (1980–2010) The experts in psychotherapy predicted a significant shift in trends from psychoanalytic approaches to cognitive-behavioral therapy, predicting a move away from long-term therapy in favor of shorter interventions.[2,3] A decade later, these experts forecasted a proliferation of masters-level practitioners, while noting a decrease in the proportion of psychiatrists engaging in psychotherapy.[15–18] In the early 2010s, the rise of third wave psychotherapies and psychotherapy delivered through the Internet was anticipated.[5] While these reports have occasionally missed the mark, they have generally provided accurate insights into the evolving landscape of psychotherapy. Numerous psychotherapies have been developed worldwide, with some enduring the test of time while others have not; those that have survived share a crucial element – their evidence base. In the current landscape, professional organizations prominently recognize cognitive-behavioral therapy and psychoanalytic/psychodynamic therapies as the two major psychotherapeutic approaches.[2] GLOBAL SCENARIO In an International Task Force on Psychological intervention recognized cognitive behaviour therapy (CBT) as the only form of psychotherapy with robust research evidence supporting its effectiveness for over 80% of psychological disorders. Furthermore, interpersonal psychotherapy, along with several other cognition-oriented psychotherapies, has been shown to align with a standard cognitive-behavioral prototype.[3,6,10] This underscores the significance of CBT as a foundational approach in the field of psychotherapy, highlighting its widespread applicability and the shared principles that connect various evidence-based therapeutic modalities.[2] INDIAN SCENARIO In the Indian context, many researchers have noted that Western psychotherapy models may be better suited for individuals in cosmopolitan cities, rather than the majority of the Indian population, which often grapples with cultural tools that can feel alien and may contradict fundamental tenets of therapy. Indian patients tend to be more dependent than their Western counterparts, who often seek integration of intrapsychic processes, leading to a tendency for dissociation between thinking, feeling, and acting that can hinder the therapeutic process. Furthermore, concepts such as confidentiality and privacy are often foreign in the Indian socio-cultural context, where these ideas can isolate individuals from their interdependent communities.[6] This necessitates incorporating family therapy or at least involving family members in sessions alongside dyadic therapy to facilitate progress. Since 2010, there has been a significant increase in momentum for empirical therapies in research settings, with cognitive-behavioral therapy (CBT) emerging as the most practiced evidence-based practice (EBP) in India. Efforts have been made to both replicate Western models and innovate new techniques suitable for global practice, leading to growing interest among Indian researchers in implementing EBP within clinical populations.[7] A consensus has developed around introducing science-based psychotherapies, particularly CBT, which has shown effectiveness for various conditions, including depression, anxiety disorders, obsessive-compulsive disorder, schizophrenia, and alcohol dependence. However, distinct features of the Indian population, such as dependence/interdependence, lack of psychological sophistication, social distance between doctor and patient, religious beliefs in rebirth, and the associated guilt from past actions, can complicate the therapeutic process. Moreover, it has been observed that the cognitive domain of CBT programs often receives less emphasis in trials, with greater focus placed on behavioral activities, leading to an imbalance. Therefore, it is crucial for cognitive-behavioral training to prioritize the cognitive domain while also integrating behavioral interventions, as this approach is likely to yield the most significant and lasting therapeutic responses.[2,19–21] DO WE NEED PSYCHOTHERAPY TRAINING? The need for effective psychotherapy skills is particularly crucial for professionals working with psychiatric patients, who have sensitive emotional needs. Practicing psychotherapy without strong soft skills can lead to poor therapeutic outcomes, resulting in dissatisfaction, treatment resistance, and potential medico-legal and ethical issues. Consequently, there has been a growing demand among both trainers and trainees for improved psychotherapy training procedures. In response, the Department of Psychiatry at NIMHANS, Bangalore, initiated a formal mandatory training program for psychiatry residents.[12] However, several factors contribute to the neglect of psychotherapy training in India, including its highly subjective nature, the novelty of psychological and philosophical concepts to trainees, the impracticality of certain psychoanalytically oriented approaches, the time commitment required that often extends beyond training periods, and a general lack of inclination among trainees. Dr. Malvika Kapur highlighted the key objectives for psychotherapy training, which include familiarizing trainees with a range of psychotherapeutic schools on an academic level, providing practical training in therapies applicable to Indian patients, teaching generic skills relevant across treatment settings, and training in client suitability assessment, case formulation, goal selection, and session documentation. In 2009, the IPS published Clinical Practice Guidelines on psychotherapies, addressing ethical and legal issues. These guidelines were updated in 2020, involving contributions from 61 experts across different regions, and a dedicated supplement was published in the Indian Journal of Psychiatry in January 2020 to benefit mental health professionals.[22] This evolution in training and guidelines reflects a commitment to enhancing the quality of psychotherapy in India, ensuring that practitioners are better equipped to meet the needs of their patients. THIRD WAVE PSYCHOTHERAPIES Third wave therapies include mindfulness-based interventions (mindfulness based cognitive therapy, acceptance and commitment therapy, and dialectical-based therapy). Just as physical exercise promotes positive changes in the body, mindfulness can facilitate beneficial neuro-physio-psychological changes in the mind. Engaging in mindfulness not only enhances awareness and emotional regulation but also fosters structural and functional changes in the brain, leading to improved mental health and overall well-being. By incorporating mindfulness into daily routines, individuals can harness the brain’s potential for growth and transformation, much like how physical exercise nurtures and strengthens the body. Mindfulness can be regarded as “medicine for the mind,” Through practices that encourage present-moment awareness, mindfulness fosters a deeper understanding of one’s thoughts and feelings, allowing individuals to manage stress and emotional turmoil more effectively. This approach is supported by the field of psychoneuroimmunology, which explores the intricate connections between the mind, nervous system, and immune function. By cultivating mindfulness, individuals can enhance their mental resilience and emotional health, ultimately leading to improved physical health and a greater sense of balance in life. Striving toward simplicity encourages acceptance, allowing individuals to let go of judgment and the interpretation or elaboration of internal events, while resisting the urge to change, avoid, or escape from their experiences. Emphasizing psychological flexibility, this perspective enables a more profound engagement with life as it unfolds, fostering resilience and a deeper understanding of oneself. Influential figures such as Kabat-Zinn and Brown et al. are the frontline authors of many documents related with mindfulness intervention models.[19–22] ONLINE THERAPY Online psychotherapy serves as a double-edged sword while it has significantly improved accessibility and proved particularly instrumental during the pandemic, it also lacks culture-based practice guidelines and evidence-based protocols. As a result, some professionals and clients continue to prefer traditional in-person therapy, valuing the nuances of face-to-face interactions. On September 4, 2024, the US Food and Drug Administration (FDA) granted clearance for DaylightRx, marking it as the first FDA-cleared nondrug treatment for generalized anxiety disorder (GAD). This clearance represents the second FDA approval for Big Health. DaylightRx is a prescription device that delivers Cognitive Behavioral Therapy (CBT) and is available through licensed healthcare providers. Designed as a digital therapeutic, DaylightRx aims to treat GAD by improving symptoms in patients aged 22 years and older, serving as an adjunct to their usual care. DaylightRx is an innovative digital formulation of cognitive behavioral therapy specifically designed for GAD. In addition, DaylightRx included guided practice exercises aimed at helping patients integrate these techniques into their daily lives over a 90-day treatment period. In a peer-reviewed clinical trial, participants experienced notable improvements, with 71% achieving clinical improvement in worry and anxiety, and 57% reporting an enhancement in overall mood.[21,23,24] Furthermore, DaylightRx is continuously and rigorously studied for its effectiveness through gold-standard clinical trials.[21,23,24] Notably, SleepioRx, another product from Big Health, received FDA clearance for insomnia disorder in August 2024. FUTURE DIRECTIONS Future directions in psychotherapy in India are poised for transformative growth through several key initiatives. The integration of technology, including online therapy platforms and artificial intelligence-powered tools, will enhance accessibility and efficiency, making mental health support more readily available. Cultural adaptation of therapies is essential, ensuring that approaches are tailored to the diverse values and beliefs inherent in the Indian society. Increased awareness and education will play a crucial role in reducing stigma and promoting mental health literacy, alongside the training of more professionals in the field. Government initiatives and policy support, such as national mental health programs and infrastructure development, will provide a solid foundation for these efforts. Furthermore, prioritizing research and EBPs will be vital for understanding the effectiveness of various therapies in Indian contexts. Emphasizing social and community-level interventions can help address systemic issues and promote social support networks. Collaborating with traditional healing practices, such as Yoga and Ayurveda, offers opportunities for holistic approaches to mental health. Preventive measures, including school mental health programs and workplace wellness initiatives, will facilitate early intervention. Addressing diversity and inclusivity ensures that therapies are sensitive to gender, sexuality, caste, and disability. Finally, establishing ethical considerations and standards will safeguard practices around confidentiality and informed consent. By focusing on these areas, psychotherapy in India can become more accessible, effective, and culturally relevant, ultimately leading to improved mental health outcomes. CONCLUSIONS The future of psychotherapy lies significantly in the advancement of Cognitive Behavioral Therapy (CBT) and third wave psychotherapies, which are increasingly recognized for their effectiveness. However, the current inadequacies in postgraduate training programs must be addressed to ensure that mental health professionals are well-equipped. While an eclectic approach is predominantly practiced, there is an urgent need for structured training initiatives, including more workshops, Continuing Medical Education, and specialized courses. A streamlined framework of at least 100 h of psychotherapy training should be integrated into postgraduate curricula. Furthermore, the foundational principles of psychiatry and psychotherapy must be formally taught to both undergraduates and postgraduates to enhance their therapeutic skills. To foster a robust system of psychotherapy in India, academic institutions and stakeholders, including various psychiatric associations and societies, should actively promote training, workshops, and academic activities that celebrate and develop the rich heritage of Indian models of psychotherapy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.