TYPES OF COUNSELLING9-To Press
A Life-span Developmental and Situational Approach
(Developmental Psychology Included)
D. John Antony, O.F.M. Cap.
2011
Types of Counselling-9-To Press
© D. John Antony, O.F.M.Cap., 2011
Other Books by the Author:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Dynamics of Counselling (1994)
Microskill Model
TA & NLP included
Skills of Counselling (1995, 2003)
Microskill Model
Kinesics & Focusing included
Types of Counselling (1996)
Lifespan Developmental & Situational Approach
Developmental Psychology included
Psychotherapies in Counselling (2003)
Includes Theories of Personality
Self Psychology in Counselling (2005)
A Textbook of Self Psychology
Family Counselling (2005)
The Classic Schools
Trauma Counselling (2005)
Emotions in Counselling (2005)
Mental Disorders Encountered in Counselling (2006)
A Textbook of Clinical Psychology Based on DSM-IV
Personality Profile Through Handwriting Analysis (2009)
A Textbook of Graphology
Principles and Practice of Counselling (2009)
Kinesics & Clinical Psychology included
The Body Never Lies (2011)
The Basics of Body Language (Kinesics)
Mw;Wg;gLj;Jk; fiy (1996)
Ez;jpwd; khjphp
Mw;Wg;gLj;Jjypd; tiffs; (1997)
tho;T KOikf;fhd tsh;epiy kw;Wk; #oy; mZFKiw tsh;epiyf;fhd cseytpay;
,izf;fg;gl;Ls;sJ
First Edition : January 1996; Second Edition: January 2011
Published by :
Printed at
:
2
Types of Counselling-9-To Press
DEDICATED
TO
ALL
THOSE
WHO
SHARED
THEIR
VULNERABILITY
WITH
ME
3
Types of Counselling-9-To Press
4
ACKNOWLEDGEMENTS
I would like to express my deep gratitude to
Fr. Alphonse Charles, OFM.Cap., Counsellor, Psychotherapist and Provincial of the Tamil Nadu
Capuchin Province, for his encouragement to bring out this book;
Fr. S. S. Sahayaraj, OFM.Cap., Counsellor, Psychotherapist and Correspondent of the Udhayam
Polytechnic College, Rameswaram, for the material provided for the chapter on Alcoholism;
Dr. K. Soundar Rajan, Ph.D., Counsellor and Psychotherapist from Pachalur, for his prompt and
painstaking editing;
Dr. Pearl Kittu, Ph.D., Counsellor and Psychotherapist from Namakkal, for the generous service of
English correction;
Mr. S. A. Rajan, Counsellor, Psychotherapist and Clinical Psychologist from Dindigul, for his technical
assistance in publishing the book, for the cover design and for the proof reading;
Fr. John Britto, OFM.Cap., Provincial Secretary of the Tamil Nadu Capuchin Province, for his ready
assistance;
May the Lord bless you for your joyful contribution towards the making of this book!
Types of Counselling-9-To Press
CONCISE TABLE OF CONTENTS
Preface
Introduction
A. Developmental Crises and Counselling
1. Counselling the Child
2. Counselling the Adolescent
3. Counselling the Young Adult
4. Counselling the Middle Aged
5. Counselling the Elderly
B. Situational Crises and Counselling
6. Counselling the Engaged
7. Counselling the Couple
8. Counselling the Family
9. Counselling the Sick
10. Counselling the Dying
11. Counselling the AIDS-Affected
12. Counselling the Suicidal
13. Counselling the Bereaved
14. Counselling the Substance Abusers
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15. Counselling the Group
Conclusion
Endnotes
Bibliography
DETAILED TABLE OF CONTENTS
Preface
Introduction
1. Types of Crisis
2. Developmental Crisis
1) Table of Developmental Theories
2) Developmental Theories
(1) Elizabeth Hurlock
(2) Robert Kegan
(3) Sigmund Freud
(4) Erik Erikson
(5) Abraham Maslow
(6) Jean Piaget
3. Situational Crisis
1) Experience of Stress
.
4. The Anatomy of Crisis
A. DEVELOPMENTAL CRISES AND COUNSELLING
1
Counselling the Child
1. Introduction
2. First Three Stages: Prenatal – Infancy – Babyhood
1) Prenatal
2) Infancy (neonate)
3) Babyhood
(1) Physical Development
(2) Cognitive Development
(3) Language Development
(4) Personality & Social Development
i) Characteristic Traits
ii) Organization of Personality
iii) Socialization
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iv) Self-display
v) Self-will
vi) Imitation
EARLY CHILDHOOD
3. Early Childhood
1) Characteristic Traits
2) Counselling Situations
(1) Child Abuse
i) Causes of Child Abuse & Neglect
(2) Handicapped Conditions
LATE CHILDHOOD
4. Late Childhood
1) Characteristic Traits
2) Needs of Children
3) Counselling Situations
(1) Identified Patient
(2) Sibling Rivalry
(3) Unrealistic Expectation
(4) Identification
(5) Handicapped Children
(6) Counselling Techniques
5. Conclusion
2
COUNSELLING THE ADOLESCENT
1. Introduction
2. Preadolescence
3. Adolescence
1) General Characteristics
2) Physical Development
3) Social Development
4) Grunt Stage
5) Alienation
(1) Effects of Alienation
6) Identity Vs. Role Confusion
(1) Identity Status
7) Cognitive Development
4. Counselling
1) Educational Counselling & Guidance
2) The Challenge of accepting one’s changing physical self
3) Sexual Relationships
4) Juvenile Crime
(1) Substance Abuse
i) Link between Adolescence & Substance Abuse
ii) Reasons for substance Abuse
5. Conclusion
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3
COUNSELLING THE YOUNG ADULT
1. Introduction
2. Characteristics
1) Settling Down Age
2) Reproductive Age
3) Physical Strength
4) Psychosocial Development (Intimacy Vs. Isolation)
5) Commitment Age
6) Value change Age
7) Cognitive Development
3. Social Relations
1) Family
4. Personal Identity & Work
1) D.E. Super’s Theory
2) J.L. Holland’s Theory
5. Counselling Situations
1) Physical Disorders
2) Career Planning
3) Financial Planning
4) Conjugal Relationship
6. Conclusion
4
COUNSELLING THE MIDDLE AGED
1. Introduction
2. Characteristics of Middle Age
1) Physical Condition
2) Vocational & Grand parenting Adjustment
3) Success of Middle Age
4) Midlife Crisis?
5) Intelligence
6) Career Pattern & Work Performance
3. Levinson’s Theory of Adult Development
1) Early Adulthood
(1) Novice Phase
(2) Settling Down Phase
2) Middle Adulthood
4. Burnout
1) Signs & Symptoms of Burnout
(1) First Level Symptoms
(2) Second Level Symptoms
(3) Third Level symptoms
2) Burnout-Prone Candidates
3) Handling Burnout
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5. Retirement
1) Patterns of Adjustment
2) Psychological Process of Adjustment
6. Conclusion
5
COUNSELLING THE ELDERLY
1. Introduction
2. Physical Condition
3. Developmental Tasks
1) Psychosocial Adjustment (Erik Erikson)
2) Psychological Adjustment (Robert Peck)
(1) Ego differentiation Vs. Work-role Pre-occupation
(2) Body Transcendence Vs. Body Preoccupation
(3) Ego Transcendence Vs. Ego Preoccupation
3) Transition period (Daniel Levinson)
4) Comparison of Developmental Tasks
4. Successful Aging
1) Personality Types Theory of Neugarten
(1) Integrated Type
(2) Passive-dependent Type
(3) Armoured-defended Type
(4) Un-integrated Type
2) Personality Types Theory of Reichard
3) Disengagement Theory
4) Activity Theory
5) Comparison of Theories of Successful Aging
5. Psychological Maladjustment
6. The Institutionalised Elderly
7. Counselling Situations
1) Depression, Loneliness & Lack of Initiative to Live
(1) Causes of Depression
i) Biological Factors
ii) Psychosocial Factors
2) Lack of Intellectual Capacity to Manage One’s Own Affairs
(1) Senile Dementia
(2) Multi-infarct Dementia
(3) Delirium
8. Counselling
1) The Depressed
2) Patients of Dementia
3) Patients of Delirium
9. Conclusion
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B. SITUATIONAL CRISES AND COUNSELLING
6
COUNSELLING THE ENGAGED
1. Introduction
2. Premarital Preparation Counselling
3. Historical Background
4. Attitude towards Marriage
5. Stage Model of Courtship (Wheel Theory of I.L. Reiss)
1) Rapport
2) Self-Evaluation
3) Mutual Dependency
4) Intimacy Need Fulfilment
6. Goals of Premarital Preparation
1) Encouraging Interpersonal Dialogue
2) Providing Information
3) Correcting Faulty Information
4) Making an Evaluation
(1) Maturity
(2) Compatibility
(3) Marital Happiness
5) Completing Administrative Details
7. Premarital counselling
1) Chronological Immaturity
2) Wide Chronological Age Difference
3) Wide Gap in Education
4) Divergent Racial or Cultural Background
5) Vast Status Difference
6) Divergent Religious Background
7) Pregnant Bride
8) Grieving or Rebounding Partner
9) Serious Physical, Emotional & Mental Handicap
10) Serious Drug Involvement
11) Psychopathic Personality
12) Financial Insecurity
8. Counselling Format & Techniques
9. Conclusion
7
COUNSELLING THE COUPLE
1. Introduction
2. Characteristics of Coupling
1) Voluntary Nature of Coupling
2) Balance in the Couple’s Relationship
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3) Temporal Aspects of Coupling
4) Merging Systems as Part of Coupling
5) Giving & Receiving Support as Part of Coupling
6) Maintaining Separateness & Individuality
3. Marriage as a Social System
1) Couple as a Subsystem of the Family
2) Stages of Couple Development
3) Rules and Boundaries Governing Couple Relationship
4) Homeostasis within Couple Relationship
4. Areas of Symptom Formation in Couple Relationship
1) Economic Issues
2) Companionship-Intimacy
3) Work & Recreation
4) Parenting
5) Household Chores
6) Relationship with Extended Family
7) Religion
8) Friends
9) Substance Abuse
10) Communication
5. Stages of Marital Conflicts
1) Stage of Typical Adjustment Conflicts
2) Stage of Disrupted Covenant
3) Stage of Private Misunderstanding
4) Stage of Social Involvement
5) Stage of Threats of Attempts at Separation
6) Stage of Legal Separation
7) Stage of Divorce
6. Characteristics of Marital Conflict
7. Counselling
1) Impact of Couple Counselling
2) Approaches to Marriage Counselling
3) Counselling Stages
4) Relationship Satisfaction
5) Family Systems Counselling
(1) A Systems Model Approach
(2) Circularity
(3) Family Homeostasis
(4) The Double Bind
(5) Circular Causality
(6) Strategic Approach
6) Communication Enhancement
7) Behaviour Contracting
8) Interactional Therapy
9) Strategic Therapy
10) Sex Therapy
11) Psychoanalytic Therapy
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12) Intergenerational Therapy
13) Structural Therapy
14) Behavioural Therapy
15) Marital Enhancement Programmes
16) Divorce Therapy
17) Guidelines for Enriching Marital Relationship
8. Counsellor
1) Role of the Counsellor
2) Approach of the Counsellor
9. Conclusion
8
COUNSELLING THE FAMILY
1. Introduction
2. Types of Families
3. Family as a Social System
4. Conjoint Family Therapy as a Systems Perspective
5. Goals of Family Therapy
1) Communication
2) Focusing on Relationship
3) Mutual Need Satisfaction
4) Nourishing Self-esteem
5) Growth Opportunities
6) Self-actualizing Ways
7) See Conflict as Growth
8) Integration of Embeddedness Vs. Autonomy
9) Growth-engendering
10) Being Open to Supportive Relationships
6. Right Brain Method
7. Family Root System Therapy
8. Conclusion
9
COUNSELLING THE SICK
1. Introduction
2. Body-mind Interdependence of Illness
3. General Types of Illness
4. Sickness in Hospital Setting
1) Nutritional & Digestive Disorders
2) Excretory Disorders
3) Skin Diseases
4) Heart Diseases
5) Neural Disorders
6) Genitourinary Disorders
5. Hospitalization
1) Psychological Reductionism
2) Disease – Dis-ease Parallelism
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3) Trauma of Surgical Patients
6. Counselling
1) Hospital Conduct of the Counsellor
2) Attitude & Procedure
7. Conclusion
10
COUNSELLING THE DYING
1. Introduction
2. Phenomenon of Death
3. Elizabeth Kubler-Ross’ Stage Theory
1) Shock
2) Denial
3) Anger
4) Bargaining
5) Depression
6) Acceptance
4. Edwin Shneidman’s Cluster States Theory
5. E. Mansell Pattison’s Process Theory
1) Acute Phase
2) Chronic Living–Dying Phase
3) Terminal Phase
6. Fear of the Dying
1) Fear of Pain and Mutilation
2) Fear of Isolation
3) Fear of the Loss of Control & Independence
4) Fear of the Future of the Loved Ones
5) Reflected Fear
6) Fear of the Unknown
7) Fear of Meaninglessness of Life
7. Old People’s Concern about Death
1) When Will I Die?
2) What is Likely to Cause my Death?
3) How can I have a Good Death?
4) Euthanasia
8. Dying involves Suffering
1) Responses to Suffering
9. The Dying Know their Death
10. Facts about Dying Persons
11. The Dying Experience
12. Counsellors in the Context of Death
13. Counselling
14. Conclusion
11
COUNSELLING THE AIDS-AFFECTED
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1. Introduction
2. Development from HIV to AIDS:
1) HIV: Initial HIV Infection
2) PGL: Persistent Generalized Lymphadenopathy
3) ARC: Aids Related Complex
4) ADC: AIDS Dementia Complex
5) AIDS: Full-Blown AIDS
3. Common Infections due to AIDS
1) Cryptococcal Meningitis
2) Central Nervous System Toxoplasmosis
3) Pneumocystis carinii Pneumonia
4) Cryptosporidiosis
5) Kaposi’s Sarcoma
4. AIDS Test
5. Preventing Mother-to-Child Transmission of HIV
6. Means of HIV Transmission
7. Harmless Associations
8. Psychological Reactions to AIDS
1) AFRAIDS
2) Fears & Anxieties
9. Behavioural Reactions to AIDS
10. Counselling
11. Conclusion
12
COUNSELLING THE SUICIDAL
1. Introduction
2. Global Epidemiology of Suicide
1) Male-Female Suicide Ratio
2) Suicide: Age-wise Frequency
3) Religious Implication of Suicide
4) Suicide: Country-wise Frequency
5) Causes of Suicide
3. Indian Scenario
4. Suicidal Potentiality
5. Sociocultural Factors
6. Clues to Understand Suicide
1) Verbal Clues
2) Behavioural Clues
3) Situational Clues
4) Descriptive Clues
5) Symptomatic Clues
6) Resource Clues
7) Cultural Clues
7. Suicide among the youth
1) Precipitants of Suicide
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2) Predisposing Conditions
3) Warning Cues to Suicide
8. Suicide among Young Married Women
1) Dowry Harassment
2) Husband’s Attitude
3) In-law’s Problems
4) Personality Factors
9. Suicidal Intent
10. Communication of Suicidal Intent
11. Suicidal Notes
12. Counselling
1) Empathetic Listening
2) Assessing Suicidal Danger
3) Distancing from the Means
4) Non-Suicidal Contract with Pacing
5) Preventing Imminent Attempt
6) Dealing with Underlying Issues
13. Conclusion
13
COUNSELLING THE BEREAVED
1. Introduction
2. Stages & Psychological Implications of Funeral
1) Separation
2) Visitation
3) Funeral Rite
4) Procession
5) Consigning
3. Nature of Loss
1) Avoidable & Unavoidable Loss
2) Temporary & Permanent Loss
3) Actual & Imagined Loss
4) Anticipated & Unanticipated Loss
4. Types of Loss
1) Material Loss
2) Relationship Loss
3) Intrapsychic Loss
4) Functional Loss
5) Role Loss
6) Systemic Loss
5. Emotional Reaction to a Loss
1) Modelled on Elizabeth Kubler-Ross’ Stage Theory
(1) Shock
(2) Denial or Disbelief
(3) Emotional Reaction
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(4) Physical Reaction
(5) Acceptance
(6) Remembering
2) George Engel’s Three Stages
3) Colin Parkes’ Four Stages
4) Comparison of Stage Models
6. Common Elements of Grief
1) Numbness
2) Emptiness, Loneliness & Isolation
3) Fear & Anxiety
4) Guilt and Shame
5) Anger
6) Sadness & Despair
7) Somatization
7. Patterns of Grieving
1) Searching for the Lost Object
2) Immoderation
3) Grieving is Spiral
4) Time Distortion
5) Grieving is Self-oriented
6) Grieving Never Wholly Ends
8. Goals of Grieving
9. Depression as a Grieving Process
10. Counsellor’s Intervention in Grief
11. Healing the Grieving by Rituals
12. Completing an Unfinished Business
13. Depression
1) Nature of Depression
2) Characteristics of Depression
(1) Affect
(2) Behaviour
(3) Physiology
(4) Cognition
3) Difference between Grief & Depression
4) Counselling the Depressed
(1) Affective Intervention
(2) Behavioural Intervention
(3) Physiological Intervention
(4) Cognitive Intervention
14. Conclusion
14
COUNSELLING THE SUBSTANCE ABUSERS
1. Introduction
2. Addictive Personality
3. Personality Field of Addict, Player & Labourer
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4. Drug Dependence & Abuse
1) Psychological Dependence
2) Physiological Dependence
DRUG DEPENDENCE
5. Addiction is a Brain Disease
6. Tetrahydroisoquinoline (THIQ)
7. Kinds of Drugs
1) Narcotics
2) Depressants
3) Stimulants
4) Hallucinogens
5) Cannabis
6) Unconventional Kinds
8. Causative Factors of Drug Dependence
1) Primary Cause
2) Secondary Cause
9. Signs of the Adolescent Addict
10. Comparison of Alcoholism & Brown Sugar Addiction
ALCOHOLISM
11. Effects of Alcohol
12. Pet Theories of Alcoholics
13. Stages in Alcohol Dependence
1) Early Stage Symptoms
2) Middle Stage Symptoms
3) Chronic Stage Symptoms
14. Characteristics of Alcoholism
15. Alcoholic Games
1) Drunk & Proud
2) Lush
3) Wino
16. Alcoholic Women & Homosexuals
17. Treatment of Alcoholism
1) Biological Measures
2) Psychological Measures
3) Psychosocial Measures
4) Taking Care of Environmental Cues
5) Follow-Up
18. Counselling the Alcoholics
1) Excuses Made by Alcoholics
2) Hurdles to Recovery
(1) Unwillingness
(2) Psychiatric Disorders
(3) People with Psychopathic Trends
3) Overall Approach
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4) Stage-wise Approach
5) The Original Twelve Steps
19. Conclusion
15
COUNSELLING THE GROUP
1. Introduction
2. Group Counselling/Therapy
3. Types of Group Therapy
1) One-to-one (Vertical Interventions)
2) Interactional Here-and-Now (Horizontal Interventions)
4. Traditional Group Therapies
5. Intensive Group Expressions
6. Encounter Group Therapy
7. Group Process in Encounter Groups
8. Group Process in Terms of Dynamics
9. Stages of Community Making in Group Therapy according to Dr. M. Scott Peck
10. Advantages of Group Therapy
11. Casualties in Group Therapy
12. Risk Factors in Group Therapy
13. Group Selection
14. Self-Disclosure in Facilitator
1) Self-Disclosure in Facilitator
2) Self-Disclosure in Participants
15. Facilitator’s Role
16. Conclusion
16
CONCLUSION
ENDNOTES
BIBLIOGRAPHY
DEVELOPMENTAL PSYCHOLOGY
(TABLE OF CONTENTS)
1. Prenatal
2. Infancy
3. Babyhood
4. Early Childhood
5. Late Childhood
6. Puberty
7. Adolescence
8. Young Adulthood
9. Middle Age
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19
10. Old Age
PREFACE
Variety marks human nature. Each individual human being is unique and so
we have as many varieties as there are human beings. Human situations vary even
though all of us face the same type of problems. Because of the uniqueness of the
individuals and the speciality of the situation we face, we need special skills specially
meant for each individual and for each situation.
The general counselling attitudes are the same for every type of counselling.
These very attitudes are converted into behaviour patterns known as skills. At the
intention level, they are attitudes and at the execution level, they are skills. These
general attitudes and skills are the same for all kinds of counselling. They form the
substratum of the counselling practice.
In attitudes we find three components: Cognitive, affective, and conative. In
defining attitudes Allport says: An attitude is a mental and neural state of
predisposition to respond, organized through experience and exerting a directive and
/or dynamic influence on behaviour. This definition emphasizes the cognitive
element of attitude. D. Katz says: An attitude is the predisposition of an individual to
evaluate some symbols, objects or aspects of this world in a favourable or
unfavourable way. This definition underscores the affective aspects of attitude. For
a change, consider the definition of M. Rokeach: An attitude is a relatively enduring
organization of beliefs concerning an object or a situation, which predisposes one to
respond in a certain preferential way. In this definition, one finds the conative
component given greater importance.
One needs to have the right attitude meant for counselling without which one
cannot do a worthwhile counselling. Since the attitudes cannot be made out just by
looking at the person, we infer the attitudes of the individual through the behaviour
patterns. In our counselling context, behaviour patterns are nothing other than skills.
Carl R. Rogers lists out the three basic necessary conditions for effective counselling
– which we can say are attitudes – 1) empathy. 2) genuineness or congruence of the
counsellor and 3) unconditional positive regard of the counsellor towards the client.
Types of Counselling-9-To Press
20
Exercising the very general skills of counselling to different individuals itself
is complex enough and added to that we need to apply the skills to different
situations. One gets usually trained to take into account the individual differences in
doing counselling. Here what addresses us are the different situations the clients may
face. Take for example, the skill of ‘personalizing the problem.’ The way you do
that in a situation of a person dealing with an interpersonal issue will be entirely
different from the way you do to a suicidal person or a teen-ager or a child. That is
why once the counsellor trainees learn the basic counselling they ask the way to
approach different human situations. Different situations need different types of
approaches. Therefore, types of counselling will mean for us the types of approaches
we will be taking to different situations while applying the skills we have learned in
counselling.
Having written the books Dynamics of Counselling, Skills of Counselling and
Principles and Practice of Counselling especially for counsellor trainees I intend to
complement those books with this work, ‘Types of Counselling’ to make it easier for
the counsellor trainees to launch into different fields of counselling. Some of the
trainees even though they possess enough knowledge, skills and practice in
counselling, are afraid of undertaking different types of counselling (and the like) for
the same simple reason that they have not learned the tips to approach various
situations. Therefore, I felt the need of giving a shape to my experience in this book.
As I rely more on experience, whatever I have learned or read I would like to see if
they are practicable in my experience. If my experience confirms the theory I
learned, I teach the same to others.
The various authors I am referring to, provide not only stimulation for me to
think but also a broad baseline for my work. Here I am constrained to interpret and
apply the approaches of counselling to various situations according to the local
culture. I am making an attempt to apply the transcultural elements in our cultural
context. For example dealing with Premarital Counselling, the approach I propose is
much different from how it is practiced in some other parts of the world. In the
Indian context, having dated many boys may be considered as a negative point for a
prospective bride whereas in some other cultures it is a plus point, because having
dated many, a girl can choose the best one. Therefore, I would appreciate if the
readers keep in mind the cultural difference and also the fact that all that is being
shared is to be taken critically.
With these words of orientation I invite you to go through the pages taking these as
stimulation for you to think and reflect and contribute to the field of counselling
psychology.
Types of Counselling-9-To Press
21
For the sake of simplicity, and unless otherwise stated, the use of ‘man,’ ‘he,’ ‘him,’
‘his,’ and ‘himself’ will apply equally to both genders.
INTRODUCTION
1. Types of Crisis
Before we enter into the different types of counselling, it will be wise on our
part to have a broad outline of the situations a counsellor normally faces. Crisis can
be understood as intrapersonal and interpersonal. The psychiatrist Gerald Caplan
divides problem situations into 1. Developmental and 2. Situational or Accidental.
These are called developmental crisis and situational crisis.1
2. Developmental Crisis
Developmental psychologists have identified fairly distinct stages of human
development. At every stage an individual is supposed to acquire certain
competencies or perform certain ‘developmental tasks.’ These tasks arise at certain
periods in the life of the individual in relation to his environment. These
developmental tasks (like biological growth) naturally follow a pattern and are
hierarchically related. They are in a way determined by biological, physiological and
cultural factors. It simply means that an individual at a certain stage should have
mastered certain skills or developmental tasks. If a particular skill has not been
acquired at a specific stage, the person is considered to be having a problem. Certain
skills are biological like walking, some are psychological like sex role typing, and
some are social like belonging to a gang.2 Each stage is marked by particular kinds of
problems. As an individual moves through different stages he is likely to experience
pain and disorganization, which are quite normal in an individual. Our development
is a process of progressive fragmentation and integration; it is a cumulative process
of development. Unless each stage is successfully handled, the individual is likely to
meet with greater stresses in his adult stage. Not only is each stage beset with
developmental tasks, which are stressful, but also the very transition itself is
sufficiently stressful. It was Edwin Schneidman who said that crises are
intratemporal, meaning the crises that appear in each stage and are appropriate, and
intertemporal, meaning crises that take place at some juncture between life stages.3 It
would be advantageous for the counsellor to have a bird’s-eye view of the different
developmental psychologists’ proposed stages, where there is a balance of subject
and object as a common ground for their developmental theories. Combining the
theories of the important developmental psychologists, we have the following table:4
1) Table of Developmental Theories
Types of Counselling-9-To Press
N
o
Age
Hurlo
ck’s
Stand
ard
stages
Kegan’s
Freud’s
Evolution psychos
ary Truce exual
Develop
ment
Erikson’s
Psycho-social
Development
1.
280
days
0-2
wks
2wk
s2yrs
Prenat
al
Infanc
y
Babyh
ood
-
-
2.
3.
-
Incorporat Oral
ive
Incorporat Oral
ive
Anal
Trust
Vs.
Mistrust
& Trust
Vs.
Mistrust
Autonomy Vs.
Shame/Doubt
4.
3Early
6yrs Childh
ood
Impulsive
Anal & Initiative
Phallic
Guilt
5.
7Late
10yr Childh
s
ood
Impulsive
Latency
6.
11- Puberty
13
yrs
Imperial
Genital
7.
13- Adolesc Imperial
18 ence
yrs
Genital
8.
18- Early
Genital
Interperso
22
Maslo
w’s
Hiera
rchica
l
Needs
-
Piaget’s
Cognitiv
e
Develop
ment
Physio
logical
Physio
logical
Sensorimotor
Sensorimotor
-
Vs. Physio Preoperat
logical ional
(symboli
c
Thinking
)
Industry Vs. Physio Concrete
Inferiority
logical Operatio
nal
(Rational
)
Identity Vs. Safety Concre
Role
te
Confusion
Operati
onal &
Early
Formal
Operati
onal
Identity Vs. Safety Early
Role
& love Formal
Confusion
operati
onal
(abstra
ct)
Intimacy Vs. Love Full
Types of Counselling-9-To Press
40
yrs
9.
adulthood
40- Middle
60 age
yrs
10 60- Old age
.
De
ath
23
nal
Isolation
Institution Genital
al
&
Interindivi
dual
Generativity
Vs.
Stagnation
Interindivi Genital
Integrity
dual
(declinin Despair
g)
Formal
Operati
onal
Adulth
ood
Estee Post
m & Formal
self
Operati
actuali onal
sation (Dialec
tical)
Vs. Self
transc
enden
ce
Post
Formal
Operati
onal
(dialect
ical)
There are many ways of working out a comparative study of the theories of the
developmental psychologists. Here in this book I have taken for easy learning the ten
stages of Elizabeth B. Hurlock, and compared the other developmental psychologists’
theories with the theory of Elizabeth Hurlock. A brief note on each of these authors
will be in place.
2) Developmental Theories
(1) Elizabeth B. Hurlock
Elizabeth Hurlock has divided the life span into ten stages starting with the
prenatal. For Hurlock the stages are: 1) Prenatal, 2) Infancy, 3) Babyhood, 4)
Early Childhood, 5) Late Childhood, 6) Puberty, 7) Adolescence, 8) Early
Adulthood, 9) Middle Age, and 10) Old Age. I have taken this model to deal with
the types of counselling in this book.5
(2) Robert Kegan
For Robert Kegan, the individual in his development in every stage seems to be
engaged in the cognitive process of meaning-making that is, attempting to make
sense of the events in his life in order to grow. For him the main stages of
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development are six: 1) Incorporative, 2) Impulsive, 3) Imperial, 4) Interpersonal,
5) Institutional and 6) Interindividual.6
For him every developmental stage is marked by an evolutionary truce. And
each of these truces is a temporary solution to the lifelong tension between the
yearning for inclusion and distinctness. The life history of the individual involves a
continual moving back and forth between resolving the tension slightly in favour of
autonomy, at one stage, and in favour of inclusion at the next. Thus the personality
of the individual develops arising from the incorporative position which is neither
embeddedness nor independence and starts with the embedded impulsive balance and
goes to the self-sufficiency of the imperial balance; and from there one moves to the
overincluded interpersonalism; and from there to the autonomous, self-regulating
institutional balance from where the person next moves to a new form of openness
which is interindividual.
Thus human development is understood as a spiral or a helical movement
going forward, oscillating between two extremes of inclusion and independence.
Impulsive, interpersonal and interindividual form inclusion; and imperial and
institutional form independence. Here growth is not seen only in terms of
differentiation, separation and the increasing autonomy but also equally in terms of
integration, attachment and inclusion.7
(3) Sigmund Freud
Freud’s personality theory includes ‘ Id’ which represents an instinctual need
for immediate gratification and tension-reduction operating under the pleasure
principle, ‘Ego’ which represents a system of thought that regulates the demands of
the ‘Id’ operating under the reality principle, and ‘superego’ which consists of
conscience and ego ideal, a set of standards towards which an individual strives. For
Freud (psychosexual theory) there are five stages. Each stage has its own
developmental crisis. The stages are: 1) Oral – the child deriving pleasure by the
activity of the mouth, especially sucking, 2) Anal – the child getting pleasure either
by defecating or withholding, 3) Phallic– here the child derives its pleasure by the
manipulation of the genital, 4) Latency – in this stage the child develops his interests
not in himself but in activity and 5) Genital – it starts from puberty and runs through
old age (with genital activity).8
(4) Erik Erikson
Erik Erikson (psychosocial theory) proposes eight stages. Human development
is a search for a mature sense of identity. In each stage, one has to master a
particular task and move on to the next. Erikson stresses the epigenic principle
according to which the new properties not contained in the original situation develop
because of environmental influences and the interaction between the former (original
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situation) and the latter (environmental factors). Here each preceding stage of
development is considered a preparatory phase for the subsequent one. Each stage
has a positive as well as a negative aspect. Erikson is of the opinion that the
personality development does not stop with childhood, which was the theory of the
Freudian psychoanalysts, but continues throughout the life of the individual.
According to him, there are ego qualities, which emerge during the stages of
development. The ego qualities at various stages are: 1) Trust vs. Mistrust - At the
very early stage, the baby learns to trust if its needs are adequately met, to mistrust if
its needs are not met. 2) Autonomy vs. Shame and Doubt – In the second stage the
child either learns to be self-sufficient in walking, talking, toileting, and feeding or
becomes doubtful about its competence to perform these activities. 3) Initiative vs.
Guilt – The child at this stage is overeager for adult activities and at the same time, it
feels guilty when it oversteps the limit. 4) Industry vs. Inferiority – A child in late
childhood masters a number of skills that give a sense of well-being and superiority,
or else feels inferior to others if not able to master the skills. 5) Identity vs. Role
Confusion – An adolescent usually figures out his own identity as to who he is. It
may be about his sex or politics or career and consequently the role he is expected to
play since the role flows from his personal identity. 6) Intimacy vs. Isolation – A
young adult seeks out companionship, love and acceptance and when they are not
forthcoming, he feels isolated. 7) Generativity vs. Stagnation – An adult in his
middle age is very productive by meaningful and significant contribution in work,
creative activities and in raising a family and when one is prevented from being
generative then he is doomed to be stagnant and inactive. 8) Integrity vs. Despair
– A person in his late middle age and typically in old age is able to reconcile all the
opposing elements in his life, both the positive and the negative, and finds a meaning
in his life and for some it is a moment of despair of not having achieved anything in
life and many of the basic questions in life not being answered.9
(5) Abraham Maslow
Abraham Maslow (hierarchy of needs) did research with healthy adults who
were high-functioning in order to determine the variables of the self-actualizing
individuals. He believed that all have the same basic needs, which are met in a
hierarchical fashion. Unless the lower needs are met normally, one does not move to
the next. People usually get stuck to a particular need when it is not met adequately
though chronologically they would have grown up. Unless there is a therapeutic
intervention, the individual will remain stuck to the need that is not met, forever
seeking occasions to fulfil them relentlessly and his behaviour will be exaggeratedly
marked by his need-fulfilment-seeking activity.
The needs are as follows: 1) Physiological Needs – They include food, water,
air, shelter, sex, and health. When these are not met one will exhibit behaviours like
hoarding, frugality, chronic anxiety, being easily frustrated, having difficulty in
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sharing and overly focused on food and environment. 2) Safety Needs – Once
physiological needs are fulfilled then the person moves to the safety needs. We all
want to feel safe, secure, and stable. One of the things infants fear is lack of support.
Inadequate meeting of safety needs leads one to be fearful of separation and physical
harm. There will be a tendency to be rigid, clinging to what is familiar, a tendency
for non-acceptance of anything new, to be fearful, unable to take risks, unable to
tolerate ambiguity, feeling helpless and dependent. 3) Acceptance Needs – It is a
social need wanting to have a sense of belonging. One desperately seeks
companionship, affection, intimacy and friendship. When acceptance needs are not
met, the individual feels chronically lonely, alienated, strange and not really part of
any group. Therefore, to get the attention and affection of others he may do
something extraordinary, become ill often and be minutely accurate in doing things.
4) Esteem Needs – It is a status need. One wants recognition, self-esteem, selfrespect, and a feeling of being important, useful, competent and needed. The
characteristic behaviour of the person whose esteem needs are not met will be to be
competitive, jealous, feeling inferior, controlling in relationships, secretly comparing
with others, daydreaming about great achievements, exaggerating the ordinary,
seeking prestige, wanting to be in the limelight and in a way being narcissistic. 5)
Self-Actualizing Needs – Here one looks for full expression of the potentials and
talents, being able to reach one’s potential and developing one’s gifts. One longs for
growth, achievement and advancement. When self-actualizing needs are not met, one
becomes restless, bored, aloof, bitter, and negative having basic dissatisfaction with
one’s life, and having the problem of faith. 6) Self-Transcendence Needs –Maslow
stopped actually with the self-actualising need which is the highest need in his
hierarchy. But some Christian developmental psychologists add this sixth one. This
need is understood as the ability to move beyond one’s own needs, mostly in a
dramatic way, to serve the needs of others. When the self-transcendence needs are
not met, one may feel empty, may go about being on the move to fill the void, and is
likely to become a loner.10
(6) Jean Piaget
Jean Piaget (cognitive development) working with children concluded that
development is a process of adaptation and active seeking to understand the
environment. He proposed four stages: 1) Sensorimotor – The infant uses his
senses and motor abilities to understand the world around him. There is not yet
conceptual or reflective thought in him. He has the sense of ‘object permanence’
which means that a thing taken out of sight still exists. 2) Preoperational – This
stage is characterized by ‘symbolic thinking’ including language to understand the
world. Here imagination is at work in children and language becomes a significant
means of self-expression. The world is understood in his own way that is egocentric.
3) Concrete Operational – In this stage of late childhood the child understands and
applies logical operations or principles to interpret his experience. The child learns
the basic ideas of conservation, number, classification and other scientific ideas. The
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attempt here is to understand objectively and rationally rather than intuitively. 4)
Formal Operational – This is the last stage in the cognitive development of the
individual. Starting approximately from the age of 12 onwards the individual is able
to speculate in thought that is from the real to the possible. Here one takes a broader
and more theoretical approach to experience in such a way that one becomes
interested and involved in social and moral issues.11
In conclusion we can say that individual growth is a continuous process,
conveniently divided into periods or life-stages characterized by certain general
features which individuals have in common; most individuals pass through similar
developmental stages in a given culture, with the imposition of responsibilities and
demands by the society. Developmental crises arise when the individual fails to
perceive the need to adjust to different situations.12
With the fair specimen of the theories of development, we are in a position to
consider the types of problem one can face in his life-span. So far what we have seen
might give us a broad blueprint of the areas of developmental problems or crises we
encounter as counsellors in the clients. Acquaintance with the type of development
one undergoes and all that accompany such transitions and the stages will go a long
way in equipping the counsellor.
3. Situational Crisis
Having seen the developmental crisis let us now turn our attention to the
situational crisis comprising of a wide variety of hazardous events like illness, death,
alcoholism, drug dependence, AIDS, war, natural disasters, loss of job and rape.
Some are external stressors like natural disaster and persecution whereas some are
internal stressors like alcoholism and suicidal ideation.
1. The Stress Experience
Let us see how the stresses are experienced by the clients. 1) First of all it is
imperative to note whether the crisis faced by the client is the hangover of an
unsolved problem in his past. When for a genuine problem, a cover-up of the defence
mechanism has been heavily used then it is likely to disturb the person quite often. 2)
The second critical factor that augments vulnerability is the person’s perception of
the event. The event in itself may be harmless or neutral but the perception of the
event by the person may be catastrophic. For example, if a person perceives a
situation as a threat, he will be ridden with anxiety; if he is experiencing a great loss,
depression will be evident on his face; if challenge is the interpretation of an event by
the client, there will be a sense of excitement along with moderate anxiety. 3) The
third critical factor that strengthens crisis is the cumulative effect. The cumulative
weight of stresses can actually trigger off great personal calamity in individuals. For
example, you might notice a rather tolerant and mild person suddenly bursting out
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into uncontrollable anger. It is a sign that this person has accumulated a lot of
resentment and that is why he is exploding at the addition of one more apparently less
significant stress. 4) Fourth, you might notice people in crisis exhibiting
disorganized behaviours, which appear to be pathological. Even though they appear
to be pathological they are not so, for they do not have deep underlying causes. In
genuine pathology the period of disorganization is longer and may require psychiatric
intervention whereas the disorganization experienced in crisis-state is short-lived.
The types of physiological upset that manifest itself in persons in active crisis are
gastrointestinal problem, sleep disturbance, dizziness, fainting, paralysis and fits of
weeping. Besides these there are also psychological upsets like helplessness,
hopelessness and confusion. 5) Finally, crises are by nature short-lived. They are in
a way time-limited. Every crisis reaches a peak point and then declines.
2. The Anatomy of Crisis
Gerald Caplan has analysed what one does during crisis and there seem to be
some distinct stages that an individual goes through in crisis: 1) To start with, faced
with a crisis or a problem otherwise called a stimulus which creates tension in the
organism, the individual mobilizes his habitual problem-solving responses. 2) If the
old problem-solving responses fail to remedy the situation, the continuing unmet
needs produce inner disturbances including feelings of anxiety, guilt, confusion,
ineffectuality, and some degree of disorganizing of functioning. 3) When the tension
of the apparently insoluble crisis passes a certain threshold, the individual is forced to
mobilize additional crisis-meeting resources. 4) If even with the mobilization of the
additional crisis-meeting resources the crisis is not solved, the inner stress of unmet
needs rises until it reaches another threshold which is the breaking point where major
personality disorganization like psychological, psychosomatic, interpersonal and
spiritual illness occurs. At this point the person is said to be in an active crisis. 13
So far we have seen that the crises one meets in counselling are either
developmental or situational. For the developmental crisis we had recourse to the
theories of many leading developmental psychologists since there is not a single
universally accepted model of developmental crisis. Later we made mention of the
situational crisis, and finally we analysed the characteristics of crisis itself. Now we
are in a position to study the types of counselling.
For convenience, I have grouped the topics under two main sections, namely,
developmental crises and situational crises. When we speak of developmental
crises we need to know what the normal developmental patterns are so that we can
identify any pathology. If one does not know the normal developmental patterns one
might take those patterns as deviations; for example, a parent complained to me that
his teenage son masturbated which he regarded as a deviation from normal
development. Therefore, it is necessary for counsellors to be acquainted with what
normally takes place in every stge. With this orientation to the matter treated in the
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book I invite you to study about the types of counselling in the following pages.
Hope your perusal of these pages will equip you to be an effective counsellor in
various situations. Wish you all success.14
DEVELOPMENTAL CRISES AND COUNSELLING
1
COUNSELLING THE CHILD
1. Introduction
When one thinks of counselling what usually comes to the mind is the adult
who may be in need of it. To be counselling a child may appear strange. But all the
same children too require psychological help; may be only in some cases it is directly
affecting them but indirectly it is affecting them in most cases. For our consideration
we could perhaps take children in their late childhood where we typically need a kind
of directive counselling. We just cannot ignore the early childhood too, for, there too
we encounter problems either with the children themselves or with the people who
care for them or with both, which is the case most of the time.
People take their roots in their prenatal existence, which grows through infancy
and babyhood. Before one reaches childhood one has to pass through the first three
stages of prenatal, infancy and babyhood (toddlerhood). Some basic information
about the type of developments of those three stages and the influences they have on
the child is traced in the following pages before we study about childhood
counselling.
2. FIRST THREE STAGES (PRENATAL-INFANCY-BABYHOOD)
1) Prenatal
Prenatal development takes place during the gestation period of 280 days on
the average for a full-term human pregnancy. The prenatal period can roughly be
divided into three: the period of the zygote, which extends from conception to the end
of the second week; the period of the embryo, which extends from the end of the
second week to the end of the second lunar month; and the period of the foetus
which extends from the end of the second lunar month to the birth of the baby.
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Another way of understanding the period of pregnancy is to divide it into three
equal trimesters. The First Trimester period is 0 to 3 months during which time all
the internal organs, appendages and sense organs begin to develop. First Month:
After the egg has been fertilized, the zygote undergoes mitosis to become two cells
and thus keeps multiplying for two weeks (called the period of the ovum). On the
fourth day the cluster of cells reaches the uterus and after three or four days gets
embedded (which is called nesting). Mitosis follows for another week and nesting
continues. The embryonic period starting from the time of implanting till the end of
second month is known by marked differentiation of the cells. Second Month:
Facial features and a neck are forming; limbs are elongating showing distinct division
of knee and elbow, shoulders, arms; hands develop fingers; under the tissue of the
arms and legs the long bones are forming and become padded with muscles. Organs
begin to develop in functional properties, with the nervous system, kidneys and
stomach becoming operative. By now some genetic characters (like ear lobes, nose
and fingers) take the shape they inherited. Third Month: Now starts the foetus
period; there is progressive maturation of both nerves and muscles with generalized
movements in response to external stimulation, and the foetus turning and rotating;
arms, hands, fingers, legs, feet and toes are now fully formed; tiny tooth sockets and
eyes are almost fully developed; the cartilaginous substance of the ribs and vertebrae
turn to bone.
The Second Trimester from 4 to 6 months is characterized by a continuation
of the developmental process with a rapid increase in growth. There are a strong
heartbeat, a fairly developed digestive system, noticeable genitals and eyebrows (in
the fourth month). Internal organs maturing with the exception of the lungs, a downy
growth of hair on the entire body, with the behaviour of the foetus including sleeping
and waking moments, crying and thumb sucking and hiccupping and head-over-heels
somersaults are evident (in the fifth month). With separated eyelids tiny eyelashes
are seen, fingernails extend to the end of the fingers, at times making a fist, with the
starting of ossification (hardening of bone) (in the sixth month).
In the Third Trimester from 7 to 9 months the foetus gains in growth and
weight; there is the rapid development of the reflexes. Most organs do reach a
maturation level to be able to operate independently of the prenatal environment.15
There are four characteristics of the prenatal period. 1) The hereditary
endowment of the individual and the gender are fixed once for all and that serves as
the foundation for the future development. 2) Mother’s body conditions can affect
the hereditary potentials depending on whether the conditions were favourable or
unfavourable. 3) Growth and development are greater in this period compared to
other periods. 4) If attitudes towards the child to be born were negative, it would
affect the mother adversely; mother’s healthy body and emotional conditions are
essential for the healthy development of the foetus.16
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2) Infancy (Neonate)
The Neonate needs to pass successfully through five overlapping stages for
survival and normal development: 1) Adjustment to the uterine contractions, 2)
Adaptation to foreign stimuli like sound, cold and light. The uterine environment had
a constant temperature, whereas as soon as the infant is born it feels varying
temperatures. 3) Changing from the dependence of placental oxygen to independent
breathing, since once the umbilical cord has been cut, the infant is supposed to
breathe on its own. 4) Numerous and massive biological changes that occur as the
neonate begins to use all the organs of the body; sucking, swallowing and elimination
are to be mastered by the infant for survival. 5) Balancing (homeostasis) of all the
physiological changes mentioned in the other four stages.17
3) Babyhood
(1) Physical Development
Physical development of the baby: During the first three years of life, overall
physical rates of growth are at their greatest. Lifting the head, chest support, rolling,
lunging, and crawling – all precede walking behaviour, which emerges approximately
between 13 and 15 months of age. There is neuromuscular control for prehension
(which is the ability to grasp an object and for artwork), coordinated hand-eye
movements and handedness (right or left handedness) developing at about four
months of age.
(2) Cognitive Development
Cognitive development is the mental process that deals with thinking,
perceiving and understanding. Jean Piaget has explained the thought process of the
infants and babies in six sequential substages of the sensorimotor stage. The first two
years mark the sensorimotor stage of the cognitive development. 1) Reflex Activities
(0-1 month): the infant is capable of primitive reflex responses like crying and
sucking. 2) Primary Circular Reactions (1-4 months): If a behaviour pattern like
sucking is pleasurable the pattern will be repeated for its own sake. 3) Secondary
Circular Reactions (4-8 months): The infants attempts to produce interesting
events in the external world that might have been caused accidentally; for example, if
a rattle shaken in a particular way produces a peculiar noise, the infant will do it over
and over again. 4) Coordination of Secondary Schemata (8-12 months): There is
the development of object permanency in the sense that when a seen object is hidden
the infant knows that the object exists even though it is not seen and will search for it
if it is its favourite object like a toy. 5) Tertiary Circular Reactions (12-18
months): The child wants to understand the construction of objects and how the
objects feel and are put together. That is why they constantly want to touch the face
of the mother or father.
6) Invention of New Means through Mental
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Combinations (18-24 months): Children are able to form mental images that will
enable them to devise new ways of dealing with their environment. Through inner
experimentation, new mental combinations are formed to attain their desired goals.18
(3) Language Development
Development patterns of speech and language follow a fairly stable sequence
with the cooing stage at approximately 2 months, and the babbling stage at
approximately 6 months. Between 12 and 18 months of age on the average, the first
word (holophrase stage since one word may even mean a sentence like ‘toy’ meaning
‘ I want the toy’) is spoken on account of imitation. There is a gap between the
understanding of the word and the expressing of the word, known as receptive versus
expressive lag. Children understand much earlier than they can express. A two-word
sentence is used by the end of the second year using pivot words (short words) and
open class words (any of a large number of words) followed by telegraphic sentences.
By the third year the baby exhibits a remarkable language development.19
(4) Personality & Social Development
The mother’s influence is the greatest for socialization. Emotions known in
infants at arousal levels are difficult to measure. Freud speaks of the importance of
oral stage during infancy and babyhood, and Erikson speaks of the psychosocial
development of trust versus mistrust. At this level children are egocentric and engage
themselves in solitary play; with improved motor skills and mental abilities they
investigate their environment and involve in more elaborate play.20
i) Characteristic Traits
The first year of life is characterized by three main phases of dependence,
control over bodily movements, and sensuous pleasure. In the first year of existence,
the infant centres its whole attention on itself, depending upon its mother for its
protection and security in exercising its bodily functions, and in sensuous pleasure: 1)
Dependence is seen in the infant’s need for sleep, for close contact with the mother,
for clinging and for uttering cries of distress. 2) Body Control: The movements for
the child take place in order from the head downwards. First the eye movements,
then the exercises of the abdominal muscles so that it can sit up after which comes
the movement of the legs in kicking to discharge the nerve tension. Slowly the infant
rolls over, crawls, creeps, stands temporarily, stands independently and walks.
Meanwhile the infant establishes control over its internal muscles of bowels and
bladder. Thus having had the spontaneous outburst of nerve energy, the infant gets
some voluntary control over its movements and then begins to experience pleasure in
controlling them. 3) The biological activities and bodily functions of the infant give
sensuous pleasure for the infant. In sucking, moving its arms, in kicking and
crawling and in walking the infant finds joy.
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ii) Organization of Personality
The first three years are of considerable importance. It is the period of the
organization of the child’s personality. During the first two years the primitive
biological impulses needed for the pursuit of life like curiosity, assertiveness and fear
do emerge. During the third and fourth year the organization and harmonization of
these various impulses under the control of the will take place.
iii) Socialization
Babyhood is a time of rapid growth, change and individuality, but of decreased
dependency and the beginning of socialization. Babies need to experience emotions
like affection, curiosity and joy; if they are deprived of these emotions severely and
for a prolonged time, it inhibits the secretion of the pituitary hormones; this affects
the growth of the baby resulting in ‘deprivation dwarfism.’ Too much of stress like a
prolonged unpleasant emotional state like anger and fear can affect the homeostasis
of the baby’s growth.21
iv) Self-display
Self-display in the second year is normal. Having concentrated on himself in
the first year the infant goes out to meet life and to take a more active interest in the
world of people and events. Unlike his first year, he now calls attention to his self
display and moves about to explore the world with curiosity. He likes to be in the
centre of the group and repeats performance that attracts attention from others.
v) Self-will
The age of two is recognized as the age of self-will. The child wants to have
his own way without obstruction and interference and he cannot tolerate delay in the
fulfilment of his will. In the first year he was dependent, curious and exploring the
world but now that he has learned about the world and events, he wants the world and
the events to obey him by doing his will and so he wants to bend the will of others to
do his will. The biological value of this self-willed phase is to control the world in
future and domesticate it for human well-being. Here the problem arises as to what
to do with a self-willed child. Absolute control and absolute freedom are dangerous
for the child. For example, a toddler wanting to hold an infant in his hands will not
have the strength and skill to hold an infant securely and when forbidden he will
become rebellious. Instead the mother can teach him to hold the infant partly
supporting the infant. Thus striking a balance between absolute control and freedom
will be the ideal guidance to follow.22
vi) Imitation
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Though imitation is evidenced a few weeks after birth, it is highly
characteristic between the age of one and two. There is an innate propensity to
imitate. Even animals learn things by imitation; thus a chick may not naturally be
afraid of eagles but when the mother hen shows signs of fear and gives an alarm, the
chick runs into hiding for safety. Whatever you do, the child wants to do. If you
serve food, he too wants to serve food to others.
EARLY CHILDHOOD
3. Early Childhood
Childhood is divided approximately into early childhood (from two to six years)
and late childhood (from seven to ten). Here my main concern is not to chalk out the
developmental tasks of the children in great detail though we may need them to some
extent but to highlight the type of problems a counsellor will meet with the children
and plan out how one can deal with them. For convenience, let us first focus our
attention on the early childhood and then on the late childhood.
i) Characteristic Traits
Let us have a cursory view of the developments that take place in the early
childhood.
1) This age is called by various names because of the developments that are
noticed in the child. It is a problematic age. In infancy and in babyhood the parents
were concerned with the physical care of the child but now the child develops a
distinctive personality and is demanding independence, which manifests itself in the
form of being obstinate, stubborn, disobedient, negative and antagonistic. It is the toy
age. Children spend most of their waking time playing with toys. It is the preschool
age because they have not yet started to go to school. It is an exploratory age in the
sense that the children want to know how the environment works and feels and how
they can become part of it. While exploring they ask a lot a questions and thus it is a
questioning age. Since the imitation of speech and actions of others are more
pronounced in this stage than in any other, it is also called an imitative age.
2) Here the physical development proceeds at a slow rate. However body
proportions change markedly with the result that the baby-look it had disappears. By
the end of this age the child has one or two permanent teeth.
3) It is a ‘teachable age’ since they learn skills by repetition, which they enjoy
and which are also helpful for learning. Hand skills and leg skills are learned and
exercised; and handedness is well established. Speech development is rapid so much
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so that this stage is called chatterbox age because many young children talk
incessantly with their acquired speech skills.
4) With regard to emotions, they express temper tantrums, intense fears, and
unreasonable outbursts of jealousy. Practically they experience most of the emotions
normally experienced by adults like anger, fear, jealousy, curiosity, envy, joy, grief
and affection.
5) Children’s understanding is not accurate and their morality is by constraint,
in the sense that they learn to obey through praise and punishment.
6) Their interest centres on the human body, self, sex and clothes. Here the
child masters sex-role typing as expected in the society.23
7) The early childhood is clearly marked by the organization of the personality.
Starting from two and a half till four the child has an organized personality.
The process of the organization of the personality takes place in four welldefined phases: 1) Imitation: The child learns to take over the actions of others,
especially of his parents. If the parents are deceitful, the child learns to be so and in
the same way if they are straightforward, the child too will behave that way. 2)
Suggestibility: Here the child takes over not only the actions of others but also their
feelings, moods and ideas. The child has become suggestible in the sense of being
acquiescent, cooperative and anxious to please. 3) Identification: Besides taking
over the actions, feelings, moods and ideas of others the child takes over the entire
personality of the other. His personality is entirely absorbed in the personality of the
other. The characteristics and the whole personality of the other are taken over. 4)
Formation of the Ego ideal: Here the child adopts the standard of the persons with
whom he identifies as his own; has a guiding principle within his own personality by
which he regulates his own personality; thus he shifts the centre of gravity of his
behaviour from the other person to within himself. In the fourth phase the child
scraps the person with whom he identified and keeps only the character of the other
person. The results of the formation of the Ego ideal are as follows: (1) Formation
of a duality in personality – On the one hand there is the Ego or natural self with its
innate impulses and desires, and on the other hand there is the Ego ideal or moral
self. (2) Self-consciousness – Here one part of the personality is conscious of the
other part. (3) Self-criticism and Conscience – Here self-consciousness necessarily
leads to self-criticism. Self-criticism constitutes into conscience. Actually,
conscience is the judgement, which the Ego ideal or moral self passes on the Ego or
natural self. (4) Self-control – Because of the Ego ideal the child has self-control.24
8) An age of individuality is between four and seven. Having organized his
own individual personality, he begins to develop, consolidate and build it up. He is
in a way egocentric to the extent of being all out for achievement, proving his worth
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and developing his sense of power. He wants to show off by all means. Because of
his egocentric endeavour, his sociability is marginalized.25
9) Cognition and Language in Early Childhood: Some of the thought
processes of children are egocentrism versus objectivity, fantasy versus reality, the
literal versus figurative language. (1) Egocentrism versus Objectivity: The child
thinks everything in terms of himself and his comfort and convenience. Because of
their cognitive limitation, children cannot be expected to be even-handed in dealing
with others and they are quite incapable of understanding the consequences of the
self-centred behaviour. (2) Fantasy versus Reality: Children do believe that the
characters like monsters that they hear of in stories and see in television are truly
living. (3) The Internalisation of Action: Children need to see and hear the things
they are thinking about. They cannot think of objects entirely in mind without the
presence of that object in front. This is illustrated by the fact that children while
doing something run an oral commentary about what they are doing. If they are in a
group doing something and each one of them is giving a running commentary it
becomes a ‘collective monologue’ as labelled by Jean Piaget. (4) Relationships and
Classes: In fact, children have difficulty in understanding the relationship of uncle,
aunt, grandfather and the like. Children’s drawings illustrate the fact that their
conception of objects is not accurate. A child may draw a cross line and say it is a
crow. (5) Language Development (refer to the section on babyhood). (6) Literal
versus Figurative Language: Children are bound to interpret words in concrete and
literal meaning rather than in symbols and abstractions. Therefore, for example,
instead of telling a boy ‘you are a monkey’ you could tell ‘you are curious like a
monkey.’26
10) Initiative versus Guilt: As a baby, one has already experienced autonomy
especially from the parents, and now the child experiences the ego quality called
‘initiative versus guilt.’ Because he feels autonomous, he is all out to take the
initiative to do many things. By now, he has mastery over locomotion and language
and with these two advantages, he is confident of taking initiatives. He is happy
when he succeeds but feels guilty when he fails for the initiative he has taken.27
2) Counselling Situations
(1) Child Abuse
The counselling situations that confront a counsellor in the early childhood are:
1. Child Abuse and Neglect and 2. Handicapped Condition. Child abuse or neglect is
understood as any commission or omission by individuals, institutions, or society as a
whole which deprives children, interferes with the optimal development and deprives
them of rights and liberties. It can also be understood as severe abuse consisting of
physical injury requiring serious medical treatment and moderate abuse consisting of
lesser degree of injury and suffocation. Neglect is caused when a child is deprived of
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food, fluids, warmth, freedom and medical treatment and when it is made to suffer
from unnecessary psychological stress, mental assaults and abandonment.28
i) Causes of Child Abuse and Neglect
1) One cause of child abuse is the family stress and this is true in families that
suffer from poverty because a lot of stress situations arise out of the need to meet
their basic needs and children become a burden to care for. 2) If the children are
hyperactive or handicapped, they are difficult to manage and the coping skills of the
parents practically prove futile thus precipitating abusive behaviour on the part of the
parents. 3) Unexpected crisis by way of death of the bread-winner of the family or a
sudden financial reversal and the like might totally or partially paralyse the parents;
so they neglect their child-rearing responsibilities which results in actual child abuse.
4) The parents care for their children the way they had been cared for in their own
childhood. Both good and bad we have learned. A certain type of punishment,
which maybe in itself, an abuse may be resorted to by us in treating our own children
thinking that the method we employ is the best one. Unconsciously, we tend to inflict
on others whatever pain we received in our lives. 5) Parents’ unreasonable
expectations could play a part in child abuse. It may be in the form of compensation
or over-compensation for what they themselves did not possess and cherish in their
lives. A teacher who himself had been an orphan and was brought up by charity was
too demanding of his children with regard to their study since he himself was
deprived of a standard education in his childhood. 6) Parents who are isolated from
social networks of support are prone to be child-abusive because when their conduct
is abusive they are deprived of the support that may be available to relieve them of
constant care of the children and even correction from the support group. That is
why in families that have grandparents, aunts and other relatives, the child abuse is
less since the members other than the parents take care of the children and even
reprimand the parents when their behaviour is abusive and rescue the children from
serious harm. 7) Defective personality development is also one of the causes of child
abuse. Because of some defects in the personality of the parents they are inclined to
abuse others and even their own children. 8) The handicapped children are more
likely to be abused when compared with the normal average children. When parents
have handicapped children they feel shame, guilt and resentment and if the children
suffer from intellectual and neurological deficits the risk of child abuse is rather
high.29
(2) Handicapped Conditions
Now we turn our attention to the handicapped conditions in early childhood.
Handicap is understood as any physical or mental characteristic that prevents children
from developing as adequately as the majority of their age-mates. Handicap can be
judged from comparing the children with the development of their own age groups.
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Handicaps are 1) Physical, like visual and auditory disorders and recognizable
damage to body organs; 2) Psychological or mental retardation, neuroses and
psychoses which when spelt out will mean learning disabilities with specific forms of
learning such as reading, writing and computing; behavioural disorders, emotional
disorders, and mental illnesses like depression, fear, feeling of persecution, rejection,
extreme shyness, aggressiveness and physical self-destruction. The second type
includes a variety of maladjustments and illnesses like infantile autism which appears
before thirty months of age, and schizophrenia.30
LATE CHILDHOOD
4. Late childhood
Now let us have a cursory view of the development in late childhood.
1) Characteristic Traits
1) It is a sloppy age in the sense that children tend to be slovenly and careless
about their appearance, habitation and possessions. Here children form habits of
being achievers, underachievers or overachievers which tend to persist in adult life.
It is a quarrelsome age in the sense that where there are siblings of both sexes, boys
pickup on girls and girls retaliate thus creating a scene of quarrel. Psychologically it
is a gang age, age of conformity and age of creativity. The major concern of children
is acceptance by their own age group, at times even buying acceptance and
membership in a gang, and that is why children are willing to conform to the groupapproved standards in terms of appearance, speech and behaviour. If not prevented
children divert their energies into creative activities. The breadth of play-interests
and activities are more here and so this age is called play age.
2) During the entire childhood, the physical growth is slow and relatively
uniform. Though the head is still too large, some of the facial disproportions
disappear. Their body disproportion and careless grooming coupled with the concern
to wear clothes like the peers contribute to their homeliness. By the end of this age
the child normally has twenty-eight permanent teeth out of the thirty-two.
3) The children learn four major skills: (1) Self-help skills like eating,
dressing, bathing and grooming almost like adults. (2) Social-help skills like helping
others both at home and in the school. (3) School skills like developing skills in
writing, drawing and crayoning. (4) Play skills like throwing and catching ball, riding
a bicycle and swimming.
4) To feel great and grown-up, children use slang-words and swear-words
mostly learned from older children in their neighbourhood (often used to attract the
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attention of others). In addition to this they also have secret vocabularies (code
words) either written, or verbal or symbolic.
5) More than anything else this age is identified with a gang. The gangs are
mostly playgroups formed of the same sex in which membership is by invitation; they
have a central meeting place away from the adults, and an insignia like wearing the
same clothes. They have games and sports, go to movies, and get together to talk and
eat with a gang leader superior in most respects to the other members. If it is the
question of socially unaccepted behaviour, it is the gang of boys who engage in it
more than the girls. Their belonging to a gang enhances the socialization of the
children like being loyal, conforming to group standards, playing games and sports,
accepting and carrying out responsibilities, competing with others, learning socially
accepted behaviour, being cooperative and independent.
6) Children like to read adventure stories with happy endings and enjoy comic
books and comic strips. Lonely children keep daydreaming and fantasizing.
7) Some of their misdemeanours at home are fighting with siblings, being rude
to adult family members, neglecting home responsibilities, lying, being sneaky,
pilfering things from other families, dawdling over routine activities; and in the
school: stealing, cheating, lying, using vulgar and obscene language, destroying
school property, fighting, bullying, clowning and being boisterous.31
8) Industry vs. Inferiority: The late childhood is marked by the ego quality of
industry versus inferiority. The child that feels autonomous taking up a lot of
initiative wants to explore and manipulate his environment. He is in an attempt to
change and adapt to his environment in which if he is successful he feels encouraged,
otherwise he is bound to feel inferior.32
2) The Needs of Children
Now it will be worthwhile to take stock of the commonsense knowledge one
can learn from our day-to-day experience with children. People who worked with
parents and children in sorting out the problems and helping them to work out have
proposed a few insights from their experience to be checked by the counsellors while
counselling the children. 1) First of all, there is a need for significance. Children
want to be noticed and they will by all means want to get the attention to feel
significant. Children could be helped to have this sense by allowing them to help
around the home, introducing them to others especially the visitors, allowing them to
speak for themselves, giving them the privilege of choice, respecting their opinion,
spending time with them and by entrusting them with responsibilities. 2) The need
for security is very much embedded in human nature. The sense of security could be
given to the child by the parents when they themselves enjoy the security of love
between them. Parents should further develop this sense of security in their child by
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continuing their love for the child, having family togetherness, having regular routine
and proper discipline, touching the child, and by giving it a sense of belonging. 3)
The need for acceptance is universal even for grown-ups. This sense of acceptance is
given to the child by the parents’ recognition of their child’s uniqueness; they should
make their children realize that they love them; accept their children’s friends, treat
them as persons of worth, and allow them to grow in their own unique way. 4) The
need to love and be loved – One of the greatest happiness is the conviction that one is
loved and in the same way one is extremely pleased to find someone whom one can
love. 5) The need for praise – Children are thrilled to be praised especially by the
significant ones. Praising them sincerely for what they do on their own will highly
satisfy their need for praise. 6) The need for discipline – Discipline means the total
moulding of the child’s character through encouraging good behaviour and correcting
the behaviour that is not acceptable. Actually disciplining will give a sense of
security to the child and in that way it is very essential for the growth of the child. A
disciplined child will develop respect for its parents. Disciplining without nagging is
what the parents should aim at.33
3) Counselling Situations
Though we take childhood in general, for our consideration we have seen
separately the developmental problems that can arise both in the early childhood and
in the late childhood. Counselling the children therefore should follow in the same
line. First, we need to locate a child in his early or late childhood and understand the
problem. The reason why we have seen the developments is to make sure that we do
not mistake the normal developmental problems as abnormal ones. The knowledge
about the normal developments of children will enable the parents to be calm and
understanding when their children undergo their usual normal developmental
problems and they can be supportive when necessary.
(1) Identified Patient
When children are brought for counselling I observe the parents more than the
children to begin with. I have not been surprised to find that often the problem is not
with children but it is with the parents. The child is only an identified patient, a kind
of scapegoat for the parents to project their problem. If the real patient is identified
as the parents, I proceed to counsel the parents first rather than the child. In this case
the child needs counselling to the extent that he suffered damage by the projection of
the parent’s problem on him. In most cases I find myself going for family
counselling (with which I shall be dealing later in detail).
(2) Sibling Rivalry
In my counselling ministry, a thing I meet quite often is sibling rivalry.
Especially when a new-born arrives, the child in early childhood feels that he is
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dethroned since the attention he would normally get goes to the new arrival and thus
he becomes intensely jealous and even he is ready secretly to punish and harm the
new-born. Even though sufficient attention is given to the older sibling, he does not
understand it as sufficient and the fact that his parents’ attention is divided is a fact he
moans inconsolably. Though feelings of jealousy would be normal at this age,
parents could have prevented a major portion of it if only they had prepared the older
sibling about the new arrival before the arrival itself. Perhaps they could give
information about the child to be born and make him ready to receive the baby and
making him proud of the new baby.
(3) Unrealistic Expectation
An employee in a reputed firm had his eight-year old son admitted to a
prestigious school with a high standard. Everything went off well until one fine
morning when the second boy was born. From that time onwards the older boy
began to feel neglected; and later the younger one went to school and did rather well
whereas the older sibling was in his late childhood with a little underachievement; at
this stage, the comparison of the performance of the younger sibling with that of the
older one triggered off a lot of study problems for the older one. The father changed
three schools for him and finally came to me for counselling. Even a layperson
looking at the family could judge where the problem lay. The boy stood aloof while
the younger one enjoyed the mother’s lap and the father’s strokes. The parents told
their version of the problem and the boy was not very willing to talk to me. After my
initial cajoling, the boy spoke out his problem. He said that his parents especially his
father, treats him as a servant. Reacting to the way he was treated he used to sleep on
the floor instead of sleeping on the mattress with the parents because he felt like a
servant. In the course of interaction with the entire family it became very evident for
me that unfavourable comparison of the boy with his younger brother was the real
cause of the problem. Then of course I dealt with the parents who were not much
aware of what they were doing. Another added reason for the problem was the
unrealistic expectation of the father. The father wanted his son to be the first and the
best in the school with regard to school achievement. Though the boy was
sufficiently clever he could not cope with the demands and expectations of his father.
Sometimes I have seen grown-up siblings taking sides with the parents in making the
problem-child more irritated.
(4) Identification
We know that the early childhood is a stage of suggestibility. But if it is
carried to the extreme, the child fails to stand on its own in later life. And in the same
way if the child, because of his tendency to identify with someone, identifies with the
wrong person who is socially a misfit, he will later end up being the type of person he
imitates. That is why the character of the parents is of paramount importance in the
formation of their children. Because of the formation of their Ego ideal, if children
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were to become too self-conscious and self-critical, they become over-shy and
develop uncompromising morbid conscience.34
(5) Handicapped Children
This is with regards to counselling caretakers of handicapped children. A
stumbling block to healthy caring is the very attitude of the parents, especially the
mother. 1) Overprotection of the child – Mothers usually feel guilty and pity for
having produced a child with defect. Therefore, she goes to protect the child so much
so that no further harm may befall the child. This in turn incapacitates the child still
more because he now begins to over depend on his parents. In over solicitous
attitude is a disguised rejection of the child. Since the parents suffer from their own
punitive conscience, being unable to reject the child outwardly, they tend to play the
overprotective role thus damaging the personality of the handicapped child, for he
feels guilty for having made his parents sacrifice for him because of his handicap. 2)
Over rejection – Unable to accept the handicap the parents project the blame onto
the environment. 3) Denial of the handicap – This type of parents usually do not
admit that the handicapped child needs a type of treatment different from what other
children get. Here the handicapped child suffers from too much of expectation from
his parents.
When counsellors face a handicap-situation, it is a must to identify what type
of attitude is at the base and explore it along with the parents to arrive at a
constructive acceptance of the handicap. The parents need to accept the situation
realistically without guilt or anger at the handicap and, in social situations, without
displaying shame and apology for the child’s condition.
The constructive acceptance of the handicap can be achieved through several
means. First of all, the counsellor needs to facilitate catharsis to unburden their
worries, resentment and guilt. Secondly, parents need to get accurate information
about what can reasonably be expected of their handicapped child and how they
could go about it. Some books on behaviour-management skills would be of
immense help to the parents. Thirdly, because the handicapped condition demands
extra energy from the parents, they need comfort and consolation from the
counsellor. Here what would be most useful are gestalt, rational-emotive-behaviour,
and reality therapies.
(6) Counselling Techniques
Counselling the children, especially the handicapped children, is not that easy.
1) Winning over the child’s confidence – First, the counsellor needs to
mobilize all his energies and ingenuity to win over the confidence of the child.
Usually children do not cooperate with the counsellor because they are too shy, or too
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confused about what is being done to them. One can expect a big success if the
confidence of the child is won over. Even if it were to take a few sessions to win
over the confidence of the child, it is worth the trouble instead of wasting your time
on sessions without the cooperation of the child. Having won over the confidence of
the child, the counsellor may use any of the following techniques.
2) Whatever aspects of the handicap can be corrected should be done forthwith,
even sending the child to specialists.
3) Using play-therapy, the counsellor could provide dolls that represent family
members. The child can be encouraged to tell how the other people including the
peers, treat the handicapped person and what the handicapped person thinks and
feels. Thus the child gets an emotional catharsis. Since play is the nature and
spontaneous medium of self-expression, it is an opportunity, which gives the child a
chance to ‘play out’ his feelings, and problems just as, in certain types of adult
therapy, the adult ‘talks out’ his difficulties. It could be either directive in which the
therapist assumes responsibility for guidance or non-directive in which the
responsibility rests with the child. The non-directive, which assumes that the
individual, even a child, has within himself, the ability to solve his own problems,
seems to be more effective. This could be practiced either individually or in a group.
In play-therapy the guidelines the counsellor is supposed to keep in mind are:
establishing a warm relationship with the child, accepting the child as he is, giving
the feeling of permission to the child to feel free to express his feelings completely,
reflecting the feelings of the child in such a way that the child gets insight into his
problem, respecting the child’s ability to solve his own problems, following the lead
of the child without being in a hurry and using limitations which will anchor the child
to the world of reality.
(1) Play Therapy
Play therapy refers to a method of psychotherapy with children in which, a
therapist uses a child's fantasies and the symbolic meanings of his play as a medium
for understanding and communication with the child.
Play therapy is generally employed with children aged 3 through 11 and
provides a way for them to express their experiences and feelings through a natural,
self-guided, self-healing process. As children’s experiences and knowledge are often
communicated through play, it becomes an important vehicle for them to know and
accept themselves and others.
Play therapy is often used as a tool of diagnosis. A play therapist observes a
client playing with toys, play-houses, pets, dolls, etc. to determine the cause of the
disturbed behaviour. The objects and patterns of play, as well as the willingness to
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interact with the therapist, can be used to understand the underlying rationale for the
behaviour both inside and outside the session.
According to the psychodynamic view, people (especially children) will
engage in play behaviour in order to work through their interior obfuscations and
anxieties. In this way, play therapy can be used as a self-help mechanism, as long as
children are allowed time for "free play" or "unstructured play." From a
developmental point of view, play has been determined to be an essential component
of healthy child development. Play has been directly linked to cognitive development.
(2) Systematic Model
The therapist's office will schedule an appointment with several children. In
one session there can be as many as 2-5 children interacting. This organic interaction
allows the psychologist and psychiatrist to properly evaluate the child’s emotions and
feelings. This form of therapy allows the child to unknowingly reveal his emotion,
while playing with other children.
Along with children interacting with other children, the therapist will have the
child play with certain toys in order to determine the source of any stress. Each toy
and each style of enjoying them represents a different emotion and feeling.
(3) Equipment
Sand tray, sandbox or sand play therapy is a form of experiential workshop
which allows greater exploration of deep emotional issues. Sand play therapy is
suitable for children and adults and allows them to reach a deeper insight into and
resolution of a range of issues in their lives such as deep anger, depression, abuse or
grief.
(4) Purpose
The aim of play therapy is to decrease those behavioural and emotional
difficulties that interfere significantly with a child's normal functioning. Inherent in
this aim are improved communication and understanding between the child and his
parents. Less obvious goals include improved verbal expression, ability for selfobservation, improved impulse control, more adaptive ways of coping with anxiety
and frustration, and improved capacity to trust and to relate to others. In this type of
treatment, the therapist uses an understanding of cognitive development and of the
different stages of emotional development as well as the conflicts common to these
stages when treating the child.
Reasons for treatment include, but are not limited to, temper tantrums,
aggressive behaviour, non-medical problems with bowel or bladder control,
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difficulties with sleeping or having nightmares, and experiencing worries or fears.
This type of treatment is also used with children who have experienced sexual or
physical abuse, neglect, and the loss of a family member.35
4) Using behaviour therapy the counsellor engages the child in tasks to be
performed in a play situation, then arranges the reward and punishment contingencies
in a manner that will encourage the child to adopt more mature form of behaviour.
5) Using role playing, the counsellor prepares a ‘let-us-pretend’ situation in
which he along with the parents if possible participates with the child in the role
playing in which the child gets new and more constructive ways of interacting with
others with his handicap. If direct role play is difficult for children who are too shy, the
counsellor could arrange toys or puppets to play the role. This provides a sufficient
psychological distance for the child to reveal what is on his mind.
6) Counsellors can also tell stories or incidents of children who made positive
adjustment with their environment.36
If the parents are abusive and neglectful of their children, not much can be
done. Unless the parents are willing to engage in extended counselling in childrearing methods, perhaps in a group setting with sharing of experience with parents
of similar problem and learn the healthy child-rearing behaviour from others, the
situation cannot be improved. Secondly, the counsellors could probe into the
possibility of finding social-support resources for the parents, the lack of which often
leads to child abuse. Thus, social support recourse will greatly minimize the chances
of the child abuse.37
5. Conclusion
Counselling the child requires a lot of knack and skills, first of all to win over
the confidence of the child if he is particularly too shy to relate to you. It may take a
few sessions before the child becomes free with you. Providing an emotional
catharsis for the child is essential, either by talking, play therapy, or by role-playing.
Since in most cases the child is only an ‘identified patient’ with the
understanding that the parents (elders) are the real patients, it is good to locate the
real patient and focus the attention on that person. Here more than anything else the
attitude of the parents needs to be changed; then slowly the maladaptive coping skills
of dealing with the problem-children can be dealt with. Very many times starting
with the child counselling, I have ended up with family counselling because a child is
a part of the family system and treating a subsystem of parent-child relationship alone
will not be enough for the total well-being. One has to consider the whole family
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system with all its subsystems. Therefore, an overall approach to child counselling is
strongly recommended.
2
COUNSELLING THE ADOLESCENT
Introduction
In our discussion on adolescence we shall also include preadolescence which is
properly called puberty. As we did in dealing with childhood as early and late
childhood, we shall have here two sections namely puberty and adolescence proper.
The term ‘adolescence’ is actually derived from the Latin ‘adolescere’ meaning ‘ to
grow to maturity.’ An overview view of the development that takes place in
preadolescence and in adolescence will be of immense help in understanding their
predicament and the means we need to employ in counselling them.
2. Preadolescence
Preadolescence or puberty is an overlapping period, which encompasses the
closing years of childhood and the beginning years of adolescence. In itself it is
marked by three stages: 1) Pre-pubescent stage – It is the closing year or two of
childhood when the secondary sex characteristics begin to appear whereas the
reproductive organs are not yet fully developed. 2) Pubescent stage – It is the period
of the dividing line between childhood and adolescence marked by the menarche in
girls and the first nocturnal emission in boys. Here the secondary sexual
characteristics continue to develop, and cells are produced in sex organs. 3) Postpubescent stage – It is the beginning year of adolescence with the fully developed
secondary sexual characteristics and the mature function of the sex organs.
Puberty is a short period of rapid growth and change in body size, body
proportion, development of primary and secondary sex characteristics occurring at a
variable age. Puberty is called ‘negative phase’ because of the ‘anti’ attitude the
individual adopts towards life, especially in the early part of puberty and its negative
attitude changes when the individual becomes sexually mature. This negative phase
is because of the rapid physical change.38 More specifically this period is known for
the rejection of the standards of the adults, and behaviour problems and delinquency
normally originate during the preadolescence. The person gains independence and
has complete sexual identification.39 Now let us see what happens in adolescence.
3. Adolescence
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1) General Characteristics
Adolescence extends from the time the individual becomes sexually mature
until eighteen. Adolescence is not necessarily a period of storm and stress as it is
popularly believed. In fact it is so in some cultures especially in the western culture
but studies by sociologists and cultural anthropologists have proved that the period of
adolescence need not be a stormy period and one can pass from one stage to another
rather peacefully and so they call adolescence as a ‘cultural invention.’
All the same, adolescence is a trying period because of the conflict an
adolescent is going through not knowing whether he is still a child or already an
adult. He is caught up between these two stages. People at times expect him to be a
mature adult and reprimand him if he fails to be so and at other times consider him to
be a child and want to guide him. Since there is a lot of ambiguity regarding the role
of an adolescent, there ensue a lot of emotional problems. Emotional problems seem
to be the most important concerns of the adolescent. An adolescent becoming
increasingly aware of himself wants to define his role in the society seeking status as
an individual, eagerly longing for recognition from his age-mates or peers. For this he
is ready to conform to the standards of his peers. He is confronted with an emerging
heterosexual interest; he experiences a conflict between his immature idealism and
reality.40
2 ) Physical Development
Regarding physical growth, there is a general slackening of the pace of growth,
and there is more marked internal development than the external one. They have
dissatisfaction with regard to some parts of their bodies and thus have poor selfesteem and unfavourable self-concepts.
3) Social Development
The important social changes of adolescence are more mature patterns of social
behaviour; increased peer-group influence, seeking new social groupings and new
values in the selection of friends and leaders. Sex interest mostly centres on
heterosexuality.41
4) Grunt Stage
Sometimes teenagers go through a phase when they will not properly answer
others. Whatever questions you ask they will just grunt. This ‘grunt stage’ is a
normal part of teen development. Perhaps it is an automatic process well beyond his
control by which he is distancing himself from his parents. Much of the trouble
between parents and adolescents is due to the adolescents’ apparent unwillingness or
inability to communicate. When communication takes place, it is through cryptic
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terms like ‘touch,’ ‘bad,’ etc. – along with non-verbal communication of hand
gestures, signals, emblems and clothes; these modes become normal for the
adolescents. Since they want to increase their independence, they actively attempt to
exclude adults by keeping themselves away from them and from cutting off
communication. Here it may be very damaging if we force him to open up. At this
time, all they need is understanding. It is not true that the adolescents do not
communicate. Verbal communication is only one way of communicating; silence
and grunts too can eloquently speak. The difficulty does not lie in his refusal to
communicate but it lies in the adult’s inability to adequately understand the
information received.42
5) Alienation
Adolescents experience alienation, which is a syndrome comprising of distrust,
anxiety, pessimism, egocentricity, not being thoughtful of others, normlessness, and
powerlessness. This is alienation between his self and the objective world. The
adolescent is figuring out things and wants to redefine his self, which will be
responsive to the new social realities. In this process of moving away from family
ties, towards a sense of independence and autonomy, he feels he is standing alone.
This feeling of estrangement is part of the normal development. He may feel isolated
from himself (intra-psychic loneliness), and cut off from the world especially from
the peers (social isolation). What may contribute to the loneliness of the adolescent
are his lack of social skills and his limited opportunities for social contacts. He may
have failed to develop the necessary prerequisite skill for gaining admission and
acceptance into the peer group. He may not be having opportunities to join a project,
tasks and interaction, which require achievement that might enhance his increasing
approachability and inclusion among members. Some of the adolescents go to the
extent of the experience of a total breakdown of their sense of attachment to, and
within, society.43
(1) Effects of Alienation
The adolescent who feels alienated may retreat, rebel, run away or commit
suicide. The adolescent dysfunctionally believes that retreating might solve his
problem of alienation but on the contrary, it only increases the alienation. His retreat
might even lead him to drugs. He might even run away from the painful situation.
Quite a number of adolescents yell at and rebel against their parents. Some go to the
point of ending their lives. Those who contemplate suicide experience anguish,
isolation, depression and a general sense of hopelessness.44
6) Identity Vs. Role Confusion
Adolescence is a critical period of the development of self-concept. Selfconcept, which does not originate at birth, evolves through the years through
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learning. The self-concept, which develops during the period of adolescence, attains
stability in later years.45
In the late childhood, conformity to group standards was far more important
than individuality but now in adolescence, search for identity is a major quest. 46 In
identity, he wants to clarify who he is and what his roles are in the society. The
period of adolescence is a time of unrealism. They tend to see life through rosetinted glasses.
According to Erikson, ‘identity versus role confusion’ is the core conflict of
adolescents. At the outset of adolescence one encounters a major threat to the older
established sense of identity of childhood. With the onset of puberty, marked
changes like maturing of the sexual functions, rapid growth in height and weight,
alterations in body contour and growth of body hair do appear. In puberty and
adolescence the individual wonders who he is and what he is supposed to do in the
society. Now his preoccupation is to define for himself from looking around and
from the expectations of the society of who he is and what he is expected to do. An
adolescent who is not successful in the resolution of his identity crisis becomes egodiffused. On account of this ego-diffusion the adolescent does not know ‘who he is,’
‘where he belongs,’ and ‘to whom he belongs.’ If this is the case the adolescent
forms ‘negative identity,’ that is, an identity which is contradictory to the expected or
socially approved norms and this could lead to delinquencies. Adolescent’s identity
confusion is the result of being overwhelmed by body changes, and by a host of
alternatives from their environment. The typical adolescent identity is wanting in
stability, appropriateness of context, and clarity; it sometimes over identifies itself
with the heroes of cliques and crowds, to the point of apparent complete loss of his
own self-identity.
(1) Identity Status
James Marcia writes that there are four types of identity status. They are: 1)
Achievement – It refers to those adolescents who have faced doubts or crises in
personal values and self-identification, weighed alternatives, and intentionally have
subscribed to a set of values. 2) Foreclosure – It refers to the adolescents who for all
practical purposes seem to have achieved identity as they appear to have committed
to a set of values; but they have not considered alternatives and made a conscious
choice; perhaps they uncritically accept someone’s values, often those of their
parents. 3) Moratorium – It refers to those adolescents who have not yet made a
commitment and continue their search. 4) Identity diffusion (Erikson’s term) – It
refers to those adolescents who make no serious attempts to consider issues of
personal goals, or values; they do not express conscious belief system or realistic and
constructive plans for the future.47
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7) Cognitive Development
According to Piaget’s cognitive development, the highest stage called ‘formal
operations’ is entered during or sometime after the arrival of puberty. Adolescents
achieve an increasing command of formal operational thought by which they are able
to grasp concepts and employ cognitive strategies like manipulating abstractions,
applying generalizations and comprehending relationships in mathematics,
linguistics, science and social affairs. Therefore, we note that the highest of the
stages of mental function appears in early or mid-adolescence. At the same time
adolescents with their acquired skills of logical thought tend to be idealistic and
expect the world to be logical. Thus they are driven to become reformers and critics
of the older generation.48
4. Counselling
The kinds of counselling cases that come up during adolescence are: 1)
Educational, 2) Acceptance of changed physical self, 3) Sexual relationships and 4)
Juvenile crime.
1) Educational Counselling and Guidance
Here the task of the counsellor along with the client will be to 1) Identify the
educational options available within his reach, 2) make a realistic selection among the
options, 3) adopt specific strategies to pursue the options chosen. Though
educational counselling and guidance are needed in all the stages, it is great during
the adolescence. Usually the adolescent around the age of seventeen will be
completing his school final, up to which time in most countries the syllabus taught for
all the students will be the same and now comes the specialization. Here assessing
the student’s interests and aptitudes, getting to know the available educational
opportunities appropriate for his interests and aptitudes and adopting relevant steps to
achieve the end are to be seriously undertaken. The task of assessing the student’s
interests and aptitudes is typically carried out by psychometricians, school
psychologists, and counsellors and even by teachers who have experience in
conducting interest and aptitude tests. Where such facilities are not available even a
casual conversation by the counsellor with the student about his likes, his ambitions,
his academic achievements of the previous years, and available means will more or
less indicate the student’s interests and aptitudes. The task of providing information
can be obtained from the established vocational information centres or from
institutions by going through their brochures.49
2) Problem of Accepting One’s Changing Physical Self
With the manifestation of the physical changes taking place at puberty the
adolescent has a heightened concern over his physical appearance. He is over-
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sensitive about how he looks and how his age-mates judge him. In an effort to appear
more like adults, the adolescent adopts such styles of dress and grooming that will
give him a get-up. Often dress and grooming can become symbols of his rebellion
against adult authority and the society in general. Some of the common concerns of
the adolescent in this area will be pimples, obesity, height that may deviate markedly
from that of the age mates, disfiguring birthmarks, lameness, defective posture,
unusually formed facial features and protruding or crooked teeth.
For treatment of the heightened concern of the adolescent about his physical
appearance, behaviour therapy seems to be more effective than the traditional forms
of techniques.
Using behaviour therapy the counsellor applies systematic
desensitisation and response prevention to reduce the anxiety about physical
appearance. Some counselling psychologists advocate rational emotive and reality
therapy. In some sizable number of cases, family therapy and group therapies are
successfully used. There are some psychologists who would use hypnotherapy with
satisfactory results.50
3) Sexual Relationship
During adolescence, sexual organs reach their peak physical maturity and the
adolescent is ready for sexual activity. With the impelling inclination to seek
heterosexual relationship coupled with the physical need, the adolescent needs
repeated sexual consummation. In some societies the sexual needs of the
adolescent is taken care of and he is allowed to engage himself with others in sexual
relationship. But in some cultures sexual relationships especially for the girls before
the marriage is a taboo with the result that the adolescent seeks alternative ways of
releasing his physical tension arising from the sexual impulses. Therefore, he may
very often masturbate several times even during a single day or engage in
homosexual activity. Depending upon the religious background, adolescents are
known to feel very guilty about masturbation and homosexuality. And that itself is
another problem added to their sexual ones. What would be problematic for the
adolescent is AIDS and other related sexually transmitted diseases. Here the
counsellor’s task is not to curtail or forbid sexual expression but to make the
adolescent to use his sexual power responsibly.51
4) Juvenile Crime
Finally we come to the juvenile crimes including drugs. The incidence of lawbreaking in any age group is an indication of the developmental confusion and
maladjustment. And since adolescence is a period of identity crisis with the resultant
role confusion, we can expect the adolescent to engage himself in law-breaking
especially when he joins his own age group with similar impulse. Self-report studies
have estimated that at least 90% of the adolescents engage in some form of
delinquency, mainly of less serious nature. It is the male adolescent who takes the
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major share in juvenile crime forming 80% as against 20% of the female adolescent.
According to the frequency of arrests, the peak is at the age of 17 for boys and 16 for
the girls. Offences are of three kinds: 1) Index offences – These are judged to be
serious crimes against persons and property like homicide, rape, aggravated assault,
robbery, burglary, larceny, auto-theft, and arson. 2) Status offences – In this
category we have first of all juvenile status offences like misbehaviours specific to
juveniles — such as wandering in the streets at night, running away from home, and
drinking alcohol which when committed by an adult, would not be considered
criminal. In status offences we have also habitual disobedience or truancy by
adolescents who are judged to be ungovernable and incorrigible. 3) Minor motoring
infractions — These are acts of breaking small rules or laws concerning driving.52
(1) Substance Abuse
Under juvenile crime, we have got illicit drugs. (For the full treatment of drug
abuse, refer to the section on Counselling the Substance Abusers.) Drug is any
chemical substance, other than food introduced into an individual’s body that alters
his state of consciousness, sense of reality, or feeling of well-being. Illicit drugs are
those that are forbidden by law and cannot be used unless prescribed by a physician.
i) Link between Adolescence & Substance Abuse
Since the whole problem and treatment of drug dependence is taken in the
section on Counselling the Substance Abusers, here it suffices to note only the salient
links between adolescence and substance abuse. Considering the adolescent and
substance abuse, what comes to our mind as a major link is the nature of adolescence
itself. An adolescent faces a variety of problems. His body-change, sexual
yearnings, conflicting values of his peers and his parents, less career opportunities,
unstabilized vocational interest and lifestyle preferences, and unclear self-identity, are
all contributing factors for the adolescent to experiment with drugs as a relief from
confusion. Another major link between the adolescent and substance abuse is the
peer pressure. As we already know from the foregoing pages, that adolescence is a
period of intense longing to conform to the group standards and the incidence of
substance abuse increases in direct proportion to the number of peers abusing
substance. Therefore, peer pressure to conform to group norms is one of the reasons
why adolescents try alcohol and drugs. The third major link between adolescence and
substance abuse is the developing low self-esteem of the adolescent himself because
of his unattractive appearance, inability to establish desired friendship, school failure
and certain sexual experiences that are not accepted by the society. The treatments
that will be useful are individual counselling, group counselling and family
counselling.53
ii) Reasons for Substance Abuse
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At times one keeps wondering why adolescents take to drugs. This aspect has
been thoroughly examined by counselling psychologists and psychiatrists and they
identify three categories of people to show the reason behind the drug use. 1)
Normative use: Normative use signifies that taking drug is a common practice by a
vast majority in a given cultural context and therefore it is quite normal for one to
take to drugs. Since our society is getting used to drug-culture, drug use in various
forms is considered acceptable. Adolescents use drugs as part of their developmental
curiosity and their desire for social acceptance.
Thus initial curiosity,
experimentation and peer pressure may drive an adolescent to use drugs. 2) Drugs as
a form of dysfunctional coping: Some adolescents do not feel the need to continue
after the initial experimentation with the drug is over. If they do continue, it would
mean perhaps that they want to give a boost or buffer to their own weak ego and
negative self-concept. It may be to socially meet the sexual inadequacy, to cope with
uncomfortable situation of life experiences, to provide a short-lived escape from
depression, and to express their anger towards and rebellion against their parents and
those in authority. 3) Drugs as symptomatic of character problems: For some
adolescents drug use is a part of the total picture of their personality difficulties.
They have a long-standing history of character defect with psychopathic trends. They
are mostly impulsive, pleasure-seeking and self-centred. Their past may be marked
by truancy, running away, lying and stealing. Adolescents of this category do not
merely use drugs as a means of release or to get acceptance but to fill in their
personality deficits. These people of course need intensive assistance.54
5. Conclusion
For the counselling and treatment of the substance-abusing adolescents, consult
the section on ‘Counselling the Substance Abusers.’ Adolescents by nature are very
sensitive, in a way more sensitive than any other group. Of their own accord they do
not seek help or counselling unless in extreme need. Usually counsellors meet the
parents who strongly recommend counselling for their adolescents but the
adolescents themselves do not want any. Counselling as such cannot be forced on
unwilling clients, especially those who are prejudiced against counselling and are
resenting. Here a redeeming factor I have observed is the quality of the counsellor.
From the developmental psychology we know that the adolescents are idealistic. So,
if they find a counsellor who is genuine, trustworthy and humane, they usually tend
to confide in him. Therefore, one of the ways of facilitating adolescent counselling is
to enhance oneself, as a counsellor by acquiring refined humanness which is highly
valued by adolescents.
3
COUNSELLING THE YOUNG ADULT
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1. Introduction
The word ‘adult’ comes from the Latin meaning ‘grown to full size and
strength’ or ‘matured’ and this word is the past participle of the Latin verb
‘adolescere’ meaning ‘to grow to maturity.’ Adulthood is a rather long period
compared to the other stages. Formerly it was thought that adulthood is a time of
stability, not a period of development but now life-span developmental psychologists
say that development occurs at every point along the life-span including adulthood.
It is divided into three stages: (1) Early Adulthood from 18 to 40, (2) Middle
Adulthood or otherwise called Middle Age from 40 to 60 and (3) Late Adulthood or
Old Age from 60 to death. Now we are going to concentrate on the Early Adulthood.
2. Characteristics
1) Settling Down Age
Early adulthood or young adulthood is a settling-down age because the young
adults are supposed to get married and take up responsibilities. In fact this was
practiced traditionally but nowadays young adults think that it is too early to settle
down and they pursue some studies as students or undertake some jobs that will meet
their needs. A person’s settling down depends upon two factors: 1) Finding a
lifestyle that will meet his needs. 2) The type of responsibilities he must assume; for
example, a person who wants to work as a professor in a college cannot think of
settling down at the age of 18 since studies will not be over by that time.55
2) Reproductive Age
Early adulthood is the reproductive age. Biologically the sexual maturity that
has been reached by the end of adolescence now manifests itself with full vigour and
operates reaching its peak during the early adulthood. Concomitant with the strong
sexual impulses comes the child-bearing. In the modern society, when both men and
women are employed they may postpone having children to a later time but in all
probability in early thirties they may desire to have children.
3) Physical Strength
It is during the twenties that most people reach their peak of strength, agility,
reaction time, and manual dexterity. These four attributes decline gradually over the
next decades. But all the same many people are reasonably healthy and even
physically sound into their fifties and sixties. It has been estimated that muscular
strength reaches its peak between 25 and 30 and by 60 only about 10 to 15 percent
loss of strength is evidenced. Generally speaking the physiological changes that go
along with early and middle adulthood do not seem to have major effect on work or
other behaviours except the athletic activities. Thus the two decades of early
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adulthood in individuals witness the rise and decline to fitness, vigour, agility, and
creativity. Physical development till the end of adolescence is determined primarily
by biological-growth factors guided by a genetic timing system, but in early
childhood the story is different. Here physical development depends upon the
personal and social factors that make up a person’s life style, as for example diet,
exercise, family stress, type of occupation, residential environment, forms of
recreational facilities, communicable diseases and drugs. The physical condition of
the young adult is due to the genetic endowment and the growth experience up to the
beginning of young adulthood, but the fitness is influenced by one’s social and
physical environments and the lifestyle factors over which one can exercise a certain
control.56
4) Psychosocial Development (Intimacy Vs. Isolation)
In the psychosocial development of the individual at this early adulthood
according to Erikson, the young adult desperately seeks intimacy especially with the
opposite sex and when rejected or not successful he feels a sense of isolation. Up to
the level of young adulthood the person was used to groups like gangs in late
childhood and peers in adolescence; but now with the settling down and taking
responsibilities his contacts with his peers are less and his dependence on them too
wanes; as a result a feeling of isolation (termed by Erikson as ‘Isolation Crisis’) sets
in which might be too difficult for some young adults. The need for intimacy is
satisfied through intimate marriage. In some cultures we find alternative patterns of
marriage like living together as unwed companions and entering into same sex
marriages. But in all these relationships what we notice is the yearning for close,
stable and unselfish relationship. When an individual fails in his attempt to secure
such a relationship then comes isolation.
Daniel Levinson proposes a model of major tasks of the young adult
complementing the theory of Erikson. 1) The young adult forms a dream of fitting
into the adult world. 2) He needs to establish an intimate relationship and enter into
parenthood. 3) From among the many interests, he has to choose an occupation and
acquire skills and credentials that will foster success in the chosen occupation. 4) He
now finds a mentor who will guide the young adult in realizing his dream of fitting
into the world.
According to Maslow’s hierarchical needs it is the period of love-needs, which
means that the person wants to love and be loved. Though his need for love has
already started in adolescence itself, it reaches its peak in early adulthood. His
concern for loving and being loved is very prominent.57
5) Commitment Age
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This period is one of commitments. The person who had been carefree and
revolting suddenly becomes responsible with a number of commitments and feels
independent to stand on his own. At this level due to the career training they are
obliged to depend upon others like parents for finance or institutions for education
though internally they resent their dependence on others.58
6) Value Change Age
Early adulthood is a time of value change. The values like jeans and movies of
the adolescence have to give way to values that are consonant with the adult
population. The person moves from egocentric to social values. First of all their
appearance which in adolescence was sloppy has to be changed to adult-approved
appearance and behaviour which are quite conventional. The adolescent who was
critical of his parents and establishments becomes all of a sudden understanding. It
has been found that the people who marry early and settle down in life have more
conservative and traditional values compared with others who marry late.59
7) Cognitive Development
With regard to physical efficiency, it reaches its peak in middle twenties after
which there is a slow and gradual decline into the early forties, and more or less the
same pattern is noticed with regard to mental abilities, but the quality of their learning
does not deteriorate. The last stage in the cognitive development proposed by Piaget
is the ‘formal operation,’ which is abstract reasoning. He did not posit any stage
beyond formal operation. Yet he says that the reasoning may operate in adults in a
way different from how it did in adolescents. Adults’ thinking is in terms of fitting
their reasoning into dimensions of real life and so their thinking is less abstract and
less purely logical. They seem to be combining abstract thinking with realistic
thinking, and arrive at the way life that actually works. Therefore, we can say that
the adult’s integration of abstract logical principles with realism represents a real
advance that goes beyond formal operations. Therefore, some researches propose
post-formal operation which is dialectical. The quality of reasoning is superior in the
case of adults as compared to that of the adolescent. In conclusion we can say that
different generations may differ in their levels of intellectual performance, but a
given individual will not change very much throughout early and middle adulthood.60
(For the treatise on Levinson’s theory of Early Adulthood, consult the section on
Levinson’s theory of Adult Development in the chapter on Counselling the Middle
Aged).
3) Social Relations
Social participation is often limited and the circle of friends narrows down
since perhaps the married people have each other for company. Even unmarried
people are selective in their choice of friends and as a result of their choice they have
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fewer but more intimate friends. Usually their adulthood friends are their old ones,
unless they have become uncongenial. Popularity becomes in a way less important
for the young adult.61
Social relations for young adults revolve around four settings: 1) Family, 2)
Occupational site, 3) Recreational or avocational sites, and 4) Locations related to
daily living routines like shopping. In every setting an individual fills a particular
role, thinking of how he will go about it and what responsibilities and privileges
accompany it. Every role entails developmental tasks which are nothing other than
problems to be solved when an adult learns to perform it successfully. The
attachment-detachment scale – here, attachment meaning affectional bond between
people, which provides them emotional support, nurturing, encouragement,
reassurance, assistance and recognition of their worth – significantly undergoes
changes in different social interactions.
1) Family
Considering social relationships in the family, taking into account that the
traditional nuclear family may not be the dominant form of family life in the future,
we could consider the seven lifecycle stages of the nuclear family with the
corresponding ages proposed by E.M. Duvall. The first four stages and even the fifth
one come during the early adulthood.
1) 20-23: Newly married couple without children. 2) 23- 27: Parents with one
or more children, infancy to 30 months old. 3) 27- 30: Parents with preschool-age
children. 4) 30-36: Parents of school age children, last baby born. 5) 36-46: Parents
of teen-agers. 6) 46-52: Parents launch children as young adults. 7) 52-65: Parents
alone again, with empty nest until retirement. 8) 66+: Old age, retirement for both
spouses until their death.
The above schema clearly indicates the changing roles the individuals meet in
every stage. Roles keep changing and with the arrival of new members in the family
the relationships are multiplied with new roles. New roles keep coming when the
children go through their growth stages. The complexity of relationship is all the
more great with the corresponding roles when we have blended families. In the
blended families the couple besides having their own children also bring in the
children of their first marriage.62
The young adults in their twenties and thirties have their identity by assuming
the family roles of spouse and parent: and nowadays they may also have problems as
they assume new roles like divorcee, separated spouse, live-in companion, weekend
parent and stepparent.63
4. Personal Identity & Work
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Let us consider personal identity and work. For many, a stable identification
of self appears to be reached in early adulthood, usually, say, in the twenties; by this
time the young adults have achieved a rather clear sense of the values they hold, their
abilities and the kind of future they envisage thus establishing a style of life.
1) D.E. Super’s Theory
D.E. Super has learned through his research that in the selection of a job, the
individual’s belief about the way his self-concept relates to the characteristics of the
given job, is the determining factor. According to D.E. Super, vocational career is
marked by four stages: 1) Try-out stage: In the years between 18 and 25 the
individual tries his hand in many jobs to find out which job actually suits his selfconcept. 2) Stability stage: In the years between 30 and 35, the individual settles
down in an occupation appropriate to his self-concept and there is greater
occupational stability. Here the established vocational identity becomes an allimportant element in his overall self-concept and he wants advancement in
occupation and salary. 3) Maintenance stage: In the years between 45 and 55, the
individual instead of striving for significant career advancement seeks to continue in
the job till retirement. 4) Retirement stage: It might start at 60, 65 or even 70, and
may be a traumatic event for many because of the tumbling self-concept which was
supported by the occupation they dearly held. Among the four stages the first two
stages come directly under the early adulthood. In brief, the theory of D.E. Super
assigns the self-concept a central place in vocational choice, occupational stability
and self satisfaction.
2) J.L. Holland’s Theory
Another model of vocational development that assigns a central role to
personal identity is the trait-factor theory of J.L. Holland; his six personal-identity
types are depicted as points on a hexagon as shown in the figure below. Each type is
suited to certain kinds of occupations and people whose personal identity represents
purely one type find compatible jobs rather than those whose traits represent a
mixture of the neighbouring types like realistic with the conventional. The ones who
find it difficult to get a compatible job are the ones who have their personality
identify composed of directly opposite types like conventional with artistic or of three
or more types like conventional with enterprising, social and investigative. This is a
personality-environment congruence theory. This theory in a way is better than the
theory of Super since Holland’s theory explains why certain people are happy in their
job and why others are not. Holland’s theory also explains better how people look
for jobs that best suit their personal identity. All the same this theory fails to account
for variables other than personality types in explaining people’s selection of jobs.
The amount of compensation that a job offers may be another factor which the theory
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of Holland overlooks. For example, people continue in their unpleasant and difficult
job if it offers high salary.64
Depending upon the significance one gives to his family-related identity and
work-related identity, problems may crop up in one’s life. If more importance is
given to work and its advancement, his involvement in the family will be minimal
and there may come problems when family events demand his energy and time. On
the other if one identifies himself as a ‘family man,’ his job demands will be too
intruding into his personal life. Therefore, when there is a home/work identity
conflict, the counsellor needs to see where the client puts the emphasis, on family or
work, whether a change of emphasis will be viable, and evolving potential methods
that will resolve the conflict between family and work commitments.65
Realistic
Motoric
Physical
Practical
Asocial
Concrete
(Engineer)
Conventional
Conforming
Controlled
Structured
Efficient
Obedient
(Clerk)
Enterprising
Persuasive
Ambitious
Verbally skilled
Status-seeking
Desires Power
(Salesperson)
5. Counselling Situations
Investigative
Intellectual
Analytical
Curious
Rational
Evaluative
(Scientist)
Artistic
Aesthetic
Expressive
Imaginative
Introspective
Original
(Musician)
Social
Supportive
Cooperative
Helpful
Sensitive
Understanding
(Teacher)
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Now we turn our attention to critical problems that confront the young adults.
They are: 1) Physical Disorders, 2) Career Planning, 3) Financial Planning and
4) Conjugal Relationship. Since conjugal relationship will be dealt with in detail in
the chapters “Counselling the Couple” and “Counselling the Family,” let us
concentrate on the other three.
1) Physical Disorders
Attention to nutrition, regular exercise, sufficient rest, and periodic relaxation
from stressful experience — all serve significantly to maintain fitness. The process
of counselling adults who complain of physical disorders, lack of energy, and
feelings of depression at their declining appearance and agility, can profitably include
an analysis of those aspects of their living habits and their environment which affect
physical well-being. As experts in weight control attest, too many adults intend to
‘go on a diet’ and ‘exercise to get back in shape’ without accepting the fact that mere
periodic dieting and exercising will fail to achieve the permanent state of fitness that
they desire. As soon as they go off the diet and abandon an exercise regimen in order
to resume what they regard as ‘normal living,’ their troubles return. The long-term
solution to their problem is either that of effecting permanent changes in life-style or
that of accepting their present condition without regret. In effect, the counselling
process may be aimed at helping the clients either to adopt life-style-change as a goal
or to accept their current physical condition and future prospects as a satisfactory
reality, so that they need make no attempt to alter their established pattern of living.66
2) Career Planning
In career planning, the counsellor needs to pay attention to two main aspects.
One of them is to recognize the types of jobs available and what training and working
conditions such jobs will require (normal information about job opportunities);
secondly the individual’s own characteristics like skills and interests (information
about the individual’s characteristics) and how the conditions of the job match with
the traits of the individual have to be considered.
Regarding the first, we have a number of jobs like service workers, sales
workers, professional workers, and executive, administrative and managerial
workers, administrative support and clerical workers, precision production, craft and
repair workers, technicians and related support workers, operators, fabricators,
labourers, agriculture, forestry, and fishing workers. The availability of the jobs may
be changing from time to time, at one time there being a great demand for one
particular kind of job and at another time demand for another job.
Under information about the individual’s characteristics, we have what is
typically called vocational guidance which can be divided into two phases like career
counselling and job-placement. Career counselling facilitates the individual to
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identify a vocational objective that is consistent with the individual’s interests and
abilities along with the job-market opportunities. Once the vocational objective has
been settled, then comes job-placement which facilitates the individual to compete
successfully in the job market.
3) Financial Planning
Personal finances are likely to create problems for the young adults. In most
cases we do not find financial problem as such; it is rather linked to a network of
other problematic issues like marital condition, social life and job.
First of all here we meet some common problems like spending without
making provision for future emergencies like sickness and childbirth, and going for
prestige items in the name of fashion instead of quality. Here a technique like
budgeting is not of much value unless the individual’s self-concept, goals and values
are made realistic.
Secondly the interaction of the couple‘s finances and their personal
relationships play a major role. Research studies have arrived at conclusions about
finance-related problems. Conflict over finance is one of the major problems couples
face. The belief that the husband should be the bread-winner still continues. The
balance of power is determined by finance. Couples engage in conversation more
about how to spend money rather than how to earn money. Therefore, when
interpersonal relationships are strained between the couple, it is wise on the part of
the counsellor to turn his attention and that of the couple to the finance to check if it
plays any part in it
Thirdly, it should be considered how best the couple can train their children in
the responsible use of money. For this, child psychologists and educators propose
two guidelines: 1) Children right from their young age are to be provided with
weekly allowance. 2) They should be encouraged to save regularly a portion of their
allowance or income.67
4) Conjugal Relationship
The discussion on the conjugal relationship and its problems are dealt with in
the chapters “Counselling the Couple” and “Counselling the Family.”
5) Conclusion:
The counselling areas of the young adult comprises of the physical disorders,
career planning, financial planning and conjugal relationship. These areas are vitally
important for a young adult and they are interrelated in the sense that a certain deficit
in one area definitely affects the other areas as well. Therefore, while counselling a
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young adult it is good to let him see how the presenting of a problem in one area does
affect the other areas and what remedial actions will have to be taken.
Again, I am inclined to think that the gravity of the problem will depend on the
importance given to a particular area by an individual young adult. For example, one
may give a greater importance to physical fitness in whose absence he may have a
major problem whereas for another it may be finance.
Therefore, in counselling it is not only enough to identify the problem area but
also it is essential to assess the level of importance one gives to that particular area.
4
COUNSELLING THE MIDDLE AGED
1. Introduction
Middle age is the period between forty and sixty. It is a dreaded period more
on account of the stereotyped unfavourable beliefs about it than the actual mental and
physical decline. Just like puberty was a transition period between childhood and
adolescence, middle age is a transition period between young adult and old age. It is
in the middle age that the individuals experience somatic, cultural, economic,
ethical/moral and psychological stresses. Sexually it can be a dangerous age since
usually the aging male wants to get as much as he could from his sex life and so he
may be rather openly promiscuous. There may be another reason for his promiscuity,
which is boredom. The same routine type of sexual activity with the same partner
brings in boredom and to get new stimulations he may be seeking any available
partner. Anxiety over declining virility and a loss of personal attractiveness can
cause some men to seek reassurance and variety through extramarital sexual
encounters. It is an age of achievement, for there is a greater earning to have the
sense of achievement. Along with achievement the middle aged person evaluates his
life and reviews his commitment made in his early adulthood. This is also called the
time of ‘empty nest’ because the children are all settled in life and the parents remain
again alone as a couple.
2. The Characteristics of Middle Age
1) Physical Condition
There is general change in appearance, in sensory abilities, in physiological
functioning, and in health. Sexual changes like menopause which is cessation of
menstruation in women at the age of 49 or 50 on the average, may appear at times as
early as the late thirties or as late as middle or late fifties; and climacteric for men
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which has no definite date since it may come during the sixties or seventies and
progress at a very slow rate with the decline in the functioning of the sex organs like
erection, ejaculation, and sperm count. For women the menopause syndrome will
include physical conditions like hot flushes, night sweats, accelerated loss of calcium
from the bones; some may experience painful coitus resulting from the vagina
becoming shorter and narrower with the inability to lubricate and expand which are
all related to reduced activity of the ovaries and to the diminishing estrogen levels.
While women may evidence an increase in sexual activity after the menopause, men
show a decline in sexual desire.
2) Vocational & Grand-parenting Adjustment
Vocational adjustment can be judged from two factors, achievement and
satisfaction, satisfaction being the major criterion. Most middle-aged persons have to
make a lot of adjustment with their children’s spouses. With the arrival of
grandchildren the middle-aged play different grandparent roles like formal as far as
care and discipline are concerned, preferring pleasure without responsibility, funseeking, surrogate parent, reservoir of family wisdom and distant-figure especially
when they are geographically or socially remote. Singlehood adjustment in the
middle age is more difficult for women than men since the women need to take up a
lot of responsibilities like caring for the aged in the family.
3) Success of Middle Age
The success of the middle age is assessed by criteria like achievements,
emotional states, and effects of the physical and psychological changes on
personality, and the degree of satisfaction or happiness the individual experiences. 68
4) Midlife Crisis
The concept of ‘Midlife crisis’ was coined by Levinson (1978) who said that
the middle adult years is a period of crisis for most people. Speaking about middle
adult era Levinson speaks of a five-year-transition phase (from 40 to 45). According
to him, in a transition period the individual must terminate the existing structure and
is supposed to explore possibilities out of which new choices can be formed. This
transition between 40 and 45 is a ‘developmental crisis.’ This crisis is supposed to be
equal in intensity to the ‘identity crisis’ of Erikson in the mid-adolescence. But
longitudinal studies done with middle aged people do not support this view. While
some people experience a crisis at midlife, most people do not. Certainly it is a time
of change but it is like any other change in the life-span and it need not be a crisis.69
5) Intelligence
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With regard to intelligence, it is understood that there are fluid intelligence
reflected in tests of figural relations, memory span, induction, and most processes
involved in acquiring new information (age-decline abilities) and crystallized
intelligence assumed to be the end product of information acquired by the activity of
the fluid intelligence processes (age-stable abilities). We can say that the fluid
intelligence will decline whereas the crystallized intelligence will remain intact in the
middle age.
6) Career Pattern & Work Performance
When we analyse career patterns and work performance we find five sources
of work on occupation efficiency as identified by Cooper (1981). They are: 1)
Work-load pressure, which can be either quantitative, which is more dangerous, or
qualitative, 2) Work-role ambiguity, when a person is not sure of what is expected
of him in a given job, 3) Interpersonal relations, that get strained at various levels
of the administrative system, 4) Career advancement, that is not well within the
reach of a middle aged person as compared with a young adult and 5) The conflict,
that ensues between conditions at work and conditions at home.70
3. Levinson’s Theory of Adult Development
Levinson has presented a theory of adult development in The Seasons of a
Man’s Life (1978) in which he divided the life cycle into four eras of roughly twentyfive years duration: (1) The era of childhood and adolescence spanning from birth to
age 22, (2) The era of early adulthood spanning from 18 to 45, (3) The era of middle
adulthood spanning from 40 to 65 and (4) The era of late adulthood spanning from 60
to 85. You will notice that in every era there is an overlapping period of five years
marking the transition from one era to the other. Levinson speaks more of the early
and middle adulthood than the other two eras.
1) Early Adulthood
(1) Novice Phase
The early adulthood is divided into two major phases: Novice phase and
settling down phase. The first one is called ‘novice phase’ from 17 to 33 in which the
first adult life structure is being formed; it has three stages: 1) 17-22: The early adult
transition stage, 2) 22-28: Entering the adult world stage and 3) 28-33: The age
thirty transition stage, which addresses the flaws that have become obvious in the life
structure as formed so far. The age thirty transition is quite difficult since the person
is not able to look back and take stock of the unclarities of his life in view of the
future since he is already committed to a life structure. In the novice phase of the
early adulthood the important stage is the second stage between 22 and 28 in which
the individual has four major tasks: forming an occupation, forming a marriage and
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family, forming a mentor relationship, and forming the dream. Here what may
require a word of explanation is the dream. It is a complex mixture of reality and
illusion. In fact it has the quality of a vision that generates excitement and vitality. A
young person dreaming about becoming a hero in his chosen profession is a case in
point. As one continues living, the mythical aspect of the dream has to be
demythologised which is called ‘de-illusionment,’ a process of making the dream
realistic. This is one of the counselling areas that come up for discussion.
(2) Settling Down Phase
The second phase of the early adulthood is called the settling down phase from
age 33 to 40 in which the individual either refines or solidifies the structure he has
hitherto formed or attempts to create a more satisfactory one. This process is called
‘becoming one’s own man,’ with the tasks of establishing a place in society,
anchoring firmly in family, occupation and community, working towards
advancement with the implication of building a better life, becoming more creative,
contributing to the society and being affirmed by it.
Within the settling down phase of the early adult era, Levinson has identified
five sequences: 1) Advancement within a stable life structure, 2) Serious failure or
decline within a stable life structure, 3) Breaking out – trying for a new structure, 4)
Advancement which itself produces a change in life structure and 5) Unstable life
structure. These sequences are possible and not necessary that all of them should
take place.
2) Middle Adulthood
The mid-life transition triggers off a process of individuation involving four
major polarities. The mid-life individuation processes in terms of the four polarities
are:
young/old,
destruction/creation,
attachment/separateness,
and
masculine/feminine.
The young/old polarity has three themes: 1) Integration of the young and the
old dimensions of the self; 2) The sense of mortality and wish for immortality; and 3)
The question of one’s legacy to future generations.
The destruction/creation entails a better understanding of our grievances
against others for the harm they might have done to us and the harm we have done to
others.
The attachment/separateness polarity requires here a balance between these
two extremes. What one aims at are both aspects instead of just one.
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In mid life the male experiences more of his femaleness and the female
experiences more of her maleness. Actually these four mid life polarities are areas
that need to be probed in adult counselling.71
4. Burnout
1) Signs & Symptoms of Burnout
While dealing with middle age it is worth considering the problem of ‘burnout’
which is the increasing disenchantment with one’s present career.72 Edelwich and
Brodsky (1980) define the term burnout as a progressive loss of idealism, energy and
purpose experienced by people in the helping professions. First of all the term
burnout is not a technical term but a popular word that conveys the notion of the total
exhaustion of available resources. It may be seen by psychiatrists as adjustment and
affective disorders.73 The burnout syndrome may be identified by enduring
symptoms of feeling fatigued, being overcome with sadness, suffering health
problems, being uninterested in sex, losing one’s sense of joy and withdrawal from
social contacts.74 The people who did research in burnout more or less point out a
certain lack, causing frustration that is experienced as a burnout. It could be
deficiencies in the following areas: education, opportunity, free time, ability, chance
to ventilate, institutional power, variety, coping mechanism, criteria to measure
impact, meaningful tasks, professional and personal recognition, staff harmony,
balance in one’s schedule, insight into one’s motivations, and emotional distance
from the client population. Any one of these deficiencies or more could be present in
human service setting and that might cause the burnout. More than any other job
human service settings demand a lot of energy on our part. Take for example, the
attention you need to pay to a client or a listening you need to lend – these entail a
tremendous strain physically and mentally and that precisely is burnout. Psychologist
Gill (1980) is of the opinion that career mainly meant for helping others may be
extremely hazardous to one’s physical and mental health.
I see there is a connection between personality types and burnout, besides its
connection with the type of career. Extroverts usually get energised when they
involve with people. The more they involve with others the more they are energized
whereas for the introverts the story is different. The introvert generates his own
energy so much that he needs to retreat in order to be replenished. His constant touch
with people especially the ones who demand so much of his attention and energy
drains him very easily and he is vulnerable to burnout.
(1) First Level Symptoms
Some of the key signs and symptoms of burnout: Signs are those which are
capable of being observed and symptoms are those that can be experienced
subjectively. The symptoms manifest themselves first quite ordinarily and later when
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not heeded they become major problems. All these can be summed up as follows: 1)
Experiencing physical symptoms like headache, backache, and stomach upset, 2)
Mentally fatigued at the end of the day, 3) Feeling frustrated, bored, tense and angry
coming into contact with the work place, colleagues, supervisors, superiors, assistants
or any potentially significant person, 4) The requirements of the present tasks seem
greater than the personal and professional resources available and 5) It may be that
the job done is repetitious and at times beyond one’s ability or may require intensity
on a continuous basis. These symptoms are identified as the first level symptoms and
what follows are second level symptoms.
(2) Second Level Symptoms
1) Disillusionment about the helping profession one is currently engaged
surfacing on a regular basis, thus the idealism and enthusiasm about the helping
profession itself waning, 2) Pervading feeling of boredom, stagnation, apathy and
frustration, 3) Experiencing a general loss of interest in the helping profession itself
for a considerable period of time, say one month or more, 4) Loss of interest in
professional resources like books, courses, conferences and innovations, 5)
Intermittent lengthy periods of irritation, depression and stress which do not seem to
lift away even with some effort to rectify the apparent causes, 6) Being ruled by
schedule and comporting in the work place with the persons who come for help
impersonally, 7) Inability to be refreshed by other nourishing elements in one’s own
life and 8) Losing criteria with which to judge the effectiveness of work and not
believing in the appropriateness of one’s approach.
(3) Third Level Symptoms
When the above mentioned signs and symptoms of the first and the second
level become chronic, the third level signs and symptoms — physical and
psychological illnesses develop. Here one experiences a life crisis and undergoes
notable ongoing psychosomatic problems when the preventive measures and selfadministered treatments have failed. Since the manifestation of burnout at the third
level is psychosomatic, the treatment should combine both medical and psychological
assistance. Along with the medical check-up with treatment, entering or re-entering
psychotherapy is essential which may take a considerably long time to get back the
balance.
Thus we find three levels of the signs and symptoms in the progression of the
burnout syndrome. The first level is marked by signs and symptoms which are rather
mild, short-lived and occurring occasionally. At the second level the signs and
symptoms become more stable, lasting longer and one is unable to get rid of them.
The third level is characterized by the development of psychosomatic illnesses.
2) Burnout-Prone Candidates
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1) The people who work exclusively with distressed people, 2) those who work
with demanding people who feel that they have a right or entitlement to your help. 3)
those who are in-charge of too many persons under them, 4) those who actually want
to work but are thwarted and frustrated by too many administrative paper-work task,
5) those who play the role of rescuers, 6) those who are perfectionists falling short of
their own expectations, 7) those who feel guilty about fulfilling their legitimate
human needs and are not able to enjoy life even in the least, 8) those who are
idealistic in their goals, 9) those who cannot tolerate novelty, variety and diversion in
life, 10) those who do not have valid criteria to measure success and want to satisfy
themselves by knowing that they do a good job and 11) introverts who take up
charges beyond their own capacity and find themselves unable to get time for
themselves.
12) There seems a certain susceptibility to burnout for certain type of
personality characteristics. People in the helping profession are sensitive to the
feelings of others and themselves. When this is carried to the extreme it will result in
sympathy which is an emotional identification with the client forgetting their own
self-identity and eventually they get burnout. Persons who have rigid standards and
high expectations for their personal performance, those who are driven to continual
achievement, those who are hurried, impatient, easily upset and unable to accept and
live with compromise are all potential burnout candidates.
13) Those with unstructured work-routine (though initially they feel free to do
what they want) eventually end up being victims of burnout; because, effective time
management is essential for keeping the work demands within reasonable boundaries.
14) Failure to negotiate clear work-objectives in people of helping profession may
lead to confusions and ambiguity about one’s functioning and that may trigger off
burnout. 15) Social isolation may come about on account of the competition with the
persons in similar profession and may cause burnout. Instead of trying to compete,
befriending and being in touch with others ward off burnout.75
3) Handling Burnout
In the following pages let us consider the ways of handling burnout.
(1) The first imperative step is to deal with the attitude. It may require
correcting one’s cognitive errors when one exaggerates or personalizes situations in
an inappropriate and negative way.
(2) Want of physical rest could be a major contributing factor in which case
keeping aside the inessentials one could take enough physical rest. Body has its own
wisdom of letting us know what it needs. One could be attuned to what is happening
to oneself physically and take proper rest.
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(3) One could check one’s nourishment whether one gets a balanced
nourishment and regular exercise to keep oneself trim. Howard Clinebell says that
one needs to revitalize one’s body by monitoring and limiting the use of nonprescribed chemicals like alcohol, tobacco and caffeine, following recognized health
guidelines especially for weight and getting sufficient exercise.
(4) If routine is the main source of irritation one could add spice to one’s life
by way of variety.
(5) Mental relaxation which may be in the form of meditation is a good way to
take care of oneself.
(6) Seeking out friends who are supportive and interaction with them will go a
long way in being healthy. Here what Howard Clinebell speaks of renewing
interpersonal relationships is in place. Our potentials unfold more in social
relationship than in isolation. Love, care, support and nurture can open up wealth of
potential for our healthy human development. One who is engaged in helping
profession should be rooted in his family, giving top priority to his family
relationship, from where he draws most of his energy, seeking friendship both within
and beyond the work-setting.
(7) Learning to say ‘no’ to demands that are beyond one’s capacity is a nice
way to care for oneself thus becoming assertive appropriately.
(8) Becoming acquainted with the professional and self-help literature on
stress management is beneficial. Howard Clinebell calls this step as enlivening one’s
mind by experimenting with continuing education that draws on the five senses,
committing to opportunities for intellectual challenge and seeking out other
professionals for stimulating conversation.
(9) Temporarily taking a break from the routine work and going for some
courses to reset, relax and update oneself will enhance one’s health.
(10) If the situation is too threatening to one’s general well-being it is better
even to seek a transfer for some time.
(11) Finding a vital relationship to the biosphere is a holistic way of remaining
healthy. The realm of nature is not meant to be used only for food and profit but to
live in harmony with it so that in turn nature builds up our health. There are many
ways of maintaining relationship with the biosphere like sitting in the backyard for a
few minutes, observing beauty and harmony in ordinary things like the flight of birds,
the chirping of sparrows and the like.
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(12) Continuing spiritual growth is the highest form of tonic for mental health.
Being spiritual is different from being religious! One may not be a religious and yet
be deeply spiritual! It is a relationship to anything transcendent in our ordinary day
to day life. One could experience new forms of worship and spirituality that is transcultural and global and seek the guidance of a spiritual mentor.76
Actually all of us experience a taste of burnout daily in our life. First of all,
one should be attuned to what is happening, that is, becoming self-aware of one’s
needs and take steps to nip the symptoms of burnout in the bud before they become
serious. If burnout has reached the second level of being severe and intractable to
brief interventions, more profound efforts like willingness to reorient priorities and
change one’s style of dealing with the world have to be made. Here counsellors,
psychological mentors and spiritual directors who are psychologically sound and
have the basic understanding of human psychology will be of immense help. When
by chance one has let burnout reach the third level, one should seek the above
mentioned psychological help along with the physical treatment for the somatic part
of the illness.77
5. Retirement
Retirement in fact is a developmental task and is a phenomenon of modern
industrial society. A retired person is an individual who is not employed full time
and who receives some kind of retirement pension from previous years of job service.
Retirement is a complete withdrawal from employment with the entitlement to
income based on the fact of having worked over a period of years.78 The retirement
age may differ from country to country but whenever it happens, it may be a crisis,
and a trauma. Psychologically retirement triggers off anxiety with the loss of
confidence and self-worth being pushed to the point of depending on others with the
preoccupation of the impending death in most cases. People connected with a
religion and religious activities do a good job in adjusting to retirement.
(1) Patterns of Adjustment
Reichard, Livson and Peterson concentrated on the patterns of adjustment and
came up with five distinct patterns prevalent among the retiring population: 1) The
Mature: The mature type of people is well adjusted without any regret about their
retirement; they achieve a sense of integration, and so are pleasant to deal with. 2)
The ‘Rocking Chair’ Men: They are persons known for general passivity,
dependency and shirking of responsibility. 3) The Armoured: These people are in a
way unable to face the condition of their retirement and try to forget about their
retirement by keeping themselves active. 4) The Angry Men: They constantly find
fault with others for their own weakness and are bitter because perhaps they
themselves did not achieve their goals. 5) The Self-haters: They turn their anger
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against themselves and are disappointed in their lives and are frustrated in many
ways, feeling a sense of worthlessness and inadequacy.79
People have mixed feeling about retirement. Some dread it to the point of even
getting stuck and some others welcome and even go for early retirement. When early
retirement is welcomed it may be due to various reasons like a favourable financial
return, a suitable standard of living, declining health, the desire to assume a lighter
work load, difficulty in keeping abreast of the developments in the given job and the
desire to feel free to do what one always wanted to do but could not do.
(2) Psychological Process of Retiring
The retiring persons normally go through a process more or less delineated by
developmental psychologists doing research with the retiring population. Two main
stages of retirement (Pre-retirement and Retirement) with a number of substages are
discussed. In the first perceived phase there is a remote stage in which retirement is
perceived as yet a distant event of the future and the second stage is the near stage
when an individual is aware of the impending retirement and is getting ready whether
willingly or unwillingly to meet the event.
Now comes the actual event of retirement and the retirement phase has five
stages: The first one is the honeymoon stage in which one is euphoric on account of
the newfound freedom and a sense of being free from responsibilities. Now, one
engages himself with whatever he wanted in his life though formerly he could not
afford any time for it. Disenchantment stage is the second one in the series and the
individual feels that everything looks empty and void and whatever allurement that
was there about retirement vanishes leaving the person depressed. Reorientation is
the third stage in which one explores new avenues of involvement. The fourth stage
is the ability stage in which with the choices the retiree has made, he is able to deal
with his life in a fairly comfortable and orderly way. The fifth is the termination
stage when one becomes invalid being incapable of housework or self-care.80
The task of planning and preparing for retirement is a major task of the wouldbe retiree with the counsellor.
6. Conclusion
In the middle age, achievement counts more than anything else. Erik Erikson
in his theory of psychosocial development of the human person assigns the task of
generativity vs. stagnation to the middle aged. People want to achieve something
worthwhile. In fact they want to contribute to the society and the world in general.
When this natural impulse is frustrated, the individual will reach a stage of stagnation
which will pave the way for despair and regrets perhaps in the next stage.
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Counsellors could pay special attention to the fact of generativity in
counselling the middle aged. It need not be a spectacular achievement objectively
but a subjectively meaningful type. The middle aged should feel a sense of
worthwhileness in having achieved something in life however small it may look to
others. When people come with such a stagnation level, I urge them to look back and
enlist all that they have achieved and are personally meaningful to them. When there
is still time in middle age, probing into what could be still achieved may be a useful
one.
5
COUNSELLING THE ELDERLY
1. Introduction
The study of the aged and the process of aging is called gerontology. Aging is
a complex degenerative, physiological process whose superficial symptoms appear
in middle age, like skin wrinkles from increasing dryness, hair turning grey and
sometimes falling out, gaining weight, with diminished muscle strength, stooping of
the shoulders, loss of agility and unsteadiness of the limbs. A major factor behind
aging is the genetic make-up. Along with the environmental factors the genetic
factor determines the process of aging.
2. Physical Condition
Physical activity seems to help the aged to keep themselves healthy. Proper
balanced nutrition is also critical for the elderly persons. Health hazards for the old
people are heart disease, hypertension, diabetes, arthritis and accidental falls.
There is a significant decline in sensory abilities like hearing impairment,
decline in visual acuity and less efficient colour vision. Atrophy of the organs
especially the nerves and end organs in the basal turn of the cochlea affecting the
hearing, atrophy of the taste buds in the tongue affecting the sense of taste, atrophy of
the cells in the nose affecting the sense of smell, hardness and dryness of the skin
affecting the sense of touch and decline in the sensitivity to pain at different rates in
different parts are all common in old age. Usually healthy aged people show little or
no loss of intellectual abilities, whereas those nearer to death or fighting with diseases
exhibit a decline. With regard to memory there is no decline with age in the
recognition memory which is selecting a correct response from incoming information
but there is a sharp decline in the recall memory which is searching for and retrieving
information in storage.81
3. Developmental Tasks
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When personality development has been assessed in old age, we find that
among the old people, reminiscing about the past is quite common; and this lifereview allows the aged to relive past experiences and to deal with conflicts. This
life-review is an important factor in the personality development of the individual. It
gives identity, provides continuity and wisdom, renews the awareness of the present
and restores the sense of wonder.
1) Psychosocial Adjustment: Integrity Vs. Despair (Erik Erikson)
According to Erik Erikson the elderly person faces the psychosocial crisis
known as integrity versus despair. Here ego integrity will mean the full unification of
the personality enabling the individuals to view their lives with satisfaction and
contentment and a sense of purposiveness. When this integration is wanting, the
person is driven to despair. Since there is no time to take another course of action,
the person ends up being regretful and disappointed. They regret that they have not
made full use of their potentials.
2) Psychological Adjustment (Robert Peck)
According to Robert Peck (1968), psychological growth during the late
adulthood is characterized by three primary psychological adjustment: ego
differentiation versus work-role preoccupation, body transcendence versus body
preoccupation, and ego transcendence versus ego preoccupation.
(1) Ego Differentiation Vs. Work-role Preoccupation
At the time of retirement, an issue that addresses the retiree is the question of
the person’s value system. The retiree’s personal worth needs to be reappraised and
redefined. Perhaps up to the time of retirement, the person thought of his worth in
terms of his job and now that the job is gone he is wondering whether he is still
worthwhile and whether there are activities beyond one’s career that give meaning to
one’s life. If one finds meaning in activities carried on beyond one’s retirement that
will make the aging smooth and successful.
(2) Body Transcendence Vs. Body Preoccupation
In late adulthood there is a decline in resistance to illness and in recuperative
powers and the body is subjected to increased aches and pains. For those elders who
equate physical fitness with well-being it is going to be catastrophic. Instead of
limiting one’s sense of well-being to one’s physical fitness alone, one can enjoy it in
one’s intellectual and social pursuits. In fact there are aging people who in spite of
their declining health greatly enjoy life. In their lives we find that mental and social
sources of pleasure and self respect do transcend their physical comfort.
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(3) Ego Transcendence Vs. Ego Preoccupation
For the elderly the inevitability of death presses itself upon their mind and
hence there is a preoccupation about their end. Their main task is the adaptation they
need to make to the prospect of death. A successful ager is one who is purposefully
active, experiencing a vital, gratifying absorption in the future, trying to make this
world a better world for his descendants.82
3) Transition Period (Daniel Levinson)
Daniel Levinson (1978) proposes a transition period. The transition he speaks
of in the late adulthood takes place between 60 and 65. At this time the physical
changes of the body have a lot to do with one’s personality. They realize now that
they can no longer occupy the centre stage of the world. Retiring with dignity and
security is also a developmental task of the elderly. Now he is forced to face the
process of dying and the preparation for death. If he believes in life after death he
has to prepare himself for some kind of after-life or else resign himself to the fate of
finality of death, and no after-life. The person gives new meaning to life and death in
general, and to his own life and death in particular. Finally we can say that the
elderly reaches the point of ultimate involvement with the self. Thus the ultimate
task now is coming to terms with the self, knowing it, loving it and being ready to
give it up, which in terms of Erik Erikson’s theory is the psychosocial task of
integrity vs. despair.83
4) Comparison of Developmental Tasks in Late Adulthood
Robert Peck
Deniel Levinson
Erik Erikson
1. Ego Differentiation Vs.
Work-role Preoccupation
Late Adult Transition
between 60 and 65
Integrity
Vs. Despair
2. Body Transcendence Vs.
Body preoccupation
3. Ego Transcendence Vs.
Ego preoccupation
4. Successful Aging
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Let us turn our attention to what makes for a successful aging. There seems to
be two criteria for judging the successful aging. The first is the satisfaction the
elderly persons have in themselves which is a psychological component and the other
is the social role and interpersonal obligations and responsibilities they have which is
the social component. These two factors go to make up the success of aging. To
explain the factors that will facilitate successful aging there are some theories
proposed: 1) Personality Types of Neugarten, 2) Personality Types of Reichard, 3)
Disengagement Theory, and 4) Activity Theory.84
1) Personality Types Theory of Neugarten, Havighurst & Tobin (1968)
(1) Integrated Type
They have identified four types with subtypes under each type. Integrated type
includes 1) The Reorganizers who involve in a wide range of activities, 2) The
Focused who engage themselves in moderate levels of activity being selective in
their involvement and 3) The Successfully Disengaged who maintain low activity
level and high life satisfaction.
(2) Passive Dependent Type
Passive-Dependent type includes 1) The Succorance Seekers who depend on
others especially for their emotional support and 2) The Apathetic who are
characteristically withdrawn and passive and have no interest in their surroundings.
(3) Armoured-Defended Type
Armoured-Defended type includes 1) The Holding-On who would cling to the
activities of their middle age as long as they can, and attain satisfaction only when
they are able to hold on to their former roles and 2) The Constricted who
considerably reduce their involvement with others and their role activities as a
defence against aging. They seem to be less integrated compared to the focused
group.
(4) Un-integrated Type
Un-integrated type has poor control over their emotions. They have
deteriorated thought process, having low level of life satisfaction being unable to
maintain themselves in the community.
2) Personality Types Theory of Reichard, Livson & Peterson (1962)
They have identified five types: mature (constructive), rocking chair
(dependent), armoured (defensive), angry (hostile), and self-haters. Among the five
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types the mature, the rocking-chair and the armoured seem successful in their late
adulthood.
3) Disengagement Theory
According to this theory, aging is the mutual withdrawal process between
aging individuals and the social system to which they belong. It may be initiated by
the individuals themselves like voluntary retirement, or by the society; e.g.
compulsory retirement. This theory has been controversial among gerontologists.
Not all the elderly persons are interested in disengagement but definitely there are
some who would like to disengage themselves from their occupation.
4) Activity Theory
This theory suggests that aging individuals want to remain productive and
active. Especially for persons who were rather active in their middle age, to be
disengaged is a great martyrdom and they by all means want to be of service to the
society.
5) Comparison of Theories of Successful Aging
Personality Type Personality Type Disengagement
Of Neugarten
of Reichard
Theory
Activity Theory
1. Integrated:
Organizers,
Focused &
Disengaged
1.Mature
(Constructive)
1. Aging
persons
want to
remain productive
& Active
2. PassiveDependent
Succorance
-seeking
Apathetic
3. Armoured
-Defended
Holding-On
Constricted
4. Un-integrated
5. -----
2.Rocking -Chair
(Dependent)
3.Armoured
(Defensive)
4.Angry
5.Self-Haters
1. Aging:
Mutual withdrawal of
individual & society
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In conclusion we can say that these four theories somehow try to give
suggestion as to what will make a successful aging. All these four theories are in a
way complementary in the sense that they highlight a certain aspect that they find
most important and that does not mean there are no other aspects to be taken care of.
In short, people who are well-integrated with emotional and intellectual adjustment of
their personality seem to age gracefully than those who do not seem to be integrated
persons.85
5) Psychological Maladjustment
First of all, come the psychogenic disorders having psychological causes and
interpersonal factors like psychotic reactions with severe mood swings, memory
distortion, and language and perception deficiencies; neuroses with considerable
anxiety; and personality disorders with the absence of any internal discomfort.
Organic brain syndromes as a result of massive loss of brain cells in the cerebral
cortex manifest themselves in pre-senile dementia, senile brain disorders, and
cerebral arteriosclerosis, and most of the institutionalised elderly mental patients
seem to suffer from them.86
According to Erik Erikson, old age is marked by the ego qualities of integrity
vs. despair. Integrity suggests that the person is able to reconcile all the opposing
elements in his life. One has both the positive and the negative. If the negative
aspects are not reconciled with the positive ones, it will result in despair over the
negative aspects. Whether one will be an integrated person in his old age will depend
much upon the former stages, especially the middle age. If in the middle age, which
is the period for generativity vs. stagnation, the person has not achieved anything
worthwhile according to his subjective estimation, he is likely to have despair in old
age instead of integration because of the emptiness that fills his life.
6. The Institutionalised Elderly
The situation of the elderly persons who are institutionalised is slightly
different from the elderly persons who live in their homes with their kin. Most of the
people who are in the institutions that care for the elderly are those who have perhaps
nobody to care for them and may have had a miserable background that brought them
to the institution. Therefore, those who are in such institutions are likely to have a
similar background (which is depressive).
Those who work with the institutionalised elderly speak of the following:
Territorial concern seems to be one of the major problems. They cannot tolerate
anybody transgressing their set boundaries and making inroads into their territories.
They tend to focus most of their attention on food and clothes coupled with a
tendency to accumulate beyond their need. For example, even if three square meals
are guaranteed, they might preserve some of the leftovers. The whole thing may look
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like being self-centred. They keep narrating their old miseries over and over again.
A feeling of insecurity is in the air among them. They are over-curious and even do
eavesdropping very often in spite of being told not to do so. Most of them are
unhappy and grumbling. There is a lot of rigidity in their outlook on life. Like any
elderly, they too want to be listened to. They want to be touched by the caretakers;
and like children they become openly jealous when others are touched, and they are
not. Though fear of death is rampant their prayer seems to be asking the Lord to take
them away from the miseries of life. A certain preoccupation with their possession
(hoarding) is evident. On the whole, there is a sense of helplessness.
This is not the whole picture. There are also people who seem well adjusted
thinking that the institutional life is their lot. Some even share something precious
with their friends and are caring. The depressing scenario that one notices in homes
for the aged may be due to their physical and mental debilities, want of security, fear
of death, and feeling of unwantedness.
7. Counselling Situations
Common types of counselling cases among the elderly persons are 1)
depression, loneliness, and lack of incentive to live, and 2) lack of intellectual
capacity to manage their own affairs.87
1) Depression, Loneliness & Lack of Initiative to Live
By ‘depression’ one does not identify either a consistent cluster of symptoms
or a single type of cause. This term is applied to symptoms more or less similar in
different persons but its causes are definitely varied and complex.
Possibly the evident emotional signs are brooding response to all aspects of
life, constant frowning, lack of expression of joy or optimism, spell of weeping and
crying, and being gloomy in general. The thought patterns that may be behind the
gloomy appearance are unrealistic beliefs that they are useless, unworthy,
unappreciated, mistreated, guilty of having mistreated others, impending thought of
death, thought of not having achieved anything worthwhile in life, and the like.
The behaviour patterns of depression are listlessness, staying alone, avoiding
company, spending a lot of time in sleep and complaining of a number of aches. One
may also attempt suicide in a state of depression.
Suicide in the elderly may be due to a combination of three conditions like 1)
Loss of vital resources like health, finance, mental abilities and significant socialemotional relationship, 2) Stressful events that decrease one’s control over one’s fate
like death of loved ones, dismissal from a job, moving to a foreign environment,
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traumatic conflict with trusted friends or relatives, and 3) Lowered self-esteem,
alcoholism, drug abuse, hopelessness and loneliness.
It is also noted that in extreme cases the depressed person may have obsessions
(constant worries that might interfere with the day-to-day living), delusions
(unrealistic belief of any sort, especially with regard to morality which in most cases
are imaginary), and hallucinations (imaginary sense perception, especially sight and
sound).
(1) Causes of Depression
The causes of depression can be grouped as biological and psychosocial.
i) Biological Factors
Various electrochemical conditions of the neural system are known to
precipitate depression in some individuals. Among them one factor seems to be the
imbalance of chemical substances (neurotransmitters) that carry electrical impulses
from one nerve cell to the other. When norepinephrine and/ or serotonin are subnormally present in an elderly person, that person is likely to be depressed. Many of
the elderly people are known to be depressed by the subnormal presence of
norepinephrine and/ or serotonin.
ii) Psychosocial Factors
Psychosocial causes are many and varied depending upon the individual and
his environment, which include his past as well. Poor health (mostly for men),
retirement from a cherished vocation, death of the spouse, and financial insecurity
(mostly for women) are some of the many psychosocial causes.
I2) Lack of Intellectual Capacity to Manage One’s Own Affairs
The intellectual deterioration affecting the elderly people can be either organic
in which the physiological causes are known, or functional in which emotional
factors are predominant. In the organic disturbance we have two types of dementia
known as senile dementia and multi-infarct dementia, and delirium. The term
‘dementia’ signifies a set of cognitive disorders characterized by the progressive
deterioration of mental functions often with the difficulty to recall recent evens. The
term ‘delirium’ denotes an acute mental disorientation similar to dementia except for
the fact that it occurs suddenly and it clouds one’s memory of both recent and past
events, possibly with visual hallucinations. It may also happen that delirium passes
away without any memory loss.
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(1) Senile Dementia
Of late this senile dementia is also called ‘Alzheimer’s disease’ and ‘negative
degenerative dementia.’ This sickness is marked by its onset of observable cognitive
deterioration before age 65, caused by anatomical changes in the brain like atrophied
brain cells or some abnormal structures. The most evident signs are loss of memory,
a decreasing orientation to time and place, inability to make decisions and a
wandering thought pattern. Most of the cases of senile dementia cannot be cured, nor
can they be checked.
(2) Multi-infarct Dementia
This type of dementia is caused by many small blockages or breakages (strokes
or infarcts) in the blood vessels that carry oxygen to the brain cells; hence the brain
cells die of starvation of oxygen.
(3) Delirium
This chemical disturbance in the brain can be set off by a variety of factors like
improper medication, diet deficiency in vitamins and proteins, accidents, stroke,
fever, constipation, drug or alcohol dependence, emotional shock accompanying the
death of a loved one, movement to a strange place, after-effects of surgery and preexisting brain damage. Reduced awareness and attentiveness to the environment
followed by a clouded state of consciousness seems to be the core symptom of
delirium.
8. Counselling
1) The Depressed
There is no single viable method to be used to help the depressed elderly persons.
Much depends upon the assessment of the situation of the depressed elderly. The
assessment should take into account the person’s health, mobility, mental abilities,
financial conditions, social support patterns like friends and relatives, and potential
interests. Elderly persons seem to respond to counsellors when they are stimulated to
narrate their past experience of great interest known as ‘retrospective biographical
recall.’ Once I visited a depressed old man who would not talk to anybody. From
the family members I learned that the old man in his younger age was a pious and
devout person visiting a number of shrines. I struck a conversation with the mention
of my visiting a particular shrine which he himself had visited, and this set off a
torrent of talk from the old man.
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2) Patients of Dementia
We normally depend upon our memory for many of our normal activities and
since the patients of dementia seem to be having problem with memory the
counsellor can be of great help especially during the early stages of this disease. He
can guide the patient to practice memory devices by word association for new names
and places the person wants to remember, devising rhymes as mnemonic devices,
writing down items to be recalled and frequent repetition of the names to be recalled
later.
3) Patient of Delirium
While helping the patients of delirium, the counsellor needs to assess the
patient’s psychological condition. Then slowly he needs to enhance the patient’s
orientation to time, place and event by conversation dealing with topics of interest,
family, past valour and hobbies. By this method, the counsellor gets an insight into
the extent of the damage the patient may be suffering from and facilitates the
patient’s ability to think logically.
9. Conclusion
Old age is a crowning age, a summing up of all that one has been. Though
physical and mental debility are major negative setbacks, one can actually age
gracefully. Counsellors can do a lot in stimulating the elderly person to look back on
his life gratefully, and reconcile both the acceptable and the unacceptable aspects of
life. The elderly person could be helped to have a non-judgmental awareness of all
that he is and that will help him to accept himself as he is without critiquing. It is not
a time to pass judgment about the past, but a time to be grateful in spite of all that
happened.
Making the elderly self-reliant to the extent they are able, and also making
them feel that they are wanted by recognizing their services, are useful techniques;
for example their baby-sitting reminds them of their services, and such reminders
make them healthy.
In city areas, when the elderly persons are confined to rooms, they develop
symptoms of artificial neurosis. Whenever possible, they need to go to the open air,
meet people other than those in their own house. Let us not forget that the elderly
want to be listened to the topics of their interest and not ours. This we make out
while conversing with the elderly persons. Though the group would have changed
the topic of conversation, the elderly person will continue to talk parallelly his own
topic irrespective of what is going on. Lending a listening ear is highly appreciated
by the elderly. Not being comfortable with the aging may be a sign that one has
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postponed considering one’s own old age and has not integrated the same into his
main life-stream.
SITUATIONAL
CRISES
&
COUNSELLING
6
COUNSELLING THE ENGAGED
1. Introduction
In marriage about 10% of the people are said to be really happy and contended.
Another 20% of the married people are happy sometime; and the remaining 70% of
the married people are said to be bored and noncommittal; and some just hang on for
the sake of their children; and some others go to the extent of obtaining a divorce to
terminate their marriage. This is the picture we have of marriage.88 Therefore, we
could study what makes the 10% of the married people to be happy and what makes
the rest of the married people to head towards failure so that we can counsel the
engaged what to do and what not to do.
2. Premarital Preparation/Counselling
When people want to get married they enter into a certain contract that leads to
marriage. The time between their entering into a contract and marriage is called the
period of engagement or courtship. The engaged need to prepare for their marriage
and so they may come for help or there may crop up some problems during the
engagement period for which they need counselling. The terms ‘premarital
preparation’ and ‘premarital counselling’ are interchangeably used in common
parlance. But actually they are different. In fact counselling is sought by the
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engaged when they have some problems. But the engaged when they want to get to
know each other better and discuss some matters related to their future life and home,
they go through what is called marriage preparation. While marriage preparation is
on, people may have problems which warrant an intervention by the counsellor in the
form of counselling. With this distinction in mind let us enter into premarital
counselling in which I also intend to speak about premarital preparation, for many
people have problems in their family life just because they have not prepared
themselves before the marriage. Just to ward off problems in the life of the couples or
in the family it is worth the trouble to spend some time on marriage preparation also.
3. Historical Background
Historically there were three main groups that provided most of the premarital
counselling; they are physicians, mental health professionals and ministers/priests.
Physicians concentrated on the physical examinations and had no time for long-term
counselling. Most of the mental health professionals, though experts in their own
field, were not adequately trained for counselling. Ministers/priests were more
worried about the marriage ceremony and the sacramental character of it though they
had every opportunity to influence the engaged. Since the whole lot of the Christian
population has to go through the ministers/priests for marriage, they naturally sought
the advice of the ministers/priests for their premarital problems. Thus the
ministers/priests began to offer such services as premarital counselling amidst their
concern for the marriage ceremony. Those who were non-Christians went to
counsellors who were qualified for the counselling service. At present, we have
people who are qualified in counselling, social workers whose special interest is also
the family and ministers and priests who have the training in counselling as part of
their formative programme.89
4. Attitude towards Marriage
People learn their attitudes towards marriage well in advance of marriage; that
is, when they were small children, say, in their early childhood when sex role typing
took place. Unfavourable attitudes towards marriage if formed early and there had
not been any change of those attitudes by some healing or therapeutic intervention,
the couple carry those attitudes into the marriage alliance. Therefore, before we enter
into premarital counselling let us deal with the premarital preparation.
5. Stage Model of Courtship (Wheel Theory of I.L. Reiss)
I.L. Resis (1960, 1980) proposed a stage model of courtship or engagement
development called Wheel Theory. According to this theory the engaged go through
four stages of relationship; namely rapport, self-revelation, mutual dependency and
intimacy-need fulfilment. During the time of engagement, the engaged may cycle
through the process multiple times.
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1) Rapport
The first sequential process aims at building a relationship in which one will
feel at ease, able to communicate and to understand the partner. Rapport develops
out of one’s understanding of the assessment of the similarity of the partner.
2) Self-Revelation
Once rapport has been built up, then the engaged automatically engage in selfrevelation like one’s values, political beliefs and religious beliefs. People from the
higher strata of society seem to reveal more of intimate matters whereas people from
lower strata of society seem to desire less personal self-disclosure.
3) Mutual Dependency
Rapport building and self-disclosure naturally lead the engaged to a feeling of
mutual dependency. The partner becomes a source of special emotional reward
which one cannot get from other types of relationship.
4) Intimacy Need Fulfilment
By now passing through the other three stages the engaged are in a position to
assess whether they can get their intimacy need fulfilled through their relationship.
Here intimacy need may refer to developing closeness to another being, and the
ability to disclose freely one’s innermost thoughts and feelings, and feel a sense of
comfort and joy in doing this.90
Some critics argue that the stage model does not adequately explain courtship
development since the reason for the sequence of the stages is not clear. All the same
even if it does not follow a sequential stage development, at least the concepts that
are used (to explain the courtship development to understand what happens between
the engaged during the times of courtship) are useful.
6. Goals of Premarital Preparation
Premarital preparation centres around exploratory, facilitative and educational
process. This can be further articulated into five specific goals such as 1)
encouraging interpersonal dialogue between the engaged, 2) providing information
through a variety of resources, 3) correcting faulty information, 4) making an
evaluation, and finally 5) completing the administrative details of the marriage.91
1) Encouraging Interpersonal Dialogue
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The first stage of dialogue (of the engaged) helps the counsellor to understand
the engaged who may not be well known to the counsellor. The engaged are
encouraged to talk about themselves, their expectations, hopes, dreams, plans, and
their life together. Some people are very reluctant to talk about themselves in which
case the counsellor can provide certain points as guidelines for discussion. They can
speak about their first encounter, what attracted them to each other, what they like
most in each other, their likes and dislikes, their expectations of each other, their
reservations about marriage, what they would like their marriage to be in five years,
and so on. A list of such dialogue-provoking points can be given to them for their
discussion.
2) Providing Information
Providing information to the engaged can be done in many ways. The
counsellor himself can share whatever he thinks will be useful for the engaged. He
can put them in contact with some experienced couple or people especially meant to
prepare people in the period of engagement. There are also a variety of books,
manuals, seminars, courses, conferences, Engaged Encounter, audio tapes, filmstrips,
and even movies and premarital discussion groups that can enlighten the engaged and
provide adequate information. Some of the most frequently used tools are the
Keirsey Temperament Sorter, Myers-Briggs Types Indicator, and the Premarital
Counselling Inventory.
3) Correcting Faulty Information
People enter into marriage with very many faulty ideas about marriage and on
entering marriage they have a lot of surprises and shocks. To avoid all those
unpleasant situations, the counsellor will do well to correct the wrong ideas
concerning marriage relationships, communication process, finances, in-laws and sex.
4) Making an Evaluation
In making an evaluation, the engaged need to have these two things in mind:
Maturity and Compatibility.
(1) Maturity
Here we speak of psychological maturity for we already take for granted that the
engaged are physically mature, otherwise there is no point in marrying.
Psychological maturity in the context of marriage will mean i) ability to look at life
realistically, ii) active concern for the well-being of the partner, iii) ability and
willingness to share, and make compromises, iv) ability to tolerate delay in the sense
of forgoing immediate gratification in order to receive a greater benefit in the future,
and v) ability to face problems and seek solutions.
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(2) Compatibility
Here, all that they need to see is in what way they are agreeable to each other.
There are many tests available for this purpose. At least a personality test would do
to interpret their compatibility and the areas where they need to grow and adjust.
Those marriages with the approval of both sets of parents, lack of conflict with the
parents, similarity of age, satisfaction with the amount and intensity of affection
being received from each other, sharing of common interests and acquaintance for
more than a year are said to be successful.
(3) Marital Happiness
The engaged along with the counsellor could look into the areas proposed by
W.A. Barry (1970) for the marital happiness: i) Possession of positive personality
traits, ii) Similarity of cultural backgrounds and in Indian context caste, iii) Socially
responsive personality, iv) Harmonious family environment, v) Compatible
religious orientation, vi) Satisfying occupation and working conditions, vii) Love
relationship growing out of companionship rather than merely infatuation and viii)
Wholesome growth of attitudes towards sexual relationship.
To this list we could also add some more like, ix) Shared values such as
commitment to each other in marriage, x) Friendship in the sense of being true to
another person, xi) Romance which adds spice to marriage and xii) Sexual attraction
which is needed for being attached to each other; when this sexual need is not
adequately satisfied, people may look for greener pastures elsewhere. But it is not all
important, for if only sexual attraction should keep the spouses together, there will
come a time when beauty will be lost and consequently the attraction too; perhaps it
is at that time friendship will uphold marriage.92
5) Completing Administrative Details
A lot of stress and strain and last minute embarrassment could be avoided if the
engaged had seen to beforehand itself the administrative details like the marriage
date, hall, invitees, meals, accommodation, and who does what and the like. A
number of people get into serious problems if they do not pay attention to the
administrative details.
7. Premarital Counselling
What we have so far seen is common for all types of people and what we are
going to see concerns specific types of people who need special consideration during
the counselling of the engaged. Perhaps, what we have seen so far can be considered
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premarital preparation and now what comes is premarital counselling or counselling
the engaged. The areas that call for special consideration and counselling skills are:93
1) Chronological Immaturity
The divorce rate of teenagers is higher than any other group for the simple
reason that the teen-agers are in their psychosocial development of identity vs. role
confusion.94 As they are still discovering their own identity, they may not be ready to
shoulder a great responsibility for a stable institution like marriage. Their personality
formation is in a fluid state and thus they lack the steadiness that is needed for
marriage. Therefore, if teenagers are coming for premarital counselling the
counsellor needs to probe into issues that relate to their chronological immaturity. It
may be that they are attracted to each other because of infatuation and nothing more.
Mere infatuation may fade away, or one may find another person more attractive than
the partner now currently engaged in. For the teen-agers as they grow old, their
infatuation may shift from one person to another and that may result in marriage
failure.
2) Wide Chronological Age Difference
An age difference of three to four years is accepted as normal in the Indian
society. If the difference were to be about ten years or more, the counsellor needs to
draw the attention of the engaged to this fact and make them understand the
implications, both sexually and socially, and facilitate them to be realistic. If this
area has not been probed, the couple regret it later. Because of a wide age difference
both the partners will be at different levels of their personality developmental tasks
and so understanding the need of each other will be a problem. In my pastoral
ministry I have often noticed that older men want to marry young girls. They do not
worry about their being much older than the bride but they by all means do not want
to marry a bride slightly older than themselves. This attitude may be due to male
chauvinism and the myth about marital happiness especially sex which proposes
young women for marriage.
Some men excessively worry about sexual
incompatibility with women older than they.
3) Wide Gap in Education
In an egalitarian society a man wants to marry a woman with the same
educational background and vice versa. In some societies, in which endogamy is
strictly practiced there will be a vast difference in the educational qualification of the
boy and the girl. I have knowledge of such a society where the boys are not well
educated and they revel themselves in drinking and debauchery but the girls are
almost always more educated than the boys. Yet, because of the endogamy they need
to marry the boys of their own caste only. Here there are problems on account of the
wide gap of educational qualification and yet due to social sanctions many of the
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brides adjust to their lot by marrying boys less educated than they. Awareness of the
implications of the gap in education will equip the engaged to face the problem that
may crop up in future.
4) Divergent Racial or Cultural Background
Urbanization has brought together people of every kind in the city and people
of different cultural background. Here in India caste plays an important and at times
formidable role in marriages. When people of different castes fall in love and want to
get married they need to be extra careful; they should have sufficiently reflected on
this issue before entering into marriage. Otherwise, sooner or later, problems are
likely to come up even to the point of breaking up. When castes are grouped
territory-wise in a village setup, a girl of lower caste marrying a boy of higher caste
and living in his locality may create social ostracism for her and her children. If she
goes away with her husband and lives elsewhere this problem may not be there. But
if a girl of higher caste gets married to a boy of lower caste and lives in his society, it
does not create social problem but it may create psychological problem for the girl,
for it is a downward social mobility for her.
5) Vast Status Difference
Status is the place one has in the intricate system of his society. The society
assigns a place for each individual. When a person of a very high status marries a
person of a lower status even if it is of the same caste, the lower status person is
likely to feel inferior and the other one to feel superior, which in turn might bring
about their disunion. The expectations of the people of higher status are different
from those of the people of lower status, and the people of lower status just cannot
meet the expectations of the people of the higher status.
6) Divergent Religious Background
Faith is something intimately personal. Mostly people cling to their faith
uncritically. In marriage if people of different religious background are united,
conflicts are likely to arise for practicing one’s own religion and the problem is
sharply acute when it is the question of deciding in which faith the children are to be
brought up. Besides, for the children themselves who need guidance and models in
their religious practices, it is terribly confusing and may have adverse effect on their
personality development. Even if both partners feel free to practice their own
religions, how far adjusting they will be is a problem to be seriously considered.
Here after looking into the problem with its ramifications, I would invite the
counsellor to facilitate the engaged to see beneath their divergent religious
background any common note of understanding. For example, if the engaged are of
different Christian denominations, their faith in Christ is the same though the practice
of the religion may be different.
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7) Pregnant Bride
Sometimes counsellors meet the engaged who are expecting a baby, and the
bride’s pregnancy may be the primary reason for contracting the marriage. The
success of such marriage of the teen-agers seems to be questionable. There had been
many failures, 60% within a year and 80% within five years in an egalitarian society.
The percentage may be lower in societies where there is male domination and
orthodox thinking about marriage. In any case, the prospect of failure of such
marriages cannot be ruled out. Hence there is the need for the engaged to look
seriously into the issue of the pregnancy of the bride and consider the implications.
8) Grieving or Rebounding Partner
Grieving is a reaction to a loss. It could be the loss of a spouse by death or by
divorce, a rebound from a divorce or annulment of a marriage, or a broken
engagement. All these require time to heal the psychological wounds and normally a
grieving person requires one to one-and-half years to come out of the grieving
process. Therefore, during the duration of that grieving period if one were to enter
into such an intimate relationship like marriage it may end in disaster. I know a
young man who married a girl who committed suicide three months after the
marriage. The next month the parents of the girl who committed suicide gave their
younger daughter in marriage to the same young man; he committed suicide on the
next day of marriage. Besides other factors, the fact that the young man entered into
marriage before completing grieving is the reason for his suicide. Therefore, it is
good to give enough time for the grieving process to get over and then proceed with
the marriage. Even if the engaged are not prepared for the postponement, at least the
counsellors should bring to their notice the implication of grieving in a partner.
9) Serious Physical, Emotional and Mental Handicap
Handicapped persons – physically, emotionally and mentally – have the right
to a married life with dignity. They are only required to see the quality of life that
might affect the partner and even the children if certain handicaps are to be
genetically transmitted to the children too. They need to understand the limitations
before getting into marriage. Sometimes more than the physical handicaps,
emotional handicaps are really serious. I have come across people who are
physically handicapped but they lead a rather enriching married life; on the contrary,
I have met enough marriages in my pastoral ministry that are wrecked by emotional
handicaps. Possessive jealousy and strong suspicious tendencies bordering on
paranoia, coupled with a life-long pattern of insincerity clearly marked by lying, and
a wide mood-change every now and then, do great harm to marriage. Emotional
handicaps need prolonged counselling and psychotherapy to set the stage right for
marriage.
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10) Serious Drug Involvement
When a partner is dependent on certain drugs or alcohol, the other partner
needs to make an immense adjustment for being together. It is a burdensome liability
on marriage. There are also persons who need to marry a drunkard in order to satisfy
their need to rescue and take care of a wayward fellow. But normally speaking if
addiction is too strong at the time of marriage it is not likely that marriage will
improve the situation. Since we are living in a drug culture it is almost taken for
granted that the youth experiment with chemicals at one time or other and if they are
out of it before marriage, it is a welcome sign. Anyway, this aspect needs serious
consideration by the engaged.
11) Psychopathic Personality or Antisocial Personality Disorder
Not everybody has a balanced development of personality. There could be
defects in our personality development. One of the serious defects is called
psychopathy. Persons of this sort are very smart, impressive and even highly
intelligent, but lack the appropriate growth of their moral sense (otherwise called
conscience). For them what matters is gratification of their every need immediately;
they do not look into the consequences. For such persons marriage is fun, and not a
commitment. There are persons who marry a number of times by deceit, may be for
some financial benefit. If one of the engaged is of that sort, careful consideration
should help to weigh the pros and cons of such a commitment before arriving at a
decision.
12) Financial Insecurity
Marriage has to be lived concretely for which material support by way of
finance is a must. Over-emphasis on the material aspect of marriage to the neglect of
personal quality is not wholesome, and in the same way stressing only personal
quality leaving out the material aspect will be illusion. Therefore, a moderate
concern for the material backing is essential. For example, if the engaged are not
employed, have no house of their own and are living with the meagre support of their
parents, the situation is serious enough.
In short, the engaged need to discuss and find out their psychological and
sociological, financial and economic, physiological, sexual, and spiritual aspects of
their marriage.95
8. Counselling Format & Techniques
The format and techniques vary considerably. There could be several conjoint
sessions. There are other alternatives too like conjoint sessions with several group
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sessions, and all the sessions in group setting. It has been found that the combination
of conjoint and group sessions provides better chances of understanding themselves
as couples and as part of the larger society with other couples in a group. There may
be times when the counsellor needs to talk to them separately; a shy person unwilling
to open up some vital information will be able to talk freely and the counsellor can
work out that particular area. It may be a good idea just to provide a chance for each
of the engaged to meet the counsellor separately for a while, so that nothing vital is
missing from the premarital discussion that could contribute to the success of the
marriage. The sessions with the engaged could be arranged according to the
convenience of the engaged and the counsellor. The duration and number are left to
their common consensus. In the first sessions they could get acquainted with each
other sharing the basic information about each other. The second session could
concentrate on the psychological and sociological aspects of their marriage, paying
special attention to budget. The third session could deal with psychological, sexual
and spiritual aspects of marriage. The fourth session is a review of all that they have
learned and achieved and to concentrate on any area that needs special consideration
and referral.96
With regard to the techniques, it is good to note the developing trend to use the
Family History Analysis which places emphasis on the person’s family of origin and
the ensuing effect on their marriage since the model they had is mostly from the type
of marriage that were witnessed in the families. If the engaged become aware of the
influence of the families of their origin, they are in a way prepared for the types of
expectations and problems they carry into their marital relationship. Being informed
is being forewarned. Counsellors must above all facilitate the trust of the engaged in
each other.97
9. Conclusion
In order to ensure stability of marital life (vital for the progress of the society
and for the balanced development of the children), premarital preparation and
counselling are to be undertaken seriously. As society is changing and evolving
rapidly, counsellors need to be sensitive to the changing phenomenon of the society
in which the mode of courtship behaviour undergoes a rather constant change.
Adapting the format and the techniques of premarital preparation and counselling is
an obligation for the counsellor engaged in this helping profession. What we have
discussed so far is proper for the engaged heterosexual partners going in for marriage;
for the most part, it is also applicable to the people of different life styles, like
engaged heterosexual partners not intending to marry but being content with
cohabiting, and to the homosexual (gay and lesbian) partners.
7
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COUNSELLING THE COUPLE
1. Introduction
Sociologically one of the institutions that have undergone drastic changes is
marriage. Selecting a partner is the task in the premarital stage, and now the main
tasks are sustaining the marriage, and if divorce is inevitable adjusting to the divorced
condition. Marital problems are the most prevalent difficulties clients usually bring
to the counsellors. Though people view divorce and serial marriages as deviations
from the accepted conjugal tradition, divorces are quite rampant and are on the
increase. With the society becoming tolerant to premarital and extramarital sexual
relations, more women in the labour force, divorce made easier by law, greater
population mobility with the concomitant witnessing of alternative lifestyles are all
some of the reasons posited by sociologists for the prevalence of crisis in marriage.
The crisis may range widely from anything like modes of sexual expression,
unsatisfactory marriage, money to be earned and be spent, division of labour with
regard to household chores, religious beliefs and practices, use of leisure time, childraising practices, obligations to the relatives, cohabitation without marriage, and
homosexuality, to divorce; and there are minor irritants too like differences of
opinion over trifling matters.98
2. Characteristics of Coupling
Couple counselling psychologists have identified six variables characteristic of
couple relationship. Knowledge about these variables will help us to understand the
emerging problems and how in relation to the characteristic variable the couple needs
to find solutions. When we think of any dyadic relationship, the couple relationship
is quite unique. The variables seen as a whole, taking marriage in general, are the
following:99
1) Voluntary Nature of Coupling
Even though there may be cases of forced marriages which may lead people to
go for divorce, the nature of couple relationship is voluntary. Most people voluntarily
enter into marriage.
2) Balance in the Couple’s Relationship
Psychologists propose that the family system, to which belongs the couple
subsystem, requires that the members maintain both a stable and steady pattern of
relating to one another and also have the ability to change the pattern when the
situation warrants. When the stability or homeostasis is disturbed by any
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developmental crisis or situational crisis, the couple find a new pattern of relating to
one another which is a new balance, or fall back on the previous old pattern which
was the old balance. Thus a couple in order to maintain a productive balance in their
couple relationship may at times need to engage in some change and at other times
hold on to the accustomed pattern. Too much stability may be a hindrance to growth,
and too much flexibility will be viewed as chaos.
3) Temporal Aspects of Coupling
The temporal component of coupling refers to the past, the present and the
future. Coupling is viewed in terms of timeline to use a term of Neurolinguistic
Programming. If in the past the couple was successful in handling their problems
amicably, one can look forward to stability and growth. Similarly when the couple is
engaged in conceptualising a future and planning for the future together that would
become an essential ingredient for binding the relationship during periods of change
and instability.
4) Merging of Systems as Part of Coupling
In a coupling relationship we find that at least two systems (of different values,
emotions, backgrounds, and thinking) come to merge. The husband had ‘his’ own
way of doing and the wife had ‘her’ own way of doing but now they will have to
negotiate for the third way called ‘our way.’ In times of crisis and conflict the ‘right’
way of doing things emerges and gets settled in one way or other. In fact this
merging of two systems is a continuous process throughout the lifespan.
5) Giving and Receiving of Support as Part of Coupling
Family systems counsellors view giving and receiving of support as one of the
chief functions of the coupling relationship. Couples in marriage chiefly want
support, especially in times of distress and crisis. Providing and receiving support is
an essential function in any intimate relationship. Here one needs to be extremely
sensitive to the needs of the other with regard to the kind of support the other is in
need of. It may not be very much spoken out but may manifest itself through nonverbal behaviour. In fact growth as an individual and as a couple is interrelated.
Perhaps transcending one’s own needs to meet the needs of the other is also a highly
growth-producing factor in an individual’s life. A person closed on himself and bent
on meeting only his own needs is not growing in the right direction.
6) Maintaining Separateness and Individuality in Coupling
As much as the couple is eager to be together they also have a need to be separate,
to have ‘space.’ Ultimately people go for divorce, maybe because they could not be
separate in their couple relationship. What would foster growth and health in the
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couple relationship is the ability to stand apart to pursue one’s own individual needs
of political affiliations, religious commitment, network of personal friends and
colleagues of work. The richer one is as an individual, the better it is for the couple
relationship.
3. Marriage as a Social System
Marriage has the characteristics of a social system.100 It is viewed as a
subsystem of a larger social system especially the family system. It is governed by
non-verbally-agreed-to rules and boundaries that govern interaction within the
couple’s relationship. The couple can change certain rules and hold on to some rules
in order to maintain a level of stability (homeostasis ) in the relationship.
1) The Couple as a Subsystem of the Family
A system is a unit with a series of interacting parts. In a family system each
member influences and is influenced by the other and their interactions become
patterns that shape the behaviour of all participants within the system. Every system
is comprised of interacting subsystems. Family members are influenced by the
behaviours of the individuals in the different subsystems. A family system may be
composed of a spousal subsystem, a parental subsystem and a sibling subsystem. The
spousal subsystem is the basic to the development of the family. Thus husband and
wife as a spousal subsystem relate to their parents, to their children, to their brothers
and sisters.
2) Stages of Couple Development
Marital subsystem can be viewed as a unit moving through time. As the
relationship of the couple develops, it may encounter different tasks in their life cycle
and may have to make adjustment to the new challenging tasks. In terms of time,
seven stages are identified for the married couples.
(1) The early years – A couple in their mid twenties have the task of becoming
independent of their parents and of communicating their needs to each other
effectively.
(2) From the second to the fourth year, the honeymoon charms fade away and the
couple is involved in having children, developing careers and establishing their own
traditions and values.
(3) From the third to the seventh year, the couple is faced with the task of
increasing their commitment to the marriage, children and their work or careers.
Certainly one will notice tension while they balance their commitment in these three
areas.
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(4) From the seventh to the fifteenth year, patterns of decision making, conflictresolution, and accomplishing tasks will become well established. Here evaluation is
had in terms of how well commitments to marriage, childbearing, career, and broader
community have been maintained.
(5) From the fifteenth to the twenty-fourth year of their relationship, being in the
early 40’s, they look back and evaluate their lives as individuals and as a couple. By
now the children are teen-agers and they want to be independent so much so that the
couple separate from involvement in parenting and again they struggle to define their
identity.
(6) From the twenty-fifth to the thirty-fifth year, the partners are in their 50’s
and 60’s and their children are leaving home; they may cope with the death of their
parents and may question their traditionally assigned roles as homemaker and
breadwinner.
(7) After the thirty-fifth year of their relationship, positively it can be a period
of more freedom from responsibilities of children and work and can become a phase
of vitality in their relationship, or they may be also facing the delicate issues of
illness or the impending loss of the spouse.
3) Rules and Boundaries Governing Couple Relationship
In every relationship there needs to be responsibility for initiating and carrying
out certain tasks, which are plenty in marriage. The couple may exhibit relationship
in dominant-submissive fashion in which one partner is in charge of the relationship
while the other follows, or in symmetrical relationship in which both partners
compete to demonstrate their power and influence. Some couples change the
dominate-submissive roles according to issues in a balanced way. If a relationship is
always in one way (of dominate-submissive fashion or always symmetrical), the
spouses will experience tension and conflict in their relationship. The rules that
govern the couple relationship can also be seen in terms of rigid boundaries in which
couple show little involvement between themselves, and between themselves and
those outside their relationship; or in terms of diffused boundaries which is
characterized by over involvement in each other’s life, and over involvement between
the couple and those outside the couple’s subsystem. Boundaries can be seen as a
continuum from rigid to diffuse. If the relationships of the couple are medially
between the rigid and diffuse (that is clear boundary), they are likely to maintain their
individuality and their relatedness, and are really healthy.
4) Homeostasis within the Couple Relationship
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The couple in their developmental tasks show some kind of flexibility with
regard to certain rules, and stability with regard to some other rules. The tendency to
maintain a steady state of equilibrium after change is called homeostasis. Whether a
change is welcome or not can be made out from the positive and negative feedback.
Negative feedback will indicate too much of change and the couple need to return to
former accepted rules of interaction. Positive feedback will indicate that the new
rules of interacting can be entertained and accepted.
Homeostasis can be maintained, and the needed changes in the relationship
ignored by triangling a third person, object, or illness into the relationship.
Triangling can be seen in two ways: 1) Detouring – Couple diverting their conflict
by a protective concern for their child’s health or by a critical demand, i.e. by
censuring the child for its behaviour. 2) Cross-generational Coalition – When a
couple is in conflict, one of them will join with the son or daughter against the other
spouse. By triangling in a third person, object or illness, customary and homeostasis
patterns are actually maintained, and the rules they have established go unchanged.
4. Areas of Symptom Formation in Couple Relationship
There is no uniform thinking in the understanding of the problems of the
couple. Some counsellors view the presented problems as such and treat them as
problems while others see the presented problems as symptoms of some underlying
deeper issues. In any case, couple counselling psychologists have grouped ten areas
of symptom formation:101
1) Economic Issues
The economic issues concern: who earns, who will spend, how to spend, how
much to save, and how to budget. Problems can be from any angle of the economic
sector causing deep or trifling distress.
2) Companionship-Intimacy
The way one spends the money and the way one spends the time are indices of
his/her personal values. The amount of time spent together with the spouse and the
time spent with the children, parents, relatives and friends may vary. Disputes can
arise regarding their coming home late, especially during the period immediately
after the marriage.
Intimacy will involve the frequency of sexual activity and the initiator of the
activity. How often to have sex and who will start it are concerns of the couple.
There may be difference of opinion between the couple with regard to this issue.
There are also non-sexual intimacy like touching, hugging, kissing, cuddling
together, massaging, bathing, stroking, exploring, surveying, mild biting, pressing,
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holding tight, and the like. In most cases, the non-sexual intimacy may be more
important for a couple’s relationship than the genital activity itself. Conflicts can
arise as to the preferences of the type of sexual expressions. What is normal and
enjoyable for one may be a taboo for another, maybe due to religious sanctions or
psychological inhibitions. Once I counselled a couple who were on the point of
going for a divorce over the practice of oral-genital contact. The husband had orgasm
only with the oral contact, and not with genital penetration. But the wife viewed oralgenital contact as religiously prohibited and personally repugnant. Therefore, the
husband was going to other women who would oblige his desire for oral-genital
contact and that posed a grave problem for the couple.
Women about the time of menopause, or immediately after, may experience a
strong desire for repeated sex, whereas their husbands mostly in their middle age by
that time experience a decline in sexual functions, and so the husband may not be
physically ready for repeated sexual activities. This frustrates the wife. Thus
frustration in the wife and inability in the husband can become a problem. Women
thus frustrated may seek sexual satisfaction elsewhere clandestinely. I counselled a
relatively young couple of whom the man complained to me that his wife wanted
repeated intercourse in the same night. As men age, they find it difficult to cope with
the increased desire of their wives for repeated sexual intercourse within a short time.
At times homosexuality (being gay in the husband or lesbianism in the wife)
may come in the way of intimacy. Under the pretext that the children are grown up,
the couple may not indulge in sex. Often in such cases, I am not surprised to find that
the real reason is the gay tendency in the husband or the lesbian tendency in the wife.
They may find out their preferred sexual partners (gay or lesbian) and deny sex at
home.
Routine and boredom could be hindrances to intimacy in couple relationship.
By the time the couple reach their middle age, sexual life will become a routine affair
and boredom usually sets in with the declining beauty and physical vigour. To ward
off boredom both the partners may seek new and exciting stimulations outside their
marriage.
People with paranoid personality disorder and people suffering from paranoid
of jealousy will be forever suspicious of their partners, and such people no doubt will
be quarrelsome with their partners, thus endangering their intimacy. In short, any
personality pattern deviation or sexual deviation will pose a grave problem to couple
intimacy.
3) Work and Recreation
For the daily sustenance, the couple may work, but the amount of overtime
(logged after the office hours) may be an indication for the other spouse, perhaps
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wrongly, that the other has no consideration for his or her interests. Apart from the
work, the time of recreation spent outside the house individually will raise suspicion
in the mind of the spouse.
4) Parenting
Parenting addresses the issues like the number of children, the spacing of
children, the time each parent spends with the children, the discipline of the children
and the kind of activities the children will engage themselves in. It may happen that
one of the couple becomes an over-involved parent while the other becomes a
peripheral parent, or both the parents may be competing for parenting in a kind of
power struggle.
5) Household Chores
For the smooth running of the family, there needs to be a division of labour.
The criteria of dividing the household chores could be the type of job one holds and
the amount of time that is available at home, and also whether both partners are
employed. If the husband is employed and the wife is at home, most of the
household chores usually fall on her, whereas if both of them are employed, a fair
division of labour according to the capacity of the spouses may prove useful.
Counsellors usually meet the couple among whom one is over-worked while the
other has a lot of leisure time. This problem may also be culturally induced in the
sense that in some societies cooking, sweeping, childrearing etc. seem to be the
assignment meant for woman. If the woman is also employed, the exclusive
household chores may be a great burden to her.
6) Relationship with Extended Family
The couple cannot live in isolation and they need the support of their extended
families on either side. But too much of time spent on visits to the extended families,
or too much of visits of the extended family members being entertained and seeking
advice from the extended family members affect the life of the couple.
7) Religion
Religious differences are potential areas of symptom formation. When people
of different religious background marry, the dominant spouse has the say as to the
practice of religion together. The submissive spouse usually yields to the wishes of
the dominant spouse; and when not willing to be pliable, quarrels ensue. Very many
times problems start not until child rearing starts. Now the couple become alert as to
which is the correct religious orientation and in what orientation the child is to be
reared.
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8) Friends
Friends are an asset to any relationship. But in marriage, especially in the early
stages, friends may become a potential source of symptom formation. One of the
partners may become jealous of his or her spouse developing or maintaining a steady
and intimate friendship with another person, especially with the opposite sex.
9) Substance Abuse
There are social drinkers and chronic drinkers. Social drinkers maintain their
normalcy under all circumstances, whereas the chronic drinkers lose their balance
with regard to the drinks, time, place and people, and are literally dependent on
alcohol. Even in social drinking, how much money is to be spent on alcohol, and in
chronic drinking what behaviours are tolerable, and what are not, are issues to be
dealt with in couple counselling.
10) Communication
Practically all the couples have problems of communication. For a number of
people, the skill of communication and empathetic listening are wanting. This may
require a few tips and a little practice. There are also couples who have developed
recriminating ways of communication. Once I counselled a couple; the husband
complained that his wife is not considerate to him. When asked, it was revealed that
the wife (after both of them arrive home after their work) asks her husband to take
her to some place which the husband obliges ungrudgingly. He had never told her
that he was too tired to take her out. This was a lack of appropriate communication.
There are some ground rules102 that we need to keep in mind while coaching couples
in communication skills training. First of all, it is good to talk about what one wants
or feels rather than what the other party does not do. For example, one may say that
one wants to be with the partner at least half an hour every day in the evening instead
of telling that the other party does not spend time at all with him or her. Secondly,
clear statements are to be made so that the other spouse knows what is really wanted
or felt. For example, it would be clear to say that one wants a baby rather than telling
how nice it will be if children are round about. Thirdly, instead of monopolizing the
talk, let the partner have a fair chance to express what he or she wants.
5. Stages of Marital Conflicts
Counselling psychologists have charted seven definable stages through which
marital conflicts can be moving:103
1) Stage of Typical Adjustmental Conflicts
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Here, conflicts are bound to be there whether the couple openly accept or not.
These conflicts can be either tangible or intangible. To deal with them, the couple
need to adjust in some of the following ways: 1) Development of an agreed-upon
schedule of work, rest, play, lovemaking and worship, 2) Development of a deeperlevel and mutually satisfying plan of communication, 3) Development of a comradely
understanding as to their masculine and feminine identities, that is, what a man is
expected to do and what a woman is expected to do, 4) Establishment of an adult-toadult relationship to parents-in-laws, 5) Growth of fellowship with other married
couples and with unmarried persons and 6) Joyous acceptance of the first child in the
family.
3) Stage of Disrupted Covenant
The second phase of conflict is the disruption of the covenant of trust. There
may be vital facts hidden from the spouse, which affect the marital relationship. I
know a man who pretended to be a person of great wealth which actually did not
belong to him and thus duped a girl to marry him. On knowing the fact, the girl was
upset and broke off the relationship.
3) Stage of Private Misunderstanding
Minor misunderstandings and distress are ignored or are not shared with the
partner with the result that one feels lonely, isolated and has the feeling of being
misunderstood.
4) Stage of Social Involvement
The couple in their silent misunderstanding may open up their problems to
others indiscriminately, which brings in more problems. If appropriately expressed to
responsible persons like counsellors, it may be constructively dealt with; otherwise,
conflicts are likely to occur.
5) Stage of Threats of Attempts at Separation
Spouses reach this stage when their conflicts are not dealt with and on the
contrary, further inflamed.
6) Stage of Legal Separation
A legal separation may arise to test the couple’s more positive feelings for each
other and to test their willingness to face the realistic hardships that divorce will later
force upon them. Engagement period is required to test their decision to marry;
similarly the disengagement period is required to test their decision to divorce.
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7) Stage of Divorce
By the time the couple reach this stage, they are already reconciled to the
divorce state, but the post-divorce bereavement situation may pose problems for the
individuals. There could be grief, marked by hostility and vindictiveness, as well as
the tears of frustrated love and devotion ending with a depression.
6. Characteristics of Marital Conflict
Conflict in marriage may have the following characteristics.104 1) There is a
polarization in the sense of two camps (of husband and wife) accusing each other and
proving that each one is right. 2) Secondly, there are differences of perception in the
sense of understanding and interpreting events and actions differently. 3) Following
the above two stages we have a change in relationship especially from being warm to
becoming cold and even cruel at times. 4) Finally we notice a marked change in the
communication pattern from being open to being withdrawn.
7. Counselling
(1) Impact of Couple Counselling
Marriage counsellors have come to certain conclusions regarding the impact of
couple counselling. They are:105 1) Receiving counselling produces positive effect
than receiving no treatment at all. 2) Seeing the spouses conjointly is more effective
than seeing them individually. 3) Stimulating interaction and giving support in early
treatment sessions tends to strengthen couple stability, whereas providing little
structure with confrontation of highly affective issues tend to lead to deterioration.
(2) Approaches to marriage counselling
The term couple counselling or marriage counselling normally includes
helping people in their premarital planning, sustaining a marriage, or adjustment to
divorce. And this also includes counselling the people who are cohabiting in a living
together arrangement (LTA), whether heterosexual or homosexual. Since we have
separately and elaborately dealt with premarital counselling, here we shall
concentrate only on sustaining a marriage. There are in fact numerous methods of
couple counselling depending upon the clients, problems and skill of the therapist.
However we can roughly group all these alternative forms into six types:
1) Individual: One spouse is counselled in one-to-one counselling sessions. 2)
Individual-Group: One of the spouses is treated in group sessions. 3) Concurrent:
Both the spouses are counselled but in separate individual sessions. 4) ConcurrentGroup: Both spouses are counselled within the same group at different times. 5)
Conjoint: Both the spouses are counselled together in the same individual session.
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6) Conjoint-Group: Both the spouses are treated together in the same group
session.106 Individual sessions are useful to give the spouse a chance to express his or
her point of view without the fear of being contradicted by the other. It is also useful
for a couple to express negative emotions like anger or grief. One might also feel
delicate to talk of certain matters in conjoint sessions with the counsellor lest the
talking out is misunderstood as betrayal by the other party; in such cases individual
sessions are good. Having given a chance for individual sessions, the counsellor can
take the couple to conjoint session.
(3) Counselling Stages
Counselling sessions could perhaps be more or less in five stages:107 Social
stage, problem stage, interaction stage, stage for defining desired changes, and the
stage involved with ending the interview. In the social stage, the counsellor gets
acquainted with the couple; in the problem stage, each partner is asked to describe the
problem as they see; in the interaction stage, the counsellor directs the couple to
interact with each other to know how they deal with or handle their problem and to
know their interpersonal style; and in the last two stages, some goals are set, like
reducing some problem behaviour, or beginning or increasing some desired
behaviour, and finally giving some homework for the couple to be evaluated later.
(4) Relationship Satisfaction
In a way, assisting couples in counselling session revolves around relationship
satisfaction which in turn will comprise three areas:108 1) Motivation: renewing the
sense of hope. 2) Meaning: developing ways of thinking about their problems and
relationship that are growth-producing. 3) Management: developing and using the
behaviour skills necessary for having a satisfying relationship.
5) Family Systems Counselling
(1) A Systems Model Approach
Of late there is a new thinking especially in sociology, which can be extended
to even psychology and counselling, known as ‘a systems model approach.’
According to the systems (or context) model, reality consists of a hierarchy of natural
systems (Levels of Organization) ranging from subatomic particles at the bottom to
large and larger systems. It was the sociologist Engel who has given us the clearest
conceptual model of what a systems model of reality encompasses. Accordingly, on
the top we have biosphere, then Society Nation; followed by culture, subculture,
community, system, organs\organ systems, tissues, cells, organ cells, molecules,
atoms and subatomic particles. In this model, every level of organization is nested
within a larger system of which it is a part. This systems thinking has its origins in
the recent developments in mathematics and physics. The linear (cause and effect)
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approach (as we find in traditional psychotherapy) is not adequate enough to explain
complex phenomena like persons, families and communities. We can no longer
afford to think of behaviour in terms of single, historical causes mediated by
intrapsychic activity, resulting in individual characteristics and unchanging
personalities. What is more important is the context or the system(s) in which an
individual functions.
(2) Circularity
There is another systems concept known as circularity, which means that as
systems become more complex, there is no question of thinking in terms of beginning
or an end, but rather the systems concept is a process that goes back and forth and
affects each other simultaneously and constantly; it is like the biological systems of
the heart, the lungs and blood vessels which are interdependent parts of the
cardiovascular system, each of this system is connected to and is influenced by every
other part, as no part operates independently. Thus human behaviour was understood
from the early 1950’s in terms of context (systems) and circularity instead of
reductionistic and linear models which dominated psychology till the 1950s.
(3) Family Homeostasis
Family systems therapy included an interdisciplinary group, developing out of
concepts like family homeostasis, the double bind hypothesis, circular causality and
strategic approach. Family homeostasis refers to the tendency to maintain its balance
at a current level even when change is desired; for example, an adolescent wanting to
be independent, whereas the parents want to protect him as a child.
(4) The Double Bind
The double bind (conflicted messages) hypothesis refers to the double message
parents may be giving their children, like asking them not to do a certain thing and
punishing them for not having done it. This double bind situation usually creates the
environment for dysfunctional behaviour.
(5) Circular Causality
Circular causality refers to the fact of family systems tending to act in
recursive or reciprocal (rather than linear) ways. Thus, behaviours in the family are
related to types of behaviours with the result that the focus (for therapy) becomes the
system itself.
(6) Strategic Approach
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The strategic approach to family therapy is based on the normal family life
cycles. The members of the family, at each stage of the family life cycle, enter and
exit the family systems in various ways, upsetting and precipitating an emotional
crisis. At each stage of the cycle, one is required to make major developmental
changes which when one does not do he/she becomes ‘stuck’ or even regresses to
earlier stages. According to this concept human problems and dysfunctions are
situations of getting ‘stuck,’ and the therapy or counselling is meant to help people to
get ‘unstuck.’ In strategic family therapy, we find another important concept called
‘triangling.’ For example, if a child is problematic of any kind, most of the time it is
assumed that at least two adults are triangled into the problem along with the child
(an overly involved parent-child dyad which is a cross-generational coalition, and
another parent who seems peripheral). The child is both a participant and a vehicle
for dysfunctional communication between the adults in the family. Therefore, the
behaviour of the child cannot be understood apart from the functions that it serves
within the very family itself and/or larger systems.
Implicit in the systems approach are the following assumptions: 1) To
understand any system we must understand the context(s) within which it functions
(For a family it will mean understanding its structure, its place in the life cycle and its
communication patterns). 2) One must understand how structure, life cycle and
communication interact in a recursive or reciprocal way within the family. Actually
in the family systems counselling, the counsellor himself is a part of the very system
he is counselling!109
6) Communication Enhancement
Since most of the problems may crop up for want of adequate communication,
this method is meant to teach the couple the art of effective communication, like
speaking honestly and clearly, and listening empathetically – by describing,
demonstrating and guiding the practice. Here effective communication seems to be
the chief factor, in the absence of which many marital problems arise; hence guiding
the couple in effective communication is undertaken.
7) Behaviour Contracting
Here the focus is on changing the couple’s specific actions, thus increasing the
person’s positive acts and decreasing the negative ones which may produce positive
effect in both the beliefs and feelings of the couple.
8) Interactional Therapy
This type of therapy has something of behavioural therapy in it. The focus is
on observing what is going on in the systems of human interaction, how the systems
continue to function and how they can be altered most effectively. Its techniques can
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be: 1) Reframing or Re-labelling which is simply changing the conceptual
viewpoints from which a situation is interpreted. 2) Homework Assignments, which
mean directing the couple to act in specific ways in their relations with others. 3)
Paradoxical Prescriptions, that is, instructing the couple to do even more of a
troublesome symptom, on the assumption that the symptom will become so awkward
that it will be dropped.
9) Strategic Therapy
This therapy resembles interactional therapy. Its main thrust is the active,
dominating and directive role of the counsellor in identifying solvable problems,
setting goals, creating interventions to achieve goals, changing the interventions if
they fail to work, and assessing the ultimate outcome.
10) Sex Therapy
It refers to an activity or set of activities meant to treat sexual dysfunctions
with a view to increase the couple’s sexual pleasure. In case of sexual dysfunction, a
sexual history from the person is to be obtained in order to determine whether the
sexual disorder is physical, psychological or social in origin; medical consultation
also will help the assessing and treating the problem. Behaviourally oriented
approach, which includes both individual and conjoint sessions, and homework
assignments of suggested practice of sexual experiences is often used in sex
therapies.
Here the problems may range from the evident issues of male impotence or
female orgasmic dysfunction to underlying resentment that manifests itself in the
form of sexual dysfunction. There are a number of techniques that are developed in
sex therapy, like: traditional psychoanalytic interview with its free association and
dream interpretation, answering and discussing (sex-knowledge-and-attitudes
questionnaires, dispelling the myths about sexual functions, sharing sexual fantasies
and preferences with each other; instructing in love-making techniques perhaps
through the use of still pictures or films and guiding the couple explore their bodies
mutually and finding out erotic zones). Resolving accumulated hurts, resentments
and anger is important before making love. One needs to avoid hurry, worry, fear,
fatigue and too much of alcohol. One need not unduly worry when one does have
occasional sexual response problems.110 Whatever be the type of specific technique
one may employ, counsellors have come to realize that the problem has to be
approached from a systems concept in the sense that a problem has to be seen as a
part of the whole complex system of the human person with its various subsystems.111
11) Psychoanalytic Therapy
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The focus is on the unconscious wishes and fantasies that influence the
behaviour of the couple. Here what is assumed is that the marital conflicts are the
results of individuals trying to meet their unconscious needs and wishes. Gaining
insight into the psychodynamics of the individual and unearthing the unconscious
needs and wishes are the highlights of psychoanalytic therapy.
12) Intergenerational Therapy
The influence of the previous generation upon the present generation is seen in
behaviour. An analysis into such an influence is made by this therapy.
13) Structural Therapy
Here the social organization of the marital unit is considered, the assumption
being that identifying and changing the physical structure change the psychological
relations between the couple. For example, when the couple sit far apart, the
therapist may ask them to sit close; this is a structural change which changes the
quality of the couple’s feelings.
14) Behavioural Therapy
Here, the concern is about changing the specific manifest behaviours of the
individual, which is based on the social learning theory: ‘Behaviour changes in
response to the rewards provided.’ In marriage or family, problems may arise just
because a person’s negative behaviour is rewarded. Or a person’s positive behaviour
was not rewarded. The therapist identifies individual or interactional problems
within the marriage unit, develops methods to reduce the reinforcers of negative
behaviours, and encourages the reinforcers of positive behaviours.
15) Marital Enhancement Programmes
These are meant to improve the quality of the marital relationship; they aid the
impaired relationship rather than the dysfunctional relationship. These programmes
have a time-limited, structured format designed to teach the participants the skills for
improving their relationship; they have a number of names, differing from country to
country like Marriage Enrichment, Marriage Encounter, and so on.
16) Divorce Therapy
Just as counsellors are concerned about preserving the stability of the marriage,
they also need to be concerned about the people who want to separate or have already
separated.112
17) Guidelines for Enriching Marital Relationship
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Howard Clinebell in his book “Basic Types of Pastoral Care and Counselling”
has proposed a few guidelines for enriching marital relationship:113 1) Ask them to
set aside regular time for communicating about what really matters to each one of
them. 2) Make them recognize and affirm the strengths and assets in each other –
warmly, caringly and regularly. 3) Let not unresolved anger, hurt, and resentment
keep growing; this can be achieved by taking appropriate steps to discuss
disagreements, negotiate fair compromises, resolve conflicts and revise the basic
commitment regularly to keep it fair, current and just. 4) Provide equal strengths and
possibilities. 5) Let there be at least a few minutes each day set apart for fun and
relaxation. 6) Help them develop their own individual support group. 7) Let the
couple increase each one’s self-nurture and autonomy to give them healthy spaces in
their togetherness 8) Let them find a bigger cause to serve than their own
relationship. 9) Let them enrich their inner life by intellectual and spiritual pursuit.
Here spiritual does not mean religious. By spiritual I mean one’s commitment to the
ultimate cause which transcends human nature.
8. Counsellor
1) Role of the Counsellor
A counsellor in a counselling situation may play many a role; he is ‘a
participant observer and an observant participant;’ a referee to see to the fairness in
expression and decision-making; a coach who facilitates them to learn how to run the
marriage; a teacher who recommends what is appropriate for them; a
communications-facilitator who helps them to get the message across effectively; an
awareness stimulator by making aware of what is happening in each one and also
what is happening between both of them; a reality-tester who allows them to check
their perception with his; and a role-model who shows the way. Thus we can go on
enumerating a number of roles a counsellor may assume, or at least the couple might
project on him.114
2) Approach of the Counsellor
The way the counsellor deals with the couple is vital for the success of the
counselling. 1) Let your dealing be warm, caring, and suffused with a willingness to
help and affirm their goodwill for seeking help. 2) Find out how much of motivation
each has got to improve the present lot and what one fears, wants and hopes for, from
counselling. 3) If one of the partners is less interested, motivate that person by your
rapport for realistic satisfaction. 4) Let each be given enough opportunities to tell
his/her part of the story while keeping silent when the other speaks. 5) Once anger
and hurt are exposed and expressed, find out what value they hold still for a march
forward together.115
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In marriage counselling, taking sides will undermine all your efforts to help the
couple. It is good that the couple realize that conflicts are part of the human
existence, especially in marriage. As a ground rule, no one will harm the other in
your presence.
9. Conclusion
First of all, to be aware of the problem areas of the couple itself is a positive
sign towards facilitation. One can always use a number of techniques available to
help the couples. There are couples who want to maintain their marriages, but are
unable to do so for want of proper skills, in which case the counsellor’s intervention
is most welcome and productive; and there are also cases where the situation is
hopeless and the couples will find solace only in separation; and there too the
counsellor’s intervention is a blessing to smoothen the process of separation. One
should not readily assume that a couple cannot get on well together unless there are
enough evidences. The counsellor’s duty is to preserve anything positive and
beautiful in the relationship. Safeguarding an institution like marriage is everybody’s
concern unless simply it will not stand. I once counselled a couple: The husband had
psychiatric problems even before the marriage and on that score the marriage would
not stand and they wanted to get separated. When all the attempts to save the
marriage were a failure, I facilitated them to smoothly separate. After two years they
both wanted to reunite and at that time too I was at their side to render my service.
Thus the counsellor must be open to the situation and render the appropriate service
in whatever direction it may be needed.
8
COUNSELLING THE FAMILY
1. Introduction
Sociologically, family is a primary group in which the members have a face to
face relationship. It is one of the basic units of the society, and the health of the
family will automatically ensure the health of the larger family which is the society.
Finally, in fact, it is the social system of primary relationships from which individuals
derive their physical, psychological, social, intellectual, moral and spiritual nurture.
2. Types of Families
There are several types of families — namely two-parent families, singleparent families, couples without children, and three-generation families. There are
also gay families, and lesbian families, though they may not be seen in our traditional
family garb.116
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3. Family as a Social System
In recent years the concept that the family is a social system is gaining ground
in many circles especially among the family therapists and counsellors.
Understanding the family as a system is the same as understanding it as an organism.
If family is a social system it should have like any other system certain subsystems
which are in this case husband-wife, mother-children, father-children, child-child,
grandparents-parents, grandparents-children, child-pet and so on. The marital pair
identity is a unique psychological identity. The identity of the family incorporates
something of the self-image of each marital partner and the image of the respective
families-of-origin and also develops something unique and new.
The family could either frustrate or facilitate the potentializing of the family
members. Therefore, the health or illness of the family members depends upon the
family itself and its need-satisfying network of relationships. An individual's
dysfunctional symptoms are in a way the product of the failure of the family in
meeting the needs of that person. It seems that all the members in the family derive a
certain emotional gain from the dysfunction of the identified patient of the family. It
looks as though the members agree upon who will be the scapegoat, in the sense who
will be sick, delinquent or alcoholic so that when the supposedly troublesome person
becomes well, the other members get disturbed because in a way the identified sick
person was actually an outlet for the prohibited or unwanted impulses of the
supposedly normal people. Of course it is an example of extreme family
complimentarity. The family members for the most part are unconsciously happy
that one of them bears all their burden, being identified as the patient. In individual
counselling we have access only to one aspect of the total interpersonal network but
in a systems-approach we have access to the total aspects of the interpersonal
network. The aim of counselling is to facilitate the whole family system to improve
their interdependent network of need-satisfying relationships.117
4. Conjoint Family Therapy as a Systems Perspective
In the past with the heavy influence of psychoanalysis, individual intra-psychic
therapies were mostly made use of for family counselling. But the focus has already
started to shift from such an approach to family-organism therapies or family group
therapies or conjoint family therapies in which the whole family is treated
simultaneously. What is assumed here is that the psychopathology of an individual is
the product of the way the family or the larger system deals with him. In a family
system therefore it is assumed that the symptomatic behaviour of an individual
identified patient is a necessity, if the other members of the family were to continue
functioning. Instead of focusing on the identified patient, it is good to shift the focus
to the relationship of the members and when the relationship changes then
automatically the identified patient will change his symptomatic behaviour. If on the
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contrary the counsellor were to concentrate only on changing the symptomatic
behaviour of the identified patient, there will be a stiff resistance on the part of the
identified patient since his symptoms are only the product of the unhealthy
relationship of the other members. Helping the entire family change their ways of
relating and communicating is the best solution to deal with the family problems.
When relating and communicating improve, then an environment conducive for
healing and growth is created for all the members.118
5. The Goal of Family Systems Therapy
In the family systems therapy the entire family is met in therapy sessions and
occasionally a subsystem within the family, with the following goals119 in mind:
1) Communication
Communication is the chief ingredient of a happy family and this should be the
primary motive in undertaking family therapy. The family members should be
encouraged to communicate their positive and negative feelings, desires, needs and
hopes openly and clearly without being judged or condemned.
2) Focusing on Relationship
Since the family as a system (with a few subsystems within it) projects its
problem on an identified patient, the therapy should concentrate on the relationship
that is the cause of the problem of the identified patient rather than on the identified
patient himself. This helps the family to identify the cause of the problem rather than
the symptom of the problem.
3) Mutual Need Satisfaction
The family members in their crisis learn to feel hurt, get angry and do attack
others. This happens in the event of their needs not being adequately fulfilled.
Therefore, instead of hurt-anger-attack cycles the members could be taught to learn
self-feeding cycles of mutual need satisfaction.
4) Nourishing Self-esteem
Self-esteem is deemed essential for personality development and also to maintain
healthy relationship. The members of the family need to fulfil the need for selfworth. All of us want to be appreciated but perhaps are reluctant to give that gift to
others!
4) Growth Opportunities
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There may be so many implicit rules, values, expectations and beliefs that may
stand in the way of the individual’s growth. It is worth the trouble to renegotiate
those accepted aspects that hinder the growth of the individuals, and give fair chances
for all to develop and grow with the responsibilities, power and satisfaction
distributed equitably.
6) Self-actualizing Ways
People’s frustrating behaviour may be due to the blocking or thwarting of the
self-actualizing aspirations. Encouraging the family members to enhance selfactualizing ways would immensely reward the family in the long run.
7) See Conflict as Growth
There is no group life without conflicts, and conflicts bring out the best in
individuals and the group. Not only that, conflicts can actually be the moments of
growth for the individuals. Therefore, recognizing the positive side of conflict itself
is a step forward.
8) Integration of Embeddedness Vs. Autonomy
In every relationship there is a period of embeddedness followed by a desire to
distance oneself from the person with whom one is embedded. These two
movements alternate with each other in our development. Complete embeddedness
or complete autonomy is harmful for health. What we need is the integration of the
conflict between embeddedness vs. autonomy. In the family situation what may be
wanting in most cases is the lack of autonomy to individual members.
9) Growth-engendering
The interaction among the members of a system and other subsystems need to
be growth-producing and inventive of new ways of relating that would enhance the
relationship itself.
10) Being Open to Supportive Relationships
A family system in itself is not self-sufficient. It needs other supportive
relationships of families, groups and institutions for its nourishment. Therefore, a
family system needs to be open to other supportive relationships.
In short, what we have so far seen as the goal can be summarized as:
individuals feeling and supporting one another’s self-worth, communicating directly
in clear terms with honesty, accepting one another’s differences and tolerating one
another’s mistakes, with the implicit rules within the family being fair and flexible
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and keeping themselves as an open system interacting with other people, families and
institutions in mutually supportive ways.
Taking into account the different therapies available, what seems most useful is
that: along with whatever therapy is applied, the approach could include the family
systems perspective with the help of conjoint family therapy.
6. Right Brain Method
For people who would like to grow into fullness, right-brain methods could be
of use. The right-brain methods presume that the two hemispheres of our brain
specialize in different and complementary functions. The left brain is rational,
analytical, verbal, technological, and educational whereas the right brain is intuitive,
metaphoric, relational, and holistic. To be whole and healthy we need the balance of
these two hemispheres. Counselling psychologists have developed some right-brain
approaches to family problems; they are: using active imagination about the way one
would like to be; giving examples in stories and parables; telling a dream and
making it end happily, if originally it was not that way, reframing a problem by
asking what one learns from the crisis; reliving creative memories of anything that
would cement family love; using jokes and paradoxes like taking lightly when one
does not have erection; playing together; and body enhancing by giving a hug or a
massage.120
7. Family Root System Therapy / Genogram
This innovative therapy is akin to the family systems approach but from a
different angle. Only by understanding the counsellees and their problems, a
counsellor will be in a position to help them. One of the vital areas of information
that will be of great utility in understanding the dynamics of the presenting,
precipitating, and underlying problem, is the information about the root of the family
or the map of the family or genogram. Thus there developed a family root system or
family map in family counselling. This map can be drawn on three generation levels
which may include its folkways, mores, values, folk faith, deaths, geographical
moves, family constellation, significance of names and the like. When these are
explored and got as background information along with the systems approach, then
worthwhile results are achieved.121
8. Conclusion
Most of the approaches meant for couple counselling can very well be used for
family counselling and so I do not want to duplicate the work by repeating the
approaches adopted for couple counselling. You may refer to the chapter
‘Counselling the Couple’ for this purpose. Yet a word about conjoint family therapy
may be in place. A young man was brought to me for counselling. The youth
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became silent all of a sudden and would not communicate with anybody in the
family. All his brothers who are his elders and parents began to blame him for the
misfortune in the family. They were in a way projecting their disappointment on him
and that seemed to be the underlying problem for which a few sessions with the entire
family eased the situation and the symptom. If I were to counsel the youth alone, he
would not have improved since the way of relating to the other members of the
family would remain the same which would only reinforce the dysfunctional
behaviour of the youth. Thus, conjoint family therapy is a great tool to the
counsellor.
9
COUNSELLING THE SICK
1. Introduction
Illness can be very grave and serious or mild. For our practical purpose we
divide sick people into two broad types, namely people on the point of death and
people who are not faced with imminent death, but have a setback in their health.
Here when I say ‘Counselling the Sick’ I do not mean the dying person (since we
have a separate chapter on Counselling the Dying,) but a person who is suffering
from ailments and is waiting to get well.
2. Body-Mind Interdependence of Illness
In this chapter ‘Counselling the sick’ we are not interested in the physical
aspect of the illness but only the psychological aspect that deserves attention from the
counsellor. Of course, since the body and mind are interconnected, one is likely to
affect the other to a greater extent. This being the case, though medical personnel are
busy with doing the utmost physically for the patient, it is the duty of the counsellor
to deal with the psychological difficulty depending upon factors like his personality.
In some cases purely psychological sickness may eventually lead to physical illness.
For the first we can cite the example of a person who met with an accident and has
his body or limbs lacerated. The nature of the illness is purely physical but from the
very moment of the accident the person is psychologically affected. It may be true
that in this case the physical setback is not that great as the psychological setback.
Let us take the example of a psychosomatic illness of peptic ulcer. A person
suffering from a certain anxiety could not get relieved of it and so the prolonged
anxiety produces changes in the stomach secretion which in turn eats up the stomach
walls, causing a peptic ulcer. In both these cases healing has to take place both at the
physical level as well as at the psychological level.
Therefore healing, in this context of body and mind interdependence, will
mean living meaningfully in all human dimensions. Here healing does not mean
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mere prolongation of life alone, for a person’s life may be prolonged but he may be
seriously sick psychologically, and socially. Healing does not merely mean
restoration of physical integrity alone, for in many instances a person’s physical
integrity may not be restored as in a person who lost his limbs in an accident or a
person whose arm is to be amputated for his total well-being and continuation of
life.122
3. Types of Illness
Sickness can be classified as follows: 1) Sickness initiated and confirmed in
the body like typhoid. 2) Sickness initiated and confirmed in the mind like
schizophrenia, 3) Mental sickness in the body like psycho-physiological disorders 4)
physical sickness (like a brain injury) causing mental illness.
4. Sickness in the Hospital Setting
Let us have a cursory view of some of the sicknesses we normally encounter in
hospital situations, the psychic dispositions of the patients and the attitude the
counsellor is supposed to adopt in dealing with them.
1) Patients with Nutritional Troubles and Disorders of the Digestive System
Hunger and eating are associated with feelings of satisfaction, and well-being
whereas starvation with dissatisfaction and insecurity. Feelings of possessiveness,
greed, jealously and envy all become linked to the process of nutrition. There seems
to be a close connection between emotions and the disorders of alimentary functions.
As a rule we can say that whenever legitimate expression of deep emotions are
repressed into the unconscious, there results a state of prolonged tension which exerts
a chronic disturbing influence on the different phases of gastrointestinal activities.
The stomach disturbances are caused by worries, fears and quarrels. The patients feel
the need for self-preservation which is satisfied by taking in, assimilating, possessing,
and being provided with. They are usually insecure, irritable, helpless, and feel
empty. There are also the needs to receive, to grab to fill themselves, feeling selfpity; sometimes there seems to be no inhibition in their behaviour. The counsellor
needs to be tender, empathetic, warm and considerate to them.123
2) Disorders of Excretory Function
Elimination of waste materials is a must for living organisms to remain
healthy. Healthy excretory function indicates that the person possesses conscious
control over the process and autonomy. When there are disorders, it means that the
patient feels lack of control, helplessness, depression, disgust, dirty, repulsive, uneasy
and isolated. Counsellors need to understand the dependence needs of these patients
and bear with the unpleasantness of their sickness.124
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3) Skin Diseases
The skin is the outer limit of an individual and it is the medium between the
inner world and the outer world. It is sensitive to cold, heat, pain, burning, sexual
pleasure, itching, viewed as beautiful or ugly, pure or impure. It plays an important
role in expression. The patients may feel non-presentable, shy, and ugly all over,
resentment and repulsion. There could be some bad odour emanating from the skin.
The patient of skin diseases may fear isolation and scars on the face and other areas.
Counsellors need to be extra careful not to show disgust and repulsion in the presence
of the patients.125
4) Heart Diseases
Heart diseases may be experienced in various symptoms like severe chest pain,
breathlessness, palpitation on exertion and excessive sweating. The patients are
obsessed more with the psychological distress than the physical distress. Once a
heart patient, he thinks that he is already condemned to die. He lives in constant fear
of dying. A heart patient used to write to me quite often that her death-knell is
already rung. Fearing death on exertion, the patient usually remains restricted in his
social and physical movements. The patients easily abandon themselves to others’
care and become over-dependent. They need the presence of someone nearby since
they are under the constant fear of dying at any moment. My interviews with the
heart patients indicate that they need more of supportive counselling than anything
else.126
5) Neural Disorders
Neural disorders are infections, tumours, and congenital defects of the spinal
cord, brain, and nerves. The patients usually experience extreme helplessness and
hopelessness coupled with anxiety, frustration and loneliness.127
6) Genitourinary Disorders
Unhealthy attitudes in our society make people with genitourinary disorders
extremely ashamed of speaking about them. Some patients even postpone going to
the doctor for fear of exposing themselves and to talk about things connected with the
genitals. If they have contracted some venereal diseases it is all the more an added
reason for them to feel ashamed of themselves. The patients want to safeguard their
good name in public and do not want to be identified as patients with some
genitourinary disorders. They normally want to be anonymous. I have seen patients
with such problems going to doctors who do not probe too much into their sexual
activities. They do not want the doctor to enquire about the details that are not
needed for the actual treatment. In a way they want to be anonymous. A counsellor
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has no need of enquiring about the symptoms; he needs to help the patient to be
relieved of the feeling of dirty, impure etc.128
5. Hospitalization
When sickness cannot be handled by ordinary medication, a person is admitted
to a hospital. It is worth noting what is happening to the patient as he undergoes
hospitalisation. First of all, the patient experiences anxiety and resentment in the
waiting room itself.
The long, tedious and usually delayed entries made before the patient is
admitted, the delay in the arrival of the doctor and the lack of attention from the
nurses and the anxiety about the sickness itself, all produce agonizing moments of
irritation, restlessness and anger. On admission, a medical examination follows that
may be awkward and painful both physically and psychologically — from the
moment the clothes are removed and examination of the various parts of the body are
undertaken. Patients who are sensitive and shy usually dread physical examination,
especially when a group of medical personnel examine them.
In the ward, unless a private room is available and affordable, there is lack of
privacy. The depressing scene of the patients is all around. At times there is the
necessity of using bed pan and catheterisation. The patient feels social estrangement;
he is worried about the family at home, financial problems, job uncertainties and
postponed responsibilities. While the treatment is on, during the stay of the patient in
the hospital, he is likely to feel the pain and discomfort on account of the therapeutic
procedures undertaken for treatment, and worry about the sickness. Change of
medicine and prolonged treatment give the impression that the sickness is rather
serious, and further investigations only confirm his doubts about the seriousness of
the illness. On discharge he has regret over the lost health, time and money, and he is
afraid of the sickness recurring, and concerned about the high cost of further
treatment.129
1) Psychological Reductionism
A sick person’s tension may be aggravated by a number of factors like the
failure to find the meaning for one’s sickness, lack of acceptance by others, and the
difficulty in understanding the sick-role.
The psychological disturbances of the hospitalised patient (or any patient for
that matter) are: feeling insecure, anxious, bored and lonely. As he feels threatened
he is in a hurry to be cured; losing inhibitions he becomes unrealistic and childish;
developing self-pity, he suffers from depression and rejection and expects attention,
care, tenderness, understanding, intimacy and supportive care. Above all, the patient
experiences what is called reductionism, that is, the person is reduced from rationality
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to emotionalism, from self-reliance to dependency, from cooperation to complaining,
from reality-facing to magic-working, from social awareness to isolation, and from
self-hood to thing-hood.130
2) Disease – Dis-ease Parallelism
When we consider the dynamics of illness it becomes evident that there are
two parallel processes namely disease and dis-ease. Here disease refers to the
physical setback whereas dis-ease refers to the psychological aspect. Though both of
them interact into a close network we can see them parallelly. They need not go
together in the sense of being proportional to each other. The level of gravity of the
disease need not be equal to the level of gravity of the dis-ease. For, a person maybe
gravely ill in the sense that the disease is at a high level, and yet because he has
worked through the very illness psychologically, the dis-ease level may be very low;
and on the contrary when the disease level is minimal the dis-ease level may be very
high. Therefore, instead of asking what sickness a person suffers from, we could ask
who is suffering. The personality makeup of the patient is very important. The
disease line may run starting from appearance of the symptom, through admission to
a hospital, tests, operation, and recuperation to discharging. The dis-ease line may
start with anxiety, fear, resentment, and frustration and run through depression; with
the intervention of the counsellor the patient may come to terms with illness, see the
meaning of illness and finally reach the ‘ease level.’ The dis-ease and disease may
influence each other. Hence the counsellor needs to take into account both these
aspects.131
3) Trauma of Surgical Patients
Operations can be undertaken for surgical purposes or for accidents. When
accidents occur the patient is already brought to the operation theatre without having
a long time to deliberate on the need of surgery itself. But in the case of premeditated
operation, the patient usually undergoes certain phases before, during and after the
operation. The appearance of the symptom itself is alarming. The patient may not
know well the whole procedure of the operation and that will create tension in him.
When the operation is inevitable, the patient experiences a shock followed by denial
as in the case of the dynamics of death. When the operation date is fixed the patient
experiences increased tension; and the night before the surgery is very critical
psychologically, especially if the patient has to lose a limb. Preliminary preparations
like shaving, enema and the surgical clothes, and the immediate preparations like
visit of the doctor, nurses, relatives and sterilization of the area to be operated on, will
greatly increase his anxiety. During the operation the patient is going to entrust
himself in the hands of doctors and nurses whom he may not know at all or may not
know well. The fear of death looms large in the mind of the patient, as he feels that
he is closer to death. Coupled with the fear of death is the fear of anaesthesia; 75% of
the patients fear the possibility of revealing personal matters under its influence, the
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length of time that will be spent in the unconscious state and death on account of
anaesthesia. There is the fear too if his needs will be attended to while he is
unconscious and the fear of the pain after the operation. The losing of an organ has
special significance if for example the organ is a vital one like a lung or if the organ
is considered important for one’s self-image like breast, uterus, testicles, penis, etc.
Patients are also implicitly aware of the possible changes in life-style, role, and job
after the operation. In the post-operative stage the patient may experience physical
trauma more than psychological trauma. Here all that a counsellor can do is physical
nearness and touch if appropriate.132
6. Counselling
1) Hospital Conduct of the Counsellor
While visiting a patient in the hospital, a counsellor could follow the following
guidelines. Before entering, get to know from the medical staff (especially from the
nurse on duty), about the person you are going to visit. See if there is any natural
point of contact. If the door is closed, find out from the nurse if the patient is being
attended to or he is resting or sleeping under medical direction in which case you are
not supposed to disturb him.
On entering, greet the person in a simple way and introduce yourself in an
understandable manner. Somehow make sure that your visit is really wanted by the
patient. Your eagerness to counsel need not be forced on him. Wait for his response
and guidance to continue the conversation. Take up a position without leaning on the
bed, where you can be seen by the patient without his straining. If you feel you are
welcome, see that you do not communicate your own anxiety to the patient. Do not
push the conversation if the patient is tired, or shows signs of desire to terminate the
conversation. It is a ground rule that you do not discuss the symptoms and diagnosis,
or even the treatment, with the patient. Let the patient have the chance to talk and
pour out and on your part lend a listening ear to him. Facilitate the patient to express
his pent up feelings as far as possible if it is not physically harmful.
While visiting, if the medical staff wants to examine the patient or attend on
him they should have the preference. It is better that you keep away from the scene
when the medical personnel do the examination unless you are invited to be present.
If you make any promise, let the promise be carried out; otherwise make only
conditional promises. Attempting to build up the confidence of the patient in the
doctors, nurses and the treatment is healing. Curiosity and arguments might be
counter-productive. With regard to your responses, let them be understanding and
supportive for the most part, coming from your Nurturing Parent and Adult ego
states. Since over a few visits you are building a rapport which is a kind of
transference for the patient, see that you gracefully take leave of the patient telling
him in advance about your terminating the visit. Put the furniture (the chair) you
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have used in its original place or in the place the patient wants. It is advisable to end
the conversation before the patient is tired of you.
Since many patients may not open up in the first visit itself, it is worth having
follow-up visits, during which something significant might transpire. There need not
be any set agenda with regard to the matter to be discussed. Financial issues are
likely to come up if the patient is a poor man. Help him to mobilize his resources
towards the financial issue. Playing the doctor or the nurse is inappropriate since
your role is not medical but psychological, and more specifically counselling. It may
be that the patient is in need of some spiritual service in which case, see that an
appropriate person who can cater to such needs is invited. Most people in distress
tend to appreciate spiritual factors like faith, love and hope. Let these be not
overlooked. Helping the patient to be specific in speaking about his difficulties and
learning to be comfortable with moments of silence are welcome tasks on the part of
the counsellor.133
2) Attitude & Procedure
Patients in the hospital experience anxiety and tension. The counsellor’s duty
is to deal with such things. First of all, the counsellor needs to listen to the patient
empathetically. Establishing a trustful, loving and understanding relationship is
essential for the process of counselling. Emotional security is the thing that a patient
wants. It is good to bring to the notice of the patient whatever changes for betterment
the patient is experiencing, without sounding phoney. Through the whole process the
counsellor needs to give his ‘therapeutic presence’ by his sustained physical
‘thereness.’134
The counsellors need to establish rapport, trust and confidence from the first
moment of their meeting. The extremes of life and death are commonplace in the
hospital setting. Between these two extremes we have suffering, loss, pain, grief,
loneliness, emptiness and joy.
When serious illness is contracted it is worth enquiring into the circumstances
prior to the onset of illness. There may be significant stressful experiences such as
the loss of a loved one, divorce, separation, moving to a new place, termination of
relationship, etc. It is estimated that the time frame for any symptom to appear as a
result of some stressful experience is 6 to 12 months.135
8. Conclusion
Apart from the influence of the medical services, a counsellor can greatly contribute
to the healing, health and growth of a sick person. When we consider the body-mind mutual
influence, what stands out as significant is the influence of the mind. In other words, ‘as
you think so you live.’ Though sick persons may be placed in the hospitals for medical
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treatment, he is in need of psychological service along with the medical service. Hence the
intervention of the counsellor is important and very essential for the total well-being of the
sick person since healing does not refer to mere physical cure only.
10
COUNSELLING T H E D Y I N G
1. Introduction
The final developmental task is dying. This chapter can either be put under
developmental crisis or situational crisis. It has both the elements in the sense that it
can be viewed as the final task of the developmental stages, or it can also be seen as a
crisis arising from a situation of the physically failing body system.
2. The Phenomenon of Death
Psychologists believe that people die when they want to die! This may sound
strange but the fact is that in a sizable number of cases we realize that this is true.
There is a process of death and it is a living process in the sense that it is a
developmental crisis. It is said to be a personal experience for as long as we continue
to live we may not quite understand what it is to die and in this sense it is personal for
the person who dies. It is not only a personal experience but also the first and last
experience for we do not die twice but only once! Even in the case of resuscitation,
the brain has not been dead which means to say that the person in actuality did not
die. There is a dying process of the organism and there is a dying process of the
person and they need not go hand in hand. Therefore, the person may die later than
the death of the organism.
It is true that death may occur at any age. Elderly people seem more aware of
its imminence and less afraid than the younger ones. It is also found that some of the
elderly people view death as an acceptable alternative to a life that might have
become meaningless. Researchers point out that the dying persons are willing to talk
about their impending death and they seem to be needing and welcoming such a
discussion. In fact they are thankful that they learned about their death. In practice,
we want to postpone telling the person about his death. Perhaps we are not
comfortable with the event of death which prevents us from communicating to the
dying person about his death.
3. Elizabeth Kubler-Ross’ Stage Theory
Stage theory of the dying process: It was Elizabeth Kubler-Ross who did a
noteworthy research in the process of death as espoused in her famous book ‘On
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Death and Dying.’ According to Kubler-Ross there are identifiable and overlapping
five stages in the process of dying.
The first stage is the stage of denial. Even before the denial we can perceive an
initial shock. Though Kubler–Ross did not posit it as a separate stage, we can take
that as a stage, for I have observed that some people remain dazed in that shocking
experience for sometime before moving in to the denial stage. Thus let us posit six
stages for understanding the dynamics of death.
1) Shock (No)
Anything unexpected, out of the way, too great to be borne, will bring about a
shock in an individual. For any individual the news of his impending death is such a
shock that the person remains stunned for a while. Most of the people do not linger
much over this stage. What greets the news of the prospect of death is the shock the
person experiences. At that time he is hardly aware of anything happening to him
and who all are around him. In shock it looks as though all the psychological
processes are suspended for a while. Here the person remains speechless. I
remember once being invited to visit a patient in the hospital to whom I was supposed
to tell the truth of his impending death. When at last I did speak about it the person
remained motionless, and there were no tears, and no words. It took sometime for
him to come to his senses and speak to me. At this stage the unconscious cries aloud
‘No.’
2) Denial (Not me)
After the shock comes the denial, a natural reaction to anything shocking. This
I have observed not only with the dying persons but even in group therapies and in
students under formation. When certain truth about them is brought home to them
they deny it violently. Another interesting thing about the denial is, the more
vehemently one denies a truth about himself, the more it confirms to me the truth.
One should not take this as a sign of insincerity or want of genuineness on the part of
the one denying. The person has already experienced shock, and denial comes as a
shock absorber. In order not to feel the impact of the shock too damaging, some
shock absorbers are required and denial is such a shock absorber. If denial (full or
partial) is not there the news will be too damaging. Denial is a defence mechanism
and a very radical one. Unless lesser defence mechanisms replace the radical denial
defence mechanism, it is a healthy sign for a dying person that he denies the truth of
the imminence of his death. Usually the person says that the tests might not have
been accurate and a re-examination is essential to confirm the first report. They even
go to the extent of visiting many physicians hoping to prove that the first report is an
error. This happens even in ordinary illness. One of my companions was diagnosed
as having cholesterol in the blood. He vehemently said that it cannot be true and
went about testing his blood in eight labs! Every time he got the report he had
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something to say about the unreliability of the test. That only proved that he was
denying. Here the patient unconsciously shouts aloud ‘Not Me’.
3) Anger (Why Me?)
The patients with the shocking news are intrigued as to why they should be
singled out for the misfortune of death. If it is a question of a young dying person, he
feels that an unwarranted injustice is done to him and he resents it very much by
getting angry with the responsible people around him like parents, medical staff and
even God; he thinks they are responsible for his death. Even his anger may be
displaced to some innocent persons who have nothing to do with his illness or
treatment. It would not be strange to note that some people are angry with
themselves. Thus the emotion of anger is expressed in one way or other. Only in the
third stage, the dying persons begin to express emotions, but in the other two stages at
least apparently nothing is evident. Once I made a visit to a dying young man in his
residence. He was in the prime of life and was about to be married when it was
diagnosed that he had terminal cancer. When I visited him I was younger to him. He
just observed aloud ‘you are young like me.’ In a way he was questioning me why a
young man like him should die when there are old people who need to die before
him. Unconsciously he was crying out aloud ‘Why Me?’
4) Bargaining (Yes me, but…)
We have learned from childhood that good behaviour is usually rewarded, and
the patient makes use of this strategy to prolong his life or get a new lease of life. By
now the patient is quite aware that death is inevitably imminent; no more can he deny
the reality of it but only he wants to postpone it because of some self-imposed
deadline like the marriage of his son or daughter. This bargaining usually takes place
with God who the patient thinks will be able to grant health and extend his life.
People who in their past did not believe in a personal God suddenly cherish strong
faith in God and especially in his miraculous power to heal. A lot of religious and
pious practices are entertained with the belief that God will be pleased with his
changed life and will grant him a miraculous cure. Among the common folks, going
on a pilgrimage and shaving off the head and among the educated and the well off,
giving donation to churches and temples, feeding the poor, establishing institutions
that will care for the people who suffer the same illness they are suffering from,
sponsoring a research centre that will do more research on the illness they are having
and promising their body organs for transplantation or for medical purpose after
death, are evident.
During my counselling field work I was visiting a teen-ager of 9th standard
suffering from blood cancer. There would be always some kind of religious books
and pictures around his bed whenever I visited him and at one time he confided to me
without letting his parents know that he was intending to become a pastor on
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recovery. The boy who was always speaking of becoming an engineer suddenly
changed his plan to bargain with God to be cured of his illness. He was indeed in the
bargaining stage with the Creator. Patients are ready to do anything in exchange for
recovery or extension of life. Though they want that one small request of theirs to be
granted, when in fact that small request is by chance granted they are not satisfied
with that and they will make another request. In this context it is worthwhile to
explore the possibility of consciously deferring one’s death. Researchers have come
up with the conclusion that in fact people do defer their own death depending upon
the reason and the motivation. If there is going to be an important event in the
family, the individuals facing death somehow control even their most basic bodily
processes and continue to live up to the event. What would be hopeless is just giving
up. In this stage they are unconsciously asking ‘Yes Me, But....’ (let me first marry
my son / build a house etc. and then die).
5) Depression (What use is my struggle)
Depression could be a reaction to any loss. There are two kinds of depression.
One of them is the reactive depression which is the reaction to a loss that has
already been experienced. Take for example, a person whose leg is amputated. He
feels the loss intensely and is depressed. Here, to alleviate the feeling of depression,
certain strategies of seeing the possibility of making a meaningful life would be
useful, once the depression has been experienced to a great extent. The other is the
preparatory depression which occurs in response to an impending loss. Here
encouragement to see the brighter side of life does not work. All that the patient
needs is to feel the ruin fully and express it. Therefore, a counsellor would do well to
be present with him empathetically rather than stimulate him to see the charming side
of life. What is happening here is that the patient unconsciously shouts ‘What use in
my struggle?’
6 ) Acceptance (Yes, it is me who has to die)
The last stage is the stage of acceptance. This stage may not be reached by all,
especially when death is too sudden and there is no time enough to work through the
other five stages. There are some people, who struggle till the end holding on to
whatever they can, and they do not seem to reach the acceptance stage; otherwise,
acceptance is the last stage for a person especially in a prolonged illness. In a way,
both the patient and the family wait for the final event. Here there may not be feeling
of resentment. It looks as though this period is devoid of apparent feeling. Now
what the patients need is being left alone much of the time since they do not have
much interest in anything. They may need frequent intervals of sleep and since they
are not able to talk much at this stage their communication is more by signs than by
words. Here the patient unconsciously tells ‘Yes, it is me who has to die.’ It is to be
noted that the patient may move back and forth mostly feeling anxiety and
depression.136
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4. Edwin Shneidman’s Cluster States Theory
There are other perspectives for the dying process. Edwin Shneidman (1978)
believes that there is no such thing as the stage process of dying. People according to
him, experience a cluster of intellectual and affective states between disbelief and
hope, anguish, terror, surrender, rage, envy, disinterest, pretence and even yearning
for death.137
5. E. Mansell Pattison’s (1977) Three Process Theory
Instead of stage, Pattison’s proposes processes or phases. There seem to be
three processes a dying person experiences:
1) Acute Phase
The person becomes aware of the impending death due to a terminal illness
and it precipitates a crisis in his life with a considerable anxiety accompanied by
emotions like anger, fear and resentment.
2) Chronic Living-dying Phase
Here there is an initially reduced anxiety followed by a host of diverse
emotional states not previously experienced. Some of the common feelings at this
stage are: Fear of the Unknown – The person wonders what is ahead of him, and
what is next after death, and how people around him are going to react to his death.
Loneliness – The person experiences not only isolation from others but the worst part
of it is isolation from himself. He stands out singularly alienated from himself and
from others. Sorrow – It is a reaction to a number of losses he is currently facing.
Loss of the Body – One’s self-concept is mostly made up of one’s body and a
debilitating loss of the functions and use of the body may mean for some, disgrace
and inadequacy. Loss of Self-control – With the sense of the loss of the body, comes
loss of self-control since the patient cannot make use of his limbs and other faculties
in the way he wants and they do not seem to obey his command. Suffering and Pain
– It is more than mere physical pain. But what depresses the patient more is the
mental anguish. Loss of Identity – Our contact with others affirms who we are, and
our contact with our family affirms who we have been, and our contact with our body
and mind affirms our own self. For a dying person all these three affirmations are
slowly waning, with the result that one feels the loss of identity.
3) Terminal Phase
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The characteristic reaction of a dying person at this stage is withdrawal;
although the emotions experienced in the previous phases are present, the person is
seen more withdrawn.138
Though we saw three different types of approaches to understand the process
of death, they are not contradictory but rather complementary. These approaches say
that every dying person is a unique individual with a lot of variation in all that is
being observed about the dying process. It would be wise to take these three views
together and understand a dying person in front of you rather than waiting for the
stage or state or phase to be manifested.
6. Fear of Dying
Fear looms large on the face of a dying person with regard to many things.
1) Fear of pain and mutilation
It could be a fear of pain and the possibility of mutilation.
2) Fear of isolation
As time passes by, there are fewer visitors, almost with the idea that the patient
is an abandoned case. This fear of isolation is greater than the fear of the disease
itself.
3) Fear of the loss of control and independence
This is a major fear for persons who were active and autonomous in their
former days and all of a sudden are being reduced to a state of utter helplessness.
4) Fear of the future of the loved ones
A gnawing fear is the fear of the future of the loved ones especially if the loved
ones are too dependent like children, handicapped individuals and spouses who are
too dependent on them.
5) Reflected fear
Sometimes the dying persons are scared to see the fear on the faces of people
who are round about. It is the fear of the dying person that is reflected on the faces of
the people around him. That is why it is called ‘reflected fear.’
6) Fear of the unknown
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People die only once and one does not know beforehand what exactly it is to
die and what one has to go through in order to die. There are also issues like what
awaits a person after death. There are some who believe in life after death in one
way or other like resurrection, reincarnation, etc. And there are also people who do
not believe in life after death. It is not the domain of psychology to discuss whether
there is life after death or not. But for the people who have a faith in life after death,
the passing through death seems easier than for those who do not believe in life after
death; for the non-believers, death is a great injustice done to a human individual.
Here the fear of the unknown refers to either with regard to what it is to go through to
die, or with regard to what awaits or does not await after death.
7) Fear of the meaninglessness of life
It has been more or less estimated that among the people who commit suicide
about 5% of the people do so since they do not find meaning in their lives. This is
not only valid for those who commit suicide but also for people who normally die.
There may come a time when one might feel meaninglessness in his life.
7. Old People’s concern about death
Death may come to a person at any age and at any time. That is why the
existentialist philosophers say that a child, as soon as it is born is old enough to die!
This being the case, normally the old people are closer to death than the youngsters.
In late childhood, adolescence and to some extent in early adulthood the interest in
death is around life after death and what causes a person to die but for the elderly
persons their concern is death per se and particularly their own death. The concerns
of the old people regarding death are specific.
1) When will I die?
Even if they do not have fear of death, old people want to know how much
time is left for them before they die because they may want to complete the
‘unfinished business’ that may still await to be done.
2 ) What is likely to cause my death?
This question centres around four major areas of concern: i) Wondering
whether they can postpone death even for a short while by doing something, as for
example, a man with hypertension may begin to relax and follow a diet; ii) Desiring
to take care of the unfinished businesses as the disease progresses rapidly; iii)
Considering the financial position, as for example, if one were to die of sudden heart
attack, there is no fun in accumulating a lot of wealth and if it is a slow death, the
person needs money to be saved for spending through the inability of the old age; iv)
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Worrying about whether the last days will be debilitating and painful, or be
physically active until the end.
3 ) How can I have a good death?
A ‘good’ death may mean different things to different people; old people more
or less speak of a ‘good’ death if i) they are able to be in control of their pain, ii)
maintain dignity especially by being included in decision-making process such as
having or not having an operation, and iii) receive affection and love from their loved
ones.
4 ) Euthanasia
In some countries the question of the freedom to take one’s life has become a
significant concern of the elderly persons.139
8. Dying involves Suffering
Death necessarily involves suffering and in fact suffering is the harbinger of
death. Suffering is unwanted pain. What makes suffering truly suffering is its
unwantedness. That is why psychologists say that when a suffering is integrated,
which means accepted then it ceases to be a suffering. We naturally do not want to
choose suffering and it is against our will and pleasure. According to Sigmund
Freud, the father of depth psychology and psychoanalysis, all of us are ruled by the
‘will to pleasure’ which means automatically that we tend to avoid pain and
suffering, and seek pleasure. Since ‘will to pleasure’ according to Freud seems to be
the dominant drive, the avoidance of pain and suffering is quite evident according to
his theory. It is a personal distress which is inescapable and inevitable and out of our
control. It forces itself upon us.140
1) Responses to Suffering
There are many ways to respond to suffering: 1) People drown suffering by
the use of alcohol or drugs and we go to the extent of distracting ourselves with some
amusements. 2) We can also use the mechanism of denying the obvious fact of
suffering. It is going about as though there is no suffering at all. 3) Personal despair
is the third way to respond to suffering. 4) Facing suffering with acceptance is
another way. It is not a stoic acceptance, nor acceptance of a suffering that can be
avoided in the sense of ‘suffering for the sake of suffering.’ By acceptance, we mean
finding meaning in the suffering. Ordinarily speaking, we cannot think of life
without suffering. Suffering is the ingredient of human life just as death is part of our
life. It is in suffering we become self-transcendent going beyond ourselves.141
9. The Dying Know Their Death
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‘Does a dying person know his imminent death?’ It is a question that can be
analysed. People have a remarkable capacity to know what is happening to them
especially with regard to death. The human body has a unique way of
communicating with the persons. As counsellors we know that the clients speak very
eloquently through their own body than by their words. Even without their own
knowledge they unavoidably reveal themselves through their body. The human body
has a wisdom of its own and somehow the dying person realizes his death. Medical
personnel who deal with the dying persons say that about 80% of the dying people
know that they are dying which means that their personal imminent death is not
outside their awareness.
I tend to think that the percentage should be even more than just 80%, since the
symptoms and the changes that are taking place in one’s own body somehow indicate
to the patient that he is dying. In this regard it is good to ask a question if the dying
person should be told of his death regardless of whether he knows it instinctively or
not. The patients have a right to know about their death. Perhaps knowing their
death they are better prepared to meet it than when it happens in ignorance. If we
keep ourselves tight-lipped when our loved ones undergo the agony of death, we are
depriving them of the precious chance of facing death with their dear and near ones.
Research shows that the dying persons usually appreciate that they have been told of
the imminence of their death.142
10. Facts about Dying Persons
Some of the revealing facts about dying persons are:
1 ) Dying persons want to talk rather than be talked to
They would like to communicate to us what they feel is important to them.
The people around them especially the counsellor needs to be sensitive to their need
to communicate even though it may be difficult to understand them.
2 ) Dying persons speak symbolically
The dying persons seem to have a certain predilection to speak in symbols like
gestures, stories, and old memories. It is not that they are trying to pass time but to
communicate something valuable but in symbolic ways.
3 ) Presence with vulnerability
The dying person wants our presence with all our vulnerability. We are not
stoics but human beings with the possibility of being deeply wounded by love and
loss. With all that, we need to be present to the dying patient.
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4 ) Dying persons want to be treated as persons till the end
Often people take away the responsibility of the dying persons, thinking that
the dying person does not hear or does not respond or he is not in a position to make
decisions for himself. All these may be true but to ignore their opinion when they are
able to express it, will amount to treating them as objects. Some people have wishes
like being buried in such and such place with so and so. We need not forget that
people who are apparently unconscious can often hear and sense what is going on
around them.
5 ) Dying people want to live until they die
Even if it were only a few days left, it is worth finding out how best those few
days can be lived. In fact the dying persons do not want to be treated as ‘dying.’
They want to be treated as ‘living’ persons and the truth is that till they die they are
actually living persons. Let the patients invest as much as they could, to the fullness
of life that is possible while they live. Therefore, in some centres that care for the
AIDS-affected children, there are birthdays for the children every month since most
of them may not even live a full year. This goes to show how they need to live their
lives fully till the moment of death. The counsellor’s duty is to see that the dying
person lives fully up to the last minute.
6 ) The dying persons may pass through phases or stages
Dr. Elizabeth Kubler-Ross in her famous book ‘On Death and Dying’ has
marked out the stages through which the dying patients pass. Though in most
instances we may notice a common stage like transition we also note that some
patients have their own peculiar stage of transition. There are exceptions to the
stages proposed and not everyone goes through all the stages and the time spent in
each stage may differ from person to person. All the dying people do not complete
their homework on death before they die. Whatever it is, being acquainted with such
stages will be of help for the counsellor to be sensitive to the dying person. Towards
the end, the dying person wants our presence and availability rather than words.
7) Family members pass through stages or phases
It is not only the dying person who passes through stages but the family
members themselves pass through such stages as the patient, but not along with him
at his pace but in their own pace.143
11. The Dying Experience
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Let us consider what it is to die physiologically and psychologically. A dying
person experiences a sequence of physiological and psychological events as
described by Ruth Gray (1977):
1) Sensation and power of motion as well as reflexes are felt most in the legs first,
and gradually in the arms. Pressure on the extremities seems to cause pain to
the patient.
2) Peripheral circulation fails and there is frequently a drenching sweat and the body
surface cools, regardless of room temperature.
3) Invariably the dying person turns his head towards light since sight and hearing
fail; any bright light catches the attention of the dying person.
4) Sensation of touch is reduced but the sense of pressure is there.
5) As in the former stages there does not seem to be much pain towards the end.
6) With regard to consciousness, many dying persons seem to be conscious to the
very end.
7) Spiritual needs often rises strongly at night and they may want to talk to a priest,
minister or rabbi.
8) There seems to be an interval of peace before death. Many even report of the
feeling of serenity, peace and calmness.144
12. Counsellors in the Context of Death
Perhaps the counsellor deals with death more than the dying person himself.
He deals with the patient primarily, and also with all the family members secondarily,
and tertiarily he deals with the medical personnel. Thus his sensitivity extends to
myriads of people and the likelihood of his being exhausted with all such draining is
high. It is imperative for the counsellor to be acquainted with the growing sensible
literature on death and dying which are of scientific nature rather than superstitious
and pious narrations.
In counselling the dying, a major hindrance, I think, is the level to which the
counsellor has dealt with the issue of his own death. People, who have not come to
grips with the issue of their own death, find it difficult to be comfortably present to a
dying person. This is certainly an area that the counsellor should be aware of. The
fact that we all die one day is certain, though we may not know the time. Therefore,
acceptance of our own death is a prerequisite to be helpful in responding to a dying
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person. He needs to be aware of his strengths and weaknesses in this regard and
accept his limitation gracefully in order to be of effective service to the dying person.
It has been found that if there is a team of professionals who are at the side of the
dying person, the work of the counsellor is made easy and also apt and adequate. He
has some people with whom he can hold consultations.
In my own pastoral experience I realized that working continuously without
interruption with depressing situations and people, I was less effective. Periodical
distancing from services to people in distress would enable us to be more effective,
fresh, energetic and insightful. The dying person wants the presence of an
understanding person to accompany him in his last journey; and counsellors are
called upon to accompany people as a pilgrim towards the destination called death.145
In brief, the duty of the counsellor is first of all to accept his own death as part
of life; to be honest with the dying person about the seriousness of the condition
because the dying person knows that he is dying; by not telling the truth we are
protecting ourselves from the news of death rather than protecting the dying person.
The counsellor should accept the feelings and ideas of the dying person and let the
dying person be responsible for himself in spite of his physical and psychological
limitations. Actually the dying persons have far more resources within themselves
than we think of.146
13. Counselling
Having seen what it is to die, let us turn our attention to what to do as
counsellors to the dying person while he is in the dying process.
If you are identifying in terms of stages, you could do the following:
When the patient is in the shock stage, your empathetic presence is all that is
important. You need to express more non-verbally than verbally, for, the patient is
not in a situation to pay attention to what you are saying since he is dazed and
stunned. Remaining too long in shock is not going to help the patient very much.
Slowly attempt should be made to make the person move to other stages.
After the shock, denial might follow or some emotional expressions may be
there. Facilitating emotional expression is an excellent way. The first stage is made
out from the non-movement of eyes and the fixed gaze. In the second stage of denial
you might notice the patient frantically searching for a favourable diagnosis. Instead
of proving to him that he is mistaken, patience and willingness to talk are important.
Here I advocate pacing, in the sense that you go along with the patient listening to all
his talk about the error in the diagnosis and going along with him for one or two extra
diagnoses may ease the situation. This I advocate because first of all the patient will
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be forced in a way to come to the realization and secondly to make sure that the
diagnosis is true.
When the patient is in the third stage of anger, let him express it the way he
wants, though it is unreasonable for the people around him. He may be directly
expressing it against the medical staff, family people, the people who he thinks are
responsible for his present condition, and God. As a cardinal rule, never return the
anger of the patient. Respecting his anger and remaining calm will contribute to his
passing on to the next stage. Here make sure that you do not get scandalized the way
the patient speaks against God and other good persons who might have been very
helpful. He does not do it wantonly but out of the necessity of a passing stage. You
need not take up the role of rescuing God from the abusive anger of the patient!
In the fourth stage of bargaining with God for a time of extension, instead of
brushing aside his futile bargaining attempt, listen to him patiently. One of my
friend’s father who was a widower had a severe heart attack. His son and daughterin-law were doing the best for him and made all arrangements for giving him medical
assistance immediately. In his despair though there was not much time element for
him to go through the supposed stages, he was pleading with his son and daughter-inlaw to save him so that he could look after their daughter. Actually his heart attack
was quite sudden and even in such cases the patients usually go through a stage of
bargaining.
In the fifth stage of depression, the patient needs to express his sorrow fully
and without any inhibition. That may not be the right time to reassure him and to
cheer him up.
In the last stage of acceptance, the person may not be angry or depressed but
remains quiet and expectant. Here the news of the outside world does not interest
him; there will be hardly any talk and your presence will be much appreciated.
We need to pay attention to the quality of life of the patient by letting him
maintain his security, self-confidence, and dignity. For those who are at the terminal
stage of their illness, physical comfort is a great necessity. Through adequate
medical assistance, care should be taken to give him maximum physical comfort.
Through the use of pain killers the patient’s physical pain can be alleviated. The
patient can also be taught if he is in a position to learn, to self-hypnotize and do some
relaxation exercises depending upon his physical condition and mental state. Above
all, love and affection should surround him more than anything else.147
14. Conclusion
Counselling the dying is the last and one of the best services the counsellor can
render to a dying person. With the ‘therapeutic thereness’ the counsellor helps the
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patient to die with dignity, courage and serenity. The dying person realizes that he
has a trustworthy, knowledgeable and able friend who accompanies him in his last
journey. Perhaps nothing will be more rewarding for the counsellor than the thought
that he has been facilitative to a dying person (at his death bed) to live his life fully
till the end.
11
COUNSELLING THE AIDS-AFFECTED
1. Introduction
AIDS is the abbreviated form for Acquired Immuno-Deficiency Syndrome, a
complex of diseases and symptoms resulting from immuno deficiency due to
infection by the human immuno deficiency virus (HIV). The letters A, I, D, and S
spell out the basic facts of the HIV infection. A – Acquired: It is an acquired
infection, meaning that people are not usually born with the problem, and even when
children are born with this problem they have acquired it from their mothers in their
womb. I – Immuno: The infection attacks the body’s immune system which is the
natural defence system, causing deficiency of operation. D – Deficiency: The
collapse of the immune system of the body causes the deficiency of operation with
the result that it leaves the body vulnerable to a host of ‘opportunistic infections.’ S –
Syndrome: The infection is recognized by the occurrence of one or several of a
group of diseases known collectively as Syndrome. Thus AIDS is the occurrence of a
disease suggestive of a defect in cell-mediated immunity occurring in a person with
no known cause for diminished immunity other than the presence of HIV. The HIV
virus attacks certain white blood cells called T-cells, and thus destroys a person’s
immune system. As a result we find that one can suffer from many diseases which a
person with a healthy immune system will normally reject. HIV infections take many
forms ranging from a complete absence of symptoms to mild illness, to debilitating
neurological disorders and fatal diseases. As the HIV infection progresses, it reaches
the tail-end stage manifesting itself as AIDS, often called ‘Frank AIDS’ or ‘Fullblown AIDS.’148
2. Development from HIV to AIDS
There are different stages and different rates of speed through which this
disease passes. Let us have a cursory view of its development.
1) HIV: Initial HIV Infection
Usually within a few weeks or even a few hours in some cases of the virus
entering the body, people experience something resembling influenza or glandular
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fever. This initial period is followed by a latent period lasting even many years
during which time the person feels all right and is capable of passing on this disease
to others.
2 ) PGL: Persistent Generalized Lymphadenopathy
In this second phase of development, there is a general swelling of the lymph
nodes or glands caused by the activity of the virus. These swellings are likely to last
for a long period, even unknown to the patient himself.
3 ) ARC: AIDS Related Complex
By the time the patient arrives at this third stage, his natural immune system is
so damaged that he has symptoms which are mild; but those symptoms are less
specific than the symptoms of the full-blown AIDS patient. There are fevers, severe
malaise, fatigue, night sweats, lethargy, excessive loss of weight, persistent diarrhoea,
and skin rashes.
4 ) ADC: AIDS Dementia Complex
When the patient reaches the fourth stage, the central nervous system along
with the brain is severely damaged since the virus has passed through the blood-brain
barrier which usually filters out substances in the blood that may damage the brain.
The virus crosses the blood-brain barrier and enters the brain besides having done
damage to the central nervous system. At this level the patient may suffer loss of
memory, confusion and may find it difficult to walk, requiring from now onwards
complete bodily rest.
5 ) AIDS: Full-Blown AIDS
The last stage is the indication of the complete collapse of the immune system.
By now, one life-threatening opportunistic infection or tumour would have attacked
the patient leaving the possibility of other opportunistic infections invading the
body.149
3. Common Infections due to AIDS
People affected by AIDS are vulnerable to a number of opportunistic infections
or cancers, and since their immune system cannot resist the infection the people
prematurely die. The common infections are :
1. Cryptococcal Meningitis which is caused by yeast like fungus. The symptoms
start with low grade fever, headache, nausea, vomiting and blurred vision.
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2. Central Nervous System Toxoplasmosis is caused by a protozoa which naturally
leads to encephalitis (inflammation of brain), characterized by seizure, fever,
headache and confusion.
3. Pneumocystis Carinii Pneumonia which is caused by a protozoa with the
symptoms of fever, cough, chills and shortness of breath causing life-threatening
respiratory failure.
4. Crypto Sporidiosis caused by a protozoa leading to debilitating diarrhoea lasting
for weeks and even months which is fatal.
5. Kaposi’s Sarcoma is a cancer of the blood vessels characterized by dark blue or
purple raised areas over the skin, often first appearing on the trunk and upper
extremities, ear and nose. The disease can affect internal organs and cause death.
6. Tuberculosis, infection with herpes simplex virus, and candidiasis causing white
painless lesions over mouth are also frequently seen.150
4. AIDS Test
Current screening tests do not directly diagnose AIDS. They just detect
antibodies to HIV in blood. The presence of antibodies usually means that a person
is infected with virus. If the test is positive, it signifies continuing infection. The test
that is used is ELISA, meaning enzyme-linked immuno-sorbent assay. Here an
electronic instrument measures colour changes in the serum when antibodies are
exposed to pieces of HIV.151 Let us see the test procedure in detail.
1) Diagnosis of HIV Infection
HIV tests are used to detect the presence of the human immunodeficiency virus
in serum, saliva, or urine. Such tests may detect HIV antibodies, antigens, or RNA.
The window period is the time from infection until a test can detect any change. Tests
used for the diagnosis of HIV infection in a particular person require a high degree of
both sensitivity (The percentage of the results that will be positive when HIV is
present) and specificity (The percentage of the results that will be negative when HIV
is not present). If antibodies are detected by an initial test based on the ELISA
method, then a second test using the Western blot procedure determines the size of
the antigens in the test kit binding to the antibodies. The combination of these two
methods is highly accurate.
2) ELISA Method
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The enzyme-linked immunosorbent assay (ELISA), or enzyme immunoassay
(EIA), was the first screening test commonly employed for HIV. It has a high
sensitivity.
In an ELISA test, a person's serum is diluted 400-fold and applied to a plate to
which HIV antigens have been attached. If antibodies to HIV are present in the
serum, they may bind to these HIV antigens. The plate is then washed to remove all
other components of the serum. A specially prepared "secondary antibody" — an
antibody that binds to human antibodies — is then applied to the plate, followed by
another wash. This secondary antibody is chemically linked in advance to an enzyme.
Thus the plate will contain enzyme in proportion to the amount of secondary antibody
bound to the plate. A substrate for the enzyme is applied, and catalysis by the enzyme
leads to a change in colour or fluorescence. ELISA results are reported as a number;
the most controversial aspect of this test is determining the "cut-off" point between a
positive and negative result.
3) Western Blot
Like the ELISA procedure, the western blot is an antibody detection test.
However, unlike the ELISA method, the viral proteins are separated first and
immobilized. In subsequent steps, the binding of serum antibodies to specific HIV
proteins is visualized.
Specifically, cells that may be HIV-infected are opened and the proteins within
are placed into a slab of gel, to which an electrical current is applied. Different
proteins will move with different velocities in this field, depending on their size,
while their electrical charge is levelled by a surfactant called sodium lauryl sulfate.
Some commercially prepared Western blot test kits contain the HIV proteins already
on a cellulose acetate strip. Once the proteins are well-separated, they are transferred
to a membrane and the procedure continues similar to an ELISA: the person's diluted
serum is applied to the membrane and antibodies in the serum may attach to some of
the HIV proteins. Antibodies which do not attach are washed away, and enzymelinked antibodies with the capability to attach to the person's antibodies determine to
which HIV proteins the person has antibodies.152
The first two strips are a negative and a positive control, respectively. The
others are actual tests.
5. The Means of HIV Transmission
The ways the virus is transmitted are:
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1) By vaginal intercourse, and anal intercourse (penetrative sexual practices). Among
sexual practices, receptive anal intercourse with an infected partner is very likely to
lead to infection. Since the mucosa lining of the rectum is delicate, it ruptures very
easily during anal intercourse. This, in fact, allows infected lymphocytes and virus in
semen to enter the tissues and bloodstreams of the receptive partner. The
transmission of virus during vaginal intercourse and the chances of infection
associated with a single act of intercourse with an infected person are not clear. It is
also not known whether the sexual practices like oral-genital contact and kissing
transmit the virus.
2) By transfusion of contaminated blood or blood product,
3) By sharing or re-using contaminated needles, razors and tooth brushes, and
4) During pregnancy, child birth and possibly breast feeding from mother to child.
AIDS is not highly contagious like measles but it requires intimate contact and
transfer through blood, semen and vaginal fluids. The incubation period, that is, the
time required for the HIV virus to develop into a full-blown AIDS may take even
seven to ten years during which time the one affected with this virus may not show
any symptom, but can infect others.153
The virus has been isolated in greatest concentrations in blood, semen and
cerebrospinal fluid; in lower concentrations in tears, saliva, breast milk, colostrums,
urine and vaginal secretions. Besides, it has also been isolated in brain tissues, lymph
nodes and bone marrow cells. The mode of transmission of this virus depends on 1)
Exposure to body fluids from an infected person, 2) Quantity of virus, 3) Route of
exposure, and 4) The duration of exposure. It is not precisely known how much of
virus and over what period of time are needed to cause infection, or what other
factors do affect the chances of infection.
6. Preventing Mother-to-Child Transmission of HIV
When a pregnant HIV-infected woman receives good medical care early and
takes antiviral medications regularly during her pregnancy, the chance that she will
pass HIV to her unborn baby is dramatically reduced. The sooner a mother receives
treatment, the greater the likelihood her baby will not get HIV.
An HIV-infected mother can receive medical treatment: 1) Before the birth of
her baby: antiviral treatments given to the mother in the third trimester can help
prevent HIV transmission to the baby. 2) At the time of birth: antiviral medications
can be given to both the mother and the newborn to lower the risk of HIV
transmission that can occur during the birth process (which exposes the newborn to
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the mother's blood and fluids); in addition, the mother will be encouraged to formulafeed rather than breastfeed because HIV can be transmitted to her baby through breast
milk. 3) During breastfeeding: In places where formula-feed is not readily available,
both the mother and the child can be treated with medication to lower the baby's risk
of HIV infection.
Recent studies have shown that mothers with HIV or AIDS who get good
prenatal care and regularly take antiviral drugs during their pregnancy now have less
than a 5% chance of passing HIV to their babies. If these babies do get the HIV virus,
they tend to be born with a lower viral load (less HIV virus is present in their bodies)
and have a better chance of long-term, disease-free survival.154
7. Harmless Associations
1. Casual contacts: shaking hands, touching, hugging, dry kissing, sharing a bed or
bed linen, travelling together, living together, and working with.
2. Sneezing, coughing, sharing food, bites by mosquitoes, flies and other insects.
It is not an airborne disease nor is it a communicable disease like common cold,
influenza, measles or polio viruses.
3. Using glasses, knives, cups, forks, spoons, cooking utensils, toilet seats,
swimming pools and showers.
4. Inanimate objects like books, pens and pencils being shared.155
8. Psychological Reactions to AIDS:
1) AFRAIDS
AFRAIDS is a new term used to indicate Acute Fear Regarding AIDS. There
is a general dread about AIDS, more than the ravages of the disease itself. AFRAIDS
affects both the patient and those who are with him; and even those who are in
remote possibility of contracting the disease (but terribly caught up in the fear of
AIDS.) Therefore, counselling should aim at people who are suffering from
AFRAIDS which include both the patients of AIDS and those who are mortally afraid
of it.
2) Fears & Anxieties
The AIDS patients and those who are afraid of AIDS have the following fears
and anxieties:
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1)
Losing their partner, families, friends, and colleagues through the fear of
sexual contact, of infecting others and of being infected by others.
2)
Of rejection and humiliation.
3)
Of being disabled and physically disfigured.
4)
Of losing control of one’s mind and of one’s life itself.
5)
Of being known as a person dying of AIDS.
6)
Of being denied medical and dental treatment and life insurance facilities.
7)
Of losing one’s job, promotion, and accommodation. As a result of the fears
and anxieties, depression sets in, with anger against others and against self;
often the patient thinks of suicide.156
9. Behavioural Reactions to AIDS
The reaction of the persons with HIV infection is practically the same as that of
any patient with a terminal illness, starting with the denial (as Dr. Elizabeth KublerRoss has postulated regarding the persons with terminal illness). I would like to draw
the attention of the reader to one particular phenomenon especially during the denial
period. This denial mechanism helps the person not to be panicky about the illness at
least for sometime till he is able to face the reality. In a way this denial is made use
of by the sick person to adjust himself interiorly to the new inevitable development in
his life that robs him of his independence, control, and future. But some may employ
it to cover their hostile and destructive impulses, which is dangerous to the society of
which perhaps later they will have remorse. Such persons will recklessly engage in
sexual activities with many partners without the least regard to the consequences of
their indiscriminate activities. They are bent on infecting as many persons as
possible with an attitude of revenge because they themselves have been deprived of
life and they got this life-threatening illness from others. Such persons do not seek
the assistance from the professional people, nor will they respond positively for their
own good if professional people offer them assistance. It is also a known fact that
there are men who go to commercial sex workers and dare to approach women with
HIV infection even against strong protest.157
10. Counselling
Counsellors propose that we use a different language in referring to AIDS than
the one we are using currently.
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1. Instead of talking about AIDS, we could speak of HIV infection because many
who have been infected with HIV have not yet moved into the full-blown AIDS.
2. Instead of talking about persons ‘dying of’ this viral infection we could speak of
‘living with’ this infection.
3. Instead of saying ‘terminal illness’ we could speak of ‘life-threatening illness’
since the term ‘terminal’ speaks of the sickness in terms of finality without any hope
which betrays our attitude towards this illness and death itself. We need to keep in
mind that no one dies of AIDS, but people die because of the depressed immune
system which is vulnerable to opportunistic infections.
4. Instead of speaking about ‘risk group’ we could speak of ‘risk activities’ since all
the sexually active persons are ‘at risk.’158
For dealing with the AIDS patients, draw from the procedures proposed for
Counselling The Sick and Counselling The Dying. The AIDS patient usually goes
through all the trauma of a dying person in ordinary circumstances, and hence
whatever skills of counselling we make use of for the dying person are really
applicable to the AIDS patients too.
11. Conclusion
There is a grave danger to public health and life by the spread of AIDS.
Because of the biological make-up and sociological encumbrances, women are more
vulnerable to AIDS though it is mostly promiscuous men who carry the disease from
one person to another. Because of the secondary role woman plays in society, she is
not even bold enough to ask her husband to use condom, even when she knows he is
carrying the dreadful disease. Some youth even openly declare that in their miserable
lives, sex is the only solace and how can one abstain from it fearing AIDS when the
offer comes.
On the other hand, we find that people in helping profession and even others
have a lot of misgiving as to the nature and transmission of HIV virus and out of fear
are reluctant to be of service to the AIDS-affected patients.
This being the case, the counsellors cannot exclude anybody from their
counselling service. Like the terminal cases, the AIDS patients are to be attended to,
so that they are able to cope with the declining health, social stigma with isolation
and psychological depression. Finding a support group for the AIDS-affected will be
immensely beneficial.
12
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COUNSELLING T H E S U I C I D A L
1. Introduction
Suicide is a social phenomenon in every culture. We find this in every country
and no society is exempt from this phenomenon. The vast majority of people who
commit suicide are quite ambivalent about ending their lives. They make the fatal
choice when they are alone and in a state of severe psychological stress; they are
unable to see their problems objectively and are not in a position to evaluate
alternative courses of action.
2. Global Epidemiology of Suicide
In 1998, the World Health Organization ranked suicide as the twelfth leading
cause of death worldwide. In most countries the incidence of suicides is higher than
the incidence of intentional homicides.
1) Male-Female Suicide Ratio
On the whole the suicide rate of male is higher than that of the female in the
world with the exception of China and India where the suicide rates of women are
higher. In India suicide rates for women are nearly three times higher than those for
men. In Western countries men commit suicide at four times the rate of women. In
general women are more likely to attempt suicide than men (that is, more men
succeed in executing the suicide than women).
2) Age-wise Rate of Suicide
Currently, more suicides (55%) are committed by people aged 5-44 years than by
people aged 45 years and older. The age group in which most suicides are currently
completed is 35-44 years for both men and women.
3) Religious Implication of Suicide
No.
Religious Denomination
Suicide Rate
Per
1
In Muslim Countries (e.g. Kuwait)
100,000 Population
2
3
4
5
In Hindu (e.g. India) Countries
In Christian Countries (e.g. Italy)
In Buddhist Countries (e.g. Japan)
In Atheist Countries (e.g. China)
and the countries where religious
observance had been prohibited
0.1
(close to zero)
9.6
11.2
17.9
100,000 Population
100,000 Population
100,000 Population
25.6
100,000 Population
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for a long period (e.g. Albania)
The statistics gives us an astonishing correlation between religious affiliation and
the suicide rate. It looks like that greater the religious affiliation, the lower the suicide
rate. It appears that for healthy living, one needs to have a certain strong religious
affiliation to buttress one during the time of stress. To this I shall also add a support
system. Those who are able to lean on a support system of any kind can endure stress
more than people who do not have any significant one.
4) Country-wise Suicide Rate
Suicide rates are highest in Europe’s Baltic (Estonian, Lativian, Lithuanian and
Russian) States, where around 40 people per 100,000 die by suicide each year.
Second in line is in the Sub-Saharan Africa (those African countries which are fully
or partially located south of Sahara) where 32 people per 100,000 die by suicide each
year. The lowest rate is found mainly in Latin America and a few countries in Asia.
Up to at least the 1950s it was the Republic of Ireland which had the lowest suicide
rate in the world.
5) Causes of Suicide
Over 90 percent of people who die by suicide have a mental illness at the time
of their death. And the most common mental illness is depression. Therefore,
untreated depression is the number one cause for suicide. By untreated mental illness
what is primarily understood are bipolar disorder, schizophrenia and others.
Some people who are genetically predisposed to depression, and thus may not
appear to be undergoing any negative life experiences, yet become depressed, and
may die by suicide. Thus some people die by suicide because of a depression that was
genetically caused.
Suicide contagion is a serious problem, especially for young people. Suicide
can be facilitated in vulnerable teens by exposure to real or fictional accounts of
suicide, including media coverage of suicide, such as intensive reporting of the
suicide of a celebrity or idol.
It is rather rare that someone dies by suicide because of one cause. Therefore,
usually there are several causes for suicide. Many people die by suicide because
depression is triggered by several negative life experiences, and the person may not
have received effective treatment.
Some of the negative life experiences that may cause depression, and some
other causes for depression, include: 1) the death of a loved one, 2) a divorce,
separation, or breakup of a relationship, 3) losing custody of children, or feeling that
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a child custody decision is not fair, 4) a serious loss, such as a loss of a job, house, or
money, 5) a serious illness, 6) a terminal illness, 7) a serious accident, 8) chronic
physical pain, 9) intense emotional pain, 10) loss of hope, 11) being victimized
(domestic violence, rape, assault), 12) a loved one being victimized (child murder,
child molestation, kidnapping, murder, rape, assault), 13) physical abuse, 14) verbal
abuse, 15) sexual abuse, 16) unresolved abuse (of any kind) from the past, 16) feeling
‘trapped’ in a situation perceived as negative, 17) feeling that things will never ‘get
better,’ 18) feeling helpless, 19) serious legal problems, such as criminal prosecution
or incarceration, 20) feeling ‘taken advantage of,’ 21) inability to deal with a
perceived ‘humiliating’ situation, 22) inability to deal with a perceived ‘failure,’ 23)
alcohol abuse, 24) drug abuse, 25) a feeling of not being accepted by family, friends,
or society, 26) a horrible disappointment, 27) bullying (including ragging in
professional colleges), and 28) low self-esteem.159
3. Indian Scenario
When we take the incidence of suicide, it seems that every twelve minutes we
have one suicide in India. And state-wise, Kerala ranks the highest; Tamil Nadu and
West Bengal coming next, and the last is Jammu and Kashmir.
If we look into the causes and percentages of suicide in India, according to the
statistics in 1994 by National Crime Records Bureau (as reported by India Today,
June 30, 1996), they are: Debilitating illness — 13.5%, quarrel with spouse — 5.8%,
failed affairs — 5.8%, quarrel with parents-in-law — 4.9%, insanity — 3.5%,
poverty — 2.2%, property-related dispute — 2.2%, failure in examination — 2.1%,
dowry dispute — 1.9%, bankruptcy — 1.7%, death of a dear person — 1.6%,
unemployment — 1.5%, fall in social reputation — 1.4% and unclear causes —
51.9%. The order of causes and their percentages were slightly different a few years
back.160
4. Suicide Potentiality
According to the research done with regard to the people who are prone to
commit suicide, the findings are:161
1) Sex and Age
In India, age-wise younger people commit suicide more than the elders; and
the female commit suicide more than the male.
2) Symptoms
People who are depressed over a long period of time, and those feeling
hopeless and those who are alcoholics or drug dependent tend to commit suicide.
3) Stress
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When we analyse the stress factors, loss of loved ones through death or
divorce, loss of employment, serious illness and increased responsibilities seem to
cause suicide. Stress factors in suicide are:
(1) Interpersonal Crisis
Interpersonal conflicts could be in marriage, or resulting from separation,
divorce or loss of loved ones. There is frustration and hostility over feeling rejected,
coupled with a desire for revenge and a desire to withdraw from the relationship that
is hurtful. If the individual had been very much dependent upon the person who died,
suicide can happen.
(2) Failure and Self-devaluation
When occupational aspirations and the desired accomplishments are frustrated,
people tend to commit suicide.
(3) Inner Conflict
The intrapersonal difficulties may be the cause of some people committing
suicide. The inner struggle is too much for them to bear, and there is no homeostasis
of internal balance in their system, and so they may commit suicide.
(4) Loss of Meaning and Hope
In the concentration camp Victor Frankl noticed that the people, who did not have
anything to live for, committed suicide. Hope usually gives meaning to life; and
when hope is lost, meaning too disappears with it. The end result is suicide.
4) Suicidal Plan
If the proposed plan is lethal, and the plans and means are thought-out in detail,
the potentiality is higher than when the individual has not thought of the method of
committing suicide.
5) Resources
When individuals do not have a family, or friends or a support group to relate
to, then they are potential candidates for suicide.
6) Prior Attempt
The individuals who have attempted suicide earlier and had not resolved their
problems since then, remain to execute their suicidal plan one day or other, especially
if they are also depressed and express repeated threats.
7) Medical Status
Since one of the chief causes of suicide is despair over dreadful disease, people
with a history of a number of treatments with little recovery are prone to commit
suicide.
8) Communication
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When communication and rapport with the support group, such as family, is
broken off and any attempt by the individual has been turned down, then the person is
a potential candidate for suicide.
9) Reaction of Significant Others
If the persons whom the individual considers as significant and important and
whose love, acceptance and support he needs most, reject him or have punishing
attitude, the individual is driven to despair and may commit suicide.
10) Acute & Chronic Aspects
When the symptoms are sudden or when there is a sudden increase in the longstanding maladaptive traits then suicide is an alternative the individuals may choose.
5. Sociocultural Factors162
The French sociologist Emile Durkheim studied the sociocultural factors of the
phenomenon of suicide and related it to group cohesiveness. People who are wellknit in a supportive social group are less likely to commit suicide, compared to
people who are not integrated into any such group. That is why, we find people not
belonging to any religious group or even recreational group, and remain single or
divorced, are likely to commit suicide.
Durkheim’s findings, along with
psychological factors, add meaning to the understanding of suicide.
6. Clues to Understand Suicide163
There are a number of clues to understand suicide and not all of them may be
seen in any particular individual. We may find some of them in clusters in
individuals committing suicide.
1) Verbal Clues
People directly might say that they want to end their lives in which case it is a
direct verbal clue; but when one says that this is the last time that he is seeing you, he
may be giving indirect clues to his suicide. Verbal clues abound in suicide incidents.
Perhaps since those clues are not picked up or not seriously heeded to, suicide occurs.
2) Behavioural Clues
When there is a marked difference in the behaviour of the individual it may be an
indication of a suicide coupled perhaps with other factors. A person settling his
accounts, calling all his children and seeing them, performing some unusual religious
duties formerly unheard of in his life are all examples of behavioural clues. I know a
student in a college who prior to committing suicide went about setting his room in
order quite unusually for he was known to be very clumsy and dirty with regard to
personal hygiene. He was giving a behavioural clue to his intended suicide.
3) Situational Clues
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Here we can cite examples of people who meet failures in life, love affairs and in
exams. Domestic quarrel and chronic physical illness also are situational clues.
4) Descriptive Clues
It refers to the type of person one is. If a person is severely depressed he is in
danger of committing suicide. If a person formerly attempted suicide and later did
not solve his problem, he is likely to end his life. I know a suicidal case that had
deep-rooted problems which could not be easily solved and after attempting suicide a
number of times, finally succeeded in doing it. By experience I also realize that if
suicide runs in the family, the individual will contemplate on suicide as a way of
escaping from difficulties since that was the pattern he might have observed in his
home situation of persons who took a shortcut to solve their problems. Therefore, I
would also enquire if anybody in his family committed suicide and by what method
and how this particular individual took that suicide.
5) Symptomatic Clues
This refers ultimately to the type of personality one is. According to the
strength of the personality, one faces crisis healthily or unhealthily. There are some
who are known to handle crisis badly while others can do it better. Suicide is an
unhealthy way of coping with a stressful situation. People known for their unhealthy
ways of coping with reality may take to suicide.
6) Resource Clues
As social beings we need the support of a number of people for our healthy
living. If one is deprived of parents, family, friends, supportive groups, and religious
groups, one is a loner. Since the resources of social dimension are wanting, he is
vulnerable to suicide.
7) Cultural Clues
In certain cultures it looks like a fashion to take to suicide even for trivial
matters, like: mother scolding her daughter, school teacher mildly punishing a pupil,
a boy in the middle school writing a love letter to his classmate, and the like. The
same incidents are overlooked in some cultures but in certain cultures these are
suicide-provoking agents.
7. Suicide among the Youth
In India more young people commit suicide compared to Europe where the
elders commit suicide more than the youngsters. But slowly the picture is getting
changed in Europe also in the sense that there is a steady increase in the suicide of
teen-agers. In India the incidence of suicide among under 30’s is becoming
alarmingly high. Psychiatrists are of the opinion that a major reason for this is the
country’s educational system, which is failing to equip youngsters to cope with the
challenges of growing up. Children have a come-easy attitude on account of the
improved living standards with the result of developing a low frustration-tolerance
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level. And so when they meet with failures or frustration or stress they easily give up
and take to suicide.
1) Precipitants of Suicide
The frequent precipitants and events preceding adolescent suicide are:164 1)
Arguments between parents, 2) Arguments with parents, 3) Loss of a parent, 4)
Divorce of parents, 5) Break-up of close relationship, 6) Failing grades, 7) Loss of
interest in usual activities and 8) Complaints of boredom.
2 ) Predisposing Conditions165
1) Depression — Being severely depressed most of the time.
2)
Victimization — Complaints of being misunderstood, and unfairly punished or
alienated. 3) Loss — Real or imagined loss of a loved one, education, social or
economic opportunities, and parents. Parental absence and parental unemployment
seem to be highly influencing an adolescent to suicide. 4) Increasing Pressure —
Overwhelming environmental pressures like family problems, failure in securing
good grades, and rejection from a group may be too much for an adolescent to cope
with. 5) Increasing Emotional Instability — It may be due to the total personalpsychological disintegration that an adolescent commits suicide.
3) Warning Clues to Suicide166
1) Any sudden change in usual behaviour, 2) Withdrawal from family and
friends, 3) Giving away cherished possessions, 4) Severe changes in eating habits,
5) Preoccupation with physical symptoms, 6) Neglect of personal appearance, 7)
Changes in personality like being sullen, aggressive and defiant, 8) Change in the
type of friends, 9) Use of drugs and or alcohol, 10) Sexual promiscuity, 11)
Changes in mood with withdrawal, loneliness and isolation. 12) Preoccupation with
death in thoughts, letters, drawings and scribbles, 13) Signs of depression, 14) Loss
(death in the family), 15) Dissolution of social relationship, 16) Expressing feelings
of helplessness, hopelessness, loneliness, isolation and alienation, 17) Increased
impulsivity, 18) Recent experience with the suicide of another and 19) Setting their
room and bookshelf in order.
8. Suicide among Young Married Women
The phenomenon of young married women committing suicide attracts the
attention of the sociologists. The woman who was well adjusted before her marriage
in her parental home, all of a sudden decides to end her life in the husband’s family.
The reasons are many and complex.
1) Dowry Harassment
Dowry harassment seems to be the main cause of suicide among the young
married women. The husband or in-laws or both in most cases are known to be
responsible for this harassment. Suicide in such cases becomes inevitable if the
situation of the parental home of the woman is depressed economically, being unable
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to meet the level of the dowry demand or unwilling to oblige the bridegroom’s
demand.
2) Husband’s Attitude
If the husband is already having some love affairs with other women and on
account of it she is rejected or ill-treated, this provokes the woman to commit suicide.
Since the husband is the only source of dependence in her new home, she is left
vulnerable to all sorts of harassment on account of his rejection. Psychiatrists say
that women increasingly are unwilling to conform to the traditional image of a doting
wife devoted to bringing up the family. They in fact demand quality time and
equality from their husbands, which when not given make the women lonely and
dejected, thus paving the way for suicide.
3) In-laws problem
It is not uncommon that the in-laws mistreat the women. Here the mother-inlaw is more to blame in most of the cases, and next come the sisters-in-law (the
sisters of the husband) either unmarried or not living with their husbands. Quarrels
and disputes mostly on account of dowry lead a young woman to suicide.
4) Personality Factors
Girls who are very protectively brought up in their parental homes and had not
been exposed to the hardships of life and those who have not sufficiently developed
independence with regard to their personality are prone candidates who may take to
suicide on least provocation.
9. Suicidal Intent or Motivation167
The motivation of the suicidal person is very complex. Actually suicide is one
way of obtaining relief from an unbearable situation. Depression seems to play a key
role in suicide for about three-fourths of persons who commit suicide are usually
found depressed before and during suicide. It is seen that those who are emotionally
engulfed have a lowered use of rationality. With regard to intent, psychologists
group people of suicidal tendency into three categories for the sake of understanding
though this grouping may not have practical utility.
1) ‘To be’ Group
The ‘to be’ group does not really wish to die but only makes use of this means
as a medium of communicating their distress and their wish that they would like to be
helped. They adopt methods that are not lethal and somehow intervention could reach
them before it is too late. For example, they may take some sedation the quantity of
which is not too much to cause death or take poison to create a scene. This group
usually responds to intervention though with some ado.
2) ‘Not to be’ Group
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These people seem to be intent on dying by all means. They are not
known to give enough warning and when they do execute their suicidal intent they
arrange it in such a way that no intervention could reach them. Sometimes they make
use of violent methods that will ensure their sure death as for example jumping from
high buildings or mountains or falling on the rail track. Some medical personnel take
a lethal injection and pretend to be going to bed and end their lives so that no one
suspects their suicidal attempt.
3) ‘To be or not to be’ Group
This group is an ambivalent type that is neither sure of living nor of
dying. This group seems to constitute 30% of the suicide population. They seem to
leave their death to chance. Though the method used by them is lethal, they see that
it does not in fact kill them or at least a slow death is maintained so that they could
get help.
10. Communication of Suicidal Intent
People in fact communicate their suicidal intention either directly or indirectly.
The belief that the people who threaten to kill themselves will not do it, is not
supported by evidence. When people threaten and yet not kill themselves, it only
indicates the ambivalence in their attitude and how they wish to be saved. It might
happen over a long time and when no adequate help is given, they execute their
threat. When people reach near-hopelessness, they may still believe that something
would turn up and they will be better off; and when that fails they take the extreme
step.
11. Suicide Notes168
Analysing the suicidal notes of many individuals, graphologists have come to
the conclusion that it has to do something with the crashing as they physically do
with their lives. The handwriting could be straight for the most part and suddenly one
or two lines crash down on the right margin. A person may be having a descending
baseline but may not have a suicidal ideation. On the contrary, a person may have a
straight baseline but may have a suicidal ideation which is betrayed by the crashing
of the last words on the right margin. This is a scientific inference. This information
is from the point of view of graphology.
Roughly about 24% of the suicides leave notes either mailed or kept on their
person or near the suicide scene. The affect of the suicidal notes are either negative
or positive, or mixed.
1) Positive Notes
About half of the suicidal population that is 51% leaves a positive note
expressing affection, gratitude and concern for others.
2) Negative Notes
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Very small percentage of the suicidal population, say about 6% leave a
negative note expressing hatred towards others.
3) Neutral Notes
Elderly people who do not find meaning in their lives and want a decent exit
from this world leave a neutral type of note addressing it as ‘To whomsoever it may
concern.’ This group of people is about 25% of the suicidal people.
4) Mixed Notes
It contains a combination of both positive and negative emotions. This is
roughly about 18% of the suicidal people.
12. Counselling
1) Empathetic Listening
When people with suicidal intent come to me for counselling, I first listen to
their stories empathetically. As they talk, the factors that make them think of suicide
may become evident. A little probing into the family history of suicide, if any, and
previous attempts, is all helpful.
2) Assessing Suicidal Danger
Getting to know the means the person has contemplated to end his life has to
be assessed. If the means are lethal and the plans are well thought-out, the possibility
of suicide is very high otherwise it may not be that dangerous. All the same taking
the suicidal intent seriously is a must, for, many tend to take the suicidal threat as
mere threats without serious intention to execute it. This very attitude, and at times
remark to this effect, might precipitate the individuals contemplating suicide to go
ahead with its execution.
3) Distancing from the Means
People adopt different means for suicide. According to the statistics, in 1994,
by the National Crime Records Bureau (as reported by India Today, June 30, 1996)
the means adopted for suicide (in percentage) is as follows: poison – 34.8%, hanging
– 23.4%, burning – 11.5%, drowning – 9.4%, jumping before train – 3.9%, jumping
from heights – 1.2%, touching electric wire – 0.9%, sharp instruments – 0.8%, taking
sleeping pills – 0.7%, firearms – 0.7% and other means -12.7%.
If certain means are already obtained like poison or a quantity of sleeping tablets, I
ask the person to hand over to me those deadly means, promising to let the person
have them after the counselling. This is to remove the possibility of suicide. The
client is not going to ask for the deadly poison from you after the counselling. This is
a smooth way of dealing with people who have the means of suicide in hand.
4) Non-Suicidal Contract with Pacing
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Before any counselling proper could start, I induce the person to make a nonsuicidal contract with me in the following manner: “I am sure you are dead serious
about ending your life. If I were to spend my time with you talking, I would
appreciate that you promise to me that you will not commit suicide either consciously
or unconsciously till the counselling is over (or till one day or two days depending
upon the situation) and get the help needed. Once the contract expires you are free to
go ahead with your plan of committing suicide.” This way of talking, first of all gives
the client freedom and he does not feel obliged or constrained. This in a way is
pacing in counselling since I go along with the client. Though some may not be
willing to make a contract most people oblige and even in the unwilling cases, for a
short duration they will not make much fuss.
Let the person himself fix the time limit of his contract. By now I will have
bought some time to delay the execution of suicide. Some may wonder why I should
ask the person even unconsciously he should not attempt suicide. For, I do believe
that what appears as accidents especially of the people who had attempted suicide and
whose problems are not yet solved, in all likelihood might be a suicide though it may
not be so apparent.
5) Preventing Imminent Attempt
In case the suicidal attempt is imminent, I do not hesitate to prevent it even
physically and foil the attempt. Here it is not a question of disrespect for the decision
of the individual, but an active concern of respect for his life, since I value life. I
think that every counsellor values life and that is why he takes to the profession of
counselling; people who come to us know our ethics with regard to life.
6) Dealing with underlying Issues
By now the ground work is over and the counselling starts may be followed by
some therapies depending upon the situation and the type of problems presented.
13. Conclusion
Suicide is a scandal in a world that glorifies life. When a suicide occurs, all the
survivors, including the counsellors who dealt with the dead person, mourn the death,
in a way feeling guilty or helpless. For any other type of problem, the counsellor can
defer his service to a later time, but in the case of suicide, any delay will mean death.
Therefore, as counsellors, we need to give top priority to suicidal persons.
Counselling is worth only when life is there and not when it is taken away. Society
has to be brought to the awareness of the causes of suicide and the detection of the
warning cues so that it can act promptly to prevent such drastic life threatening steps.
On the other hand, the suicidal individuals need to be strengthened with the
awareness of the resources they have for standing on their own, in spite of the
depressing scenarios around them.
13
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COUNSELLING THE BEREAVED
1. Introduction
The nature of grief or bereavement can be seen in the context of attachment
and separation. It is intrinsically connected to these concepts. Before we were born
we were attached to our mothers. That was a total dependency for survival. At birth,
the attachment was snapped and we became separate and we lost forever the
attachment we had in the womb. While being born, we experience loss. Grief is a
reaction to a loss. Grief is a cluster of ordinary human emotions in response to a
significant loss, intensified by the relationship to the lost person or object. Therefore,
the origin of grief can be located at the moment of birth. There is no life without
attachment and no attachment without separation and there is no loss without
separation.169
Bereavement comes from the word ‘reave’ which means ‘to be dispossessed’
as though robbed of something belonging to the person. We moan for a number of
things not necessarily for the dead persons. Of course in the case of a death, it is very
dramatic but in most cases it is subtle and yet certain. There are incidents of rape,
chronic illness, break-up of a love affair, birth of a defective child, loss of personal
belongings in a fire or flood or earthquake or robbery, loss of a job, loss of a
relationship, loss of a limb, loss of finance, loss of face, loss of status and role, loss of
a dream or a set goal of personal choice, a major geographical move leaving behind
one’s friends and relatives and leaving behind a stage of our development
(developmental losses) in our growth. All of them indicate that something has been
lost and in most cases they are lost irrevocably.170
2. Stages and Psychological Implications of the Funeral
Though bereavement can be a reaction to any loss, in this chapter we
concentrate on the reaction to the death of a loved one. The process of bereavement
starts immediately after the death of the loved one and in the case of a prolonged
illness, some time before the death itself. The funeral ceremonies are in a way means
to deal with the bereavement process though they are primarily meant to consign the
dead body to the earth or flames. Let us consider the funeral with its implications for
the bereavement.
Funeral is an organized response to the event of death involving certain rites
and ceremonies and placing of the body into a resting place by burial or cremation.
In fact funeral is a multidimensional experience for the survivors.
However Raether has identified five stages in the funeral.
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1) Separation
The dead body is separated from the living. In some cultures it is done to
make the necessary arrangements and in some cultures the dead body is given a bath
and for which purpose the body is temporarily separated. In some cultures the body
is immediately taken to the mortuary.
2) Visitation
The deceased is placed in state for the visitors to condole the family members.
3) Funeral rite
A leader either religious (in 75% of the cases) or lay (in 25% of the cases)
officiates the funeral rite.
4) Procession
Psychologically it is believed that the definiteness of the separation is finally
accepted in a gradual way.
5) Consigning
Consigning means committing the body to its final resting place by burial or
cremation hoping that the dead returns to the creator; the humanists may think that
the dead person returns to the cyclical nature of life and death to start another
beginning. If the body is cremated, the ashes are ceremoniously immersed in a
river.171
3. Nature of Loss
1) Avoidable and Unavoidable Loss
For example the stage we leave behind by aging is an unavoidable loss. When
I felt discomfort for the first time in reading, I consulted an oculist. He said that I
should wear glasses; I asked him if he could cure me with medication and spare me
the trouble of using glasses. He looked straight into my eyes and asked me if there is
any medicine for aging. The message went home deep in me that the freedom I
hitherto enjoyed is gone and now starts the burden of wearing the glasses. The
freedom I lost is unavoidable. Avoidable losses are those which result on account of
a particular life-style chosen. A nurse leaves her profession and becomes a teacher in
a school. The loss she endures of the former profession of a nurse is an avoidable
loss.
2) Temporary and Permanent Loss
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Couples who are separated on account of misunderstanding and yet have love
for one another is an example of temporary loss. The possibility of reuniting one day
remains open whereas a wife losing her spouse in accident is a permanent loss.
3) Actual and Imagined Loss
A woman complaining that her husband abandoned her may be actual or
imagined depending upon the veracity of the fact of abandonment.
4) Anticipated and Unanticipated Loss
When we lose our loved ones, say, by sudden heart attack, it is unanticipated
loss but if we lose our loved ones after a prolonged illness it is anticipated loss; in the
anticipated loss much of the mourning is done even before the person dies and most
of the unfinished business is taken care of.
4. Types of Losses
The losses human beings experience can be grouped under six headings.172
The types of losses we will enumerate below may be found singly in an individual or
they may be clustered in an individual.
1) Material Loss
Material loss can be described as the loss of a physical object or even the
familiar surroundings to which one is significantly attached. Objects to which we are
attached may have intrinsic value in themselves or an extrinsic value like the gift
given by a friend. The fact that the gift has a special significance because it was
given by a close friend is an extrinsic value that was not in the object but the value
we invest in it. When a material object cannot be replaced then our grief is great.
The loss of a pet too provokes grief since we treat our pets as quasi-humans.
Rabindranath Tagore was a shy person as a child. When his father’s house was filled
with lots of visitors and guests, this shy boy used to seek a favourite spot of
loneliness and found the abandoned palanquin in which he used to hide himself for
privacy. That was his favourite spot. When hurt or wounded he would retire into his
world of the palanquin. Likewise we too cherish some spots at home or in our
neighbourhood and leaving them behind is a matter of grief. I remember in my own
life when I nurtured a few saplings in the courtyard. They were growing well as they
were meant to be shady trees. When I was transferred from there to another place, I
used to keep enquiring about those trees for I used to spend a lot of time in caring for
them as I would care for a child.
2) Relationship Loss
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It is connected to relationship with other human beings. It is the cessation of
opportunities to relate oneself to, make love to, have sex with, share experience with,
talk to, touch, fight with, settle issue with and be in the emotional and physical
presence of another human being. Relationship losses can be temporary or
permanent. Sometimes what is lost in the relationship may not amount to anything
but the fact that a possibility is lost is of significance. A young girl lost her mother
who had been a psychotic patient ever since the girl was born. This girl was wanting
in her mother’s care and concern. Yet when the lady died, the girl was inconsolable
because she said that the possibility of relating to her mother was lost though the
relationship did not enhance the life of the girl a bit.
3) Intrapsychic Loss
Material losses and relationship losses are experienced even by a child. But
intrapsychic loss occurs at the stage of adolescence when it is perceived for the first
time by an awareness of the self in a new way after puberty. This basic awareness of
the self extends to other areas too in adult life. Thus intrapsychic loss means the
experience of losing an emotionally important image of oneself, losing the possibility
of what one could have been, by abandoning particular course of actions or plans for
a chosen future, and the dying of a cherished dream for oneself. When we lose a
secret, a hope, a dream, faith, courage, and our grip we in fact experience
intrapsychic loss. Intrapsychic loss is also experienced on completing an important
task wondering what else is still there to do.
4) Functional Loss
It is losing some of the muscular or neurological functions of the body.
Usually functional losses go along with aging. Whether it happens in old age or in
young age it does matter and the psychological pain could be just the same.
Functional loss means, loss of autonomy to manage things by oneself. The loss of
autonomy on account of functional loss is more painful in some cases than the
functional loss itself; when others make comments even positive about the
compensation, the person becomes angry and touchy. I know a smart and handsome
person whose friends complimented on his dyed black hair. He was furious. His
reaction of anger is a bereaving process of his lost black hair.
5) Role Loss
It is the loss of a role one has been playing in the intricate social network.
Depending upon how much one was identified with a particular role that is lost, the
pain will be great. Our personal identities are influenced by the job we do and the
role we play. If a role is lost, our self-identity too is shaken at the very foundation.
As a result one may experience disorientation not knowing how to behave in social
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situations. Retirement is an instance of role loss; likewise being promoted to a higher
level, one loses one’s former freedom and friends; a single person marrying, a
married person losing his spouse, an elderly person assuming the role of a student for
the sake of a degree in a university, being admitted to a hospital for treatment
assuming the role of a patient and losing one’s role as a father, mother etc. are all
examples of role loss.
6) Systemic Loss
We all belong to some interactional systems in which to keep the homeostasis
we maintain certain types of behaviour patterns of relating. Any change by way of
any member leaving or someone entering in shifts the balance and the former
homeostasis is changed and a new homeostasis has to be developed. The loss of the
former homeostasis in the interactional system is called systemic loss. In a joint
family the daughter is given in marriage and leaves the house for her husband’s
house, the son marries and brings in the daughter-in-law and these will cause
systemic loss in the family circle.
5. Emotional Reaction to a Loss
Whatever be the loss, the individuals more or less follow a set-pattern
discernible not necessarily in the same order, at times overlapping with one another
and in some cases spending enormous time for one particular stage more than in any
other stage. Here I would like to add a note of caution in the sense that we need not
try to fit persons into the stages but rather be present with the person as he
experiences his bereavement reaction.
1) Modelled on Elizabeth Kubler-Ross’ Stage Theory
(1) Shock
There is first of all a shock experienced by the survivor. This is the absence of
any emotional expression. The person remains stunned so much so that people
around him begin to wonder whether the person feels the loss at all. In fact the
person has felt so much loss that to avoid greater danger to the personality and wellbeing of the person his own mental mechanism has devised this shock to spare him
from grave danger.
(2) Denial or Disbelief
Close on the heels of shock comes denial or disbelief. The person may be dead
but it looks as though it is not true. It is an apparent contradiction in perception.
What one perceives as the reality of death is denied by the person in spite of the
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evidence to the contrary. Once in my pastoral ministry I had to visit a community in
which a member had died. It was the second day after the death of the person and the
body started to bloat and blood was oozing out of the mouth and nose and there were
signs of decomposing. The superior of the community said that the dead person was
a diabetic patient and used to get into coma; she thought that the dead person was in
coma in spite of the evidence to the contrary. She even asked me to call in a doctor
to check the dead person if she is really dead. The paradox was that in that very
community there was an experienced physician who certified that death had occurred.
Like this, we come across many examples of disbelief with regard to the fact of
death.
(3) Emotional Reaction
Now comes the stage of emotional reaction of increased sadness within six to
eight days. It seems that among the survivors, men suffer more than women. In
mourning, depression deserves more attention than any other emotional reaction.
Depression is very characteristic of the mourning process and it has various degrees
of manifestation. While suggesting how to deal with the mourning person I shall
elaborate more on it. Everything seems to be the reminder of the loss — like photos,
films, songs and places. At this level the preoccupation with the loss is intense in
earlier months. Emotional reactions may range from sadness, guilt to anger. There
could be even hallucinations such as a widower on returning home or while sleeping
experiences the presence of his wife going about doing her household chores. It is
only the vivid memory of his wife’s presence and is not pathological unless it
continues without an end. There is a sense of loneliness, helplessness, vacuum and
emptiness. Sadness, depression, wanting to withdraw, feeling of the loss of potentials
are all common. There could be anger against God, doctors, nurses, relatives and
friends. There is the feeling of guilt even if everything was done to save the life.
Guilt could be realistic or unrealistic in the sense that the survivor is responsible or
not responsible for the death. For example, if there had been a real neglect to take
care of the patient and the person died, we call the feeling of guilt realistic but
everything has been done that was within the reach of the survivor and yet death
occurred then the feeling of guilt is unrealistic. The survivor can also get angry with
the dead person as a sign of emotional reaction to the loss. Once, in a village, a man
was dying of snake-bite. As soon as death occurred, the brother of the dead person
got up and shouted angrily at the dead body with abusive words telling that he went
away without informing him. This is also an emotional reaction to the loss. The
dead person may be idealized beyond the stretch of imagination as though he was the
only ideal person in the world. This is another emotional reaction.
Emotional reactions are released through talking, crying, and beating the chest.
Hurt, anger and guilt when not dealt with or released appropriately, one day will
come up to wreck the life of the individual. The more one suppresses them, the more
they express themselves at least in the body, causing heavy damage physically.
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(4) Physical Reaction
Weeping need not be only through tears. Our bodies have many ways of
weeping through various types of illnesses. People suffering from serious illness are
likely to have suffered certain grief in the preceding months. The cumulative
affective effect of grief perhaps expresses itself in bodily ailments. Most commonly
experienced physical ailments are digestive disturbances, aching limbs, headaches,
insomnia, restlessness, irritability, and loss of appetite and in some increased appetite.
There will be a lack of interest in activities and some are known to engage in frenzied
activities. Muscle tension, poor memory, fatigue, difficulty in concentration and
discomfort go along with grief. There are cases of physical symptoms resembling
those of the dead person. Some even feel dizziness, palpitation, and acute anxiety
attacks. People, who are below forty, show more intense symptoms than older people
while mourning. Normally the physical symptoms diminish after the first three
months of bereavement. If in some people the symptoms were to persist beyond this
time it may be a sign that they need psychiatric care.
(5) Acceptance
Slowly the person gets reconciled to the irrevocable absence of the dead
person. And adjustments are made slowly to various aspects of life. Looking after
the house or farm or providing for the maintenance of the family which were done by
the dead person have to be taken care of by the survivors. Thus adjustments are made
at various sectors and at different levels depending upon the demand.
(6) Remembering
To start with, people remember the positive side of the dead person and even to
the point of idealizing. The tendency to idealize and to canonize the dead person is
frequently a signal of buried anger. Later even the negative aspects of the person are
remembered. It is like falling in love; when we fall in love with someone we
perceive the attractive features first and later after a lapse of time we begin to notice
the unattractive features of the person. All these are to be listened to by the
counsellor.173
2) George Engle’s Three Stages
As in the case of the dynamics of death, several researchers have proposed
stages or phases of mourning. George Engel (1964) proposes three stages of
mourning. The first is supposed to be shock and disbelief. In this stage the survivors
do not grasp what had happened and deny the reality of death that has taken place.
The second stage is the developing awareness in which the individual comes to
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accept the reality of the situation and displays a host of emotional reactions. The
third stage is the restitution and recovery marked by inner peace and well-being.
3) Colin Parkes’ Four Stages
Colin Parkes (1970) has proposed four stages. The first is the numbness
characterized by the lack of overt emotional responses. The second is the pining
stage in which the person exhibits a morbid preoccupation with the deceased.
Articles used by the deceased might trigger off intense grief. The third stage is
known by dejection and life becomes meaningless. The definite loss of the dead is
finally accepted with apathy and passivity. The fourth stage is the recovery in which
the bereaved rediscovers his self and the world in general.174
4) Comparison of Stage Models
Stages
1.
2.
3.
4.
5.
Modelled on George Engel
Kubler-Ross
Shock
Shock & Disbelief
Denial or
Disbelief
Emotional Developing
Reaction
Awareness
Physical
Reaction
Acceptance
Restitution &
Recovery
Colin Parkes
Numbness
Pining
Dejection
Recovery
6. Common Elements of Grief175
The stages we notice in the process of dying need not be the same for grieving.
These two processes do not have the same end, for a dying person is letting go of his
valued possessions of persons and things in order to die whereas a grieving person
lets go what has been lost so that he can live again. Many aspects of the dynamics
may be the same while there are some aspects particular to each of them. Grief is not
systematic and may appear in many unpredictable combinations. For convenience
we could group them as numbness, emptiness, loneliness, and isolation; fear and
anxiety; guilt and shame; anger; and sadness and despair. What we see now is
another approach to the process of grieving.
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1) Numbness
Any organism when faced with a sudden shock usually tends to protect itself
from its full impact by entering into a state of numbness. Numbness is the absence of
feeling. Accompanying this state of numbness is the delusion that the loss has not in
fact occurred. Thus a sense of unreality will pervade the very early stage of grieving.
With a sense of unreality, disbelief, and muted feeling, the shock may even cause a
person to wander about aimlessly in a state of disorientation. This period of
numbness may last for hours or even days.
2) Emptiness, Loneliness and Isolation
Emptiness is experienced by a person by his feeling of being diminished from
within. Loneliness is something similar to emptiness but it is experienced in
interpersonal relationship. The one feeling loneliness experiences emptiness in his
surroundings as though the surrounding is empty of people who care or matter.
Isolation is experienced as being divided from others by invisible and
incomprehensible boundaries.
3) Fear and Anxiety
These two emotions are experienced in three different ways.
(1) Dread of Abandonment
The infant will experience the fear of abandonment when it is prematurely cut
off from the mother’s care. Fear of abandonment usually starts early in life and
continues to trouble us all through our life unless some therapeutic interventions are
made or some corrective emotional experiences are had. In adult life experiencing
abandonment is the recapitulation of earlier helplessness especially in early
childhood.
(2) Anxiety of Separation
We start our life with dependence and grow into autonomy. For some people
autonomy does not come so easily and they define their self mostly in terms of their
dependence on a parent, or the spouse, or a child or any object or a role. When any
of the object of dependence is lost then comes the anxiety of separation. Depending
upon how heavily one leaned on the lost person or object the anxiety of separation
will be greater.
(3) Fear of the Future
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Anxiety is vague with regard to its object but fear is concrete. With the loss
comes the fear of how one is going to deal with future works and events especially
when one has depended on someone who is no more for support, encouragement,
sharing of works and responsibilities. Even the trivial works seem Herculean.
(4) Guilt and Shame
Guilt is perceived as one of the chief components of grief. It might result from
three combined factors such as assuming responsibility for the loss, decisions the
survivor made that perhaps hastened or contributed to the loss and residue from the
relationship with the lost person or object. Even if all the care and precaution were
taken to save the lost person or object there will always normally linger the sense of
‘if only.’ The phrase ‘if only’ presupposes that if something had been done, the loss
would not have taken place.
Once I was in charge of a monastery to which a guest had come to stay for a
few months. I was ignorant about his medical history. Once late at night he
complained of a shooting pain in the arm and I proposed that I would take him to any
of the two hospitals that were near by. He would not agree to my proposal. In spite
of my insistence he refused to oblige. When all went to bed he came to me telling
that he was feeling bad. Immediately I called in a doctor who gave him first aid and
then took him to the hospital. Within an hour after admission the person expired.
Practically speaking I had done everything that was within my capacity to save his
life and yet the lingering feeling of guilt was there. For a long time I was moaning
within myself, ‘if only I had taken him to the hospital forcefully when he complained
of pain, he could have been saved.’ I find this same pattern with many grieving
persons.
As close relatives of the dying person we take a decision, for example, for an
operation of a cancer person. It would have been taken in good faith intending the
cure of cancer but it might happen that the operation hastened the process of death.
Here again one is likely to feel guilty. The feeling of guilt is augmented if the residue
of the relationship with the lost person or object is big and intense. The personal
attachment the lost person had for the survivor will fan the guilt that is already being
experienced. Along with guilt one finds that the grieving people at times experience
shame for grieving. Maybe society does not understand the need for people to grieve
and that causes the grieving person to feel ashamed. Grief may strike an individual at
awkward times when being with friends, enjoying a party and the like; so the grieving
person thinks that it is inappropriate to be grieving at a time when everybody is happy
and this could be a reason to be ashamed of his grief.
5) Anger
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Anger is a concomitant of grief. Anger could be against the doctors, nurses,
relatives, friends, neighbours, God and even the very dead person. In my pastoral
ministry I was once called to the hospital emergency room when one of my
parishioner’s son swallowed some poison. The parents of the boy were teachers.
They moved heaven and earth to save the boy and were extremely anxious about the
life of the boy. As I reached the hospital at dead of night there was a noisy scene
created by the mother of the boy. In spite of her anxiety to save the boy she was
furious with the boy shouting that if he really wanted to die he should have taken
enough poison to make sure that he dies.’ I knew that she would never want her son
to die but only she was venting her anger against her son who was dying. On another
occasion I went to a house to conduct the funeral service. On reaching the house I
observed a lot of broken pieces of glass all over the courtyard. On enquiry I was told
that the dead man’s son had taken out all the framed holy pictures and smashed them
in the courtyard expressing his anger towards God for taking his father away.
6) Sadness and Despair
What one obviously observes in a grieving person is sadness and despair.
Sadness is about the loss and despair is sadness coupled with the futility of the future.
7) Somatization
Because of the mind-body link the grief that is experienced intensely is likely
to express itself on the body. Mostly people are said to be complaining of physical
pain in the limbs and sleep disturbances.
7. Patterns of Grieving176
Some of the patterns are intentional or semi-intentional and others are
phenomena that tend to happen when a person grieves.
1) Searching for the Lost Object
Grieving persons usually search for the lost object even when they realize that
the loss is irretrievable. Their intellectual understanding of the fact of the
permanency of the loss does not stop them from looking for the lost object. Along
with this we also notice the phenomenon called ‘time-freezing’ which means that the
survivor wants to stop time passing, the time prior to the loss. That is why people try
to preserve the room, keep the clothes used by the dead person intact or remember the
last meeting before death. On a New Year’s Day a boy went to a river to bathe with
his friends and got drowned. Before going to the river the boy left his room in a mess
and yet his parents preserved the room intact with the articles and the litter as they
were left by their son.
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2) Immoderation
Grieving is in fact a disorderly process which cannot be had in a controlled
way with a time-frame. It has its own pattern of manifesting itself irrespective of
time or place or people.
3) Grieving Is Spiral
The spiral concept is the opposite of the linear concept. It starts at the low
point and moves upwards circularly as the griever comes out of it. In this there is
progression and regression whereas in a linear concept of grieving there should come
one stage after the other and that is not the case entirely with grieving.
4) Time Distortion
Time distortion is not the same as time disorientation. The grieving person
may remain only in the present forgetting the past and the future. This is a time
distortion. When a person does not know what day and what hour it is he is having
time disorientation. In grieving we find time distortion. At times, time seems to pass
quickly and at other times it goes very slowly. There is a tendency to deal only with
the present shutting off the past and the future. These people are to be helped to
remember the past and to hope in the future. The funeral rituals need to be initiating
the mourners to remember the dead and their past and help them look forward to the
future with hope. As long as the loss is present, the grieving will go on.
5) Grieving Is Self-oriented
It is turning inward; maybe because the grieving person has invested a part of
his self in the lost person or object and so the self is damaged by the loss. Thus the
temporary withdrawal serves to protect oneself from future emotional damage, or
maybe, to experience the grief fully; interacting with people and the world may be
too much for the already overloaded emotional circuit.
6) Grieving Never Ends Wholly
Loss of any sort cannot be completely wiped away from our memory. All the
emotional investments we had done in a former relationship or persons or objects are
still in memory which can be revived at any time in the future. Of course we have
occasions like anniversary reactions during which time we recall the moments of the
past. All the past relationships still live in our memory and so grieving cannot be
complete at any time. That is why in therapy for the grieving persons we instruct
them to give themselves the permission to remember the dead person and even to
shed tears.
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8. Goals of Grieving177
1) Grieving is to acknowledge the deep feelings aroused by the lost person or
object and to give expression to the feelings rather fully.
2) In grieving our attachment to the lost person or object is not completely
given up and the reality of the loss is accepted with the strength to live without
constant reference to the loss.
3) The emotional investment which is stopped for the time being following the
loss, is once again resumed and the person begins to invest in other persons and
things.
4) The belief system that was changed drastically due to the loss is regained
slowly.
9. Depression as a Grieving Process
Depression is one of the phases of mourning process and it is a quite natural
form of reaction to a loss. Since depression experienced by a mourner and depression
experienced by a person habitually inclined to be depressed are the same apparently,
the counsellor needs to distinguish one from the other; otherwise he may be labouring
in vain. Hence I thought of clearly describing the ordinary depression towards the
end of this chapter. Normally speaking the depression of a mourner will disappear
rather automatically after a few months but not the depression of the pathological or
morbid case which I call simply as depression. I have also observed that in some
cultures the depression of the mourner lasts for a longer period. Even though the
period is longer, it is shorter than pathological depression which seems to be endless.
10. Counsellor’s Intervention in Grief
As soon as death occurs, being with the family members and assisting them to
express their feelings, and talking openly about the death is the first service of the
counsellor. Special attention should be paid to those who did not participate in the
funeral. If shock and denial were to be prolonged over a period of long time, it will
indicate trouble. The individual needs to move to some sort of emotional state. It is
good to take stock of any excessive behaviour. The word ‘excessive’ is a relative
term culturally-conditioned. All the same if the cry is too loud and uncontrollable
with excessive handling of the dead body, for too long, using suicidal language, the
grief is really too great. After the funeral the grieving individuals are likely to enter
into depression, especially within 6 to 8 days and during those days the counsellor’s
visit will be beneficial. Raising questions about some of the important urgent works
is essential, for example, paying the bills, management of the house or business.178
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11. Healing the Grieving by Rituals
Healing the grieving can be done through rituals. According to the
anthropologists, the life of the primitive people was filled with a number of rituals.
In our modern term the rituals of the primitive people is a form of group therapy.
The funeral rites of every religion are a beautiful way of assisting the grieving
members to cope with the loss. Meaningful rituals in every culture have to be valued
and made use of for the healing of the grieving persons. There should be a place for
people to cry and there should also be a time for crying. Making such provisions is
part of the healing the counsellors could undertake in support of the grieving.179
12. Completing an Unfinished Business
For some kinds of grieving, certain therapeutic interventions may be essential
to complete the mourning process. Certain persons may go on mourning the death of
a loved one or object for years. When an individual is pathologically deranged, he is
to be taken to a psychiatrist but when an individual is normal except for the fact of
unfinished mourning, it is good to assist him with some therapy. The ideal will be to
remember our lost loved ones and cherished objects without being unduly disturbed
and without any disturbance to any of our normal private and social life.
There is a simple method in Gestalt psychology to assist people who have not
completed their mourning in one way or other. Incomplete mourning can remain
with people who have not attended the funeral of their loved ones or could not
express their grief just because they were so busy with the administrative matters
regarding funeral services or legal matters if it is a question of suicide or accident.
The method is as follows: Through a fantasy exercise, lead the person to the
graveyard, or to the scene before the body was cremated, or to the time the person
last saw his loved one. With the eyes closed, the person vividly imagines the scene.
He is asked to dig out the earth in the grave and take out the coffin to the surface. Let
him slowly open the lid of the coffin and describe how he sees the body. Now ask
the person to speak whatever he wants to say. This is mostly done with a lot of
weeping and talking. Once he is satisfied with talking, ask him to be the dead person
and respond. Thus a dialogue ensues which reaches a climax when both of them
having said everything they wanted, want to take leave of each other. When there is
nothing more to say on either side, ask the person to close the coffin and gently place
the coffin in the grave and cover it with earth as it was before. Finally giving himself
permission to remember the loved one and even shed tears, he comes out of the
fantasy state and opens his eyes.
13. Depression
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What follows now is the description of the depression which is pathological
and not as a result of a loss (and the methods of counselling people of such a
condition). The reasons why I include pathological depression here are first of all to
know the difference between the depression as a reaction to a loss and the
pathological depression; secondly by being acquainted with the pathological
depression, one will be in a better position to understand and counsel the
pathologically depressed persons undergoing grieving.
1) Nature of Depression
The question whether depression is caused by environmental factors
(psychosocial) or physiological factors (especially genetic, biochemical and
neurological predispositions) is still not settled. Research seems to favour the idea
that depression is organically or physiologically based. There are patients who are
not able to identify what triggers off dysphoria, a generalized depressed feeling of
being ill, which is the opposite of euphoria. Considerably less number of people is
able to identify the environmental event that sets off their depression. Now the
question is that if depression is mainly caused by physiological factors, the best
method of treatment is antidepressants rather than counselling. Actually 60% to 65%
of people respond to antidepressants while the rest do not. At least for 35% of people
counselling is beneficial; also for the people who take antidepressants it is useful,
because of the other psychological factors that enter into the organic factors like the
habit of getting depressed even though it is organically induced. Thus the coping or
cognitive habit and making use of depression to get attention do need counselling
even if depression as such does not need, on account of the antidepressants. The
modern trend is to combine antidepressants with Cognitive Behaviour Therapy
(CBT), exercise, diet and lifestyle changes180
2) Characteristics of Depression
(1) Affect
Depressed people have a pervasive feeling of sadness; they feel down and low
at the feeling level most of the time unless they are manic-depressive (bipolar) which
has a wide range of mood change from euphoria to dysphoria. They feel guilt and
anger at themselves considering themselves as failures, helpless and hopeless, losing
interest in activities that once enthralled them and they cry easily for no apparent
reason.
(2) Behaviour
Depressed individuals have a lowered activity level, actually doing very little.
They just sit, stare into space, idly watch TV, leaf through a magazine, often
abandoning spiritual activities altogether. Normally they avoid the usual routine
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works and do what they feel like doing at the moment. They have increased tendency
to depend upon others. Even small tasks become for them awesome. Most depressed
people eat and sleep less, although some may do more.
(3) Physiology
There is retardation of movements and speech pattern. They just sit and if
obliged, speak slowly and at a low pitch perhaps in a lifeless monotone. There is the
general feeling of exhaustion or fatigue even if they rise from bed after a long sleep.
Some may oversleep and others have difficulty in sleeping. They experience
headaches, constipation or diarrhoea. Loss of appetite and lack of interest in sex are
common.
(4) Cognitions
They tend to distort reality and misinterpret it; events, self and the future are
viewed in an idiosyncratic, bleak manner.181
3) Difference between Grief & Depression
We should keep in mind that grief is not depression, though an individual
while grieving will usually be depressed for a time. There are differences between
the depression that accompanies grief and the depression that is chronic. The major
difference is that a grieving person will experience bouts of depression that come and
go with decreasing intensity and frequency after they suffer a loss; the chronicallydepressed individuals do not seem to have bouts of depression and find no relief for a
very long time even for years.182
4) Counselling the Depressed
(1) Affective Intervention
i) For some people expression of emotions and discussion of the problem may
be enough. Repeated talking without any demand from the listener may sometimes
perpetuate depression.
ii) Resignation is a useful method especially when people are grieving. It is
letting go and release the attachment to the dead. It is not resignation to helplessness
but only to the fact of the loss but they need to learn the skills necessary to cope with
reality.
iii) From the psychological school of psycho-synthesis we have a technique
called dis-identification, or self-identification exercise. Whatever we identify with
dominates us, and when we dis-identify we have control over it. One needs to say ‘ I
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am sad but sadness is not me.’ Mildly depressed people are helped when they are
made to repeat the dis-identificatory statement for ten to fifteen minutes in a relaxed
position with closed eyes.
iv) We have what is called diversion technique. Here one plans out in detail
the daily timetable, especially doing something absorbing during the time of
depression; for example, in the morning when one usually gets depressed at 8 0’
clock, he could take a walk.183
(2) Behavioural Intervention
i) Activities: Since depressed individuals tend to see themselves more or less as
ineffective, it is imperative to keep them engaged in activities; the counsellor can
give them some homework. They need to be engaged in interpersonal activities in
which the individual feels appreciated, accepted, and valued, and can demonstrate
competence and independence, and have fun in the very execution of them. If the
interpersonal activities have meaning to them they are ideal since meaning is crucial
for survival.
ii) Learning specific social skills: Role play, learning the social niceties
required in a social gathering, associating with some support group, and joining
group therapy are all helpful.
iii) Keeping a journal of activities: Since the depressed persons do not know
how they spend their time, this technique will be of help to understand their own
behaviour besides the chance to plan out the future fruitfully.184
(3) Physiological Intervention
i) Drugs: Here the intervention is mostly medical using antidepressant drugs
like tricyclics, lithium carbonate, and selective serotonin reuptake inhibitors (SSRI)
like fluoxetine. There are some drugs that cause depression, as for example, alcohol
which is a depressant, though initially giving some relief, will only aggravate
depression. Hence it is not advisable for people of depressed nature to indulge in
alcohol. Even caffeine found in coffee, tea, and soft drinks seem to cause depression
though they may give a momentary feeling of alertness initially. Sugar taken in
excess can act as a drug inducing over-stimulation of the pancreas, resulting in higher
insulin output and causing low blood sugar levels, irritability and later perhaps
depression.
ii) Sleep: One of the physiological symptoms of depression is sleep
disturbance. As a rule the bed should be used only for sleep or for sex. Studying,
reading light materials, watching TV from the bed is not advisable since these
wakeful states will be associated unconsciously in the mind, with the result, that,
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instead of getting sleep in bed people become more awake. People with sleep
disturbance could avoid stimulants like coffee and tea before going to bed.
iii) Exercises: Regular exercises except two hours just before going to bed will
be helpful. Cardiovascular exercises like jogging are said to have beneficial
effects.185
(4) Cognitive Intervention
1) Cognitive Restructuring
Since the information-processing of the depressed person is faulty on account
of the misconstruing of the reality, the counsellor could help the depressed to
restructure the cognitive process. First let us see how the depressed misconstrue the
reality and then how the restructuring can be done.
A) Misconstruing Reality
In the depressed individuals certain thoughts predominate to such an extent
that they misconstrue and misinterpret reality and their perception is biased and
negative. There seem six typical ways of misconstruing their experience in a
negative way.
a) Arbitrary Inference: It is making a conclusion in the absence of evidence.
b) Selective Abstraction: Choosing one small detail for focus mostly negative
and leaving out the rest.
c) Overgeneralization: It is making conclusions about oneself and one’s ability
and worth from a few isolated incidents.
d) Magnification & Minimization: Negative aspects are magnified to the
maximum and the positive achievements are reduced to the minimum.
e) Personalizing: Assuming responsibility for the negative events when there
is no real connection.
f) Either-or-Thinking or Black-and-White Thinking: It is an absolutist and
dichotomous thinking of depressive categories in one of two opposites such as perfect
or defective, all or none etc. All their experiences are qualified with absolutist
categories especially the negative ones. Their actions are mostly defective and not
perfect, they think.
B) Restructuring the Cognitive Process
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a) Assessment: Understanding the erroneous beliefs.
b) Learning: Learning realistic beliefs about themselves and the world around.
c) Practice: When depression does occur immediately they need to go back and
identify the irrational thought pattern that triggered off depression and rectify the
irrational thought pattern.
i) Thought stopping
Whenever negative and obsessive thoughts overwhelm, the individual is
literally asked to shout ‘stop’ and later subvocally say the word ‘stop’ thus learning to
put a full stop to the negative thinking.
ii) Worry Time
Those who are overwrought with worry need to set apart some specified time
for worry and during that worry time they need to think only about their worry and
nothing else. This will help them not to drag their worrying pattern into the other
hours of the day. Actually setting a ‘worry time’ will help the individual to plan out
his programme since during the time of worry he will have to think of executing the
things that keep him bothered and worried.
iii) Blow-up Technique
The individuals are asked to exaggerate their disturbing negative thoughts
saying in the first person what they are thinking, feeling, seeing and experiencing so
that they become ridiculous and humorous. In fact thought stopping and blow-up do
not automatically lead to positive thoughts, especially in the severely depressed ones.
In addition to these they need to learn positive, reality-based thoughts.
iv) Alternative Technique
Recognizing their negative biases and substituting them with more accurate
interpretations of their experiences.
v) Cognitive Rehearsal
The individuals are asked to go through a certain activity mentally and report
all the roadblocks and conflicts they might experience. Here forewarned is
forearmed. Using paper and pencil is better than thinking in the mind.
vi) Reattribution
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It is assigning accurately blame or responsibility for negative events to the
appropriate persons.186
14. Conclusion
Any loss has to be grieved or mourned. A loss induces disturbance in the
internal emotional homeostasis of the individual. Mourning takes its own course.
Counselling can only assist the individuals to go through the process of mourning and
they cannot altogether stop it. To regain the internal equilibrium after a disturbance
of a loss, one needs to mourn. It may be a futile attempt to try to end mourning
before it is fully experienced. A cat losing her kittens goes about mourning and
searching for the kittens for a few days. Then grieving comes to an end. The same
patterns occur to human beings but with a difference. A grieving cat cannot get stuck
to the grieving process or attempt to commit suicide whereas human beings can do
such things. That is why we need the help of the counsellors. In brief, the
counsellor’s duty is to facilitate the mourners to experience the grief fully and express
it verbally and assist them at the recovery process to the ordinary life. But, remember,
take an appropriately enough time to grieve, do not fast-forward or quicken the
grieving time.
14
COUNSELLING THE SUBSTANCE ABUSERS
1. Introduction
There are a number of people who drink and remain as social drinkers in the sense
that they can have a drink periodically without feeling addicted or feeling dependent. Of all
the drinkers only 15% of the persons get addicted and so far medical science has no answer
why only 15% get addicted. Researchers perhaps could look into the personality of those
who get addicted for an answer.
2. Addictive Personality
Adrian van Kaam has the following to say about the addictive personality. The term
addiction comes from the Latin words ‘ad dicere’ which basically means to give oneself up
or over. There are two dimensions in man – active and passive. Latin root seems to indicate
the passive dimension of the addictive personality. Since the passive dimension takes up the
whole arena of activity in the addict, there is no room left for the mastering dimension.
I think that this passivity may have its own roots in the development of the ego
qualities of the individual spoken of by Eriksson especially during the years between 3 and
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6 as one of Initiative vs. Guilt and between 7 and 10 as one of Industry vs. Inferiority. When
the child takes a lot of initiative from the 3rd year onwards he is plagued by the fear of failure
since his physical condition and the lack of skills do not produce worthwhile activities to be
proud of but rather he is reprimanded for the clumsy way he handles and destroys things.
Later from the 7th year onwards he is engaged in learning a lot of skills of mastery and when
his inclination to master skills is thwarted he is frustrated and feels inferior. Therefore, what
Adrian van Kaam speaks of passivity may have its root in the early and late development of
the child who may prove to be an addict in later life because of the type of personality he
has shaped for himself along with the environment.
3. The Personality Field of Addict, Player & Labourer
The attitude of the addict is highly marked by passivity. In fact in every balanced life
we find passivity playing a certain role but in the case of addicts it plays an overwhelming
role. This will become clear if we compare the personality field of the addict with those of
the player and the labourer. The player moves in a field of meaning which is at the same
time real and imaginary. The world of the labourer is real and not imaginary. Here life is
linked to practical aims. The world of addict differs from those of the player and the
labourer. The personality field of the labourer is real and the field of the player is partly real
and partly imaginary while the world of the addict when satiated is not real. He seems to
live at the moment of satiation in a make-believe universe, a field of inauthentic imagination
that is no longer meaningfully or playfully related to the reality of his daily surroundings.
The addict’s world is neither utilitarian nor a commitment to a planned activity of play and
celebration guided by definite rules and limits. We can say that it is purely a world of
passivity, of dependence, an aimless world devoid of orientation.
There does not seem to be any commitment on the part of the addict but the addict
feels compelled to satiation which he cannot resist. The addict may not feel guilty in his
world of satiation since his world is marked by an absence of rules and concern for progress.
In his world, time stands still. He lives in an eternal present returning to the cyclic time of
the primitive man. For us now the concept of time is linear but for the addict it is cyclic like
of the primitive man. He has no past or future. All that is there is the present as though the
whole is frozen into the now. It is like being in the ecstasy of love after which we know that
we have to return to the time that has a past and will have a future. Of course for the player
too time stands still but the difference is that the player knows that timeless sense will cease
once the play is over and he has to take up his world of responsibility while the addict
craves to remain in that timeless world being satiated indefinitely without assuming any
responsibility in the world. His longing is to be taken out of the world of task and
commitment. He sees his world as a world of conquest and decision whereas he is not a
person of decision and conquest; so there is an inherent feeling of despair, disgust,
impotence and worthlessness. He wants wholeness and fulfilment but without commitment
and engagement. His satiating object can vary from anything like quasi-mystical experience
to the use of alcohol and drugs. There could be milder addiction like eating, smoking and
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the like but we speak of addiction in its pure form when the whole life revolves around an
object and everything else becomes subservient to it for the most part of his life.187
4. Drug Dependence & Abuse
Drugs can be used or abused in many ways. The term ‘dependence’ was reserved to
indicate psychological reliance of a person on a particular drug while the term ‘addiction’
signifies physiological dependence indicated by withdrawal symptoms (in the case of drug
the person is so agitated, depressed, or otherwise miserable that he can think of nothing but
getting the next dose; and in the case of alcohol, tremor, delirium, convulsions and
hallucinations collectively called delirium tremens) if the drug is discontinued. Of late
‘drug dependence’ indicates both psychological and physiological dependence. The term
‘drug abuse’ indicates the excessive consumption of a drug, regardless of whether one is
truly dependent on it or not. Of course abuse naturally leads to dependence. Recently the
word ‘drug’ is replaced by the word ‘substance’ and thus we have the title of the chapter as
‘Counselling The Substance Abusers.’ Here substance will include both alcohol and drugs
though in fact the term drug will also include in itself alcohol. The commonly used drugs or
substances are alcohol, barbiturates, amphetamines, heroin, and marijuana.188
Let us understand the drug terms more clearly. The term ‘drug abuse’ indicates an
excessive consumption of a drug, may be even just once, for which perhaps one is
hospitalised regardless of his addiction to it or not. Drug abuse does not necessarily mean
that the individual is addicted. But the term ‘drug addiction’ implies dependence that is the
person is dependent on drug and it includes drug abuse. Dependence can be either
psychological (mental dependence only) as in the case of ganja (marijuana) or charas (hash
or hashish) or psychological as well as physiological (both mental and physical dependence)
as in the case of opiates like opium, morphine, heroin, and brown sugar.189
1) Psychological Dependence
It denotes an irresistible mental craving or compulsion or urge for the drug that the
person will go to the extent of begging, borrowing, stealing, robbing, and even killing to
satisfy his need regardless of the place, people and time.190
2) Physiological Dependence
The person’s body is so accustomed to or dependent upon the drug that if he refrains
from it, he will, in a few hours (8 to 10 hours) from the last intake of drug, will experience
withdrawal symptoms. For an illustration, the initial withdrawal symptoms for the brown
sugar are watery eyes and nose, perspiration, restlessness, heavy breathing and these
symptoms intensify and reach the peak in about 36 to 72 hours. Now the symptoms are
vomiting, diarrhoea, abdominal cramps, pain in the back and at the joints, headache and
insomnia. There could also be convulsions, violent shaking of the body, and dehydration of
the body due to vomiting and diarrhoea and hallucinations. There are also cases of cardio-
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vascular collapses. Involuntary orgasm is experienced at the peak of the withdrawal
symptoms.191
In this chapter ‘Counselling The substance Abusers’ I have two sections under the
headings ‘Drug Dependence’ and ‘Alcoholism’ though in fact alcohol is also a drug and as
such it is already included in the term ‘drug.’ In fact there are some differences between
drug dependence and alcoholism though both of them can be grouped under the concept
‘drug.’ Besides, there are cases purely of alcoholism which may not have the implications of
drugs proper like narcotics. And so a separate treatment of the topic of alcoholism is
warranted.
Again a word about the treatment is in place. The process of detoxification and
counselling are more or less the same for both types of problems. And so towards the end of
this chapter whatever is spoken of as the procedure for the treatment of alcoholism, will also
apply to the treatment of drug dependence.
For information about the adolescent substance abusers, consult the chapter
‘Counselling the Adolescence.’
5. Addiction is a Brain Disease
Drug addiction is a brain disease that develops over time as a result of the initially
voluntary behaviour of using drugs. This brain disease expresses itself in the form of
compulsive behaviour. The brain mechanisms through drugs acutely modify mood,
memory, perception, and emotional states. Using drugs repeatedly over time changes brain
structure and function in fundamental and long-lasting ways that can persist long after the
addict stops using them. Addiction comes about through an array of neuron-adaptive
changes and the lying down and strengthening of new memory connections in various
circuits in the brain.
Though we do not know yet all the relevant mechanisms, we are sure that longlasting brain changes are responsible for the distortions of cognitive and emotional
functioning that characterize addicts, particularly including the compulsion to use drugs that
is the essence of addiction. Addiction involves inseparable biological and behavioural
components. It is the quintessential bio-behavioural disorder. Though addiction is a brain
disease, it does not mean that the addict is simply a hapless victim. Addiction begins with
the voluntary behaviour of using drugs, and addicts must participate in and take some
significant responsibility for their recovery.192
6. Tetrahydroisoquinoline (THIQ)
When the normal adult drinks alcohol it is processed at about one drink per hour. The
body converts the alcohol into acetaldehyde (a very toxic substance which if accumulated
would make one very sick or could even be fatal). But our body is designed, via biological
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processes, to quickly rid itself of this toxic acetaldehyde. It is changed into acetic acid
(vinegar), and then into carbon dioxide and water, which is dispelled through the kidneys
and lungs. This is what happens in a normal drinker. But in the alcoholic, a very small
amount of acetaldehyde is not eliminated. A small amount goes to the brain where, through
a very complex biochemical process, it is transformed into THIQ.
Firstly, THIQ is created in the brain. Secondly it is not created in the brain of the
social drinker. Thirdly it is created only in the brain of the alcoholic. THIQ is an excellent
pain killer and also it has addictive qualities. In virtually all the cases of alcoholism, there is
a family predisposition that is an abnormality in the body chemistry toward the
manufacturing of THIQ.
The alcoholics-to-be are not equipped to process alcohol in the normal way. They are
unaware of their predisposition towards the THIQ production their brain’s chemistry has
inherited. So the alcoholics-to-be innocently start drinking moderately in the beginning and
then might get seriously drunk by which time their brain accumulates THIQ. So far medical
science cannot predict with accuracy how much THIQ an individual brain will stockpile
before the person becomes an addict. For some it may be in their teens, and for others in
their 30’s, 40’s, 50’s or later. Thus, alcoholism in a way is neither the fault nor the choice of
the alcoholics.193
With this prelude, I enter into the detailed description of the drugs, symptoms, and
treatment and later into alcoholism.
DRUG DEPENDENCE
7. Kinds of Drugs
The drugs that are used or abused can be grouped into five categories as narcotics,
depressants, stimulants, hallucinogens, and cannabis. Unconventional abuses of snake bite
venom and scorpion bite venom can be added as the sixth category.194
1) Narcotics
Narcotics are opium, its derivatives and synthetic substitutes. Narcotics are most
effective pain-relieving agents and are also used as cough suppressants and in the treatment
of diarrhoea. For medical purposes they are administered either orally or by intramuscular
injection. But as drug they are usually introduced by 1) smoking through a cigarette, 2)
snorting – inhaling through the nasal passage, 3) fixing/mainlining – by injection the
liquefied drug intravenously so as to reach the blood stream directly, 4) skin-popping – by
injection the liquefied drug just beneath the skin; usually it is done in the loose skin at the
back of the palm. Narcotics are of three kinds: natural origin, semi-synthetic and synthetic.
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(1) Of Natural Origin
The poppy plant, papaver somniferum is the main source of natural narcotics. Opium
gum is produced from the milky fluid that oozes from incisions in the unripe seedpod and is
air dried. Recently the method of harvesting is by the industrial poppy straw process
extracting alkaloids from mature dried plants. The extract may be either liquid or solid or
powder. Its various forms are:
1) Opium: Opium is gummy substance of chestnut-brown colour and when it is old,
it is hard, brittle, dark brownish or blackish in colour. It may be got as rounded or irregularly
formed or flattened with bitter taste. 2) Morphine: It is a odourless, bitter-tasting white
crystal or injectable preparation, taken in by skin popping, intramuscularly or intravenously.
3) Codeine: It is used in relief of moderate pain and cough in the form of syrups.
(2) Semi-synthetic Narcotics
Its various forms are: 1) Heroin: It is a bitter tasting while powder in its pure form
though what we get in the market may be brown because of impurities. It may be
adulterated with diluents like sugar, starch, powdered milk and other powders. It is taken in
by smoking, snorting, injecting (fixing/mainlining) and skin-popping. 2) Brown Sugar: It is
a light brownish bitterish substance taken in usually by smoking (From a cigarette a little
tobacco is removed and the rest is made loose and the desired quantity of brown sugar is
poured into the cigarette and made to sink to the level of filter and the joined portion of the
cigarette paper is usually made wet with spittle to ensure a longer smoking), or chasing
(Brown sugar is placed on a strip of aluminium foil like the silver wrapper in a cigarette
packet and the foil is heated from underneath by a candle or a matchstick. The heated brown
sugar liquefies and rolls along the foil emanating blackish fumes. The fumes are inhaled by
using a hollow tube, which is called ‘Chaser’ about 3 inches in length. Since the fumes are
chased by the user it is called chasing). Or injecting (Brown sugar is mixed with sour lime
(limbo) and ordinary tap water in a spoon and the solution is heated and drawn into a
syringe and injected intravenously which is called fixing or mainlining). It is not taken
orally.
(3) Synthetic Narcotics
Synthetic narcotics are prepared in the laboratory. 1) Meperidine (pethidine) – It is
used orally or intravenously. 2) Methadone – It can be taken either orally or by injection.
2) Depressants
Depressants are sedatives or tranquillisers and are prescribed by physicians or
psychiatrists for relief from anxiety, tension, irritability and insomnia. When used
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excessively it produces a state of intoxication similar to that of alcohol. Its various forms
are:
(1) Barbiturates are called ‘downers.’
(2) Methaqualone is administered orally whose larger doses may cause coma
accompanied by convulsions.
(3) Meprobamate is a muscle relaxant and does not produce sleep and is less toxic but its
excessive use can result in psychological and physiological dependence.
(4) Benzodiazepines – Its family contains Librium and Valium meant to relieve anxiety,
tension, and muscle spasms, produce sedation and prevent convulsions. But regular high
doses will result in psychological and physiological dependence.
3) Stimulants
While depressants slow down the activities of the central nervous system, the
stimulants speed up the activities of the central nervous system. This is taken to feel more
active, stronger, more decisive and self-possessed. It gives a temporary sense of
exhilaration, abundant energy, hyperactivity, extended wakefulness and a loss of appetite.
To intensify these effects, users might inject this intravenously. If withdrawn, users exhibit
profound depression, apathy, fatigue and disturbed sleep. Its various forms are:
(1) Cocaine (Coke, Flake, Snow)
It is extracted from the leaves of the coca plant (Erythroxyln coca). In the illicit
market it is sold in white crystalline powder often adulterated with sugar. It could be either
snorted or taken intravenously.
(2) Amphetamines ‘Speed’
It will stir up activity and help the users to function temporarily above their normal
capacity.
(3) Hallucinogens
This drug which can be found both in natural and synthetic forms is believed to
induce hallucinogens, which is the distortion of the perception of objective reality. Of course
it excites the central nervous system with the alterations of mood, mostly euphoric and at
times depressive. There is the impaired judgment which might lead one to rash decisions
and accidents. There will be disorientation with regard to direction, distance and time. Its
various forms are:
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(1) Mescaline
It is derived from the fleshy parts or buttons of the plant called peyote cactus or
prepared synthetically.
(2) Psilocybin and Psilocyn
These are mushrooms which when eaten have effect on mood and perception similar
to Mescaline and LSD. Now it can also be prepared synthetically.
(3) LSD
It is the product of lysergic acid. LSD is the abbreviated form in German language of
lysergic acid diethylamide. It enables the users to discover and put to use their latent talents
and potentials with the objects becoming clearer, sharper and brighter. The LSD ‘trip’ could
either be pleasurable or horrifying.
(4) Phencyclidine (PCP)
It is called PCP and is being referred to, by terms such as Angel Dust, Supergrass,
Crystal and Rocket Fuel. In its pure form it is a white crystalline powder which dissolves in
water easily and when contaminated it becomes brown and gummy. It is marketed in
tablets, capsules, powder and liquid form. It is also applied to leafy materials like Ganja
(Marijuana) and is smoked. Its users usually feel a sense of detachment, estrangement and
distance from their surroundings. They feel numb, strong and invulnerable and their speech
is slurred with a blank stare, rapid and involuntary eye movements and an exaggerated gait.
There may be auditory hallucinations, image distortion and severe mood disorder.
5) Cannabis
Cannabis sativa is the hemp plant which has a mood-altering (psychoactive)
ingredient which is known as THC (delta-9-tetra-hydro-cannabinol). This THC ingredient
can also be synthetically prepared in laboratory. It is normally smoked in the form of loosely
rolled cigarettes (‘joints’ or ‘reefers’) or in a pipe/chillum. It can also be administered orally.
Low doses include an increasing sense of well-being, then a dreamy state of relaxation with
hunger especially a craving for sweets. Changes in sensory perception of vivid sense of the
five sense organs are experienced. Prolonged use usually impairs memory and reduces the
ability to concentrate and to make swift decisions.
(1) Ganja (Marijuana)
Ganja known as Marijuana, grass, pot, weed, reefer comes from the leaves and
flowering tops of the cannabis plant; it is smoked by filling it into a cigarette, pipe or
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chillum. The tobacco is removed from the cigarette and is mixed with ganja, refilled into the
cigarette and then smoked. The leaves can be immersed in hot water and the water can be
drunk and ganja can be baked in pastries, biscuits and other food items according to one’s
taste. The effect of Ganja makes the experience of the world very pleasant with richer
sensations. There will be disorientation with regard to time. Pleasurable experiences like sex
play and intercourse will be enhanced.
(2) Charas (Hash or Hashish)
It is the resinous secretion of the cannabis plant, collected, dried and compressed into
a variety of forms like balls and cakes. It is smoked in a cigarette or chillum. The tobacco of
the cigarette is removed. The charas roasted over a flame, mixed with tobacco, is refilled
into the cigarette/chillum and then smoked. The user experiences an enhanced, cheerful,
laughing and talkative mood.
6) Unconventional Abuses
People who can no longer afford the usual drug from the market on account of
poverty or nonavailability of the drugs and are chronic in their dependence on drug, take to
snake bites and scorpion bites. Snake bites are given between the fingers or toes and some
even take a bite on the tip of the tongue. A tourniquet may be used to regulate the flow of
poison into the bloodstream.
8. Causative Factors of Drug Dependence195
1) Primary Causes
In the case of drugs that produce only a psychological dependence it is the
personality disorders of the user that brings about addiction whereas for the drugs that
produce both physiological and psychological dependence the high addiction potential of
the drug itself is primarily responsible and the personality disorders are responsible for the
relapse.
2) Secondary Causes
1) Peer group pressure, 2) As a rebellion against parents, 3) Curiosity with a desire to
experiment, 4) Pleasure hunting attitude, 5) False beliefs such as enhanced creativity, and
supposed overconfidence. 6) Easy availability at reasonable cost, 7) Addict pushers who
hook innocent individuals, 8) It may be a sign or symptoms of a mental illness (especially
depression) or in other words the mental illness could push a person to abusing drug in the
prodromal phase of the illness, 9) To reduce self-awareness one may take to drugs. Because
life is full of misery one may not want to face the reality of one’s miserable existence and so
one may take to drugs. A reduced self-awareness will not perceive the full reality of the
miseries of life.
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9. Signs of the Adolescent Addict196
The following are the signs that an adolescent is getting addicted or is already an
addict: Late coming at night, new set of dubious friends who do not want to be identified,
demand for more pocket money, agitation and unjustified outbursts of anger with abusive
language, fatigue, restlessness, glassy eyes with dark circles under the eyes, withdrawal, loss
of appetite and sudden losing of weight, occasionally vomiting, lesser resistance to
infectious diseases, irregular attendance in school and colleges, sleep disturbances, lack of
personal hygiene, disappearance of personal belongings and household articles, compulsive
lying, burnt fingers, skin rashes, irregular menstrual cycles, and needle marks on the
forearms.
10. Comparison of Alcoholism & Brown Sugar
In India alcoholism and brown sugar seem a major problem. Both of them are drugs
though there are some differences with regard to the addiction part of it. Let us consider the
differences that exist between them.197
1) For a person it may take a span of several years to become an alcoholic, whereas for the
user of brown sugar it is a matter of a week.
2) For alcoholism the personality disorders of the person is the main contribution factor,
whereas for the brown sugar the high addictive potential of the drug itself is primarily
responsible.
3) Tolerance (the body is able to withstand or tolerate increasing doses to obtain the same
effect or satisfaction) for the alcoholic increases gradually, whereas for the user of brown
sugar it is much faster.
4) For an alcoholic to be a chronic it is a matter of years, whereas for the drug abuser it is a
matter of months only.
5) Craving for alcohol is not as intense as for brown sugar.
6) With regard to changing moods and feelings, alcohol is rather down to earth whereas the
brown sugar induces a trip that is not in touch with reality.
7) The effect of the alcohol is felt later than the effect of brown sugar.
8) Compared to alcoholics, the changes of physical and mental health, insanity and
impotence are higher for the brown sugar addicts.
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9) During the withdrawal symptoms, physical pain is there for the brown sugar addicts but
for the alcoholics only in rare cases; and hospitalisation is necessary for the drug addicts but
for the alcoholic it may not be necessary.
10) At the relapse, the alcoholic starts off from where he last left (that is he was taking two
bottles at the time of giving up, now on relapse he will start from two bottles) whereas the
brown sugar addict will start from the very scratch (if he left the habit with ten ‘joints’ a day,
on relapse he cannot start with ten ‘joints’ but may be with two).
ALCOHOLISM
Alcoholism is an illness resulting in uncontrolled drinking of alcoholic beverages.
11. Effects of Alcohol198
Alcohol is a depressant which affects and numbs the higher brain centres thus
impairing judgement and other rational process and finally lowering self-control. There will
be motor in-co-ordination and lack of discrimination and perception of cold, pain, and other
discomforts are dulled. There is the general sense of warmth, well-being, expansiveness,
self-esteem and adequacy. What affects an individual is not the amount that is consumed but
rather the amount that enters into the bloodstream that intoxicates. The effect of alcohol will
depend upon the personality, the physical condition, the amount of food in the stomach and
the duration of drinking. A person will be considered intoxicated when 0.1% of alcohol
enters the bloodstream at which level muscular co-ordination, speech, and vision are usually
impaired and the thought processes are in a way confused. If alcohol reaches 0.5% level in
the bloodstream, the entire neural balance is upset and the person becomes unconscious
which perhaps acts as a safety measure since concentration above 0.55% of alcohol in the
bloodstream is lethal. Since alcohol is a high-calorie drug, it reduces the drinker’s appetite
for food. But it has no nutritional value and the person who drinks excessively usually
suffers from malnutrition. If the prolonged alcoholic debauch is followed by abstinence, the
individual will experience delirium tremens; this means that the person suffers from the
withdrawal symptoms such as disorientation of place, person and time, vivid hallucinations
especially of small and fast-moving animals like snakes and rats (which is rare), acute fear,
extreme suggestibility, marked coarse tremors of the hands, tongue and lips, and
perspiration, fever, rapid and weak heartbeat. The symptoms last from three to six days.
12. Pet Theories of Alcoholics
Alcoholics have pet theories about ways and means of sobering up such as drinking a
strong black coffee, eating a big meal, taking vitamins, taking a cold shower and taking
aspirin. All these theories are not scientific to tell the least.
13. Stages in Alcohol Dependence199
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We can roughly divide the whole process of dependence into three stages as early,
middle and chronic.
1) Early Stage Symptoms
(1) Frequent Desire: There is an increasing desire to drink quite frequently and the person
will meticulously see to the maintenance of the steady supply of alcohol.
(2) Increased Tolerance: There is a phenomenon called ‘increased tolerance’ which denotes
the need for higher amounts of alcohol to experience the same degree of pleasurable
feelings experienced at the previous drink.
(3) Black Out: There is usually a ‘black out’ relating to the time of intoxication. It is an
inability to recollect incidents or parts of them while one was in intoxication. One may fill in
such gaps of black out with fanciful tales. In his drunkenness one might have promised
many things but on becoming sober may not remember any of them. People around him
mistake him for telling lies or withholding the truth but in fact he genuinely does not have
any memory of the events that took place when he was intoxicated.
(4) Sneaking Drinks: Since the person still appears to be a social-drinker and not yet
dependent on alcohol, he wants to maintain that image and at the same time wants to have
the required quota every now and then and so he hides alcohol and drinks secretly.
(5) Preoccupation: The one preoccupation for an alcoholic is the next drink and how to get it
for which he needs money to ensure a steady supply. There is a fear that he may run out of
supply and so extra care is taken to hoard stock. When he goes to social gathering, where
alcohol is being served he takes a few drinks ahead of time lest there should be shortage of
alcohol.
(6) Avoiding any Reference of Alcohol: People at this level do not want to hear of alcohol
dependence since they feel terribly guilty about it. Even people who are not normally seen
angry get violent when reference to it is made. Once, I remember, I was in charge of an
institution in which there was a man who used to clean the toilets of the institutions. He used
to spend all his money on drinking. I proposed to him that if, instead of spending a large
amount in drinking, he saves some money from his salary I would add the equal amount as
an incentive and put that amount in the bank for him. The person who used to be extremely
submissive to all the people in that institution began to flare up and started abusing me at the
very mention of drinking. Definitely his guilt-feeling was stirred by my mention of drinking.
I have seen persons even in later stages of dependence avoid drinking socially with others
when invited, since they feel a tremendous guilt-feeling. People at this level do not even
want to hear of the mention of alcohol. With all these a person passes to the middle stage.
2) Middle Stage Symptoms
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(1) Loss of control: There is a marked loss of control over the amount, time, and occasion.
Their social sensibility is lost with regard to their surroundings. All that matters is the drink
and nothing more. Now he stops sipping and drinking but just he gulps down the quantity.
(2) Morning Drinking: when a person wants to drink as soon as he gets up from the bed it is
a clear sign that the condition of alcoholism is going beyond control. Morning drinking may
be to get rid of the hangover of the drinking of the previous day or to steady himself to face
the realities of the new day.
(3) Rationalization: Every drinking person at this level has a strong network of
rationalization or justification. They find out a number of reasons why they should drink. I
saw a bank manager repeatedly three times in a psychiatric clinic for de-toxification and at
every time he was complaining to me that he takes to drinks to forget his worry about not
having a child.
(4) Grandiose Behaviour: With all the rationalization, the self-esteem of the alcoholic is
very low and so to boost up his image he exhibits extravagant and grandiose behaviours by
spending lavishly, presenting gifts to friends, talking too loud, and monopolizing
conversation.
(5) Unsuccessful Attempts: In an attempt to give up drinking he changes companions,
places, the type of beverages but fails in all his attempts. He keeps himself away from
alcohol for sometime and obsessively starts drinking. On abstinence, he develops
withdrawal symptoms like nervousness, tremors, anxiety, convulsions and hallucinations.
The bodily dimension of the addict’s personality is affected by his satiation. Our bodies are
in tune with the type of work we do. The type of work we engage in, effects a specific
tuning in of our nervous system and of our biochemical and physiological dynamisms. The
more one remains in one mode, the more it is difficult for that person to turn to any other
mode, for, the body strongly resists such a change. For example, the one who is doing
office work most of the time suddenly cannot take to manual labour without a considerable
physical strain and likewise a person who had been doing manual work cannot take to office
work without a considerable physical strain, because our bodies get tuned in, to the type of
work we do. For an addict whose body is tuned in to the presence of alcohol in his system,
the abstinence will be protested by the body by way of withdrawal symptoms.200
(6) Binge Drinking: He drinks for several days and stops for a while only to return to
drinking obsessively. This binge drinking symptom in itself does not indicate addiction
because as psychiatrists believe, it is a sign of mental illness mostly – depression. It is to
cover one’s mental illness of depression one takes to drinks. Therefore, binge drinking is a
mental disorder rather than an alcoholic problem. So binge drinking is practiced by people
having bipolar disorders or eating disorders. Binge drinking is only a cover-up.
3) Chronic Stage Symptoms
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(1) Decreased Tolerance: Just as the increased tolerance marked the early stage, the
decreased tolerance marks the chronic stage. At this level the alcoholic gets drunk even with
a small amount of alcohol.
(2) Physical Deterioration: The physical condition of the person is completely broken down
with the result that he becomes so feeble in health. Repeated and excessive drinking usually
affects various vital organs of the body; Heart – Unstable blood pressure, irregular pulse,
enlarged heart; Pancreas – Painful inflammation of the pancreas; Liver – Severe swelling of
the liver, Hepatitis and cirrhosis; Muscles – Weakness of the muscles and the loss of
muscle tissue; Stomach – Intestine lining becomes inflamed, ulcers; Nervous system –
Tingling and loss of sensation in hands and feet; Brain – Cell damage resulting in loss of
memory, confusion, hallucinations; Lungs – Greater chance of infections including T B;
Genitals – Temporary impotence; Skin – Flushing, sweating and bruising; and Blood –
Changes in red blood cells.
(3) Ethical Breakdown: Whatever be his status, he is now willing to beg, borrow, steal and
even kill to maintain his steady supply of alcohol.
(4) Paranoid Condition: At this level the alcoholic is likely to have paranoia of persecution
and jealousy. He may think that others are against him and are plotting against him. Since
alcohol is a depressant, his sexual powers though appear to have been aroused will not
easily consummate. His desire for sex increases but his capacity to perform sexual acts is
decreased. Consequently he becomes impotent on account of which he usually suspects his
wife of infidelity and ill-treats her. I met a case in a clinic where a man was admitted for the
treatment of alcoholism. He was suspecting his ten-year-old son of having sex with his wife.
(5) Suicidal Tendency: It will not be uncommon for counsellors to meet alcoholics at this
last stage with suicidal tendency. The physical and mental conditions are completely broken
down with the result that there is a general inability coupled with the delusion of persecution
and jealousy which drive the alcoholic to suicide.
14. Characteristics of Alcoholism
(1) It is a primary disease in the sense that it is a disease per se. (2) It is a progressive
disease in the sense that when one after a period of abstinence relapses, he starts off from
where he left and not from the very scratch. (3) It is a terminal disease in the sense that the
person dies a premature death. (4) It is a permanent disease in the sense that it cannot be
treated; it can only be arrested. An alcoholic can never become a social drinker. It is like a
one-way traffic.
15. Alcoholic Games
An alcoholic’s situation can be analysed from his psychological game position. He
seems to be playing three major games in his life to perpetuate his basic life position.
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1) Drunk and Proud
This is one of the games played by an alcoholic. His existential position seems to be
one of ‘I am not OK and you are OK, ha, ha.’ Apparently he seems to be putting himself
in a disadvantageous position of being disapproved of, but in fact he is taking the upper
hand and persecutes the one whom he apparently proclaims to be O.K. The very ‘ha, ha’ is
an indication that he is unconsciously sure of the ‘not O.K.ness’ of the other. In this position
anybody trying to help an addict will end up feeling foolish and angry and definitely not
O.K. This is precisely what the alcoholic wanted.
2) Lush
The player of this game is a stroke-starved person, mostly sexual in nature. The
person does not get enough strokes from his or her partner and so plays the game of lush to
get the needed stroke. Getting drunk does not necessarily obtain for him or her the needed
stroke since his or her partner is not in a position to give the stroke. The person goes out
seeking a partner (mostly sexual) who can give the stroke since with the drinking, parental
prohibitions and adult objections are eliminated from oneself. The player, as it were says, ‘I
am crazy (depressed), you can make me feel better (cure me) ha, ha.’ This is played to
the partner who is unable or for whom it is difficult to give strokes. The cynical ‘ha, ha’ is
an indication that the partner will not be able to give the stroke. And so he or she is justified
in going to another partner for strokes (may be for sex). By playing this game one feels
justified in seeking sexual partner (for strokes) outside the marital bond.
3) Wino
It is a game from the self-destructive life script. He says, ‘I am sick, you are well,
ha, ha.’ Here the alcoholic becomes ill to get the strokes he wants. His bodily integrity is
sacrificed for the sake of strokes. In all the three games it is not to be taken that the player
really considers the others as O.K. Deep down in his unconscious he is convinced that the
others are not O.K. and that is why the cynical ‘ha, ha.’ I would interpret these games as
those of a persecutor to put the others down by playing apparently the victim’s role. No
doubt these are unhealthy and manipulative ways of getting strokes. Training the alcoholic
to become aware of what he needs and ask and get it in a healthy way is the task of the
counsellor.201
16. Alcoholic Women & Homosexuals
There are special alcoholic populations such as women and homosexuals. Women
drinkers seem to suffer greater physical damage more because of the disapproval and
negative attitude of the society in which they live; in fact, they are more vulnerable due to
their deficient parenting practices and sexual misconduct. Because of the lowering of the
sense of decency, inhibition is absent; practically all the addicts have sexual promiscuity; on
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recovery they are ashamed of it and even want to end their lives by suicide overcome by
guilt and shame. There are clandestine homosexuals and open homosexuals. In some
societies homosexuals are openly acknowledged whereas in some, they are ignored.
Depending upon the social climate the alcoholic homosexuals feel estranged mainly due to
the lack of support group unless they join Gay AA. Counsellors working with women
alcoholics and homosexual alcoholics need to free the former the guilt feeling and the latter
from loneliness.
17. Treatment of Alcoholism202
1) Biological Measures
(1) Detoxification
In acute intoxification when individuals are brought to the hospital the process of
detoxification which is the elimination of the harmful alcoholic substance from the
individual’s body starts. A hospital setting is helpful to handle withdrawal symptoms and to
ensure detoxification.
(2) Aversion Therapy
Whatever aversion therapy was used formerly is now abandoned by the medical
practitioners on account of the risk it involved to life. The one currently practiced is the
method of using disulpherim (Antabuse) which is a drug that creates horrifying
uncomfortable effects when followed by alcohol intake. This method may act as a deterrent
to further drinking.
2) Psychological Measures
Individual Therapy: Alcoholics have personal problems like anybody else and they
need to be handled by the counsellor for which counselling and psychotherapies are
employed. Here, whether the patient is psychologically dependent on drugs or
physiologically and psychologically dependent on drugs is assessed and the therapies are
given depending upon the nature of the patient and the extent of damage he suffers; the
therapies could be from any discipline like psychoanalysis, rational emotive behaviour
therapy, reality therapy, transactional analysis and the like.
3) Psychosocial Measures
(1) Group Therapy
Once the de-toxification process is over the person will profit if he is introduced into
a group therapy. In group therapy the alcoholic is made to realize that he has a drinking
problem and there are evil consequences of drinking.
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(2) Sociotherapy
Family therapy assumes great importance in the treatment of the alcoholic. In
treatment, rehabilitation into the family with the roles he formerly held is emphasized.
When a person returns home, the other family members who have already started to take his
position will not be willing to let him have his role and status at home and many even do not
believe his conversion and so being frustrated he is likely to relapse into alcoholism. It has
been noted that the older children especially boys are so angry with the recovering alcoholic
that they will not at times admit him into their homes. Some children do not forgive their
father because of the misery to which the family was brought on account of the drinking. If
the drunken father had sexually abused the female children, it is unlikely that they forgive
him so easily. Therefore, family counselling is necessary for rehabilitating the alcoholic. He
is helped to learn more effective coping skills and an attempt is made to see that his
environment does not react to sobriety with hostility. If the family members are not
adequately counselled, their negative attitudes and their degrading treatment will induce the
recovering alcoholic to relapse.
(3) Alcoholics Anonymous (AA)
Joining an Alcoholic Anonymous serves as a support group of people who had
similar problem with regard to drinking. They are not only supportive but also models for
his coping skills. Treatment also must take into account the relapses which is part of the
process of recovery. In spite of the relapses it is worth helping the alcoholic to remain
sober.
The wife and children of an alcoholic are called co-dependents, and they also need
therapy and support groups. Al-Anon is for the wives, and ACOA is for the adult children
of alcoholics.
(4) Taking Care of Environmental Cues
All the environmental cues that surround initial drug use and development of the
addiction actually become conditioned to that drug use. When those cues are present at a
later time, they elicit anticipation of a drug experience and thus generate tremendous drug
craving. Cue-induced craving is one of the most frequent causes of drug use relapses, even
after long periods of abstinence, independently of whether drugs are available. An addict
who became addicted in the home environment is constantly exposed to the cues
conditioned to his initial use, such as the neighbourhood where he hung out, drug-using
buddies, or the places where he bought drugs. Simple exposure to those cues automatically
triggers craving and can lead rapidly to relapses. Therefore, one of the major goals of drug
addiction treatment is to teach addicts how to deal with the cravings caused by inevitable
exposure to the conditioned cues.203
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(5) Follow-up
Apart from the motivation of the alcoholic what stands out as the unique factor for
success is the follow-up programme for the alcoholic. We take for granted that relapses are
normal among the alcoholics and therefore to strengthen them in their resolve to remain dry
and sober, follow-up programmes are absolutely essential. Where follow-up programmes
are lacking, recovering alcoholics are known to have relapsed into their former condition
very early.
18. Counselling the Alcoholics
1) Excuses Made by Alcoholics
Before an alcoholic admits frankly that he has a problem and wants treatment, he
would have had a set of psychological defence mechanisms aimed at protecting his image.
Here below there are some stereotyped addictive defences. 1) Psychotic Defence
Mechanism: The addict asks the question ‘Problem? What Problem?’ Since it denies or
distorts reality itself it is called psychotic defence mechanism. The addict denies that he has
a serious problem with alcohol/drug. 2) Downplaying the Problem: Of course, the addict
admits that he has a problem with alcohol but he thinks that the problem is not as bad as
others make it out to be. He will say ‘I am not that bad!’ 3) Rationalization: The addict
construes alternative explanations and stoutly defends himself. If for example an addict is
arrested he would say that the officer is a corrupt individual. He will say ‘It was not my fault
or It is not the way it looks!’ 4) Justification: The addict believes that he has been
victimized and seeks consolation from his addiction. He thinks that alcohol is the only
source of comfort he has in a cruel world. He says ‘All I want is a little relief!’ 5) In
Control: The addict believes that he can stop drinking any time he wants to. His stopping
will not easily come through even though he says he can. 6) Procrastination: The addict
thinks that today is not the right time to stop drinking or taking treatment. Perhaps tomorrow
he can do that. 7) Freedom to be Oneself: The addict says that he has every right to be
himself and nobody has the right to tell how he has to be. After all he is not hurting anybody
but only himself, he says. 8) Attacking the Attacker: The addict believes in the adage: The
best defence is a good offence. The addict has a keen eye and a sharp tongue for the
shortcomings of others and thus he attacks those who point out his alcoholism. 9) Obliged
to Drink: The addict says that he has to drink in order to earn his living or to drown his
trouble and sorrow. 10) You are the Cause: The addict thinks that it is because of the other
that he takes to drinking. He will really be all right if it were not for the other. These are only
some of the excuses and you might have encountered a number of other excuses.204
2) Hurdles to Counselling
(1) Unwillingness
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What stands as one of the biggest hurdles for recovery is the unwillingness of the
addict / alcoholic himself. Recovery does not mean mere abstinence. Most alcoholics do not
want to give up drinking. Perhaps they have no alternative forms of behaving, spending
time, dealing with problems and meeting their needs and so they cling on to their drinking
habits.
(2) Psychiatric Disorders
People with a psychiatric problem of depression taking to drinks will not respond to
treatment unless their psychiatric problem of depression is treated. Therefore, diagnosing
the cause of drinking is essential for treatment and if psychiatric disorders are the cause of
drinking, the person needs to be treated psychiatrically which itself enhances the chance of
getting out of the clutches of alcoholism.
(3) People with Psychopathic Trends
There is another category of people who according to the psychiatrist will not
respond positively to treatment. They are the persons with psychopathic trends of
personality. They take drinks for ‘kicks’ and gratification without any social sensibility.
They may appear to be repentant; since they are above normal in intelligence they cleverly
manipulate the situation to their advantage. There is a lot of pretence to show that one is
truly changed whereas clandestinely one will carry on drinking. There was a man with
psychopathic trends who was treated for alcoholism. On his return home after the discharge
his wife found him drunk on the way. This is a clear sign of psychopathic trend in
personality. Otherwise he would not have drunk on the very day of his discharge. If it were
only addiction without psychopathic trend, the person would have found it difficult to
remain dry for a week or so and then would have taken to drinks because of the addictive
tendency. Since that individual had personality disorder (of psychopathic trends) he wanted
the ‘kick’ at the earliest after the discharge.
Therefore, in treatment and counselling it is good to know what causes a person to
drink. Unwillingness, psychiatric disorders and psychopathic trends are all major hurdles to
recovery which a counsellor faces in his counselling situation.
3) Overall Approach
Let us now concentrate our attention on the counselling of the recovering alcoholic.
The fact that he has been given treatment is not enough to ensure that the problem of
alcoholism is over. Counsellors are rather reluctant to help an alcoholic because of the low
rate of recovery among them. It is true that relapses are as common as alcoholism. Rarely
we find anyone just recovering from alcoholism once and for all. Most of the alcoholics
have relapses which might provoke anger in the persons who are helping them rehabilitate.
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A developmental overview of the recovery process will be useful in helping the
alcoholic. In the developmental overview we have three separate but not always
distinguishable stages. The first stage is the ‘de-compulsifying’ stage which in a way takes
away the compulsion to drink and focuses primarily on physical recovery. The second stage
deals with the psychological aspects which make the effects of alcohol so seductive. The
third stage is focused on integrating the person’s identity as an alcoholic with an acceptable
vision of the meaning of life. Research has been done to evaluate death among alcoholics
who die in a year after becoming sober. Among them 20% die of suicide which means that
the recovery is not over just because a person has reached sobriety. If a counsellor responds
even in the slightest way judgmental to the alcoholic, he is likely to behave negatively. In
the beginning stage of recovery it is advisable not to deal with issues of ethical
responsibility.205 Otherwise it will jeopardize the recovery process.
4) Stage-wise Approach
Recovery can also be understood in terms of three stages each having tasks such as
physical recovery and psychological recovery. Thus we may find the following:206
(1) Early Stage
The two main issues here are ‘de-compulsifying’ drinking behaviour and the
physical restoration of the body.
i) Physical Recovery
Alcohol is known to harm virtually every major organ system in the body. Hence
referral to a physician is a must especially to deal with the emergency of the withdrawal
symptoms. The process of natural body restoration may last even two years. The alcoholic
is easily fatigued and his sleep patterns are disturbed at least for a year since brain
restoration is a slow process. Excessive use of alcohol would impair cognitive functioning
altering the structure of the brain resulting in measurable intellectual deficit. It could be a
chronic brain damage not restricted to the period of intoxication alone. Recovery of
cognitive functioning continues for several years and may not be total. Short-term memory
is rather poor and the ability to deal with abstractions is impaired resulting in difficulties in
learning new programmes.
ii) Psychological Recovery
Here the counsellor along with the alcoholic discovers the antecedents of drinking to
prevent lapses. Two major categories are identified as responsible for relapses and they are
intrapersonal and interpersonal determinants.
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(i) Intrapersonal Determinants: 1) Negative emotional states such as anger, anxiety,
depression and the like 2) Urges and temptations 3) Testing personal control in the sense of
whether one can again be a social drinker.
(ii) Interpersonal Determinants: 1) Interpersonal conflict, negative confrontation 2)
Social and peer group pressure to take a drink. Therefore, we can summarize the
antecedents of relapse as negative emotional states, interpersonal conflicts and social
pressure.
(2) Middle Stage
Here the major concern is psychological recovery. The alcoholic faces the naked
primary life struggles without alcohol. Here physical recovery continues and
psychologically the alcoholic sees clearly the fundamental realities such as marriage, family
relationships, career and friends. There could be a sense of isolation as separated from his
drinking partners. There could be feelings of guilt over unresolved sexual issues since
during the drinking period the alcoholic usually messes this aspect of his life. With regard to
sexual behaviour two patterns are noted: one of them is that sexual behaviour starts with
alcohol and ends with alcohol and therefore after sobriety there is no misconduct. The other
is having problem independently of drinking though drinking may accompany such sexual
activities.
(3) Later Stage & Beyond
The major task is to integrate and accept one’s identity as an alcoholic. Now the
physical and the psychological recoveries tend to stabilize.
Once one becomes an alcoholic, he is always an alcoholic in the future. For him no
social drinking is safe.
5) The Original Twelve Steps
What seem to help addicts are 12 steps as guiding principles. Here below you have
the original 12 steps published by Alcoholics Anonymous. It can be modified and tailored
to the needs of the groups or individuals. Some groups change the religious tone of some
steps.
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
understood Him.
4. Made a searching and fearless moral inventory of ourselves.
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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 understood Him, praying only for knowledge of His will for us and the power to
carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics, and to practice these principles in all our affairs.207
19. Conclusion
Among all the types of counselling the one most discouraging for the counsellor is
counselling the substance abusers. Whereas in other types of counselling the counsellor is
rewarded psychologically seeing the change and growth of the client, here he is rarely
blessed with such success because of the relapse which is part of the recovery process. To
my knowledge the rehabilitating institutes can boast of 60% of recovery among the
substance abusers and that too for two years. This only indicates the failure rate in this type
of helping. There is a tendency among the counsellors not to take up such cases and if taken
by chance they would like to abandon it at the first relapse. Of course, it is definitely
discouraging for a person in helping profession. If we go by success alone, especially in
helping profession we may be missing the mark. Success may be there or may not be there
but what is praise-worthy is the fact that the counsellor was an understanding person with
the substance abuser in spite of the relapse. Though the natural reaction of the counsellor is
to get angry and give up, seeing the manipulative psychological games of a drug abuser, if
he only perseveres in his attitude to help him he would have ameliorated the life of the
substance abuser to a greater extent. Therefore, undaunted by the failure in this case, the
counsellor is called upon to render his service, knowing beforehand that there may be
failures. Whatever help we can afford to even a relapsing substance abuser, it is worth the
trouble.
15
COUNSELLING THE GROUP
1. Introduction
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Sociologically a group is an aggregate of persons who are seen by themselves
and others as psychologically interdependent and interactive in pursuit of a shared
goal. The purpose of the group may be to prevent, or correct something, or to
enhance something.
2. Group Counselling Therapy
In our discussion the phrase ‘group counselling’ and ‘group therapy’ are
interchangeably used though of course there are differences. In fact, in therapy, deeprooted personality changes are aimed at; whereas in counselling, problems of
emotional nature are undertaken. It is the emotional instability that brings in problems
for a normal individual and this requires counselling. Psychotherapy is used for
severely disturbed persons while counselling is used for moderately disturbed
persons. In psychotherapy the therapist leads the client giving direction and changing
methods and procedures as he deems it necessary, whereas in counselling the
counsellor accompanies the counsellee. Therapy attends to people’s needs that are
unconscious, and their past, to bring about personality change. Now even healthy
people take to therapy for healthier living. Counselling focuses on conscious
problems which are not psychotic but problems that are social, educational,
vocational and personal. These were rather strict differences practiced formerly but
now the differences narrow down and there is a blending of these two types of
techniques for the betterment of the individual. One may start with counselling and
end up with a therapy, or start with a therapy and end up with counselling. In my own
experience I make use of both of them as the situations warrant.208 Let us sum up the
differences as follows:
Counselling
1. Aims at
Problems of emotional,
social, educational,
vocational & personal
nature
Therapy
Deep-rooted problems &
personality change
2. Addresses Conscious needs
Unconscious needs & to resolve the past
to bring about a change in the present
3. Role of Accompanies the counsellee
counsellor operating between being
moderately directive
and moderately
non-directive
Directs & leads the counsellee,
proposing methods & procedures
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3. Types of Group Therapy
Counselling the group means that counselling is done in a group setting instead
of one-to-one. This being the case, even in group setting, one can adopt two types of
approaches.
1) One-To-One (Vertical Interventions)
Some group counsellors may attend to the individual participants, paying little
attention to other group members. In a way they are said to be doing individual
counselling in a group setting. This is referred to as vertical intervention. In this
method, the therapist or the counsellor deals with one individual of the group at a
time, while the rest of the group members observe the work in progress and their
services (interventions) are utilized when needed by the therapist to facilitate the
process that is going on with the individual. As the therapy proceeds on one-to-one
basis, suddenly the client may become aware of, for example, his lack of courage to
say ‘no’ to significant people or to his peers. At this juncture the therapist may ask
the client to look around and identify the persons who look like his significant
persons and go and stand in front of them and say ‘no.’ Here the therapist makes use
of the group members for aiding a particular client to learn a certain skill. When one
completes his work, another volunteer is taken up for therapy with the call ‘who
wants to work next?’ Or it may happen that one individual was working for sometime
and got stuck in the middle. The therapist leaves him where he is with the instruction
to report to the therapist when he is ready to wok further, and he goes to another
individual. So it is also possible that several members are engaged, one after another,
without any of them completing the work. Thus we find a lot of variations in the oneto-one basis psychotherapy. This is the model used by Perls (1969) in Gestalt
Therapies and Berne (1966) in Transactional Analysis (TA).
2) Interactional Here-And-Now Model (Horizontal Intervention)
Some group counsellors focus the attention on the group setting, group
relationship building, group tasks, and group process with a view to plunge the group
into the here-and-now experience and to draw attention to the implications of the
nature of group member’s relationships with one another. Here the group focuses its
attention on itself and moves towards the group goals. This is referred to as horizontal
intervention. In this model the group as a whole decides how to go about and what to
work with; in a way the whole responsibility rests with the group in their interaction,
and the therapist’s major responsibility is to facilitate the process of the group with
one another. Here too I find therapists taking responsibilities at different levels. Some
take a very non-directive approach while others take a moderately directive approach.
Whatever be the level of approach the therapist may take, his main thrust is to
facilitate the interactional process of the group members.
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On my part I do not stick to one particular group mode. I may start with an
individual and involve the group, or take an issue of the group process and end up
with one individual who is significantly involved. For example, a person in a group
feels vulnerable on account of many individuals in the group. It is an individual’s
perception followed by a feeling of being hurt. While dealing with that one individual
on the issue of being hurt I may make the group focus its attention on individuals
who are involved with that one person. Or, many speak of a disturbing element of the
group in veiled terms. The group may be asked to identify the disturbing element and
focus its attention on perhaps one individual. I find more useful to combine both
approaches than adhering to only one approach depending upon the situation.
Practically speaking, for certain groups it will be beneficial to leave them to
themselves to manage their affairs giving very little direction, especially when a
group is a select and screened one. For other groups, the facilitator could give some
more stimulation by a little more of direction. For beginners who have no experience
of any sort with groups, the facilitator could plan out certain exercises and direction.
This is only as a preparation and later it should lead them to stand on their own. By
experience I have learned to leave the group for sometime in the beginning without
any direction and this helps the group members to unfold their interpersonal style for
themselves and for me; the rudiments of the personal problems could also be noted.
Later, I begin to respond and then aid the members to come to grips with their
problems. Depending upon the gravity of the problem, there are also times when
before the other members respond I seize the occasion to respond and set the tone for
healing and later involve the whole members.209
4. Traditional Group Therapies210
1) Didactic Group Therapy: This method involves presentation of more or
less formal lectures, group discussion on the lectures and presentation of visual
materials. 2) Psychodrama: It is a role-playing technique. The participants along
with the staff or by themselves are asked to act out their problem situations in a
theatre-like setting. No doubt this technique frees the individuals from their anxieties,
fears, and hostilities and helps them relive their traumatic experiences in real life-like
situations without being found fault with for their expression. The individuals get an
emotional catharsis, greater insight into themselves and enhanced interpersonal
competencies. This technique of psychodrama is used for children with emotional
problem in an unstructured manner of playful nature, so that children are able to act
out their emotional problems without any interference.
5. Intensive Group Expressions211
There are a number of group experiences that can go on in a group. Let us list
below some of the common experiences. They can also be taken as separate groups
catering to particular needs of the participants. 1) Sensitivity Training Groups: It is
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also known as T-Group focusing on the development of human relations skills. 2)
Encounter Groups: It has a variety of forms, focusing on the modifications of the
maladaptive behaviours and the fostering of effectiveness among the normal persons.
3) Awareness Groups: Using non-verbal expression, spontaneous dance and the like,
the focus is on the sensory awareness, body awareness and body movements. 4)
Creativity Groups or Workshops: Through painting and other art media, the focus
is on spontaneity, free expression and creativity. 5) Therapy Groups: The main
thrust here is to treat the patients. Now even normal persons are helped by therapy for
effective living. In my practice, I combine all the five group expressions depending
upon the need of the given group.
6. Group Therapy
Among group expressions, Encounter Group deserves our attentions as it is the
one most practiced. For all practical purposes, nowadays Encounter Group Therapy is
the same as Group Therapy. Therefore speaking about Encounter Group Therapy, we
are actually speaking about the Group Therapy, since basically all the group
expressions are the same, with only some variations.
Encounter-Group Therapy212
Encounter groups are many and are different in forms. Some of them are the
offshoots of Sensitivity Training or T-groups and some others are from some of the
leading growth centres. Some of the encounter groups concentrate on helping normal
individuals learn more about how their feelings and behaviour affect themselves and
others and focus on the treatment of personal problems.
1) The Format and Goals
There is a great deal of flexibility, experimentation and format in encounter
groups. There are leader-led groups, leaderless groups, marathon groups and
confrontation groups. Usually the group consists of participants from 6 to 12, with
one or two group leaders. Actually a group process can be formed of persons from 8
to 16. I find that if the number is below 8, the group process is too intense for the
participants and if it is more than 18, the participants feel anonymous. A group
formed of 12 members seem to be ideal for the group process. Though the goals of
the groups may vary, what is commonly aimed at is to provide an intensive group
experience to work through emotional problems and achieve effective coping
techniques. The group leader creates a climate of psychological safety and
encourages the participants to give descriptive feedback (of what one feels) rather
than evaluative feedback (what others are).
2) The Group Process213
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The aim of the process is to aid people to remove their masks, give free and
honest expression to their feelings, and resolve conflicts that arise within the group
by giving honest and prompt feedback whether it is positive or negative. Non-verbal
warming up exercises such as eyeball-to-eyeball gazing (into each other’s eyes) for
60 to 90 seconds, blind mill of all the members walking around with closed eyes,
learning how to communicate by touch, and trusting exercises of members in turn
being lifted and passed around in a circle, and at times partial or total disrobing to
enhance spontaneity are all used in the group process. There is also a marathon
format of encounter group in a live-in weekend in which opening up to one another is
hastened and facilitated by the lowering of inhibitions that accompanies fatigue due
to the heavy schedule. Such a marathon encounter group has also been called a
‘pressure cooker’ because of the built-up emotional tension and the reduced amount
of time required for therapeutic purposes. In the sessions, both intrapersonal problems
and interpersonal problems can be dealt with.
3) Termination and Re-entry
The life lived outside is different from the one that is lived in encounter groups
where one can give honest feedback, be straightforward and choose to be what one
wants to be. To facilitate the transition from the life of the encounter group to the real
life situation, in some cases, the participants are asked to share how they will go and
meet life in the everyday context. Some other leaders guide the group members in a
fantasy-like meditation of taking leave of the present group and of facing the
hardships of life.
7. Group Process in Encounter Groups214
1) Milling Around
The group is made to understand that it has the unusual freedom and also the
responsibility for the direction of the group. There is the initial silence, hesitation,
confusion, awkwardness and frustration followed by questions about the group itself.
2) Superficial Talk
Group members avoid talking about personal matters and show only their
public selves.
3) Expression of Negative Feelings
The first expression of feelings could be negative ones directed against the
other members or the leader.
4) Exploring and Expressing Personal Matters
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A climate of trust begins to emerge so much so that the participants feel rather
free to express their personal matters.
5) Expressing Immediate Interpersonal Feelings
Participants express their positive and negative feelings they are experiencing
here and now.
6) Group Healing and the Beginning of Change
The group as such, or at least a few of the members, spontaneously respond
to the pain and suffering of the group which effects a change in the individual.
7) Demand for Unveiling
There comes a time in the group life when the members demand that nobody
should hide behind a façade. Any sign of insincerity and hiding is sharply resented to.
There is a demand from the members to be one’s true self and show one’s
vulnerability. There was a well educated man in my group experience. He was
portraying himself as a man without blemish and well balanced. As the days passed
by, the group members demanded that he should reveal his vulnerability. As the
group process progresses, anything insincere, phoney, invulnerable and invincible is
strongly resented to by the group members.
8) Expression of Positive Feelings
By now the group members have a rather high regard for one another
especially for those who invested more by way of opening up their wounds. There
develops warmth, friendship, appreciation and acceptance among the members. In
short we can say that there is forming, storming, norming, and finally performing;
or as orientation, resistance, negotiations, intimacy and finally termination. Some
see the process as one of information stage, involvement stage, transition stage,
working stage and ending stage.
8. Group Process Dynamics215
Whatever be the type of group one may form, attention is paid to the
interacting process otherwise known as group dynamics. The forces that interact to
influence one’s behaviour in groups are fluid and changing and that is why we term
them dynamics. There are four areas of group dynamics.
1) Communication Patterns
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For a group, the communication patterns are important whether they are verbal
or non-verbal. Paying attention to the type of communication, the facilitator can aid
the group to adopt healthy ways of communicating to achieve their goals.
2) Cohesiveness
Cohesiveness means the members’ attraction for one another. Research has
shown that the higher the cohesiveness the greater the self-disclosure, support and
acceptance. Therefore, group cohesiveness is an important determinant of positive
therapeutic results. Group cohesiveness is simply the compatibility of the
personalities of the group members.
3) Social Control
Social control refers to the methods by which the group gains sufficient
compliance and conformity from its members for functioning in an orderly manner.
Social control will include aspects of norms, roles and status of the individuals
forming the group. The group learns how to control the destructive behaviours of the
members. In this sense it functions as an agent of social control within the context of
a group.
4) Group Culture
It refers to the beliefs, customs and values shared by the group members.
9. Stages of Community-Making in Group Therapy according to M. Scott
Peck216
Group functioning can be analysed from different angles; it can be studied in
terms of the process or in terms of the dynamics, or in terms of the stages of
community-making. Whatever angle one takes to study the group functioning, one
will soon realize that ultimately all these analyses point out the same characteristics
in different words. We have already seen the group functioning in terms of the
process and dynamics, and now let us consider it in terms of the stages of
community-making according to Dr. M. Scott Peck. For him, there are four
discernible stages in community-making though all the stages may not be there when
a group is formed in response to crisis. Otherwise, it is natural for any group to
undergo the four stages described by Scott.
1) Pseudo Community
The first response of the group members as soon as they come together in any
interaction is to be pleasant to one another in a faking way. Their pleasantness to one
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another is only pretence and not genuinely expressive of their true selves and that is
why this stage is called pseudo-community.
(1) Conflict Avoidance
The pseudo-community is characterized by its attempt to avoid conflicts.
Conflicts and pleasantness will not go together, and in order to maintain pleasantness
the members meticulously avoid conflicts. One does not say anything that will
displease another, nor does one show one’s annoyance when irritated by the others’
behaviour.
(2) Denial of Individual Difference
In pseudo-community the members pretend as though all seem to have the
same experience and conviction and so they speak in terms of generalities without
referring to personal experience. One may say for example ‘How hard it is to deal
with the teenagers!’ instead of saying ‘I am finding it difficult to deal with my teenage son.’ Individual differences exist just because we have different experiences.
The joy experienced by one may not be the same as experienced by another; it is
because of the individual difference. Whenever people speak in terms of generality
they seem to be denying individual differences; on the contrary whenever people
speak in personal terms, they are accepting and confirming the individual differences.
Members in pseudo-community purposely avoid using personal terms and use
generalities thus denying individual differences.
(3) Flight
The pseudo-community usually flees from troublesome issues and problems.
The flight or fleeing is from anything that might cause conflicts. Flight or fleeing can
also be seen in ignoring the emotional pains of the individuals. An individual might
be sharing his vulnerability but the group may ignore it altogether and attend to
something quite different thus leaving him to fend for himself.
2) Chaos
Chaos marks the second stage of the community-making. The group cannot
remain too long in the state of conflict avoidance. The pleasant front is slowly
removed and there emerges confusion and fights.
(1) Fights & Struggles
Each one in the group has his / her own proposals and expectations and when
pooled together it only creates confusion since nobody helps to set the right direction.
In despair, not knowing what to do and how to go about, the group members become
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frustrated and blame one another and even fight with the leader for his lack of
leadership to steer the group process.
(2) Emergence of Secondary Leaders
Since the group members believe that they do not have a worthwhile leadership
to guide the course of actions, some spontaneously become the spokespersons of the
group and take up the leadership giving directions and proposals as to what is to be
done. Usually the secondary leaders propose something that will be more organized
and stable. It is in fact a flight into organization instead of facing their problems
squarely.
(3) Pairing
Pairing of the members might interfere with healthy community-building.
Pairing in itself may not be wrong but if the pairing is going to separate the pairs
from the group, it will not facilitate community building. Since the attention of the
pair is given to each other exclusively, the other community members receive less
attention from them.
(4) Dependency
In chaos, the members look up to the leader to take up the direction of the
community. In a true community it is not the leader who bears the whole burden of
decision making. Each one of the members has the responsibility towards the success
of community-building. Most people in chaos long for a father figure to guide them
and if the leader is non-authoritarian, the group resents him very much. Until the
members realize that they are a ‘group-of-all-leaders,’ their dependency will continue
to disturb community-building.
3) Emptiness
There seem to be only two ways to get out of the chaos. One is through
organization in which confusion does not exist or at least minimized. The other way
is through emptiness. But organization will not help community-building. Let us
consider in detail what one needs to empty in order to build up the community.
(1) Expectations & Perceptions
We are more deceived by our expectations than by the external events. If our
expectations are of one type and the unfolding event is of another type, we get
frustrated. We carry a lot of expectations (and our own way of perceiving) into
community-building. When we enter a community with our own preconceived ideas
and expectations we want the people and the situations to fit into our expectations. If
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that were so, things usually do not work out well. One profits more, when one keeps
an open and flexible mind to fit into whatever is happening over in the group.
(2) Prejudices
Prejudices are more unconscious and they are judgments made about other
people without any experience of them. Thus they may be far removed from reality
and one cannot think of community-building with unreality. The members need to
shed their prejudices about others in the group in order to be open to accept reality.
(3) Ideology & Solutions
Each one in the group thinks that his ideology is the best and the solutions he
proposes will solve all the problems. Little do we realize that we have only partial
truth and others might have a mighty share to contribute to the fullness of truth. One
needs to empty oneself of one’s ideology and pet solutions so that one can profit from
others’ ideologies and solutions and thus build up the community.
(4) Need to Heal, Convert, Fix or Solve
The need one feels to heal, convert, fix or solve in a group may be self-centred.
It may be disturbing for one to see one’s friend suffering and so wants to heal; it is
equally disturbing for one to see that the other is not on the right track and so one
wants to convert the other; it troubles one deeply when problems are left without
being solved, for solving problems gives a sense of surety.
(5) Need to Control
The temptation to control the group is more for the group leader than for the
members. All the same, the members too experience this particular need strongly at
times. When things are not under control, everything looks shaky. We implicitly
believe that in control, community-building is done more easily. But the fact is that
control usually stifles growth and community-building. One needs to empty oneself
of one’s need to control the group in order to build the community.
4) Community
The final stage is community, in which there is peace, harmony and
tranquillity. The members would have known one another at deeper level especially
the vulnerability of each other. Individuality of each person is totally respected and
appreciated. There is no compulsion of any sort to hide, heal and convert. Joys and
sorrows are equally expressed. One wants to embrace everyone — all at once. It is
like falling in love with everyone! Now problem-solving comes very easily. If there
is true community-building, problem-solving is effortless. The reason why many
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groups struggle to solve problems is that they have not first completed communitybuilding. For any problem-solving groups, the cardinal rule should be: Communitybuilding first, problem-solving second. Sometimes the experience of true community
might release enormous sexual energy. Here the sexual energy will mean the
expression of the joy of the community. Group members need to be aware of this
aspect of their life and channel the energy of their sexuality by appropriate closeness
congruent to one’s culture.
In brief, we have seen the different stages through which a group goes in
community making. Practically in every group we encounter such stages. They are
not much different from the process or dynamics of the group we have seen in the
foregoing pages. Dr. M. Scott Peck’s insights give us additional information about
the functioning of the group.
10. Advantages of Group Therapy
Group therapy or counselling has some compelling reasons for which it is
worth practicing.
1) Our life styles and walks of life often do not socialize us enough to be at
ease with people from different walks of life and life styles. By mingling in a group
of heterogeneous members, one gets socialized.
2) Each one acts in a group the way he will act in any other group. Our
behaviour in a particular group is a fair specimen of our behaviour in similar
situations. Therefore, to get insight into the way we behave in any group can be
understood in group therapies. This is what we mean by telling that we will gain
insight into our interpersonal style of relating to others. Being immediate with a
group, one learns to be immediate with others in real life. Interpersonal style is
nothing other than one’s characteristic ways of thinking about and interacting with
other people together with one’s interpersonal skills and one’s successes and failures
in one’s human relationships. The notion of interpersonal style might include such
traits like extensiveness in the sense of how much of time one spends with how many
people, needs and wants, caring, competence, feelings and emotions, intimacy,
rejection and loneliness, interpersonal influence, mutuality, work relationships and
values.
3) Seeing the other group members working out problems similar to those of
oneself, provides one with a model to work out one’s own problems.
4) One is substantially helped by the group to work out one’s problem and to
learn new coping skills.
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5) One gets a support system which means that a person gets a group of people
who are both nourishing and realistic.
6) In a one-to-one individual counselling the client has chance to reality-testing
only in a limited way, whereas in a group he has a wider reality-testing ambience.
7) In a group one helps himself by helping others. In a group setting one helps
and is helped in the same session. The interdependence that is experienced in a group,
facilitates one’s growth when one becomes an agent of healing in the lives of other
participants.
8) Group therapy is a short-term educative system compared to individual
counselling or therapy.
9) In a group, individuals in a way lose their identity and become less
conscious so that they could naturally respond to one another.
10) Counselling or doing therapy for each individual is time-consuming and if
a number of them get together and start working, a lot of time can be saved and in
this way it is more economic compared to individual counselling.
11) Personality develops in contact with others; and group therapy provides
such a rich ambient so that individuals can experience a tremendous growth in their
personality.
12) One learns to understand other people and their viewpoints.
13) One could develop deep respect for people who are much different from
oneself.
14) We learn social skills to deal with our peers.
15) We gain confidence in our perception and decisions. Thus socialization,
knowledge of one’s interpersonal style, modelling, support, getting a support system,
getting a wider range of reality-testing, being helped while helping others, educating
a number of participants in a short while, responding spontaneously, developing
one’s own personality, understanding other people’s views, learning some social
skills and becoming confident seem to indicate valid reasons in favour of group
therapy.
I find that group therapy is the easiest means to bring about awareness in an
individual because of the resources of the other participants. Not only awareness, but
even change is easily effected through the intervention of the participants, and above
all, the interpersonal style of the participants automatically unfolds itself without their
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consciously doing anything about it; whether one interacts or withdraws, it can very
well indicate one’s interpersonal style.217
11. Casualties in Encounter Groups
Encounter groups may meet with failure for various reasons. They are:
1) Inadequate training of the leader: Group counselling is not the same as
individual counselling. Though the basic attitudes and the skills may be the same, the
context is entirely different. Here the context makes a world of difference. The
counsellor and the participants provide a number of stimuli to a given individual of
the group because they form a system and in every system, there is the circulatory
relationship. This is precisely the difference for which the counsellor should have
training to deal with. If the training he received does not equip him sufficiently he
may not be adequately facilitating the group on account of which setbacks may creep
in.
2) Indiscriminate selection of the participants: I have noticed this fact a number
of times especially in the counsellor training groups. When I have not previously
selected the participants, there used to be a lot of problems. Some by very nature
react negatively to the group process and sabotage the effort of the facilitator.
3) Inappropriate confrontation is another cause of failure. One needs to keep in
mind that without caring confrontation, no worthwhile growth can be stimulated in
individuals. Only the low level functioning counsellors do not make use of the skill of
confrontation, otherwise called challenging. But the manner of confronting might
undermine the intended service, as when there is no preparation before the
confrontation and no care after the confrontation. Normally preparation should
precede confrontation, and care should follow it. Confrontations or challenges are to
be given in terms of feedbacks. Feedbacks are not one’s reaction to what another
person is or does, but it is a sharing of one’s perception about the other. Instead of
telling how the other person is, one could say what one feels or thinks; for example,
instead of calling a person a liar, one could express the difficulty in understanding
him as telling the truth; that is, instead of telling ‘you are a liar, 'one says ‘I am not
able to understand exactly what you mean, by what you said earlier and now.’ With
regard to challenges and feedbacks, one could follow the general principles laid down
in counselling psychology for the use of the skill of challenging.218
4) Inadequate follow-up: Normally group sessions are for a short while, and if
growth were to continue and new behaviour patterns were to be imbibed, they require
time and repetition which reinforce the new behaviour. For this purpose, follow-up
programmes are helpful. When there are no sufficient follow-up measures, the efforts
of the group therapy may die out eventually.
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12. Risk Factors in Encounter Groups219
The results of group therapies are quite positive, though there are also failures
and risks. Let us consider those risk factors in group therapies.
1) Temporary change: Of course in the beginning people feel a lot of
enthusiasm about the change they experience, but in the course of time, people
relapse, with the result that the change is only short-lived.
2) Some participants get very much involved in revealing themselves in groups
but may not have enough time to work through; many issues may remain unfinished.
3) In mixed groups (of both genders), there may be the danger of getting too
involved with another person, even sexually, and it might jeopardize the marriage.
4) Loneliness: For some in group therapy, loneliness poses a trouble. Loneliness
is part of human existence. In group, when an individual drops some of his defences,
he is most vulnerable to loneliness. Though loneliness can be experienced at different
levels, it is sharpest in the person who has shed his customary defences. One of the
reasons that keeps us locked in our loneliness is the belief that the hidden self of ours
will not be loved by others if they come to know of it. But the paradox is that unless
one is ready to risk being and revealing more of his self to others, there is no healing
of the loneliness. There are also many ways to allay loneliness; encounter groups are
one means, if only people want to be their true self to others in intimate encounter in
a group.
13. Group Selection
Since the success of the group can be sabotaged by the inappropriate selection
of the participants, the organizer needs to keep certain guidelines in mind while
screening the participants:
1) Persons who suffer from brain damage may not be ideal. Much depends
upon the severity of the damage. People with major brain damage may not contribute
very much to the growth of the group, and they perhaps may profit from other forms
of therapies than group therapies.
2) Strongly suicidal persons may be demanding so much of time and energy
that the group might feel it too much to invest in just one individual. Certainly there
could be people who have suicidal tendency, but in a minor degree, and such people
could be very well dealt with in the group.
3) Psychotic patients: All of us suffer in someway or other from neurosis, but
people typically undergoing psychiatric treatment for psychosis need not be included
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in groups that are meant for the growth of ‘normal’ individuals. Here particular
mention should be made of paranoid type since suspicion is their main problem; this
disorder might create unnecessary animosity among the group members.
4) Excessive substance abusers: Substance abusers are those who
immoderately use alcohol or drugs; they may not fit into the normal functioning of
the group since they may be in their ‘trip’ while the session is on.
5) Persons who are highly self-centred: I remember having such a type of
person in a group. She would talk for hours together. A session of one-and-half hours
was not enough for her to introduce the problem she was facing. Self-centred people
want to keep the whole session revolving around them and the other participants may
not get anything for their own nourishment. One need not misunderstand that the
categories mentioned above should not have the benefit of group therapy. Of course
they need to have such a benefit and we should provide opportunities for them. All
that I am trying to say is that in a group of ‘normal’ persons aiming at enhanced life,
the above mentioned categories may not fit in. On the contrary we need to organize
special groups for alcoholics, drug dependents, suicidals and psychotics under
treatment to help them become better-adjusted.
6) Homogeneous Vs. Heterogeneous: Homogeneous group is easy to handle,
but heterogeneous group provides a wide range of reality-testing and experience.
14. Self-Disclosure in Group Therapy
1) Self-Disclosure by the Facilitator
Self-disclosure in counselling is a skill to be used prudently for the benefit of
the client. It is the sharing by the counsellor of his experience bearing on the problem
of the client when he judges that such a sharing is going to be beneficial for the
client. Here one needs to follow the principles laid down in counselling psychology
regarding how self-disclosure ought to be.220 Of course, counselling psychologists
are divided among themselves with regard to its effectiveness and so it is said to be
ambivalent in its effects. Generally speaking, excessive self-disclosure may be a sign
of exhibitionism and too little of the same may be a sign of closedness, which may
indicate ill-health. Therefore, facilitative self-disclosure will be appropriate, which
strikes a balance between the two extremes.
2) Self-Disclosure in Participants
Among the participants there are different levels of self-disclosure: 1)
Impersonal ideas and information, 2) Personal experience of the past and also that
which had taken place outside the group; e.g. ‘Two years back I was betrayed by a
close friend of mine,’ 3) Dealing with current events but that which takes place
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outside the group; e.g. ‘Whenever I see my father coming late at night, I am angry
with him,’ 4) Feelings and thoughts one is experiencing or having right now in the
session; e.g. ‘I dislike the way (pointing to the facilitator) you are mentioning my
name,’ 5) Sharing personal problems which are not ordinarily discussed; e.g. ‘I have
an affair with a young widow and I feel guilty about it.’
Self-disclosure is a risk, and no growth is possible without risks! It may be true
that some of the self-disclosures might bring in problems; but fearing problems, if
one were to refrain from self-disclosure, no worthwhile growth is possible, nor can
one facilitate a high degree of growth in another. There are also researches that
indicate that the people who are transparent on account of self-disclosure do respond
favourably to medicine. There is also evidence that self-disclosure is related to selfesteem. The higher the self-esteem, the higher the self-disclosure. I think
cohesiveness and self-disclosure too are related. In groups of greater cohesiveness,
the members are spontaneous to share their very personal problems.
15. The Facilitator’s Role
After discussing so much on the group and its process, our discussion will not
be complete if I do not comment on the role of the facilitator. So I would like to share
some of my understanding based on the proposals of Carl R. Rogers regarding the
specific role and attitudes of the facilitator.221
1) Psychological Educator: Because of his learning, training and background,
he is able to give accurate information about human behaviours and thus he can
educate the participants and impart psychological knowledge. As a psychological
educator he is able to (1) motivate the group members, (2) support the group in times
of crisis, especially when individuals feel victimized, and (3) employ his skills for the
growth of the group.
2) Facilitating personal growth and monitoring the same.
3) Reinforcing the Behaviour Change in the individuals in the group. The
group therapy is like a lab in which people can experiment new behaviours in which
they may not have much confidence, but with the reinforcement of the counsellor,
individuals practice the new behaviour patterns with ease and comfort.
4) Climate Setting: An extremely unstructured opening of the group seems to
produce good results. Giving the freedom to the group (to make the session what they
want to make of it) seems to be the right attitude of the facilitator. For example, if
they decide to waste their time on trivial things or keep intellectualising, it is their
business since they want it that way and they are responsible for it. Let the group take
the responsibility for the group work. The facilitator will ensure a psychologically
safe climate. A participant may feel uncomfortable in the group but the facilitator
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should not let a person feel unsafe. This psychological safety does not spare the
individual from the risks and the pains he may experience on revealing his
vulnerability or on receiving an honest feedback from the group members regarding
what he is and how he comports. But the vulnerable individual should feel that at
least there is one person in the group who listens to him till the end and will
understand however absurd and abnormal he may seem to be.
5) Acceptance of the Group: Every group is unique because of the unique
members who make up the group. Encountering a group with any preconceived idea
is doomed to meet with failure since the group may not fit into the type of image the
facilitator has already formed of it. It is definitely rewarding to take the group as it is
instead of saying ‘if only there were some more educated persons or more
experienced persons’ and the like.
6) Acceptance of the individuals: This is already implicit in one’s accepting of
the group. If a particular individual wants to remain without committing, he should be
given that freedom to remain on the periphery. The fact that he has the freedom to
withdraw will impel him to participate in later sessions. When I was participating in a
group therapy the facilitator was very hard on a person who was excessively fearful
since he had no previous experience of having participated in any group process. I
thought that if left to himself, the person would have participated in later sessions.
7) Empathic Understanding: Empathy means the accurate understanding of
what the client is experiencing within himself and communicating this understanding
either verbally or non-verbally or by both to the satisfaction of the client. Thus there
are three components of empathy. First, it is to understand what is really going on
within the individual. The second component of empathy is communication of your
understanding to the client. Mere understanding and communicating our experience
are not enough but it should be communicated to the satisfaction of the client, which
is the third component of empathy. We can also distinguish between basic empathy
and advanced empathy. Basic empathy means understanding the apparent or surface
feeling of the client and communicating that understanding of the apparent feeling.
Advanced empathy will mean that you pick up the buried feelings of the client and
communicate the same to his satisfaction. Here in group therapy, being empathic will
mean that the facilitator picks up the feelings of the participant, both apparent and
buried, and reflects them to the satisfaction of the participant.
8) Operating in Terms of One’s Feeling: That one experiences a particular
feeling at a given moment is the reality. Being truthful to oneself, one learns to be
truthful to others. In a group process, for example, that I get annoyed at the way one
functions is true but my expression of my annoyance may or may not be appropriate
depending upon the situation and the person. Not to be true to one’s feelings in group
situation is not genuine but one has the choice to express it at the very moment or not.
When called upon, the facilitator may need to “own” his feelings.
Types of Counselling-9-To Press
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9) Challenges & Feedbacks: Challenges given in terms of feedbacks are
essential for the growth of the individuals. This needs to be done without accusing a
person, or being judgemental. When the person has had enough of challenges and
wants to be left alone for the time being, the facilitator should be sensitive enough to
give him the respite.
10) Expression of Own Problems (Self -Disclosure): It is the self-disclosure of
a disturbing element in the life of the facilitator, at that particular moment. The
facilitator needs to deal with his problems with a counsellor or in any other group in
which he is a participant. But a thing that is very much on the mind of the facilitator,
which prevents him from listening properly but at the same time it will not divert the
attention of the group or its process, the facilitator is welcome to come out with it.
The counsellor shares with the group that which prevents him from being facilitative
right now like anything from the set up or from the group that disturbs him.
11) Avoidance of Excessive planning and Exercises: Nothing rewards a group
more than spontaneity. If a planned strategy is given, the members have to fit into it
whereas if left to themselves they can give expression to their own needs without
being interrupted or feeling guilty for doing so. This does not mean that the
facilitator need not outline a procedure for the group.
12) Physical Contact & Movement: In a spontaneous group there need not be a
lot of protocol with regard to movements in the group or physical contact unless it is
intended otherwise for therapeutic purposes. For example, if a person works through
a grieving process I gently urge the group members to express their care and concern
to the individual. Mostly all of them express it physically. What comes as a natural
form of expression of care and tenderness needs to be fostered.
13) Non-Facilitative Behaviours: (1) Wanting to create a name for oneself at
the expense of the group (2) Pushing the group and manipulating with rules and
regulations (3) Judging the success or the failures of the group by its dramatics (4)
Holding one single line of approach as the only essential element in group
counselling (5) Centring the group on oneself because of the great problems he may
be facing (6) Giving frequent interpretations to the motives and behaviours of the
participants (7) Withholding oneself from emotional participation in the group; the
facilitator too forms a part of the total system of the group and so it is also
appropriate that he emotionally participates in the group.
16. Conclusion
Individual counselling and group counselling are alternative forms of healing.
Both forms have their own rightful places in counselling psychology. People respond
differently to individual counselling and group counselling. For some people
Types of Counselling-9-To Press
211
individual counselling seems to be more beneficial than group counselling. For some
others, group counselling seems to be more beneficial than individual counselling.
At times for the same person, individual counselling is appropriate for some issues
and group counselling is profitable for some other issues; for example, in couple
counselling there are some sessions, which are individual and some other sessions,
which are in a group. Therefore, a categorical statement about the effectiveness of
individual and group counselling cannot be made.
All the same, group counselling provides more stimulation for growth if an
individual is open to it. For persons who are too shy, group counselling is traumatic
and therefore they may not see the effectiveness of group counselling in their lives in
the beginning stages. But later, in the long run, they will realize how useful group
counselling had been. I for one would resort to group counselling whenever possible,
for I realize that group counselling has more potentials for change than individual
counselling on the average.
16
CONCLUSION
Counselling is an art. One needs to have the know-how and the skills
necessary for counselling. The counselling skills, which flow from the attitudes, are
more or less the same for any kind of counselling but they are exercised in different
contexts.
Those who know counselling skills in general need to know the context in
order to exercise the skills. For example, empathy is a skill; it can be used in
individual counselling of a child or an adolescent, in couple counselling, and in group
counselling. The very same skill is being used in different contexts. The way
empathy is used while counselling a child and counselling an adolescent may appear
different because of the different contexts. Therefore, dealing with Types of
Counselling, we learn the different contexts that constitute the setting for the use of
counselling skills.
All the preceding chapters focus on different contexts a counsellor will meet in
his counselling situations. If knowledge about the contexts themselves is not clear to
the counsellor, he may take a normal phase as pathological, or a pathological case as
a normal development. For example, ‘black out’ relating to the happenings while a
drunkard is intoxicated is a normal phenomenon and the drunkard will not have any
memory of what he said or did in intoxication when he becomes sober. The way he
is refusing to accept or own the things he said or did while in his drunken stage does
not mean that he is lying and thus it is not a character defect but the effect of
alcoholism. Thus, acquaintance with all the normal phenomena of life-span
Types of Counselling-9-To Press
212
developmental and situational crises is essential for a counsellor to be effective in
counselling. Therefore, we have dealt more or less with all the phenomena of
different life situations.
Types of Counselling presuppose that the counsellor is rather well versed in the
skills of counselling. In the treatise on the ‘Types of Counselling’ one cannot look
for the skills. A counsellor being conversant with the skills of counselling alone is
not enough. He needs some therapies to be used appropriately according to the
context. There is no fixed rule as to which type of therapy is to be used in each
situation. It may vary from situation to situation, from person to person, and from
counsellor to counsellor. The more the counsellor is acquainted with the many
schools of psychology and their methods of therapy, the better and more efficient he
is to deal with any situation. One may respond to Gestalt Therapy while another may
respond to Rational Emotive Behaviour Therapy. A counsellor may have a
preference for one form of therapy from a particular school of psychology. Therefore,
taking into account such facts, I have given only general guidelines as to counselling
the various types of people. I have given a broad spectrum of orientation so that the
counsellor can choose what he wants.
There is a new trend in humanities, especially sociology and psychology, to
understand the human phenomena in terms of systems. We have a tendency to
explain an effect in terms of a single cause. A single cause-effect link does not
adequately explain the complex phenomena of a human person and society. Human
problems are multifaceted and so the solutions to his problems too are multifaceted.
Everything in the world is a system being embedded in a larger system and having
parts, which are subsystems that reciprocally interact with one another. This systems
concept makes us become aware of the complexity of the human situation, warning
us not to be simplistic in our explanation. System is the same as context. Therefore,
it is worth taking into account (while counselling) one’s context, antecedents and the
like.
While speaking of a system, I am inclined to think that the counsellor himself
forms a part of the system of the counsellee. Therefore, there is no question of
detached non-personal counselling but an involved and personal counselling in which
both the counsellor and the counsellee are vulnerable to each other and to the whole
context (system). Therefore, when the client gets healed, the counsellor himself is
healed of some aspects of his life, and when the client gets frustrated, the counsellor
too is frustrated in some aspects. This idea only reinforces the concept that
counselling is a mutual collaborative process.
In counselling, an approach I found useful is, concentrating on the relationship
more than on the individuals. Be it individual counselling, or dyadic counselling or
group counselling, it is always effective to concentrate on relationship and its quality.
For example, an individual having a low self-esteem is having problem in his
Types of Counselling-9-To Press
213
relationship; a couple quarrelling over finance is having problem in the relationship
between them and not the finance; a member in a group sulking is having problem
with his interpersonal style (relationship with others). Thus, low self-esteem, finance
and sulking are all symptoms of the dysfunctional relationship people have. Instead
of focusing on things like low-esteem, finance and sulking, the counsellor could
focus on the relationship and its quality the respective people have. For, if the
relationship of the couple and its quality are healthy, they are not going to quarrel
with each other over finance.
Another idea I would like to highlight is the distinction between ‘identified
patient’ and the ‘real patient.’ Counsellors usually meet the identified patients only
and not the real ones. A sick family projects its problem on someone in the family
and identifies that person as a patient. That identified patient’s behaviour, in fact,
shows the problem, but the truth is that the identified patient’s maladaptive behaviour
is initiated and maintained by the entire family. Treating the symptoms of the
identified patient is not going to solve the problem, but the entire sick family has to
be treated. Every family has its own identified patient and likewise every group,
every society and every nation. This again brings us to the idea of the system (the
context) that is sick.
While writing this book (Types of Counselling), I am having in mind the
counsellor trainees who are rather novices in the field of counselling. For their sake,
I have attempted to synthesize and pack a lot of information hoping that they will find
them useful. My preoccupation with the beginners need not deter the professional
counsellors from profiting from reading this book. Beginners are bound to make
mistakes, and I invite the counsellor trainees not to be discouraged but to go ahead
practicing counselling in various situations in spite of the initial setbacks.
I have not proposed the last word on every type of counselling, but rather I
have attempted to stimulate the reader to understand the complex phenomena with
available information, coupled with my comments on them. I wish that the reader
would find them stimulating to learn further and practise counselling. Hope you had
a rewarding and enriching perusal of the book, and I wish you success in your
counselling ministry.
ENDNOTES
1
R. Murray Thomas, Counselling and Life-span Development. New Delhi: Sage
Publications, 1989, 186; Robert J. Wicks, Richard D. Parsons & Donald Capps. (Eds.),
Clinical Handbook of Pastoral Counselling. Volume I, New York: Integration Books,
1993, 186-190.
2
S. Narayana Rao, Counselling Psychology. New Delhi: Tata McGraw-Hill Publishing
Company Limited, 1987, 34-35.
Types of Counselling-9-To Press
3
214
Eugene Kennedy & Sara Charles, On Becoming a Counsellor. Mumbai: Asian Trading
Corporation, 1992, 376.
4
Doug Stevens, Called to Care. Michigan: Zondervan Publishing House, 1985, 54-55;
Sheri A. Wallace & Michael D. Lewis, Becoming a Professional Counsellor. New Delhi:
SAGE Publications, 1990, 14; R. Murray Thomas, Counselling and Life-span
Development. New Delhi: SAGE Publications, 1989, 143-148; Clifford T. Morgan,
Richard A. King, John R. Weisz and John Schopller, Introduction to Psychology. New
Delhi : Tata McGraw-Hill Publishing Company Limited, 1993, 473; Jeffrey S. Turner &
Donald B. Helms, Lifespan Development. New York: CBS College Publishing , 1983, 28,
32, 35, 47.
5
Elizabeth B. Hurlock, Child Growth and Development. New Delhi: TATA McGraw-Hill
Publishing Company Ltd., 1998, 14; D. John Antony, Skills of Counselling. Nagercoil,
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6
Sheri A. Wallace & Michael D. Lewis, Becoming a Professional Counsellor. New Delhi:
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7
Robert Kegan, The Evolving Self. London: Harvard University Press, 1982, 107-109.
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9
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10
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11
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12
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14
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18
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