Spirituality

Indian Psychiatric Society In Association with Medical Wing, R.E.R.F.

Editor Avdesh Sharma

Spirituality & Mental Health

Spirituality & Mental Health:

Reflections of the Past Applications in the Present Projections for the Future

Indian Psychiatric Society ‘Spirituality and Mental Health’ Task Force (2008-2009)

: In association with :

Medical Wing,
Rajyoga Education and Research Foundation, Mount Abu

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Spirituality & Mental Health

Spirituality & Mental Health: Reflections of the Past, Applications in the Present; Projections for the Future

IndianPsychiatricSociety 2009 All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright holder.

The views expressed in this publication are the authors own and do not reflect directly or otherwise the Indian Psychiatric Society or Rajyoga Education and Research Foundation/Brahmakumaris.

Printed at Om Shanti Press, Mount Abu

Indian Psychiatric Society’s ‘Spirituality and Mental Health’ Task Force (2008-2009) In association with Medical Wing, Rajyoga Education and Research Foundation, Mount Abu

 

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FOREWORD

‘Spirituality and Mental Health:
Reflections of the Past; Applications in the
Present; Projections for the Future’ is in your
hands. It is through the efforts of Indian
Psychiatric Society’s Task Force on
‘Spirituality and Mental Health’ in association
with Medical Wing of Rajyoga Education
and Research Foundation. Yet, in a way, it is reflective of the inner needs of larger number of mental health professionals in India and indeed globally.

The book is a mix of philosophy and spirituality in various shades; essence of religions and meditative practices, as well as the cutting edge scientific knowledge in the field. It focuses on how we could learn to incorporate best of knowledge from all essential dimensions of life, utilize them synergistically through a workable holistic model to cost effectively reach the largest numbers.

The book has attracted leading International and National authorities, who have written, worked on, lectured or thought about these dimensions. The ultimate benefit would be when these aspects are experimented upon and utilized on a day to day basis. It is then only that we may be able to create a model of holistic mental health care delivery for India and hopefully rest of the world.

I commend the work done by the I.P.S. Task Force on ‘Spirituality and Mental Health’ and the authors for their time and efforts and hope that the book would become both a practitioner’s manual and work of reference.

Dr. P.C. Shastri,

President (2008-2009) Indian Psychiatric Society

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Introduction Spirituality & Mental Health SPIRITUALITY AND

MENTAL HEALTH

Spirituality refers to the individual’s
personal experience that provides a greater
sense of inner peace, harmony,
hopefulness, and compassion for others
and oneself. The term ‘spiritus’ in Latin means ‘the breath’ that is most vital to life. It involves individual’s experience of and relationship with a fundamental, nonmaterial aspect of the universe that may be referred to in many ways-God, Higher power, Mystery whereby an individual finds meaning and connectedness to something greater than oneself. Religion is an organized belief system promulgated and sustained by a human institution, ethnic group, tribe or culture and involves definite rules of behaviour, practices and rituals. The English word religion comes from the Latin ‘ religio ‘ meaning reverence, though a deeper study reveals it to be a combination of two words, ‘ Re ‘ meaning return and ‘ Ligare ‘ meaning ‘to bind’. Religiousness may focus on the personal attitudes, emotions and personality factors. Spirituality may encompass positive emotions- love, hope, joy, forgiveness, compassion, trust, gratitude and awe. Religion refers to the interpersonal and institutional aspects of religio-spirituality based on the doctrines, values and traditions of a formal religious group. In this context, religion draws circles that draw others out, whereas spirituality draws circles that draw others in. Spirituality is based on our biology, whereas religion is based on our culture.

Spiritual practices have been documented to improve physical functioning, self esteem, drug compliance, and longevity. Anxiolytic, antidepressant, and anticraving effects of religio- spiritual practices have also been cited in the literature. Positive desirable effects of religio-spiritual practices include decreased functional disability and better perceived health. Religious salience or spiritual practice may be a protective factor in depression. Intrinsic religiosity is significantly associated with a greater

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likelihood of remission. Involvement in religious/ spiritual practices

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may also reduce suicidal risk. Similarly spiritually augmented cognitive behaviour therapy (CBT) is superior to CBT in relapse

prevention of illnesses, especially substance use disorders.The mechanisms underlying beneficial effects of spiritual practices may include biological factors involved in positive emotions. Also, lifestyle modifications necessitated by methodical religious/ spiritual practices may add to the positive outcome in subjects. Group religious/ spiritual practices may help in developing better coping strategies and a sense of hope born out of compassion and empathetic understanding.

Neurobiological explorations may partly explain the changes in the brain related to attentional network and in regions implicated in positive emotions. The relaxation response in spiritual practice may be related to parasympathetic overdrive. However, sympathetic overdrive may be manifest in extreme stages of some of the spiritual practices. Neurochemical alterations may reflect primarily dopaminergic activation. Alterations in serotonergic, cholinergic and glutamatergic system have also been documented.

However, the research has not shown that lack of spiritual/ religious inclination results in disease, or that spirituality is the most important health factor. It would be better to conduct research to unearth the need for a spiritual history, spirituality related inputs in culturally relevant psychotherapeutic interventions, and the possible health promoting and neuroplastic attributes of religious/ spiritual practices.

The present book focuses on all these aspects and the diverse inputs from authorities in their field makes it a work of reference and starting point for future research and practice.

Dr. E. Mohan Das

President, Indian Psychiatric Society (2009-2010)

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SECRETARY’S DESK

I am glad to know that a book on
Psychiatry & Spirituality has been
published. As per WHO, Health is a state
of complete wellbeing — physical, mental,
social and let us not forget spiritual. A book
linking the two dimensions of health, mental and spiritual is indeed needed.

Especially in the Indian tradition, many senior psychiatrists have used spirituality as an integral part of psychotherapy. Heartiest congratulations to Dr. Avdesh Sharma for the successful culmination of his efforts in the form of this book. I am confident that his work as the Chairman of Mental Health and Spirituality, a Sub Specialty of Indian Psychiatry Society will continue in the same vein and help us all enrich ourselves– both mentally and spiritually.

Dr. Govind Bang

Hon. Secretary General, Indian Psychiatric Society (2008-2010)

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INSPIRATIONS

The world today is at crossroads. We have made tremendous progress in the field of science and medicine yet we are notabletoeliminatedistress. Theutopian dream of having health, peace, happiness apart from physical and mental comforts is still that – A Dream. It may not be a possibility unless we bring in Spirituality in Scientific endeavors.

Mind is the ‘experiencer’ of the inner and outer worlds and unless the perceived reality is in tune with the original nature of the soul, a sense of incompleteness would exit. It is thus extremely necessary to include spiritual dimension in all aspects ofhealth,especiallymentalhealth. We,attheRajyogaEducation and Research Foundation believe that one of the main tasks of human endeavors is to regain our original, perfect condition of the soul. It is heartening to note that leading mental health professionals also are looking at spirituality as one of the important ways to lessen human suffering. I congratulate the Indian Psychiatric Society for this important endeavor.

This book ‘Spirituality and Mental Health’ – Reflections of the past, Applications in the Present and Projections for the future’ is a labor of love by professionals on topics that are essential to humanexperienceofspiritualbeings. Itismybeliefthatitwould serve the purpose of bringing awareness amongst professionals to serve humanity better.

Wishing all success to those associated with this ambitious project of bringing out a new publication!

B.K. Nirwair

Secretary General, Rajyoga Education and Research Foundation Prajapita Brahma Kumaris Ishwariya Vishwa Vidyalaya, Mount Abu (Raj.)

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EDITORIAL

Spirituality & Mental Health

Mental Health has come a long way in
the last century. The scenario in terms of
understanding and management of mental
illnesses has changed dramatically in the
last 100, 50 or even ten years. The strides
in the world have translated into better
services in India as well. We have seen a
jump in the number of mental health
professionals from when Indian Psychiatric Society (IPS) was formed from a few dozen to now a few thousand. The same trends are seen in the number of beds, availability of professionals (even at district levels), availability of various groups of medicines and the budget outlay. Yet, A Gap exists in provision of Mental Health to the community.

The mental health gap exists for the numbers who need it and what is available (professionals, hospital beds, integration of mental health with physical health and the type of services that can be available). The gap also exists for encompassing other important dimensions in the gambit of health. Spirituality, the essence of religion and one of the essential ways of understanding human existence needs to be in the center but is largely ignored. Thus, it creates a Spiritual Gap.

Spiritual dimension (we would like to demarcate many negative and regressive practices from it) already exists to provide and supplement the prevalent indigenous and modern medicine practices for reduction of burden of mental illnesses. Unfortunately, due to dualistic approaches, they are in conflict or competition with each other rather than complementary and synergistic. It is important to also realize that there are larger numbers who suffer from mental agony and emotional distress which is not classifiable. What about promotive and preventive mental health for which we have very few workable models in modern day mental health armamentarium?

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We have not been able to contain mental illnesses (they have increased in numbers and percentage of total pool of human suffering). Similarly, the biological basis of dis-ease may not be the cause but may co-relate with other dimensions. We do not have the time or resources to stem the human suffering, especially that caused by war, militancy, terrorism, disasters (manmade and natural), social breakdowns, economic and environmental crisis etc. except by inculcating a ‘higher dimension’ to what we are used to in our practice.

It is surprising that ‘Spiritual dimension’ which is seen as a support by 80-90% of the population worldwide (as measured by many international surveys) is largely left out by the mainstream mental health systems. We should not blindly incorporate any practice without it being substantiated on a scientific basis , but there is enough evidence now, especially when studied with modern day scientific tools that point towards robust role of spirituality in mental health. We may have to look at what is possible, what is applicable, how it can be done and how to have workable cost effective models for largest numbers.

The present book is a unique attempt to look at ‘Spirituality and Mental Health’ through ‘Reflecting on the Past’, ‘Applying it in the Present’ and ‘Projecting it for the Future’. We have tried to divide the book into three sections (Past, Present and Future) for the purpose of convenience of readers although there are no watertight compartments in Spirituality or Mental Health. We have tried to bring updated, scientific knowledge in the field from an international faculty who have knowledge of/worked in the field. Some of the essays are longer than others but the length is not reflective of quality; similarly, some essays are more ‘scientific’ and others more reflective. We have tried to include topics from diverse fields although it is not possible to be all encompassing.

The views expressed by the authors are their own and not necessarily of the Editor, Indian Psychiatric Society or Rajyoga Education and Research Foundation/ Brahma Kumaris.

 

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The attempt has been to involve mostly mental health

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professionals as authors so that they can focus on the concerns and mindset of fellow professionals. Yet, an enormous body of evidence and literature is available by thinkers and spiritualists who are doing yeoman service to lessen the burden of human suffering. Let the light come in from all openings, illuminating the path towards a common cause.

Editor

Dr. Avdesh Sharma

sharmaavdesh@gmail.com avdeshsharma@rahat.org

Editorial Team

Dr. Sujatha D. Sharma Rajeev Verma Manasi Sharma Dr. Nikhil Patel B.K. Sister Mathilde B.K. Manoj Singhal Dr. Partap Midha Dr. B.K. Banarasilal Sah B.K. David B.K. R.S. Bhatnagar B.K. Rishiraj Mehta Dr. Mahesh Hemadri Anil Kochar

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ACKNOWLEDGEMENTS

Some activities are blessed by God, The Supreme Father, and this one is. We would like to thank God for the blessings and the energy provided for our efforts.

We would like to thank the entire executive of Indian Psychiatric Society, specially Dr. P.C. Shastri, Dr.E. Mohandas, Dr.Govind Bang, Dr. Asim Mallick and Dr.T.S.S. Rao for their support and encouragement at each and every step. We also thank them for their faith in allowing us to carry out this work in a smooth manner.

We would like to extend our thanks to the Brahmakumaris, especially the Medical Wing of Rajyoga Educational and Research Foundation, Global Hospital, Janki Foundation and Om Shanti Press for providing the inputs at various levels including subsidized printing. We would specially like to thank Dadi Janki, Dadi Hridaymohini, Dadi Ratan Mohini, B.K. Nirwair,Dr. Ashok Mehta, Dr. Partap Midha, Dr. B.K. Banarasi Lal Sah, Dr. Girish Patel, B.K. Atam Prakash, Raj Suneja and many others who have made our task possible and easier, supporting in more ways than one.

We would like to thank our contributors, who have taken great pains at short notices, sometimes at the cost of their personal time to make this book possible. They have patiently cooperated

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Dr. Avdesh Sharma

Chairperson
IPS Task Force on ‘Spirituality & Mental Health’

Dr. Nikhil Patel

Convener IPS Task Force on ‘Spirituality & Mental Health’

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out of love and commitment for the subject to make it possible in a record time. There may be some differences in style of writing, or the length of essays, or the focus by each author. We feel it has added to the flavor of the end product rather than having just stuck to the ‘narrow confines of scientific literature’ alone. The views expressed are those of the authors and not necessarily of the editor, Indian Psychiatric Society or the Brahmakumaris/ Rajyoga Educational & Research Foundation.

We would not have finished this book without the active and untiring support of Mr.Rajeev Verma (who for three months was involved in the secretarial section), Dr. Sujatha Sharma (who gave her time willingly for editorial work), Manasi Sharma, who ably assisted her in these efforts and Sis. B.K. Mathilde, B.K. Manoj Singhal, Dr. Partap Midha, Dr. B.K. Banarasi Lal Sah & B.K. David, B.K. R.S. Bhatnagar, B.K. Rishiraj Mehta & Dr. Mahesh Hemadri for their editorital support. We acknowledge their commitment and services.

The book would not be here except for those whom it is meant for – YOU. We believe that the material in the book, after being processed by your wisdom will provide succor to those who need it. We also hope that the book would help in YOUR personal and professional growth. We wish that it can serve as an impetus for action – more literature, more research, more actionable programs on the ground. That would be our reward for many of our sleepless nights, days away from work, family and personal time.

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Contents

Foreword : P.C. Shastri iii

Introduction Secretary’s Desk Inspirations Editorial Acknowledgements Contents

: E. Mohandas
: Govind Bang
: B.K. Nirwair
: Avdesh Sharma
: Avdesh Sharma, Nikhil Patel :

iv-v vi vii viii-x xi-xii xiii-xv xvi-xx

xxi-xxii

Executive Committe of I.P.S.
Executive Committe of Medical Wing , R.E.R.F.

Section (I) : Reflections of the Past :

1. Mental Health and Spiritual Values: A view from the
East; N.N. Wig …………………………………………………….3-21

2. Mental Health in Ancient India & its relevance to Modern . Psychiatry; Shiv Gautam……………………………………. 23-52

3. Concepts of Spirituality and Ancient wisdom in Relation
to Modern Psychiatry; S.C. Malik…………………………. 53-73

4. Spirituality & Psychiatry : Complimentary or Contradictory – Based on Bhagavad-Gita; Mrugesh Vaishnav ………… 75-95

5. Yoga, Mind and Mental Health; Usha Sundaram ……. 97-110

6. Contemporary Relevance of Hinduism to Mental Health;
R. Srinivasa Murthy …………………………………………. 111-135

7. Islam and Mental Health; Afzal Javed ………………… 137-146

8. Vipassana Meditation: A Positive Mental Health Measure and the Path to Spiritual Fulfillment; R.M. Chokhani …… 147-159

9. Preksha Dhyan; Manaswi Gautam ……………………. 161-176

10. Sexuality and Spirituality; T.S.S. Rao & M.R. Asha 179-188

11. Spirituality: Biology of the Soul; Sanjeev Jain …….. 189-199

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Section (II) : Applications in the Present :

Spirituality & Mental Health

12. Soul, Mind, Body Medicine; Nikhil Patel …………….. 203-212

13. Rajyoga – Power of Silence for Positive Mental Health;
B.K. Nirwair …………………………………………………… 213-218

14. Healing Head and Heart; Usha Kiran …………………. 219-226

15. Blending Science and Spirituality; Mohit Gupta …… 229-236

16. Values in Healthcare: A Spiritual Approach for
Mental Health Practitioners; Sarah Eagger,
Arnold Desser, Craig Brown ……………………………. 237-250

17. Spirituality in Action: Global Hospital Experience;
B.K. Sister Mathilde ………………………………………… 251-260

18. Furthering the Spiritual Dimension of Psychiatry in the
United Kingdom; Andrew Powell ………………………. 261-283

19. Fostering Spirituality and Well Being
in Clinical Practice : ……………………………………….. 285-310 Part – I : Spirituality ,religion and Psychiatry : it’s application to clinical practice
Part – II : …… The Spiritually Augmented Cognitive Behavior Therapy – A meaning therapy for sustaining mental health and functional recovery; Russell D’Souza

20. Spirituality and Child Mental Health; P.C. Shastri ….. 311-325

21. Spirituality – A journey within the blossoming youth;

Jitendra Nagpal ………………………………………………

22. The Role of Spirituality in Disaster Situations:
Pir, Faqir and Psychotherapists and Psychosocial Intervention of Trauma; Mushtaq A. Margoob, Huda Mushtaq ………………………………………………..

23. Religion: A protective Factor in Suicide;
Lakshmi Vijayakumar ………………………………………

24. Spirituality and the Elderly; O.P. Sharma …………….

25. Spirituality for Ageing Gracefully;
Mahesh N. Hemadri ………………………………………..

26. Introspection and Spirituality:
A tool for Growth of Therapists; Veena Kapoor ……

27. Utlising Spiritual tools for Psychotherapy;
Dr. Rajesh Nagpal …………………………………………..

327-334

335-353

355-367 369-379

381-386 387-400 401-406

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Section (III) : Projections for the Future :

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28. Religion, Culture and Mental Health: Challenges Now and into the Future; Dinesh Bhugra & Keir Jones …….. 409-422

29. Spiritual Aspects of Psychiatry – The way Forward for the Future; Ajit Kumar Avasthi & Suresh Kumar ……… 423-432

30. Integrating Spirituality and Indigenous Methods in Mental Health Delivery; Rajesh Sagar & Rohit Garg ……… 433-454

31. Combining Spiritual Principles in Mental Health Care;
Uday Chaudhuri …………………………………………….. 455-463

32. Spirituality and Mental Health; Sudhir Khandelwal .. 465-474

33. Utilizing Tools of Spirituality in Day to Day Practice;
A.K. Agarwal ………………………………………………….. 475-490

34. Spiritual and Religious Beliefs in Health Care Delivery in a Developing Country; Haroon Rashid Chaudhry,
Raumish Masood Khan & Ismeet Leghari …………. 491-498

35. Neural Corelates of Spirituality;
E. MohanDas & V.Rajmohan …………………………… 499-516

36. The Biology of Spirituality: Religion from a Pill;
Chittranjan Andarade & Rajeev Radhakrishnan …. 517-530

37. Neurobiology of Spiritual Practices; A Brief Review
Arun V. Ravindran & Lakshmi N. Ravindran ………. 531-551

38. Spiritualism as a Preventive Strategy;
P.K. Singh & Vinay Kumar………………………………. 553-567

39. Meditation: The Future of Medication?;
Avdesh Sharma and Sujatha D. Sharma. ………….. 569-584

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IPS EXECUTIVE COUNCIL MEMBERS

Interim President: Dr. P. C. Shastri
Vice President: President Elect: Dr. E. Mohandas General Secretary: Dr. Govind Bang Treasurer: Dr. Asim Kumar Mallik
Editor: Dr. T. S. S. Rao

Dr. I. R. S. Reddy ( Immediate Past President) Dr. R. R. Ghosh Roy (Immediate Past Secretary)

IPS EXECUTIVE COUNCIL MEMBERS (DIRECT)

Dr. Malati Ghosh
Dr. T. Sudhir
Dr. S. M. Badur Mohideen Dr.(Col) H. R. A. Prabhu
Dr. Rajeev Jain ( Newly Elected) Dr. N. Dinesh ( Newly Elected) Dr. Rangarajan ( Newly Elected)

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ZONAL REPRESENTATIVE TO EXECUTIVE COUNCIL

NORTH ZONE:

Dr. Chander Mohan Dr. Lalit Batra

EAST ZONE :

Dr. Prabir Paul
Dr. K. L. Narayanan

WEST ZONE :

Dr. Govind Bang
Dr. Mukesh P. Jagiwala

SOUTH ZONE :

Dr. G. Swaminath Dr. K. Ashok Reddy

CENTRAL ZONE :

Dr. P. N. Shukla Dr. Rajeev Jai

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CHAIRMEN OF IPS COMMITTEES (TERM – TWO YEARS)

CME: Dr.S.Nambi (2007-2009)
Awards: Dr. Ajit Awasthi (2008-2010)
Ethics: Dr.Ajit Bhide(2008-2010)
Constitution: Dr.Tophan Pati(2007-2009)
Journal: Dr.T.S.S.Rao (2007-2009)
International affairs: Dr.Vikram Patel (2008-2010) Mental Hospitals: Dr.Sudhir kumar (Agra) Membership: Dr.Gautam Shah (2008-2010) Parliamentary: Dr.N.Bohra(2008-2010)
Psychiatry Education: Dr.Subhangi Parkar(2007-2009) Finance: Dr. R. Ponnudurai (2007-2009)

Speciality Sections: Chairmen and Convenors (Term: Two Years)

Military Psychiatry:

Col.D.S.Saldhana and Dr. (Lt.Col) P.S.Bhat (2007-2009)

Biological Psychiatry:

Dr. B. N. Gangadhar and Dr. Y. C. Janardhan Reddy

Child Psychiatry:

Dr.V.D.Krishnaram and Dr.Devashish Konar

Geriatric Psychiatry:

Dr. Charles Pinto (2006-8) & Dr. Venu Gopal Jhanwar (2008-10)

Forensic Psychiatry:

Dr. Yusuf Matcheswala and Dr. Kuruvilla Thomas (2008-10)

Rehabilitation:

Dr. Dr. Radha Krishnan and Dr. Arnay Bannerji (2008-10)

Community Psychiatry:

Dr. B. Prasad and Dr. Sanjay Gupta (2008-10)

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Private Psychiatry:

Dr. M.R. Jhanwar and Dr. M.P. Madhvan (2008-10)

Addiction and Alcoholism:

Dr. Vivek Benegal and Dr. Rajiv Gupta (2008-10)

Sexual Medicine and AIDS:

Dr. Mrugesh Vaishnav and Dr. Omprakash (2008-10)

IPS Task Forces: Chairmen and Convenors (Term: One Year)

Mental Health Legislation:

Chairman: Dr. Nimesh Desai
Convener: Dr. Rajesh Nagpal
SAARC Psychiatric Federation Constitution: Chairman: Dr. Prabir Paul
Convener: Dr. U.C. Garg
IPS Website:
Chairman: Dr. Mohan Raj
Convener: Dr. Mainak Mukherji
Research and Training:

Chairman: Dr. Chitranjan Andrade Convener: Dr. Nilesh Shah Women and Mental Health: Chairman: Dr. Gauri Devi Convener: Dr. Sonia Pariyal Disaster Management: Chairman: Dr. G.K. Vankar Convener: Dr. Jayant Chatterji Spirituality and Mental Health: Chairman: Dr. Avdesh Sharma Convener: Dr. Nikhil Patel

Media and Mental Health:

Chairman: Dr. Vidyadhar Watve Convener: Dr. Harish Shetty Clinical Practice Guidelines:

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Chairman: Dr. Shiv Gautam Convener: Dr. Ajit Awasthi

Suicide Prevention:

Chairman: Dr. A.K. Kala Convener: Dr. Laxmi Vijaykumar

Social Security Scheme:

Chairman: Dr. Roy Abraham Convener: Dr. Mukesh Jagiwala

Election Commission of IPS:

1. Dr. Ramanan Erat (Chairman)

2. Dr. Sarvesh Chandra (Convener)

3. Dr. Vinay Kumar (Member)

Tribunal of IPS:

1. Dr. S.C.Malik-Delhi

2. Dr. A.K.Agrawal- Lucknow

3. Dr. S.M.Channabasanna- Bangalore

4. Dr. Shiv Gautam-Jaipur

5. Dr. A.B.Ghosh Kolkata

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EXECUTIVE COMMITTEE OF MEDICAL WING

RAJYOGA EDUCATION AND RESEARCH FOUNDATION

Head Quarters: Pandav Bhawan, Mount Abu-307 501 (Raj.) India

President

Vice-President

Organising Secretary

Executive Secretary Mount Abu

Joint Secretary

Nagar

Treasurer Banjara Hills

: Dr. Mehta Ashok, Mumbai Vile Parle (W) : Dr. Midha Pratap, GHRC, Mount Abu
: Dr. Patel Girish, Mumbai Borivali (W)
: Dr. Sah Banarsilal, Pandav Bhawan,

: Dr. Shah Niranjanaben, Baroda, Alkapuri : Dr. Masand Prem, Indore
: Dr.Budhiraja Usha Kiran, Delhi, Shakti

: Dr. Agrawal Radheshyam, Hyderabad,

Executive Committe

 

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Section (I) : Reflections of the Past

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DR. N. N. WIG

Dr. Narendra Nath Wig is among the
foremost psychiatrists internationally. He
is a Fellow of the India’s prestigious National
Academy of Medical Science. In 1991, the
Royal College of Psychiatrists, London,
honored him with their highest award of the
Honorary Fellowship of the College. Prof. Wig is the only psychiatrist from India to be thus honored. In 1997, Dr. Wig was designated as Professor Emeritus, Postgraduate Institute of Medical Education & Research, Chandigarh.

Dr. Wig worked in PGIMER, Chandigarh and later AIIMS, New Delhi. In 1984, he joined World Health Organization as the Regional Advisor, Mental Health and remained at Alexandria, Egypt, till 1990. In this capacity, he was responsible for developing mental health programs in 22 countries, from Pakistan to Morocco in the Middle East and North Africa.

He has published over 300 scientific papers in different journals and books. He is currently a member of the WHO Advisory panel on mental health. For the last ten years ,he is on the Steering Committee of World Psychiatric Association’s International Program to reduce stigma and discrimination due to mental illness.

Dr. Wig has won many national and international awards. In October, 2000 on his 70th Birthday, a book ‘Mental Health in India 1950-2000’ was published in his honor in which many leading national and international mental health experts contributed. In April, 2003, Bombay Psychiatric Society honored him with Life Time Achievement Award.

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MENTAL HEALTH AND SPIRITUAL VALUES: A VIEW FROM THE EAST

N. N. WIG

1. Introduction : I come from India – a country which is associated with Spiritual traditions for thousands of years; which has been the home of some of the greatest religions of the world, like Hinduism, Buddhism, Jainism and Sikhism. All other great religions of the world like Islam, Christianity, Zoroastrianism, and Judaism have also deep roots in India for many centuries. It is a land where spirituality is almost a way of life; where even an illiterate farmer, or a poor worker or a housewife may surprise you with their knowledge and familiarity with philosophical issues of life.

I was brought up in such a tradition but I was also brought up in a Western education system where I learnt about science, art and humanities as seen in Europe or North America. I became a medical doctor, a physician and later a psychiatrist in the best tradition of Western Science. However, my inner conflict continued. I started seeing the world through Western eyes but continued to feel with an Indian heart. I marveled at scientific achievements but continued to feel the spiritual vacuum in my learning. To give an anology, in a lighter vein, the Western alcohol products like whisky, gin and rum are now manufactured in India. In the government excise records they have a funny common name, ‘I.M.F.L.’ or ‘Indian Made Foreign Liquor’. I often felt that I had similarly become an ‘Indian Made Foreign Doctor’. I was aware of the tremendous power of the Western medicine but I was also conscious of the value of my own cultural heritage. I am still struggling to learn how to combine the two for the good of my people.

I have lived with this dilemma for most of my life. Over the years, I have worked in many countries and cultures. I had my psychiatric training in the UK and the USA. Later I worked as a

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professor of psychiatry in India for many years and still later, through the offices of World Health Organization, I served in the countries of Middle East and North Africa and travelled extensively to many parts of the world. This cross cultural exposure has further convinced me that my experience is not unique in India. Most of my colleagues in health professions in non-western countries had faced similar conflicts in combining western science with their cultural traditions.

Along with that also came the realization that: 1) the spiritual values are not the monopoly of any single culture: each and every culture, East or West, had deeply experienced and examined such issues and 2) in the matters of health, science alone cannot provide all the answers. The spiritual dimension is an essential and important aspect of health, particularly mental health. I propose to discuss these two issues in detail with you today.

2. The Indian View of Mind and Mental Health : I begin first to give a brief account of how the question of mind and mental health has been seen in the Indian philosophy. It must be clarified at the outset that there is wide diversity of cultures and philosophical systems in India and a historical mix with Western modes of thinking in recent years has made it difficult to identify a uniform Indian paradigm of mind and mental health. The following account is more in the nature of a personal perception.

I began first with the certain obvious differences between Jewish-Christian-Islamic religions and the religious traditions as evolved in the Indian subcontinent. The first difficulty comes with the very word ‘Religion’. In the Indian languages there is no equivalent term to convey the meaning of the word ‘Religion’. The nearest term ‘Dharma’ is not an equivalent of religion. It is a mixture of cosmic order, sacred law, and religious duty. In Jewish- Christian-Islamic tradition there is one God, one book, one final prophet. As a result, religious history and written code of laws

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play a very important role in the Jewish-Christian-Islamic religions. In India, on the other hand, philosophy and mythology occupy a much more prominent position in the religious teachings.

Working in Islamic and Christian societies, I have been often struck by how different their concept of what is ‘religion’ is as compared to what I have understood as ‘Religion’ in my country. I remember once in Egypt, I spent considerable time in explaining to a Muslim friend what ‘Hindu’ religion is. He kept listening patiently and finally burst out: ‘All what you are telling me, Dr. Wig, is some kind of philosophy but I am sorry, it has nothing to do with religion’. I was reminded of an equally amusing anecdote mentioned by the famous writer Joseph Campbell in his book ‘Myth to Live By’. A Hindu Indian friend in U.S.A. told him the same thing about the Bible. He said, ‘I have read the Bible but I am sorry I cannot find any religion in it’. It is interesting, how our upbringing controls our understanding of even such common and universal concepts as ‘religion’.

Another striking difference between Indian and Western religions is the concept of ‘God’ or ‘Divine Reality’. In Jewish- Christian-Islamic tradition, ‘God’ is the Creator of the universe and everything in it. Thus the Creator, in a way is ‘Outside’ this world which he has created. In Indian tradition ‘God’ is not ‘outside there somewhere’ but is within you and within everything. The creation is continuity of the Creator like a spider’s web which is part of the spider. This thought is beautifully expressed in Sanskrit in the opening invocation to the famous Isa-Upanisad. I quote:

“purnam adah, purnam idam, purnat purnam-udacyate. purnasya, purnam adaya purnam evavasisyate”. (That is whole. This is whole. From the whole emerges the whole. The whole is taken from the whole but the whole remains).

In other words, the Ultimate Reality or ‘brahman’ as we say it

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in India is both transcendent and immanent. The creation of the universe does not in any manner affect the integrity of ‘brahman’.

2.1. Some Significant Features of Indian Philosophy : At this stage it may be useful to list some of the important features of Indian philosophy as they relate to our understanding of mind and mental health. The following account which has largely been taken from the book on Indian Philosophy by Dr. Radhakrishnan and Charles Moore (1967), illustrates the major differences of Indian and Western philosophical traditions:

1. The chief mark of Indian Philosophy in general is its concentration upon the spiritual. Both in life and in philosophy the spiritual motive is predominant in India. Neither man nor the universe is looked upon as physical in essence and material welfare is never recognized as the only goal of human life.

2. In India, philosophy and religion are intimately related. Philosophy is never considered as merely an intellectual exercise. Every Indian system seeks the truth not as ‘academic knowledge for its own sake’ but to learn the truth which shall make the man free.

3. Indian philosophy is characterized by introspective approach to reality. In pursuit of truth, Indian philosophy has been strongly dominated by concern with inner life and self of man rather than the external world of physical nature.

4. Indian philosophy is essentially idealistic. The tendency of Indian philosophy, especially Hinduism, has been in the direction of monistic idealism. Almost all schools of Indian philosophy believe that reality is ultimately one and spiritual.

5. Indianphilosophymakesunquestionedandextensiveuse of reason, but intuition is accepted as the major method through

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which the ultimate can be known. Reason and intellectual knowledge are not enough. Reason is not useless or fallacious, but it is insufficient. To know reality one must have actual experience of it. One does not merely know the truth in Indian philosophy, one has to realize it and live it.

6. TheIndianphilosophyisdominatedbysynthetictradition which is essential to the spirit and method of Indian philosophy. According to Indian tradition, true religion comprehends all religions, hence the famous Sanskrit saying ‘God is one but men call him by many names’.

2.2. Mind-Body Dichotomy : One common and recurrent theme in European literature is the body-mind dichotomy. It may be interesting to note here that in most of the non-European cultures this is not such an important issue. It seems to me that European thought, for some reason, is very much preoccupied with thinking in terms of dichotomies, be it body or mind, good or evil, nature or nurture. It is a kind of mind set. Science and medicine are full of controversies like what is more important; nature or nurture? genetics or environments? physical or mental? biological or psychological?, cognitive or emotional? and so on. Most of the time, we end up accepting that both sides are important.

In the Indian philosophical tradition, the world is seen more as a cyclic phenomenon or a continuum like the Chinese concept of ying and yang. As a result there is more tolerance and acceptance of opposing points of views than in European cultures.

2.3. Mental Health in Indian Tradition : One-line definitions do not do justice to complex cultural concepts. There are many references in Indian philosophical texts as to what constitutes an ideal person. The most often quoted text is from Srimad Bhagwad Gita describing the balanced person as one who has controlled

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his mind, emotions and senses.

For understanding the concept of mental health, perhaps more important than any one quote is the broad Hindu view of life as summed up in the well known four ends or broad aims of life (purushartha). These are dharma, kama, artha and moksha. dharma is righteousness, Virtue or religious duty. kama refers to fulfillment of our biological needs or sensual pleasures. artha refers to the fulfillment of our social needs and includes material gain, acquisition of wealth and social recognition. moksha which is a very typical Indian concept means liberation or release from worldly bondage and union with the ultimate Reality.

These four aims are a beautiful example of harmony of different dimensions of life: kama as the biological dimension, artha as the social dimension, and moksha as the spiritual dimension. dharma appears to be more as central axis around which life rotates. If you pursue kama or artha without dharma, the long term result is suffering for the individual and others around him or her.

3. The Cultural Context of Mental Health : I have been fortunate to have worked in a number of countries in Asia and Africa. Working in these countries, I have become even more aware of the important role which culture plays in mental health practice in this part of the world. In many documents on mental health programs in the countries of Middle East, the ‘Aims’ of such programs have been listed as promotion of mental health ‘in keeping with the cultural tradition of the country’. References to cultural factors including religion are repeatedly found in the publications on psychiatry and mental health in these countries. Almost all major psychiatrists in India, Pakistan, Iran, Egypt, Sudan or other countries of this region have written something or other about the importance of the cultural and religious factors in psychiatry. Many psychiatrists regularly use the religious

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teachings as a basis for the treatment of their patients and also for promoting community mental health programs. Here I refer to the works of Dr. Abou El Azayem about the role of Mosque in mental health including drug de-addiction programs in Egypt. Dr. Mubbashar and his colleagues in their work in schools and in the community in the villages of Rawalpindi district in Pakistan have included religious teachings as part of mental health promotion and so have Dr. Mohit and his colleagues in their work on mental health care in Iran. In India, Dr. Vahia’s work on the role of Yoga in the treatment of anxiety disorders is well known but it is more a novelty and now Yoga as a therapy is regularly used in many centers. One can multiply such examples from Japan, South East-Asia or Africa. The fact remains that cultural and religious methods are now very much a part of what goes on in the name of mental health practice in most of the countries of Asia and Africa.

While I fully support these developments in Non-Western societies to include the role of culture and religion in the mental health programs, I am conscious of two lurking dangers: One is that of ethno-centricity or the belief that ‘my culture is the best’ and the second is the likelihood of mental health becoming a movement away from science which is at present the basis of medicine and health.

4. TheDangerofEthno-Centricity:Historiansrepeatedly remind us how people in every major civilization in the past have been convinced that they are very special people and they are the very best of the best; may it be the Greeks or the Romans, the ancient Egyptians or Persians, the Vedic Aryans in India or people of May-Inca-Aztec civilizations in South America. All of them have shared this common belief.

At this point I would like to refer to the works of the great historian of this century, Arnold Toynbee. He wrote in 1946, what

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appears to me a very profound observation. I quote him:

“What will be singled out as the salient event of our time by future historians looking back at the twentieth century, say, in the year 2046? Not, I fancy, any of those sensational or catastrophic political and economic events which occupy the headlines of our newspapers today… The future historians will say, I think, that the great event of twentieth century was the impact of Western civilization upon all other living societies of the world. They will say that of this impact that it was so powerful and pervasive that it turned the lives of all its victims upside down and inside out, affecting the behaviour, outlook, feeling and belief of individual men, women and children”. (Toynbee, 1946)

What will happen still later in the centuries to follow? On this topic, the views of Arnold Toynbee are even more interesting. He foresees that “By that time, the victims will have produced tremendous counter effects in the life of the aggressor… The impact of the Western civilization on its contemporaries in the second half of the second millennium of the Christian era, will be regarded as the epoch making event of that age because it was the first step towards the unification of mankind into one single society”.

I find this analysis of Arnold Toynbee very relevant for understanding the cultural conflicts of our times. I would only add that the process of ‘Counter effect’ of other cultures on Western culture, which Toynbee thought would take a long time to come, has probably already started much earlier.

5. Science and Spiritual Values : When I was a young student in the mid-nineteen fifties we looked upon science and technology as the main solution to the problems of poverty and disease. The great Indian leader, Jawaharlal Nehru, repeatedly reminded us the need for a ‘scientific temper’ to banish ignorance

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and superstitions which have been dominating our culture for centuries. Alas, things have changed rapidly. Towards the end of 20th century, science no longer seems to occupy that exalted position as a panacea for all of life’s problems. The irony is that Western culture, the originator of modern science, is itself having serious doubts about the dominant place of science in life.

In June, 1995, I was in USA. A visit to USA is always stimulating in terms of new ideas. I do not think that, anywhere else in the world, one comes across such rapidly changing and conflicting ideas as one does in USA. This time I picked up two contrasting events related to science and spirituality from the daily press which I want to share.

The first one is the phenomenal success of the book ‘The Celestine Prophecy’ by James Redfield published in 1994. Since its publication it has been almost continuously on the best seller list. One is puzzled by the popularity of the book. It is the story about an ancient manuscript discovered in Peru with nine ‘insights’. The thin story revolves around how the hero goes to Peru in search of the ancient manuscript, how various coincidences occur and how one by one he discovers nine ‘insights’. The author seems to convey that by studying these insights we can become more spiritual, transporting ourselves to a higher plane of being. Rarely a book on philosophy or ‘Do-it- yourself-spiritualism’ as some people have called it has been so successful in the USA. It has been translated into over twenty languages.

Critics who in the beginning ridiculed the book as literary trash are now seriously examining how the book has attained so much success and popularity. One critic said that this book has “tapped into the spiritual hunger of a beleaguered world. A huge number of people today are dissatisfied with old ways of looking at the world. They want more out the world”. Randall Balmer, a

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professor of religion at Columbia University said, “After an era in which we are fixated with science and technology we are now realizing that although they made our lives easier, they did not teach us how to live”.

Around the same time, when the Celestine Prophecy was making a big splash in the USA and was being considered a symbol of new spiritual awakening, there was a meeting of leading US scientists at New York Academy of Sciences in June, 1995. The title of the meeting was ‘The Flight from Science and Reason’. Defenders of scientific methodology were urged to counter-attack against faith-healing, astrology and various other kinds of non- scientific creeds and practices. Scientists seemed to be in an aggressive mood. Dr. Gerald Weissman of New York University Medical Center said, “Medicine and Science today are being confronted by lunatics, fascists and the practitioners of bizarre magic”. Dr. Saul Green formerly of Sloan Kettering Cancer Institute, New York, declared that “It is time to get nasty – to launch a crusade against quackery” (N.Y. Times, June 6, 1995).

It seems that the intellectual climate is changing fast. Science which was earlier considered supreme is now suddenly on the defensive. The people all over the world are now talking about ‘alternatives’ to science, alternative to modern medicine and so on. I think three factors have played an important role in this development. The first is that though achievements of science continue to dazzle, people are now seriously worried about the heavy price which science demands in terms of destruction of natural resources and pollution. Its more malign creations like the nuclear weapons have made people doubt its value and question its virtue. The second factor is that though science continues to proclaim its ‘neutrality’ and ‘objectivity’, the people from the non-Western societies see science predominantly as a symbol of Western Civilization and not free from cultural bias. Margaret Lock, Professor of Humanities and Social Medicine at

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the McGill University, who delivered the Margaret Mead Memorial Lecture at the WFMH Congress in Japan in 1993, touched on how this attitude effects the field of mental health. I quote her, “Much recent research shows that the Western scientific endeavor is a product of specific historical and cultural contexts…… Analysis of knowledge and practice in health care sciences reveals the extent to which psychiatry and psychology in particular, are culturally informed. To embrace psychology as it is understood today, one must accept the European concept of ‘mind’ and its relationship to ‘body’, usually now embellished by a Freudian style unconscious or some variant of this concept”.

Prof. Vander Heer of Groningen who also spoke at the last WFMH Congress, observed that, “A theoretical reflection on and evaluation of the goals of Western psychotherapy and Western concept of normality, are intimately linked with the history of Western Christianity”.

The third and perhaps the most prominent factor is that science has produced a vacuum in our spiritual life. Science has inspired a vision of the universe, of the world and of man that was utterly opposed to all proceeding versions. It has denied man the possibility of finding an ultimate meaning and purpose of his life.

Bryan Appleyard writing under ‘Post Scientific Society’ in New Perspective Quarterly (1993) observed that, “By insisting on an open ended view of the world, liberal science based societies, deny the possibility of any stable conviction or positive virtue – only bland tolerance. But the soul of man requires explanations and guides for living – Is it any wonder that pious Muslims on the upsurge find our liberal societies so incomprehensible in their moral laxity and tolerance of anything that come along? Are they right in their suspicion that though the scientific west has triumphed economically and politically we may now be sinking

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beneath the weight of our own impiety?”

The Japanese philosopher Takeshi Umehara has gone even further and has written that the collapse of Marxism, which was only a side current of modernity, was the precursor to the collapse of secular liberalism, the main current of modernity. Both excommunicated ‘the other world, the world of spirit’.

Where do we go from here? My own conviction is that we are moving towards some kind of merger of scientific and spiritual cultures, though at present it is very difficult to say how it will come about. May be the initiative will come from science itself. Science by its very nature is constantly changing. One generation’s certainty is quite likely to be overthrown by the next. Czeslan Milosz, the poet, has argued that the new development in science – chaos theory and quantum physics – actually open the way for the reinvigoration of the religious imagination, of piety, or virtue, because they reintroduce complexity and eliminate reductionism in science. Above all, they promise to restore man to his pre-Copernican identity, rescuing him from the role to which he was assigned by 19th century science as a mere speck among others in the vast stretches of time and space.

6. MentalHealthandSpiritualValues–MovingTowards a Synthesis : There is no perfect definition of mental health acceptable across all cultures. Definitions differ, according to the point of view of the one who is defining it. Still, there is a broad agreement in most of the definitions to include under the term mental health, a state of harmony within the individual and harmony between the individual and others around him. My erstwhile senior colleague in the WHO, Norman Sartorius, has very well brought out the common pitfalls when we try to define mental health. First of these, is to believe that mental health or somatic health can exist on its own. Health is indivisible. Next is the belief that mental health and mental illness are mutually

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exclusive. Health is always present regardless of the presence of disease: as the skies are present in spite of the clouds on the horizon (Sartorius, 1988).

Is it necessary to include a spiritual dimension in our attempts to define mental health? I, of course, believe that it is so. Perhaps it may not be necessary if we are satisfied to work with a limited medical model and define health as merely absence of disease but to most of us especially those who are involved in the long term care of the mentally ill, or promotion of mental health, such limited definitions are not sufficient. When we consider mental health as a harmony within the individual and with the environment outside, I think we are talking in spiritual terms.

Furthermore, whatever be the debate among professionals, for a common man, the ideal state of mental health always has a spiritual connotation. This has been my experience working with people in many countries in Asia and Africa. Edith Morgan in her paper on Women, Family and Mental Health at WFMH meeting in Japan beautifully brought it out when she asked women in different countries. “What do you understand about mental health”? In both the examples she quoted, one from Greece and one from Canada, the respondents have mentioned spiritual aspect as an essential part of mental health. One said mental health is, “a strong spiritual sense of oneself”, the other said, “it is day to day awareness of balance between spirit, mind and body”. Dr. Shimazone of Tokyo University, again at the last WFMH meeting defines, “mental health a state in which the mind attains harmonious and good life”. Alan Roland who recently wrote a book In search of self in India and Japan, has proposed a four part structural theory of the self that includes 1) familial self, 2) individualized self, 3) spiritual self and 4) expanding self. According to Roland, the spiritual self, which Freud ignored, remains “deeply engraved in the pre-conscious of all Indians”. He further states that, “to interpret spiritual strivings, merely as a manifestation of

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psychological conflict, would be grossly misleading”.

I think we, the mental health professionals, must accept both science and spiritual values as essential ingredients for understanding another human being and to help him/her. Traditionally, mental health has been a bridge between the medical sciences and humanities. This special position should not be given up. A secular medical science without a spiritual basis slowly tends to become mechanized and dehumanized. Margaret Lock, in her paper on ‘Technology and Body and Utopias of Health’ at the last WFMH Congress, has beautifully brought out this danger of technomedicine when she says, “Contemporary medicine is perhaps best characterized by as technomedicine, a mind boggling outcome of Spencerian tradition, rushing onward and upward to a Utopia where health is understood purely in terms of biology, tamed through technological intervention and maintained by responsible individuals. In technomedicine the questions related to the moral and spiritual side of the individual are considered merely as frills of culture and have no place in an economically driven scientific regime”.

Can we accept this position? By only following the dictates of scientific technomedicine we have often moved away from issues which deeply concern human beings, to issues which we feel can be ‘scientifically solved’, of course with the huge material benefit to the health industry and professionals. Even the nature of our questions has changed. As the philosopher Hacking has pointed out, we no longer ask seriously, as was the case until this century. “What is human nature?”, instead we now ask, “What is normal, and now we can measure it?” In an earlier paper on psychiatric diagnosis and classification I have touched on this issue (Wig, 1985). For example, in all cultures, uncontrolled emotions like fear, anger, lust, greed are considered bad for the happiness of the individual and the society. In European psychiatry we have arbitrarily taken two emotional states, i.e.

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anxiety and depression, and in keeping with the tradition of modern secular technomedicine, we have raised them to the status of mental disorders. I ask you, if an excess of anxiety or depression is a mental disorder, why an excess of anger, lust or greed should not be regarded as mental disorders? Incidentally, who benefits from such classifications? The maximum benefit of course goes to the pharmaceutical industry. No sooner psychiatrists label anxiety or depression as diseases, the industry is out with ‘anti- anxiety’ or ‘anti-depressant’ drugs.

The central theme is a spiritual approach to life; that there is an essential mystery at the heart of all things. This mystery cannot be understood but has to be experienced. From the experience of this mystery we get this urge for ‘transcendence’, which is the essential feature of all spiritual approaches. In the past, mythic images in all cultures partly fulfilled this human need. One sad thing in our times is the slow erosions of our mythologies and their place in our lives. As Joseph Campbell has beautifully said in his book, The Inner Reaches of Outer Space, the seat of the soul is there where the outer and inner worlds meet. That is the wonderland of myth. He further adds, “The old Gods are dead or dying and people everywhere are searching, asking: What is the new mythology to be, the mythology of this unified earth as of one harmonious being… One cannot predict the next mythology any more than one can predict tonight’s dream; for a mythology is not an ideology. It is not something projected from the brain but something experienced from heart”.

Some of you may have noticed that throughout this chapter, I have made no effort to define the term ‘spiritual’. The standard dictionary phrases like ‘A system which affirms the existence of immaterial reality imperceptible to senses’ or ‘any philosophy accepting the notion of an infinite personal God or immortality of the Soul’ did not seem to cover all the various ways in which I have used this term in my address. What is the essence of

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Spirituality? In some ways it is nothing, and in some ways it is everything. I close with the following lines from Tao te Ching – the great Chinese book of wisdom, beautifully translated in English by Stephen Mitchell recently:

We join spokes together in a wheel, But it is the centre hole,
That makes the wagon move. We shape clay into a pot,
But it is the emptiness inside, That holds whatever we want. We hammer wood for house, But it is the inner space
That makes it livable.
We work with being,
But non being is what we use.

References:

Appleyard, B., (1993); Post Scientific society, New Perspectives Quarterly.

Basher, T. (1987); The Spiritual Dimension and Mental Health, Mary Hemingway Rees Lecture. Proceedings of WFMH, 1987, Congress, Cairo.

Lock, M. (1993); Towards Immorality: Technology of the body and Utopias of Health. Margaret Mead Memorial Lecture. Proceedings of WFMH 93 Congress, Japan.

Mitchell, S. (1993); Tao Te Ching – A New English Version. Proceedings of WFMH 93, Congress, Japan

Morgan, E. (1993); Women, the family and mental health.

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Proceedings of WFMH 93, Congress, Japan.

Roland, A. (1998); In Search of Self in India and Japan: Toward a cross-cultural psychology. Princeton University Press.

Sartorious, N. (1988); Health Promotion Strategies. Canadian J of Public Health, Supplement 2, 79.

Shimazono, S. 91993); Concept of mental health in modern Japan’s Religions. Proceedings of WFMH 93, Congress, Japan.

Toynbee, A. (1946); Civilization on Trial. London: Oxford University Press.

Vander Heer, P. (1993) Questions concerning western conception of healthy religion. Proceedings of WFMH 93, Congress, Japan.

Wig, N.N. (1985); Psychiatric classification – A view from the Third world. In Pichot, P., Berner, P., et al (eds.) Psychiatry – The state of the Art vol. I, New York: Plenum Press, 9, 45-50.

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Dr. Shiv Gautam

Born in 1952 at Chirana, a small
village of Jhunjhunu district, Rajasthan; he
did his post graduate studies (D.P.M.1976
& MD.1978) from NIMHANS, Banglore,
(India). He is currently Professor, Head of the Deptt.of Psychiatry & Superintendent of Psychiatric Centre, S.M.S. Medical College, Jaipur and Member Secretary, Rajasthan State Mental Health Authority. He has received Bhagwat Award, 1986, B.P.A.Award, 1988, Tilak Venkoba Rao Oration Award, 1989 and Marfatia Award, 1994. He also received the International New Horizon Award, 1989.

Dr. Gautam is known for his contribution in Mental Health Education to masses through print and electronic media.Professor Gautam has written 2 books, published over 110 original research papers in various national and international journals.

Dr. Gautam has served as North Zone President (IPS) and Chairman of International Affairs Committee and Parliamentary Committee of Indian Psychiatry Society, National Vice President (1998) and President (1999) of Indian Psychiatric Society. He is founder President of Mental Health Foundation, Jaipur.Prof. Gautam is member of Specialty Board of Psychiatry at National Board Examinations, Delhi.

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MENTAL HEALTH IN ANCIENT INDIA AND IT’S RELEVANCE

TO MODERN PSYCHIATRY
Shiv Gautam

On various occasions in the past in last two and half decades as a student of psychiatry, I have heard the leaders of Indian Psychiatry, past presidents of IPS and academicians involved in psychiatric education and research like Prof. J.S.Neki, Prof. Venkoba Rao, Prof. N. N. Wig, Prof. R.L.Kapoor, Prof. D.N.Nandi and many others stating that we must develop Indian models of psychotherapy for Indian patients, and they should be culturally oriented, as Western models of psychotherapy are not so well suited for Indian patients. In order to develop Indian models we have to have adequate knowledge of our heritage, how complexities of mind have been understood in the past and how there has been a subtle transfer of attitude from generation to generation without really having been through a formal education of this subject.

According to Hindu mythology the age of human race on the earth is over 8 million years which has been divided in four yugs- Satyug which lasted for 5.6 million years; Tretayug which lasted for 1.4 million years; Dwapar which lasted for 4.68 lac years and the present Kaliyug which started about 5000 years ago will last for 2,32,000 years. Modern geologists tell us that the earth is 4500 million years old and the earliest forms of life (protozoa) appeared 2700 million years ago. Two million years ago we were not yet men which we became just over a million years ago. The Indian thought and astrology claims the creation of Vedas few million years ago however the estimation of the age of ancient Indian literature by some Western researchers like Max Muller, Wintervitz has been estimated between 5000 to 1000 years B.C.

I have tried to review the ancient literature from pre vedic

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period (times immemorial), Vedic period (approximately 10000- 5000 BC), era of Upanishads (5000 to 2500 BC), era of the Mahabharata (Bhagwad Gita 3500 BC), Ayurvedic era(1400 BC), Yog darshan (approximately 5000 to 1000 BC), and other literature from 500 BC to 100 BC (The Puranas, Ramayana by Valmiki, Mahabharat, Abhigyan Shakantulam by Kalidas, Nyay darshan and Sankya darshan), and the Vendantas 2000 BC to 700 BC.

Access to this literature was possible at a library of ancient literature and quotes of various authors. Authenticity of historical era is not very important, what is important is how various aspects of mental health were perceived and understood in ancient India in the pre-Christ Era when most of Western civilizations were yet to develop.

Concept of mind in Vedas (10000 to 5000) BC

Mind has been conceived to be a functional element of ‘atman’ (soul which is self) in the Vedas which are earliest written script of human race. In Rig Veda and Yajur Veda there is mention of prayer through mantras (rhymes) for noble thoughts to come in the mind. Thought determine facial appearance, thoughts can be purified through mantras and purified thoughts influence instincts. In Rig Veda there is emphasis on prevention of mental pain (Depression)

In Rig Veda (Chapter 1- Richa 71, 76, 94, 46, 48) the speed of mind, curiosity for methods of mental happiness, prayers for mental happiness and methods of increasing medha (intelligence) have been described. It has been further stated in Rigveda that purification of mind prevents disease in human beings therefore one should have noble thoughts. The power of mind in healing has also been described in Rigveda. For the first time the three traits of personality – Sattva, Rajo, and Tama, were described in Rigveda (Rig 4/42/4) and also mental illnesses were independently identified along with physical illness in Rigveda (Rig

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1/105/7) where it has been prayed that may these mental illnesses not destroy this body.

In Yajur Veda mind has been conceptualized as the inner flame of knowledge. In 34th Chapter of Yajur Veda, the first six mantras lucidly describe various aspects of mind which says, “what is mind?” Perceiving knowledge is mind; mind is described as Yog and Samadhi (state of mind), All our sensory organs are under control of mind and they function under the control of mind.

In first six mantras of Shiv Sankalpamastu, important characteristics of ‘manas’ (mind) has been described. It speaks of speed of mind, state of mind during wakefullness (Jagrat) and dreamy state (Swapna). Mind has been described as a basis of consciousness and instrument of knowledge. Functions of mind have been described and a prayer has been made that the mind may work for welfare of all.

One Vedic statement tells us that Atman (Soul) consists of three elements

1. Mind 2. Vitality 3. Matter : We may see these three elements pervading us, as well as the whole world. Our mind represents knowledge, vitality represents action; and matter represents all worldly objects (earth) and all literature. One Vedic shruti says –

Knowledge begets will and will begets effort; effort begets action, action includes all born. Absolute as referred to above is the form of knowledge and will is in the form of mind. This knowledge manifests itself in the form of will in the world or the universe is the byproduct of this will hence the gross matter and the vitality pervading in the material world are the product of will – a product of manifest form of the Absolute.

In Atharva Veda, ‘manas’ has been described as an instrument

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of hypnotism. In the 6th chapter of Atharva Veda there is detailed description of preservation of will power, subjects related to psychology like emotion inspiration and consciousness. It describes various emotional states like grief, envy, pleasure, hostility, attachment, laziness, etc.

The description of ‘unmad’ (psychosis) in the Vedas is rather brief and it has been described as a deluded state of mind. The etiological factors described in the Vedas are fever, bacteria (krimi) which is equivalent to organic psychosis; those due to rakshash, gandharva, apsara etc., and sins towards Gods (with feelings of guilt) are equivalent to functional psychotic conditions as understood today. The methods of treatment of described in Vedas include ‘bheshaj’ (medicines) and prayer to the God by mantras (psychotherapy). There has been a mention of treatment of aggression (anger), epilepsy and sleep disorders, and prevention of mental disorder by Yam, Niyam, Asan, and pranayam. The first two refer to behavioural control while the latter two refer to physical activities (yogasan) and breathing exercises. (Atharvaveda)

Era of Upnishads (5000-2500 BC)

Upanishads are most important from the point of psychology, literal meaning being ‘sitting near’- as a student listening to a teachers secret teachings, it dates back to between years 5000 BC to 4000 BC. We are concerned with the profound psychological insights. The most important Upanishads are ‘Chhandogya upanishad’, ‘Shwetashwaropanishad’ which describe what is mind, various states of mind, and ‘Brihadranyaka Upanishad’ which describes the theories of perception, thought, chitta and smriti (memory). The Unpanishads also describe ‘prakriti’ which can be equated with personality in modern understanding.

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Sharirkopanishad, prakriti and characteristics of various prakrities. Three types of Manas prakriti have been described as Sattva, Rajas and Tamas and characteristics of all the personalities have been described. The characteristics of prakriti are based on objective observable behavioural patterns of the individuals and it is very interesting to note that even at that time the classification of character traits was as systematic as seen in modern personality inventories which have been developed after rigorous statistical exercises. The other important Upanishads which describe prakriti include Akshamalkopanishad, Bhavmantarnopanishad. Gopichandopanishad, while Saraswati rahashyopanishad has described philosophical prakriti as a separate personality.

This is the era when states of mind had been understood and four Avasthas – Jagrat (Waking state) Svapana (Dreaming state) Sushupti (Deep sleep state) and Samadhi were described. In present day we know various levels of consciousness from conscious to unconscious.

The psychic states were described as instincts, impulses and emotions and methods of how to control emotions and impulses were described. Various mental faculties are three Shaktis (Power/Potencies): Ichha Shakti (will) Kriya Shakti (Action) and Jnana-shakti (Knowledge). While the mental powers described are Vedana Shakti (Power of perception), Smarana Shakti (Power of Memory), Bhavana Shakti (Power of Imagination), Manisha Shakti (Power of Judgment) Sankalp Shakti (Will or Volition) and Dharana Shakti (Power of Hold) are the six important powers of the mind (Sivananda, 1983). The psychopathology was understood by Trigunas and Tridoshas.

The Era of Lord Rama (5000-4000 BC)

The era of Lord Rama (Treta yug) dates back approximately

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to 5000-4000 BC. However Ramayana was written by the scholars later on but several anecdotes of mental sufferings and miseries like the melancholia and depression of Dashrath, Lord Rama’s father who suffered from and ultimately died in despondency, is an illustration of major depressive disorder. Ramcharitramanas was written later, Valmiki Ramayana is said to have been written much earlier (500-300BC). Several other anecdotes of depressive disorder and grief reactions have been described in Ramayana.

The Era of Bhagvad Gita (3500 BC)

One may wonder why the Bhagvad Gita came in existence when we already had such scriptures as the Vedas and Upanishads. The great Vedantic sage Shanakra explained. “The Vedic dharma was practiced over a long time. But eventually discrimination and wisdom declined. Unrighteousness became more predominant then righteousness. The Vedas are the source of all streams of Indian philosophy, and the Upanishads are the later parts of the Vedas. With the decline of discrimination and wisdom, it became difficult for those who were not scholars to understand the teachings of the Vedas and Upanishads. So it was necessary to restate these teachings in a way that could be appreciated and assimilated by all”. (Swami Rama, 1978)

The Bhagvad Gita contains in condensed form all the philosophical and psycholoical wisdom of the Upanishads. It is said that the Upanishads are like a cow that Sri Krishna milks to bestow its nurturing wisdom to his dear friend and disciple, Arjuna. Sri Krishna imparts all the wisdom of the Vedic and Upanishadic literature through the teachings of the Bhagavad Gita. Rather than imparting a new trend of thought or expounding a new philosophy, Sri Krishna modified and simplified the Vedic and Upanishadic knowledge. He speaks to humanity through his dialogue with Arjuna. The word Arjuna means “one who makes sincere efforts” and the word Krishna means “the center of consciousness”. One

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who makes sincere efforts inevitably obtains the knowledge that directly flows from the center of consciousness.

Bhagvad Gita describes all aspects of yoga, psychology and is unique among the psychlogical and philosophical teachings for a student of psychotherapy, various aspects of psychotherapeutic techniques are described in it.

Earliest written description of symptoms of anxiety and depression is found here when Arjuna says:

My limbs are frozen, my mouth is drying up, my body trembles and hairs stand on end.

Gandiva, the great bow is slipping from my hands and my skin is burning. Nor can I stand up my mind is as it were whirling.

And I see inauspicious omens o Krishna, nor do I see any good occurring upon killing my own kinsmen in the battle.

– Bhagvad Gita: Chapter 1/29, 30, 31

My true nature subdued by the fault of miserableness, my mind deluded as to the righteous conduct I ask you whatever is definitely better do tell me that. I am your disciple surrendering to you do teach me and guide me.

I do not see anything that might remove this grief that is drying up my senses – not even a prosperous kingdom without enemies nor sovereignty over the gods.

– Bhagvad Gita, II: 7, 8

Anxiety sticken, sorrowful, depressed Arjuna is converted into the victorious warrior of the battle of Mahabharta through psychotherapy by the therapist Krishna.

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To him who was thus possessed with a pitiful mood, whose eyes were distressed and filled with tears, who was suffering from sadness the destroyer of Madhu, Shri Krishna addressed these words:

From where has this ignominy favoured of the ignorable, unheavenlyanddisreputable entered you at such a trouble some time O Arjuna?

– Bhagvad Gita 11. 1, 2

Do not lapse into impotency O son of Pritha; it does not behoove you. Abandon this littleness and weakness of the heart and rise O Scorcher of enemies.

The contact between the elements O son of Kunti are the causes of heat cold, pleasureand pain being non eternal, these come and go; learn to withstand them O descendent of
Bharat.

O Bull among men, the person to whom these do not cause any suffering, the wiseman who is alike to pain and pleasure he alone is ready for the immortal state

– Bhagvad Gita 11, 3, 14, 15

In this excellent model of psychotherapy through 18 chapters, way of self knowledge, the Yoga of action, knowledge of renunciation and action, the path of meditation, knowledge of the absolute and eternal, yogic vision, yoga of devotion, profound knowledge of three Gunas and the wisdom of renunciation and liberation have been described at length, which leads to a personality transformation in Arjuna. In modern psychotherapy ‘cognitive restructuring’ is a tool of psychotherapy which can be accomplished a great deal through the Bhagvad Gita.

Self realization is the goal of human life. The purpose of

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Eastern religion, philosophy and psychology is to fulfill that goal. That word ‘philosophy’ is a compound of two words ‘philo’ and ‘sophia’ which means “love for knowledge” but this term is not applicable in East. Those who consider the prime question of life such as, “Who am I?”, “From where have I come?”, “Why have I come?” and “Where will I go?” are not interested in intellectual answers to these questions. The subject matter of Eastern philosophy leads the student through a systematic way of directly experiencing the truths of existence and height of self realization. After realizing one’s real self one knows that this self is the self of all (Swami Rama, 1985).

The Ayurvedic Era (1500-1400 BC)

Ayurveda derives its roots from Atharvaveda and it is one of the ancient sciences which mean science of life. Though principles of Ayurveda find a mention in Vedantic treatise also, the classic written documents are Charak Samhita (1400 BC) and Sushrut Samhita (1500 BC). These two classics describe mental disorders, personality types according to trigunas- The satva, rajo and tama and tridoshas – the three humors in the body vata, pitta, kapha. The chapter on manasrog describes hetu the causative factors for mental disorders. Fourteen causative factors have been described which include –

1. Pragyaparadh – involving in socially unsanctioned behaviour and involving in actions arising out of envy, pride, fear, anger, greed, attraction, Proud and deluded thinking. All activities arising out of rajo and tama are included in pragyaparadh. Chakrapani has defined pragyaparadh as duties not performed at appropriate time.

2. Anuchit Bramhachary – one who is not following the rules of brahmacharya which includes ‘indriya nigrah’ i.e. control over demands of instincts. Due to these when the person carries out activities to gratify his instinctual needs his consciousness is not

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able to control his mind, he becomes conflict ridden which leads to mental disorders like depression, anxiety, irritability, fears and phobias, restlessness, leading to mental illnesses.

3. Durbal Satva – people who have weak satva characteristics have increased rajo and tama characteristics which leads to emotions like anger and uncontrolled emotions which leads to mental disorder.

4. Durbal Sharir – Nutritional deficiencies leading to weak physical structure can lead to mental disorders.

5. Sharir Dosh Vikrati – According to theory of tridosha it has been described by Sushrut, as well as Charaka that increase in one of the three humors of body either vata, pitta, or kapha leads to vataj, pittaj, kaphaj types of mental disorders for example increased vata leads to insomnia, while increased pittal leads to reduced sleep and unconsciousness and decrease in kapha also leads to insomnia. While decrease pitta leads to fear, anger, unconsciousness and deluded thinking. It has also been said that certain behaviour increases the humors of body which have been outlined in text of Charak Samhita.

6. Manas dosh – (Psychological factors) different detrimental emotions arise out of disorder of raj and tam which leads to mental illnesses.

7. Manobhighat Kardravya – Trauma to mind because of substance abuse. There are certain substances which derange the chitta e.g. alcohol.

8. Agantuk Karan – (exogeneous factors) factors coming to the body from outside like krimi (bacterias), rakshash, paishach, pret (evil spirits) can also cause mental illnesses.

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9. Malin ahar vihar – Bad food and bad life style both leads to mental illnesses.

10. Manoabhighat – Trauma to mind because of stress, extremely pleasant and extremely fearful events (which may be equated to stressful life events) lead to ‘unmad’ (mental illnesses).

11. Ashasht Manah – Conflicts arising in the mind, out of doing actions mentioned in pragyparadh.

12. Ojokshaya – loss of confidence leads to weakness of mind, depression and mental illnesses.

13. Ayukta Nidra – excessive sleep and sleep at inappropriate time also leads to mental illnesses.

14. Chintya Man – Inappropriate anxiety.

Classification of mental disorders based on exogenous and endogenous factors trigunas, and tridoshas has been very systematically done in the ancient ayurvedic text. The classification is as follows :

1. Nijmanas Rog (endogenous mental illnesses.)
2. Agantujmanas Rog (exogenous mental illnesses.)

Nijmanas Rog has been further divided into (a) Manas Dosh Janya caused by psychological factors and (b) Sharir Doshanubandh Janya caused by physical illnesses.

Manas Dosh Janya illnesses arising out of psychological factors are those due to pragyaparadh e.g.- Kam, Krodh, Lobh, Moh, Irshya, Man, Mad, Shok, Chinta, Chittodvaig, Bhayh, etc. These disorders can be equated with neurotic disorders. It has

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been mentioned that occasionally ‘manas rogas’ may have contract with physical illness which may be equated to psychosomatic or Somatoform disorders. While Sharir doshanubandh janya are those disorders where there is involvement of physical factors for e.g.- Unmad (psychosis), Apasmar (epilepsy) etc. which may be equated organic psychosis and organic brain dysfunction as we understand today.

Apart from this classification major mental disorders have been described based on etiological factors, various stages of illness, their signs and symptoms and treatment using psychological principles, ayurvedic techniques (shat karma), yogic techniques and medicines of plant origin.

A detailed description of sleep disorders, epilepsy, unconsciousness, diseases due to excessive intoxication (substance abuse), excitement, unmad (vatajunmad, pittajunmad, kaphounmad) and agantuj unmad have been described in detail with ayurvedic treatment prescriptions and methods of treatment.

There is also a detailed description of mastishka jawar (Brain fever) leading to mental disorders, its varieties, signs and symptoms and their treatment. It is very interesting to see that in the ancient text the system of classification of mental disorders was very scientific and clear.

Yoga Darshan (5000 – 1000 BC)

Yoga had been the way of life in ancient India. There are many aspects of Yoga which are not commonly known. Some of the systems and principles of Yoga have been outlined in different vedic and upanishadic scriptures as well as tantrik traditions. There are eight common points known as Asthanga Yoga or the eight fold path of Yoga does not necessarily belong to any one branch of Yoga. It is common knowledge that the systems of

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yoga have to be used in relation to the techniques that we learn. The Ashtanga yoga are as follows (1) Yam (restraint), (2) Niyam (discipline), together these help the individual toward self regulation, (3) Asanas (Body posturing), (4) Pranayama (control of breathing), (5) Pratyahar (withdrawal), (6) Dharna (fixed attention), (7) Dhyana (contemplation), (8) Samadhi (the state of complete tranquility). The set of last four exercises are concerned with psychological dimensions of personality and these basic principles of Asthanga yoga can be used with any system of yogic techniques. (Niranjananada, 1993).

Six yogic disciplines have been described in the Upnishads. They are 1) Karma Yoga (yoga of action), 2) Jnana Yoga (yoga of knowledge an wisdom), 3) Hatha Yoga (yoga of attaining physical and mental purity, shudhi), 4) Raj Yoga (Yoga of awaking the psychic awareness and faculties), 5) Mantra Yoga (the yoga of freeing the mind by utilizing a sound vibration) and 6) Laya Yoga (the yoga of conscious dissolutions of individuality). The aim of these spiritual practices is to convert the self into a transcendental being. Each one of these yogic disciplines has specific techniques of lifestyle and attaining self realization. What is being practiced most these days is the Hath Yoga which has traditional Shatkarmas (the six actions), known as Neti, Dhauti, Basti, Nauli, Kapalbhati, Trataka. Various asanas are methods of attaining these shatkarmas. Later additions to Hathyoga are mitahara (balanced diet), Ahimsa (non violence), Asana and Pranayama, Bandha and mudra. It will be out of place and practically impossible to give details of all yogic techniques at this juncture, but a mention of the current schools of yogic thought will do justice to this subject. The popular yogic techniques being currently widely used are Raj Yoga (Patel, 1993); Vipassana (Fleischman, 1990); Preksha dhyana (Mahaprajna, 1987,1988);

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meditation (Chinmayanand, 1989); Pranayam (Sivananda, 1984) and Hath Yoga (Niranjanand, 1993).

Understanding of Personality

According to the Indian ancient thought, personality has been understood on the basis of three vrittis and three doshas. The mind has three gunas, viz., Sattva (light, bliss, goodness), Rajas (Passion, motion) and Tamas (inertia, darkness). There are three vrittis in the mind corresponding to the three gunas: Shanta Viritti (peace), that comes out of Sattva Guna; Ghora Vritti from the Rajo Guna; and Mudha Vritti from the Tamo Guna. Equilibrium of balance is Shanta Vritti; anger is Ghora Vritti; laxiness (alasya), carelessness (pramada) and drowsiness (tandr) are Mudha Vrittis (Swami Sivananda, 1983).

Though Sattva, Rajogun and Tamogun (the trigunas) were conceived even in Vedic period, it was during the time of Charak (1400 BC) that psychical characteristics of personality Vatik, Paittik. Shlaishmik, psychological characteristics of personality Sattvik, Rajsik, Tamsik were described in Charak and Sushrut Samhita. Basically three personalities are recognized in Ayurveda, namely the pure (sattvic), passionate (rajas) and ignorant (tamas). “The pure mind is considered to be without any taint as it represents the beneficent aspect of the intelligence; the

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passionate mind is tainted as it represents the violent aspects; the ignorant mind also is tainted on account of its representing the deluded past”

Several variations of personality types are possible due to several combinations of body type. Charak Samhita (1949) describes 16 personality types: 7 belong to the sattvic type: 5 to the rajas type and 4 to the tamas type. The development of the constitution is determined by the time of conception, the diet and drink of the mother during the period of gestation (Rao, V., 1978).

Sattvic Personality

Brahma type: He is impartial, pure, devoted to truth, self- controlled, endowed with knowledge, understanding and power of exposition and reply, possessed of good memory, free from greed, conceit, desire, infatuation, intolerance. He is capable of scientific, philosophical and religious discourses. The name Brahma is derived from one of the Indian Trinity responsible for creation.

Rishi type: He is devoted to sacrifice, study, vows, celibacy; he is hospitable, devoid of price and endowed with genius, eloquence, and retentive power, Rishi is one who is devoted to contemplation and is a bachelor.

Indra type: He is brave, energetic, and authoritative of speech; endowed with splendor; possesses foresight and is given to pursuits of wealth, virtue and sensual pleasures. He is blameless in his work. Indra was known as the king of gods.

Yama type: His conduct is governed by considerations of propriety, authority, he is free from passions, attachment, is unassailable, is constantly up and about, and has a good memory. Yama is the god into whose realm the souls enter after the death of the body.

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Varun type: He is valiant, courageous, intolerant of uncleanliness, devoted to the performance of sacrifices, fond of aquatic sports, and his anger and fervor are well-placed. As indicated earlier, Varuna is the deity who presides over the cosmic order.

Kubera type: He commands status, honor, luxuries, and attendants; is given to pleasures of recreation and his anger and fervor are patent. Kubera is known for his wealth. Gandharva type: He is fond of dancing, song, music and praise, and is well versed in history, poetry, and stories. Though addicted to the pleasures of fragrant garlands, women and recreations, he is free from envy. Gandharva denotes a celestial dancer living among the trees.

Among the seven types described above, the Brahma type is considered the most desirable since the “beneficent aspect of the mind is represented in it.” Nevertheless all the personalities are beneficial to the society in which they live.

Rajas Personality

Asura type: He is valiant, despotic, possessed of authority, terrifying, pitiless, and fond of self-adulation; Asura is an enemy of god.

Rakshasa type: He is cruel, gluttonous, intolerant, and full of hate, fond of flesh, foods, somnolent and of indolent disposition. He is capable of biding time and striking. Rakshassa is a demon with evil designs.

Pisacha type: He eats voraciously, is fond of secret company with woman, hates cleanliness, and is given to indolent

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disposition, arouses fear in the beholder, and is addicted to pleasures of food and recreation.

Sarpa (snake) type: He is brave, touchy, of indolent disposition, arouses fear in the beholder, and is addicted to pleasures of food and recreation.

Preta type: He is fond of food; his character, pastimes and conduct are of painful disposition; he is envious, covetous, and disinclined to work. He lacks power of discrimination. Pretas haunt the burial ground and live on human corpses.

Sakuna (bird) type: He is constantly devoted to eating and sports; he is fickle, intolerant, and un acquisitive.

Tamas Personality

Pssva (Animal) type: He is mentally deficient, disgusting in his behaviour and dietetic habits, abandoned to sexual pleasures, and given to somnolent habits.

Matsya (Fish ) type : He too is poorly endowed, cowardly, gluttonous, fickle, prone to anger and sensuality. He loves water and is of roving habits.

Vanaspatya (Plant) type: He is lazy, and exclusively devoted to the business of eating. He is of subnormal intellect.

It may be seen that the Ayurvedic writers conceived personality as comprising multiple dimensions: intellectual, social, emotional, spiritual, and moral. The sattvic and rajasic represent the intellectual and emotional types respectively. The tamasic group broadly represents the intellectually deficient ones. The descriptive types of mentally deficient as animal, fish and plant

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varieties are interesting (Varma, 1965).

In an interesting study of typifying personality according to Ayurvedic system, Ahulwalia (1990) compiled signs and symptoms of prakrati given in the two samhitas and found that there are 477 characteristics observable in human beings based on which personality was identified during this era. Deh Prakrati (physical characteristic) included: Vatik Prakrati, Paitik Prakrati and Shlaishmik Prakrati having 102, 87, 88 characteristics respectively; Manas prakrati (psychological characteristics) were classified as Sattvik Prikriti, Rajsik Prikriti and Tamsik Prikriti having 111, 63,26 characteristics respectively. This research study concluded that based on this Ayurvedic personality inventory, the Jaipur Prikriti Parikshan Prashnavali, patients and normal controls could be classified into six major personality types and patients and normal controls could be differentiated statistically and correlation of certain personality types could be found between type of personality and type of unmad (psychoses). (Ahluwalia, 1990).

Composite Personality

According to Vedanta treatise (Parthasarathy, 1989) Atman is the core of personality. It is the prime mover of three material equipments. But vasanas (inherent tendencies) determine the nature of activities emanating from them. If vasanas are sattvic in nature, thoughts, desire and actions will also be sattvic. If vasanas are rajasic or tamsic their manifestations again will be of the same type. If vasanas are of a kind and generous nature, intellectual ideas, emotional feelings and physical actions will be kind and generous. If they are cruel and wicked so will be their manifestations. ‘As the vasanas so the thoughts, desires and actions’.

Composite personality is created by Atman functioning in the body, mind and intellect. (See chart below)

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When Atman functions in organs of perception (gnana indriyas) one becomes the ‘perceiver’. Perceiver means the combined ‘seer-hearer-smeller-taster-toucher’. The perceiver perceives sense objects of the world. The perceiver is one part of physical personality. The other part is the ‘actor’. When Atman functions in organs of action (karma indriyas) one becomes the ‘actor’. The ‘actor’ perpetrates actions in the world. The perceiver- cum-actor is physical personality. Again the Atman functioning in mind creates the ‘feeler’. The ‘feeler’ is an emotional personality feeling emotions of different sorts.

The same Atman functioning in gross intellect is the ‘thinker’, the intellectual personality. Human intellect is of two distinct types i.e. gross and subtle intellects. When intellect engages its discriminating faculty in the realm of the terrestrial world it is said to be ‘gross’. Gross intellect thinks of thoughts pertaining to the world. It discriminates between the pairs of opposites all within the boundary of this world. It could range from the simplest of

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discrimination of a dog between its master and a stranger to the finest discrimination of a scientist in nuclear technology. But all of them are still classified as gross by virtue of its field of operation being the terrestrial world. When however intellect crosses the boundary of the terrestrial world and conceives the possibility of transcendental reality it is called ‘subtle’ intellect. No other creature except a human being can posit the transcendental reality. The subtle intellect is the discriminating faculty which contemplates upon and distinguishes the transcendental reality from the terrestrial world, discerns the difference between spirit and matter, between Atman and the world one experiences through material equipments. When Atman functions in the subtle intellect, one becomes the ‘contemplator’. The ‘contemplator’ revels in the thought of Atman, Brahman, God, transcendental reality, supreme consciousness or whatever name you give it. The ‘contemplator’ distinguishes between Atman and the worlds of waking, dream and deep-sleep. The ‘contemplator’ is a spiritual personality.

Personality Layers

According to Vedanta treatise (Parthasarathy, 1989) the structure of man can be further divided into five material layers enveloping Atman. Atman is the core of personality. It is represented in the diagram below by the mystic symbol ¬ (pronounced OM). The five concentric circles around the symbol represent the five layers of matter. They are called sheaths or

 

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kosas in Sanskrit. The five sheaths (pancha-kosa) are :

· Food sheath (Anna-maya kosa)
· Vital-Air sheath (Prana-maya kosa)
· Mental sheath (Mano-maya kosa)
· Intellectual sheath (Vignana-maya kosa) · Bliss sheath (Ananda-maya kosa)

Treatment of Mental Disorders

During the Ayurvedic era a detailed description of various mental disorders and their treatment has been described in Charak samhita, Sushrut samhita and Bhel samhita. The subsequent text of Ayurveda like Kshyap samhita, Harit samhita and Madhav nidan carry concepts from the earlier texts.

However as opposed to modern psychiatry where diagnosis (funku) is based on phenomenology, in Ayurveda it is based on etiology (the three doshas) and based on the effect of these doshas – vatta, pitta, kapha or sannipat (when all the three humors are involved), manifestations of the manas rog (mental disease) were described. According the prescription of ahar (edibles), vihar (Behavioural life style); psychotherapeutic management by advice of Yoga, meditation and medicinal management by use of plants of medicinal importance in various permutations and combinations were advised.

Detailed description is available on management of mental disorders. Eighteen principles of treatment of mental disorders have been described of which eleven are psychotherapeutic and behavioural and seven principles are related to Shatkarma and medicinal management.

The psychotherapeutic management principles include methods of guilt reduction, cognitive therapies, assurance, support, activities involving religious prayers and Yagna, use of

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opposite thoughts for stopping the thoughts and astrological techniques like prayer of unfavorable stars.

Elaborate description of sleep disorders, alcohol and other intoxication, unconsciousness, six types of unmad (vatgaj, pittaj, kaphaj, sannipataj, adjij, vishaj), epilepsy, brain fever are available along with various strategies of management

The plants of medicinal use/combinational medicines have been classified into

1. Medhya (to improve memory)

2. Madkari (intoxicating)

3. Sangyasthapan (Analgesics and to improve conscious
level and mental faculties)

4. Jivniya (tonics)

5. Shirovirechan (for local application on head)

6. Unmad Nashak (Antipsychotics)

7. Apasmar (Anticonvulsants)

8. Madatyay (used for deaddiction)

9. For insomnia

10. For hypersomnia
Observation from ethology – At some places it has been

advised that certain medicines should be used with cow’s milk and others with buffalo’s milk based on observation of behaviour of calf and baby buffalo.

Medicinal plants- As many as 210 medicines of plant origin have been described under various categories of narcoleptics. Medicinal names of these mentioned in the ancient text with their Hindi and botanical names are available with the author.

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Relevance to Modern Psychiatry

In the recent past there has been lot of research on use of many Eastern techniques of healing in health sciences. Lot of emphasis is being laid on life style and health. Modern era and its increasing stresses call for stress management techniques and medicines devoid of side effects increase the importance of alternative methods of medicine.

Scientific research on Transcendental meditation programme has shown effectiveness of meditation on reducing neuroticism (Tjoa, 1976) improving learning (Miskiman, 1976), improving academic achievements, prevention of alcohol (Shafii, 1976) and drug abuse (Katz, 1976) There have been several reports on effect of transcendental meditation on reduction of anxiety, neuroticism (Ross 1976).

Alexander and Schnieder (1995) reported comprehensive effects on neuroendocrine, psychological, social and spiritual factors related to substance abuse. Role of yoga in stress and sleep management, improving performance in sports and executives is being stressed recently. Prekshyadhyan a combination of meditation and relaxation technique has been found useful in improvement of concentration, memory and anxiety reduction in a study conducted at Jaipur by the author. Effectiveness of Vipassana meditation as a therapeutic tool in psychological and psychosomatic illnesses has been reported by Iyer (1989) and Flechman (1990).

Some Ayurvedic combinations have been used as anti- anxiety and anti-depressants, reports of which are available from National Institute of Ayurveda, Jaipur. Vacha (Acorus calamus) and Jyotishmati (Celastrus Panniculatus) were found useful in treatment of depression (Bahetra, 1996). Unmad Bhanjan Ras a combination of 24 compounds was found to have anti-psychotic effect equivalent to chlorpromazine.While communicating with

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cancer patients it was found (Gautam and Nijhawan, 1987) that Indian patients tend to accept the diagnosis of cancer rather easily. The concept of death prevalent in Indian culture based on philosophy of Gita where soul is accepted as immortal and it is believed to transfer through death from one to another human/ species plays a significant role in the easy acceptance of the diagnosis and the planning for the rest of the life.

The understanding of human psyche in Vedantic model is more acceptable to Indian patients because of transfer of attitudes from generation to generation. Anecdotes from Bhagvad Gita as a psychotherapy of dying patient is virtually a tradition in Indian culture. Even now in many families when death is anticipated preaching of Lord Krishna stating that thoughts at the time of death determine the species of next birth help the individual to accept the death in a more gracious manner. The concept of ‘sthit pragna’ how a person can remain detached from pleasure and sorrow unaffected by losses and gains inculates peace in the mind. One of the Neeti Shlokas says:

“It is not your duty to grieve the past nor should you worry about the future. Only he, who lives the present and thinks about the present is a wise man,” This can help a depressed patient worrying for a recent loss. Similarly many other anecdotes from ancient literature like Ramayana, Mahabharata and later writings like Neeti Shlokas and Panchatantra can be very usefully employed in supportive psychotherapy. There is need to re-explore this vast treasure of knowledge which may be culturally relevant and useful for Indian patients. What is needed is to make our patients aware of their hidden potentials as was done by Jamwant to Hanuman before going to Lanka in the epic of Ramayan. These ancient texts should be re-explored for models of conflict resolution, understanding psychopathology and attainment of self- realization.

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References:

Ayyar K.S., (1989): Value of Anapana and Vipassana in psychological and psychosomatic illnesses. A seminar on vipassana meditation for relief from addictions and better health. Nov. 28 – Dec.9, 1989. Vipassana Research Institute Jogeshwari, Mumbai.

Ahluwalia, S.K., (1990): Construction of (Personality inventory) and study of mental disorders based on Prakrati as described in Ayurveda. M.D.thesis submitted to University of Rajasthan, under guidance of Dr.R.K.Sharma and Dr.Shiv Gautam, National Institute of Ayurveda, Jaipur.

Alexander C.N. and Schneider R., (1995): Treating substance abuse using the transcendental meditation programme. A review and statistical meta analysis. First International Conference in Life style and Health, Jan 20-21, New Delhi.

Baherta G., (1996): A comparative clinical study of Acorus Calemus (Vacha) and Celestraus Panniculatus (Jyotishmati) on depression. Thesis submitted for the degree of Doctor of Medicine (Pharmacology) to University of Rajasthan, National Institute of Ayurveda, Jaipur.

Chinmyanand Swami (1989): Meditation and life. Chinmaya Mission Trust, Sandeepany, Sadhanalaya, Mumbai. Fleischman, P.R., (1990), Buddhists Publication society, Sanghraja mawatha, Kandy, Srilanka.

Gautam S. & Nijhawan M., (1987): Communicating with cancer patients. British Journal of Psychiatry, 150, 760-74.

Katz, D. (1976) : Decreased drug abuse and prevention of drug use by transcendental meditation programme. Scientific research on transcendental meditation programme collected

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papers Vol. I edited by David, W. Orme Johnson and Jhon T. Farrow. Maharshi European Research University Press, Seelisberg, Switzerland.

Mahaprajna Yuvacharya, (1987) : Prekshadhyan theory and practice. Tulsi Adhyatma Nidam , Jain Vishwbharti, Ladnun. Mahaprajna Yvacharya, (1988): Prekshadhyan therapeutic thinking. Tulsi Adhyatma Nidam, Jain Vishwabharti, Ladnun.

Miskiman D.E. (1976): Effect of transcendental meditation programme on organization of thinking and recall. Scientific research on transcendental meditation programme collected papers Vol. I edited by David, W. Orme Johnson and Jhon T. Farrow. Maharshi European Research University Press: Seelisberg, Switzerland.

Miskiman D.E. (1976): Performance of learning task by subjects who practice transcendental meditaion technique. Scientific research on transcendental meditation programme collected papers Vol. I edited by David, W. Orme Johnson and Jhon T. Farrow. Maharshi European Research University Press: Seelisberg, Switzerland.

Neranjananand Paramhanss, (1993): Yoga Darshan: Vision of the Yoga Upnishads. Bihar School of Yoga:, Munger, Bihar, India. Patel G. (1993): Rajyoga in health and disease. Prajapita Brahmkumari Iswharia Vishywavidyala: Mount Abu, India.

Ross, J. (1976) : Effect of transcendental meditation programme on anxiety, neuroticism and psychoticism. Scientific research on transcendental meditation programme collected papers Vol. I edited by David, W. Orme Johnson and Jhon T. Farrow. Maharshi European Research University Press: Seelisberg, Switzerland.

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Shaffi M., (1976) : Meditation and Prevention of alcohol abuse. Scientific research on transcendental meditation programme collected papers vol. I edited by David, W. Orme Johnson and Jhon T.Farrow. Maharshi European Research University Press: Seelisberg, Switzerland.

Sharma, M. M., (1998): The Concept of mind is Vedas, Souvenir, ANCIPS-WPA, Jaipur, Jan, 4-8, P. 35-40.

Shukla, (1998): Tanne manah Shiv Shankalpa Mastu, Brahmagosh (7) 4-5, Rajasthan Brahmin Mahasabha Yog Nilyam: Jaipur. Pp. 1-3,

Sivananda Swami (1983): Mind- Its Mysteries and Control. The Divine Life Society: Tehri Garhwal, U.P., India.

Sivananda Swami (1984): The Science of Pranayam. Divine Life Society: Tehri, Garhwal, U.P., India.

Swami Rama, (1978): Perennial Psychology of the Bhagwat Gita. Himalayan International Institute of Yoga Science and Philosophy of the USA. Honesdale, Pennsylvania.

Tjoa, A. (1976): Increased intelligence and reduced neuroticism through transcendental meditation programme. Scientific research on transcendental meditation programme collected papers Vol. I edited by David, W. Orme Johnson and Jhon T.Farrow. Published by Maharashi European Research University Press, Seelisberg, Switzerland.

Venkoba Rao, A., (1978): Psychiatric thought in ancient India. Presidential address delivered at the 30th Annual Conference of Indian Psychiatric Society, Jan. 16, New Delhi.

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PROF.S.C.MALIK

Born in Mailsi, a small village near Multan in Pakistan, he came to Delhi after partition as a refugee from Pakistan as a child of nine. Prof. S.C. MALIK received his education in Delhi and did his graduation and post graduation from All India Institute of Medical Sciences. He went into a regular teaching cadre in 1971 and joined the faculty in NIMHANS, Bangalore. He has been a post graduate teacher, examiner and on the academic bodies of various universities/institutions. He has been inspector for Medical Council of India, National Board of Examinations. He received his training from Maudsley Institute of Psychiatry and also was awarded Commonwealth Fellowship, Canadian Govt. Fellowship, Columbo plan fellowship & WHO fellowship. He was UNDCP Consultant in Drug De-addiction Program.

He was elected as President of Indian Psychiatric Society as also Indian Association of Social Psychiatry. He has about 100 publications to his credit and won many awards, notable among them being the prestigious D.L.N.Murthy Rao award. He is founder member of South Asian Forum .He has been Secretary, Central Mental Health Authority, Govt. of India and also National WHO Consultant and Advisor in Mental Health Govt. of India.

Presently, he is a senior consultant in Sir Ganga Ram Hospital, New Delhi and also honorary consultant advisor with ICMR, New Delhi.

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CONCEPTS OF SPIRITUALITY AND ANCIENT WISDOM IN RELATION TO MODERN

PSYCHIATRY
S.C.MALIK

If we trace the history of Modern Psychiatry, it has its origins from the time Philip Pinel who created a revolution by unchaining the inmates of the mental asylum in Bicetere, France. Similar reforms in treatment by William Tuke at York Retreat in1790, and by Benjamin Rush – these humanistic reforms – led to the term ‘Moral Therapy’. However, with the confrontation of church over development of science and ultimately the arrival of the scientific age, the moral and spiritual aspects in the field of mental health had to take a back seat as it were, in favor of a search for scientific truths in terms of causes and treatment of the mentally ill. Sigmund Freud, a neurologist and pupil of Charcot came up with the theory of Psycho-Analysis to explain the mental signs and symptoms, not only of mental illnesses but also had an explanation through this theory on mental phenomenon seen in everyday life. Thus slips of tongue, and memory lapses etc; were explained in ‘Psychopathology of everyday life’ as unconsciously determined. If we examine closely, the entire theory of psycho-analysis was based on the theory of psychic determinism –through linear causality and these concepts he used from the prevailing concepts from physics. The psychic phenomenon, mental symptoms and other behavioural abnormalities are explained on the basis of sexual repression and by the use of psychic defenses that one

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makes against the emergence of instinctual drives of sex and aggression. Freud’s thought had an immense impact on the social thought of the times. Thus sexual urges, it was thought, must not be repressed or suppressed, if one has to save oneself from neurosis .Those were Victorian times and the impact was in shedding all such inhibitions. United States of America being the new civilization, where freedom was the mantra of life expressed beatifically through the Statue of Liberty, became the torch-bearer of the modern times. The Western world shed its prudish approach to sex and morality, and it went on further to experiment and live with the free capital economy that it possessed. Thus we have laws in USA that allows one to keep lethal weapons and also the sexual freedom of expression in the form of gay marriages, live- in relationships etc. The waves can be felt in our country also, thanks to the information and communication revolution. With the advances made in neurosciences to explain behaviour, modern psychiatry adopted neurobiological approach to explain complex mental phenomenon and also came up with psychopharmacological agents which changed the total management of these patients. The patients could thus be treated in the community itself .Whereas there are exciting changes occurring in the field of psychiatry in terms of genetics, neuro-imaging and finding newer and better drugs for the mentally ill, it is being increasingly realized that somewhere we are missing out and unable to give the much needed peace of mind to the patients or clients.

If we look at the definition of health provided by the W.H.O, it says “as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. Inclusion of mental heath and social wellbeing is bracketted with physical health, thus giving enough scope to planners to integrate mental health programs with physical health planning.

However, the spiritual dimension to health is missing. If one

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looks at our ancient systems of thought, we have always conceived of the person in his totality. Let us examine this ancient thought more closely. Whereas the Western science is reductionist and based on Cartesian duality (-Nature vs. Nurture, Psyche or Mind vs. Soma or Body etc), the Indian way of thought has a more holistic and synthetic approach as propounded through Ayurveda and Yoga. Ayurveda is believed to have been written around 1400 BC, centuries before Hippocrates. According to it, the human body is composed of five elements –earth, water, fire, air and space. Thus, man is a microcosmic reflection of nature and has all the properties of the cosmos. Jiva or individual, according to Sankhyan system of Hindu Philosophy has an inert equipment Prakriti (the field), and Purusha (knower of the field). These two factors determine the personality. Hindu philosophy talks of Sanskaras, with which we are born with — (a sort of genetic material), but that which is also based on our past deeds or Karma in our previous births, and our upbringing. By doing good karmas in the present birth we can change them.

Bhagavad Gita distinguishes between what is pleasurable or Preya, and what is desirable or Shreya. Man is supposed to go beyond the satisfaction of biological needs which give immediate pleasure (Freud’s pleasure principle) and move towards self-actualization and self-realization which are the desirable goals.In Hindu philosophy, is the Absolute reality – the absolute Godhead. The Upanishads have elaborated on the position of Brahman (Sivananda, 1983). The Kenopanishad gives a detailed exposition of Brahman. According to this Upanishad, The Supreme Brahman, who is unborn, unchanging, birth-less, un-decaying, immortal, fearless, eternal, self-luminous, all- blissful, and all-pervading, is covetable to all. Atman (or Brahman) is beyond the reach of senses and mind. Brahman is the source for the mind also. The mind is gross, inert and finite. How can the finite know the infinite? (Ken U. I: 3, commentary). Brahman cannot be an object of perception; it can only be intuitively realized

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through meditation. To define Brahman is to deny Brahman (Ken U. I: 3, commentary). “Brahman is beyond the unknown also” (Ken U. I: 3, commentary). Brahman is the only reality. He is the basis or source for everything. … He is all-pervading, mysterious, incomprehensible – pure consciousness (Ken U. I: 3, commentary). Brahman can be known only by instruction from an illuminated teacher, and not by logical discussions, nor by intelligence, great learning, exposition, austerity or sacrificial rites, etc. (Ken U. I: 3, commentary) “What cannot be seen by the eye, but by which the eyes are able to see, know that alone as Brahman” (Ken U. 1:6). The eye is made to move towards its objects by the enlightening intelligence of Brahman. Brahman is the real unseen seer of sight. In the same way, it applies for ears, breath, etc. This knowledge [of Brahman] is not to be obtained by argument, but is easy to understand when taught by a teacher. (Kath. U. 1:2:8-9) .Thus, the ancient thought laid quite an emphasis knowing or rather experiencing the truth through a guru or sadguru.

The psychic structure

The psychic apparatus according to ancient Hindu thought consists of:

• Manas: mind, perception

• Buddhi: intellect

• Ahamkara: ego or self -consciousness
Intellect is the seat of desire. There is no desire in the atman (soul), the atman is ever-pure and taintless. “Beyond the senses are the rudiments of objects, beyond these rudiments is the mind (mana), beyond the mind is the intellect (buddhi), beyond the intellect is the great Self” (Kath U. I: 3:10). Intellect is superior to mind because intellect is subtler, greater and more internal than the mind. “the senses are superior to the body, superior to the senses is mind, [still] superior to mind is intellect; one who is even superior to intellect is he (the atman) (Gita iii: 42). Beyond the great (mahat) is the un-manifested (avyakta). Beyond the

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avyakta is the purusha, beyond the purusha there is nothing; that is the end that is the highest goal” (Kath U. I: 3:11).

“It (atman) is motionless, one swifter than mind.” Before the mind reaches a place, the atman is already there” (Ish U. I:4). “It (atman) is the ear of the ear, the mind of the mind, tongue of the tongue and also life of the life and eye of the eye. Having abandoned (the sense of self or I-ness in these) and rising above sense – life, the wise become immortal” (Ken U.1:2) Further according to Hindu thought, the Vedas are the ancient text known. It is believed that they were not written by any person but rather were revealed to the seers or rishis. They are four — Rig Veda, Atharva Veda, Yajur Veda, Sama Veda. The science of mental illness is described in Bhoot Vidya. It is elaborated in the 4th part of Yajur Veda, 800 B.C.

According to the Vedic concepts, personality is composed of three elements (gunas): Satva (pure qualities); rajas (pleasure- seeking propensities and emotions); tamas (animal-like behavioural tendencies leading to deterioration).

The theory of gunas
The gunas are the constituents of the prakriti and are therefore

always present in every individual.

The three gunas: There are five negative tendencies in the form of kama (sexual lust), krodha (anger), lobh (greed), moha (attachment), ahankara (egoism), which we need to master and overcome. Other tendencies to overcome are to be intoxicated (mada); jealousy or envy (eershya). It is worth noting that here Western thought and teaching in modern psychiatry differs. Thus, even though sexual urges and aggression need to be expressed and/or sublimated in keeping with societal mores, there is no mention anywhere of disorders arising out of excessive lust (kama), greed or lobh ,or moha or attachment, to which Hindu

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thought subscribes. Thus, ability to detach oneself from the worldly objects or desire, or pain and suffering, would be an ideal state of mind.

Another Indian concept is of the times in which we live. Time is conceived in the form of cycle rather than linear and divided into 5000 year period called yuga .Thus we are living in at present in Kaliyuga and the cycle of time has passed from Satyuga, when values of truth and virtue prevailed, to Treta, to Dwapar. When this Kaliyuga will come to an end, the souls that are good based on their karma and sanskara will pass on to Satyuga. Hindu concept of transmigration of souls and rebirth is very important. Whereas, other religions emphasize on the concept of heaven and hell after death, Hindu thought conceives of soul or spirit being immortal and believes in transmigration of souls, and your karma in this birth determining the sanskaras with which you are reborn. Aim of the individual should be seeking moksha or nirvana (liberation) from this cycle of rebirth. Moksha makes us realize the world around as unreal and illusory (maya) thus running after fulfillment through senses will lead us nowhere. For that can come through self-realization and self-actualization and ultimately self enlightenment through a direct experience of Truth or God. That is the ultimate goal of every individual soul: to be united with God or Paramatma and realize the eternal truth. This state of being produces the state of mind called sat-chit-ananda.

The science of mental illness is known as bhoot vidya in ancient texts. Prof. K.C. Dube (1979) has extensively worked on this aspect and has tried to give a corresponding classification of mental illnesses as per Ayurvedic texts.

In India we have now adherents of various religions. Hindus, Muslims, Christians, and Sikhs can be called the major religious sects. Then there are Jains, Buddhists and some other sects. It must be said that all these religions are practised in spirit of

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tolerance and co-existence since times immemorial (barring a few incidents of intolerance here and there). An attempt must be made to distinguish religion from spirituality. I would like to point out herein that the Hindi translation of religion would be Dharm but it has a totally different meaning – it is more in the sense of sacred duty and obligation that a man is supposed to perform at a particular time or phase of one’s life or towards society. There is nothing like Hindu religion in the sense of the word as it is used to denote Christianity and Islam where there is one God and one Holy book that is to be followed by its adherents. Also, as per ancient concepts, the individual is supposed to spend the first 20-25 years in observance of Brahmcharya where besides receiving good education and learning various skills, he has to learn the control of his senses, particularly his sexuality. The next phase of 20-25 years is to be spent in procreation, raising the family and perform his duties towards the society .This has been termed as Grahasthashram. After this he must learn to detach himself from the worldy attachments and learn renunciation or tyaga from worldly duties and materialistic possessions and prepare for his final journey. For this one was supposed to go away into jungles and that is why it was called Vanaprasthaashram (Vana-means ‘woods’).

An attempt must be made now to distinguish religion from spirituality .Religiosity refers to participation in or endorsement of practices, beliefs, attitudes, or sentiments that are associated with an organized community of faith.

Spirituality refers to personal views and behaviours that express a sense of relatedness to a transcendental dimension or to something greater than the self. There is obviously a wide overlap, but spirituality seems more clearly a personalized, internalized version, a composite of both. Can spirituality or religion mix with science? It was Albert Einstein who said, “Science without religion is lame; religion without science is blind”. Science always

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searches for what can most easily be measured. Science and ethics have become increasingly secular. Freud saw religion as universal ‘obsessional neurosis’; Jung differed and discussed the search for spiritual enlightenment as the central core of human experience. This difference of opinion is one of the reasons why Freud and Jung parted company. The word religion has the same root as ligament, ligature and obligation. An operational definition of ‘spiritual’ for psychiatrists and other clinicians might include: aims and goals – looking for the meaning in life; what one regards as essential human solidarity – the interrelatedness of all, both doctor and patient; consciously and unconsciously-shared beliefs; wholeness of the person – the spirit is not separate from body or mind, but includes moral aspects – what is seen as good, beautiful or enjoyable, as opposed to what is bad, ugly or hateful; awareness of God – the connection between God and man.

Religion :

• Community focused
• Observable, measurable, objective
• Formal, orthodox, organized
• Behaviour orientated, outward practices • Authoritarian in terms of behaviours
• Doctrine separating good from evil

Spirituality :

• Individualistic
• Less visible and measurable, more subjective • Less formal, less orthodox, less systematic
• Emotionally – orientated, inward directed
• Not authoritarian, little accountability
• Unifying, not doctrine – orientated

In the majority of studies, religious involvement is correlated with :

· Well-being, happiness and life, satisfaction

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· Hope and optimism
· Purpose and meaning in life
· Higher self-esteem
· Adaptation to bereavement
· Greater social support and less loneliness
· Lower rates of depression and faster recovery from

depression
· Lower rates of suicide and fewer positive attitudes towards

suicide
· Less anxiety
· Less psychosis and fewer psychotic tendencies

·  Lower rates of alcohol and drug use and abuse

·  Less delinquency and criminal activity

·  Greater marital stability and satisfaction
According to Bhugra, (2007) positive mood states, many of which are religiously encouraged, play a role in reducing depressive mood and illness. These include purpose in life, joy, optimism, and forgiveness The main aspects of religion which may foster depression are first, beliefs that God is punishing, vengeful, or simply indifferent and secondly, situations in which religious forces encourage persecution, warfare and other horrific circumstances. There may also be this tendency by one religious group to feel that their religion and god is superior to others’ religions and gods.
Depression is widely concluded to be more prevalent among women than among men. Referral rates also show a similar pattern. However, there are some groups among which depression may be as prevalent among men as among women. These groups have in common low or no use of alcohol. The alcohol-depression hypothesis suggests that societies in which men are as likely to be depressed as women, positive mood states, many of which are religiously encouraged, play a role in reducing depressive mood and illness. These include purpose in

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life, joy, optimism, and forgiveness. A number of studies as reviewed by Bhugra and Bhui (2007) have indicated that religiosity is associated with higher levels of sub-clinical anxiety and obsessionality. Clinical levels of anxiety and obsessive- compulsive disorder are not more likely among the religiously active, though cultural-religious context can affect the shaping of symptoms). The second important effect works in the opposite direction. Heightened spirituality, religious faith, awareness that all is in the hands of Heaven (once one has done what is humanly possible) – these beliefs and states of awareness are associated with lower anxiety. This effect can be obscured by the tendency for individuals under stress to increase their levels of religious and spiritual activity – notably prayer and meditation.

In cross-sectional studies this can give a muddled picture. But with sufficient attention to research design, measurement and interpretation, there is now reasonable confidence that these effects dominate the relations between anxiety and religious/ spiritual factors (Koenig etal, 2001). An important example is the mis-diagnosis of fervent prayer and other religious coping behaviour as psychotic symptomatology. Bipolar (manic- depressive) disorder may be influenced by spiritual factors, notably meditation) has suggested that meditation may precipitate manic episodes, possibly the result of neuropsychological factors. It is possible that the affected individuals are predisposed to the disorder (perhaps as a result of genetic factors), and some professionals may be concerned the religious and spiritual barriers to seeking professional help may result in further deterioration. We commonly see this in this part of the world where faith healers may be the first contact between the patients and their families. Sometimes this can be disastrous as was evident in Erwadi incident in Tamil Nadu where the patients were tied to their beds and could not escape when fire broke out and they were charred to death leading to a Supreme Court enquiry into the incident.

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In India early work was done in the field of yoga in relation to mental health by Prof. N.S.Vahia (1966) in Bombay. Yoga and transcendental meditation was made popular in Western world particularly in USA by Maharishi Mahesh Yogi and recently by Deepak Chopra. Recently a scientific study undertaken by Janakiramiah et al (1998,2000) in NIMHANS, Bangalore, India showed that Sudershan Kriya, a part of the yogic techniques as propounded by Sri Ravi Shankar through ‘Art of Living’, does help in overcoming anxiety and depression.

Thereisquitearesurgenceof yogaatpresentinIndiawhich is quite a healthy trend, thanks to Swami Ramdev. There are, of- course other schools of yoga like Kundalini yoga, Sahaj yoga(Mata Nirmala Devi),Rajyoga and meditation as propounded by the Brahmakumaris which are quite effective. However, vigorous scientific studies on these are yet to be undertaken. Gurbani – hymns from Guru Granth Sahib the sacred book of Sikhs has been employed in psychotherapy particularly by Col. Kirpal Singh.

Here, I would like to mention my and my family’s brush with spirituality. I came along with my family during partition to Delhi from Pakistan penniless and had to face lot of hardships with practically no place to stay except in a single small room where the entire family of ten had to live and study. Besides, I saw a lot of looting and murders being committed on both sides of the border in the name of religion. Having now been taught about various types of stress-related disorders particularly post- traumatic stress disorder, I often wonder how my family was saved from falling into this pit. One thing that stands out clearly in my memory is my father’s utmost faith in righteous living based on teachings of Guru Granth Sahib which he would read and recite daily and explain to all of us in this family congregation the meaning of each hymn. His face would often light up during this explanation and he would pursue the path of right karma with greater strength and determination.

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Mahatma Gandhi also mentions in his autobiography ‘My Experiments with Truth’ how he would always turn to the Gita whenever in doubt and difficulty and he writes, “The Gita is my Mother”. Prof. Venkoba Rao (1980), has written about Indian psychotherapy based on the principles derived from the Gita and Ramayna. Prof. N.N.Wig (2004) has recently drawn our attention to the Hanuman Complex. As the story goes in Ramayana, Hanuman along with the entire vanar sena (monkey brigade) is standing on the shores of the ocean thinking and wondering how to cross the sea and reach Lanka so as to rescue Sita from the clutches of Ravana, the demon king. At this juncture , Jambavat a wise senior bear in the army, reminds Hanuman of his real potential which he has forgotten due to a curse .Thus the patient can be similarly reminded how at the time of stress, his mind becomes clouded forgetting his true strength and potential. I have found that use of parables drawn from our ancient scriptures is very useful in psychotherapy. Thus to a patient who is contemplating suicide, in addition to tackling these urges through medication and psychotherapy, I remind him that he may have to face the same situation and dilemma after rebirth again unless he faces it right here.- here and now. I often remind my patients that they should do their duty or karma without thinking of the end result. This I find particularly relevant and useful in anxiety, say examination anxiety. During periods of stress and anxiety and people would go to any extent to extract from the therapist the exact period when they will be rid of anxiety. Often an astrologer will also be consulted. Gita teaches us to do our karma and leave the result to Him. When one follows this, one can become tolerant of uncertainty and thus free from anxiety. I often ask my patients who are religiously inclined to observe chaliya (abstinence for forty days) and during this period of forty days they have to stay away from alcohol or drugs, besides visit to gurudwara/temple which gives me the all important period to detoxify him even without admission. ‘Detachment’ is another very useful concept

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from the Ramayana and Gita and one can strike a chord when you talk in psychotherapy about such concepts based on our old scriptures. Mahatma Gandhi had practised it to the extent that he underwent a surgical procedure without an anesthetic. Muslim patients may require the doctors’ sanction not to observe fasting during Ramadan otherwise they feel very guilty. Work has been done in Pakistan by Malik Mubasher (cited by Wig, 1995) and Haroon Chaudhary (2006) where they have used religion in service of psychotherapy and to help the mentally ill persons. Afzal Javed (1999) another psychiatrist from Pakistan now settled in the U.K. has similarly incorporated religion in psychotherapy.

Let us examine the negative aspects of religious or spiritual therapy. There is a common cultural belief that mental illness is a result of bad spirit possession, jinn, or also called upri. Thus one of my patients who was getting better told me that he was going to his home town where he was going to ask his mullah if his son who had started showing mental symptoms was really mentally ill needing psychiatric treatment or was as result of upri or bad influence of some spirits. Many patients visit Balaji temple in Rajasthan .Thus, one of my patients with schizophrenia related to me how he was tied upside down from a ceiling fan in this temple so as to drive his spirits out. Only when he was getting worse, they decided to consult me. Similarly, another of my Muslim patients who was blind but was having both visual and auditory hallucinations and had employed a mullah who would immediately recite verse from the Quran so as to drive away the devil. Thus due to such beliefs and practices, patients can be subjected sometimes to cruel procedures, lose precious time and spend a lot of money too in the process.

At present, the aim of psychiatric treatment is to make the patient symptom free and adjust to the environment. However, sometimes the environment itself is such where he is supposed to be a part of the chain where dishonest procedures, accepting

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bribes etc. is part of the adjustment and thus psychiatrist is also in an ethical dilemma. Also, what one must ask is, “what is the ‘meaning’ of present suffering that the patient is undergoing at this juncture?”. Jung has described the middle age crisis where the patient may develop outwardly just anxiety and depression but the crisis has to be understood with special meaning to the patient and the re-adjustments that one may have to make in one’s life. However with the art of history taking deteriorating to just filling up of certain questionnaires and checklists, and then ‘making a correct diagnosis’ this aspect may just escape one’s attention. Goethe mentions how he became impotent once when he was faced with a situation when he could have committed adultery and after analyzing, he understood the meaning behind his symptom which he says saved him from the situation of having extra-marital sex. Gautam Buddha, Guru Nanak showed lack of interest in material comforts and showed signs of withdrawal from the ‘material world’. They would have been labelled abnormal or ‘schizophrenic’ going by these criteria. Prophet Mohammed (peace be upon him), said he was in touch with God. In India, in the early forties, we have the case of Mr. Lekh Raj a Sindhi businessman, who was apparently doing very well till he suddenly had visions and had some extra-ordinary experiences which transformed him to a totally different individual. He founded the order of Brahmakumaris much to the opposition that he faced at those times, as he was trying to uplift women spiritually and empower them. He was highly misunderstood by the common man at that time as such ideas were unthinkable. A visit to their headquarters in Mount Abu, makes one aware about the satgunas and the satvic personality traits as also the importance of purity of thought and action. Even the vegetarian food that was being cooked, I was told by the cook, is different there as it is cooked with thoughts of God in one’s mind at the time of cooking. See the contrast when the doctor advises about food only in terms of vitamins, calories or breaks-down into carbohydrates, proteins etc. The importance of home-cooked food served with love and

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eaten together will be totally different in effect than gulping quickly the junk food.

It is clear that the spiritual aspects are very important and can be useful in psychotherapy but this treatment should be done by the psychiatrist rather than clergy or the mullah or priest. Thus we must include training in spiritual therapies as part of post graduate training programs. The trainee has to understand the cultural beliefs of the patient and his religious background. It is ironic that our trainees don’t hesitate to ask intimate questions about details of patients’ sex-life but hesitate to ask about spiritual and cultural beliefs.

Recently the WHO realized the lacuna in their definition of health and involved more than 30 collaborating centers in the development of its instrument for measuring quality of life, the WHO Quality of Life (WHOQOL) Below, I am reproducing these modules as follows in the tables:

The World Health Organization Quality of Life (WHOQOL) domains: Physical health
Psychological health
Level of independence
Social relationships
Environment
Spirituality, religion and personal beliefs

Facets proposed for a World Health Organization Quality of Life Spirituality, Religious and Personal Beliefs module: Transcendence

Connectedness to a spiritual being or force Meaning of life
Awe

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Wholeness/integration
Divine love
Inner peace/serenity/harmony Inner strength
Death and dying Detachment/attachment Hope/optimism
Control over your life

Personal relationships
Kindness to others/selflessness Acceptance of others
Forgiveness
Code to live by
Freedom to practise beliefs and rituals Faith
Specific religious beliefs
Specific religious beliefs

Elements of spiritual care :

· An environment for purposeful activity such as creative art, structured work, enjoying nature.

· Feeling safe and secure; being treated with respect and dignity and allowed to develop a feeling of belonging, of being valued and trusted.

· Having time to express feelings to staff members with a sympathetic, listening ear

· Opportunities and encouragement to make sense of and derive meaning from experiences, including illness.

· Receiving permission and encouragement to develop a relationship with God or the Absolute (however the person conceives of what is sacred).

· Thus a time, place and privacy in which to pray and worship; education in spiritual (and sometimes religious) matters; encouragement in deepening faith; feeling universally connected and perhaps also forgiven.

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Central, spiritually relevant themes in Depression (Swinton, 2001) :

· The meaningless abyss of depression
· Doubt and the questioning of everything
· Abandonment, by God and other people
· Clinging on, through faith
· A continuing desire to relate to others, while

relationships fail.
· Exhaustion, demoralization and feeling ground down. · Feeling trapped into living
· The crucible of depression – a transformative (and

ultimately beneficial) experience.

Benefits of spiritual care:

· Improved self-control, self-esteem and confidence

· Recovery facilitated, both by promoting the healthy grieving of loss and through maximizing personal potential.

· Relationships improved – with self, others and with God.

· A sense of meaning, resulting in renewed hope and peace of mind, enabling people to accept and live with their problems.

Spiritual values and spiritual skills : Spiritual values

· Kindness Compassion Generosity · Tolerance Patience Honesty
· Creativity Joy Humility
· Wisdom

Spiritual skills

· Being able to create a still, peaceful state of mind (as in meditation).

· Being able to stay mentally focused in the present, remaining alert and attentive.

· Developing above-average levels of empathy, discernment and courage.

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· Having the capacity to witness and endure distress while sustaining an attitude of hope.

· Being self-reflective and honest with oneself, especially about areas of ignorance, also when angry, afraid or in doubt.

· Having an above-average level of being able to give without feeling drained.

· Being able to grieve appropriately and let go.

References :

Bhugra D, Bhui, K (2007) Spirituality and Cultural Psychiatry. In Text book of Cultural Psychiatry, (ed.) D.Bhugra & K.Bhui, Cambridge University Press.

Chaudhary HR, Arshad N,Niaz S,Mufti KA; (2006) Gender issues in mental health in Pakistan. WPA Annual meeting: Program and abstract book; Trans-cultural Psychiatric Section 8; 23

Dube, K.C: Nosology and therapy of mental illness in Ayurveda. (1979) Comparative Medicine East and West, 6(3):209- 28.

Javed, A. (1999) Religion, spirituality, and psychiatry. Presented at the 6th International Congress of the WIAMH, August; Tulza, Bosnia.

Janakiramaiah N,Gangadhar BN,Naga Venkatesha Murthy PJ,et al.(1998) Therapeutic efficacy of Sudershan Kriya Yoga(SKY) in dysthymic disorder, NIMHANS J.(Jan), 21-28

Janakiramaiah N,Gangadhar BN,Naga Venkatesha Murthy PJ, et al.(2000) Antidepressant efficacy of Sudershan Kriya Yoga(SKY) in Melancholia; A randomised comparison with ECT and Imipramine, J.Affective Disord, 57, 255-259

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Swinton J. (2001) Spirituality and Mental Health Care: London and Philadelphia: Jessica Kingsley

Sivananda Sri Swami (1983)The Principal Upanishads Shivanandanagar The Divine Life Society

World Health Organization (1998): WHOQOL and Spirituality, Religiousness and Personal Beliefs: Report on WHO Consultation, Geneva WHO.

Koenig, H.K., McCullough M.E. & Larson, D.B. (2001) Handbook of Religion and Health Oxford: Oxford University Press.

Vahia, N.S., Vinekar, S.L. & Doongaji, D.R (1966): Some ancient Indian concepts in the treatment of psychiatric disorders. British Journal of Psychiatry, 112(492):1089-96.

Rao A. V.(1980) Gita and Mental Sciences. Indian Journal of Psychiatry. 22, 19-31

Wig N.N. (2004): Hanuman Complex and its resolution. Indian Journal of Psychiatry. 46(1) 25-29

Wig, N.N. (1995) Mary Hemingway Rees memorial lectures delivered at the World Congress of Mental Health, Dublin, Ireland Aug.1995

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Dr. Mrugesh Vaishnav

He is the Founder Chairman, Spirituality & Mental Health Task Force of Indian Psychiatric society. He has conducted workshops on Bhagvad gita in disaster-management, and self management. He has authored Gujarati & Hindi Sahitya Academy Award winner book on “Faith, Blind Faith & Mental illness”

His positions in professional organizations are as Consultant Psychiatrist & sex therapist,President, Indian Psychiatric society, West Zone Branch (2008-09),Chairman Spirituality & Mental Health Task force Of Indian Psychiatric Society (2006- 2008),Editor, Archives of Indian Psychiatry,Advisor, Divine Life Society.

Dr. Mrugesh Vaishnav has published more than 100 articles in National & International journals Of Psychiatry, psychology & sexology. He has also published more than 2000 articles in National & regional newspapers, published more than 25 books on psychiatry, sex education, spiritual practices, faith healings etc. He has appeared as expert in more than 1500 articles in Popular press for Public including international magazines & National newspapers.

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SPIRITUALITY AND PSYCHIATRY

COMPLIMENTARY OR CONTRADICTORY-

BASED ON BHAGAVAD-GITA Mrugesh Vaishnav

Om Saha Na Vavtu Saha Nau Bhunaktu Saha Veeryam Karvah Vahai Om shanty… shanti…shanti…

Abstract

Spirituality means personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self. It is a subjective experience that exists both within and outside of traditional religious systems. Religiosity can serve as a nurturer or channel for spirituality, but is not synonymous with it.

Psychiatry has a history of ignoring, being in conflict with and attacking religion, and dismissing spiritual experience as ‘universal obsession neurosis’, ego regression, pathological thinking in need of modification, and a sign of emotional imbalance. The truth is that mental health is a state of harmony within the individual and harmony between the individual and others around him; this means that psychiatrist cannot ignore spirituality.

It is evident from the research that there is more than sixty to eighty per cent correlation between religion or spirituality and better health in the areas of prevention, recovery and coping ability, in a wide range of physical and mental conditions. Spirituality is a biological, inbuilt dimension of human beings. Psychiatry should

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which is person centered and meaningfully holistic.

The Bhagavad Gita is the most respected sacred book of Hindus like Bible of Christians. It describes several anxiety and depressive disorders and has given concept of a mentally healthy person five thousand years ago. It also offers psychotherapeutic solutions for day-to-day conflicts, relationship issues, performance pressures etc.

Lord Krishna prepares Arjuna for Mahabharata war after nervous Arjuna wanted to leave the battlefield of Kurukshetra. It is an excellent resource book for one-to-one psychotherapy. It teaches how to overcome guilt, remorse and fight a Dharma yudhha, that is, fight against evils. In the metaphysical sense the human mind is the Kurukshetra where there is a constant struggle to choose the righteous actions over the unrighteous ones or to attain transient happiness by fulfillment of desires over the attainment of the Supreme Bliss by practising working toward selfless action.

The conflicts of emotions and intellect, the likes and dislikes, dos and don’ts have always remained real for all human beings. The seekers of eternal happiness or freedom have at their command the infinite ocean of knowledge through the chapters of the Bhagavad Gita. It has remained a solace for the life of all through the ages. Preaching of the Bhagavad Gita can compliment treatment of several mental disorders. It explains how psychotherapeutic healing can be facilitated by augmenting the same with spiritual preaching.

Key words: Spirituality, Bhagavad- Gita, Karmayog, Krishna, Arjuna

What is spirituality?

Trying to define spirituality is rather like trying to define your self. There always seems to be an invisible block on your assessment, until someone or something electrifies your

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awareness.

A definition of spirituality could include “personal views and behaviours that express a sense of relatedness to the transcendental dimension or to something greater than the self”. Spirituality can encompass belief in a higher being, the search for meaning, and a sense of purpose and connectedness.1

Religiosity and Spirituality are different

Religiosity is defined as participation in the particular beliefs, rituals, and activities of traditional religion. It can serve as a nurturer or channel for spirituality, but is not synonymous with it. Spirituality is more basic than religiosity. It is a subjective experience that exists both within and outside of traditional religious systems.2 Spirituality relates to the way in which people understand and live their lives in view of their sense of ultimate meaning and value. It can be seen as comprising elements of meaning, purpose, value, hope, love and for some people, a connection to a higher power or something greater than self. Spirituality is not simply needed in ‘religious patients’, but may be for treatment of all patients2, 3. Researchers have partially established a biological basis for spirituality in medial prefrontal cortex, posterior superior parietal lobe, temporal lobe and the limbic system.

WHO recommended that “the health professions are not treating only material body of the patients, the value of elements such as faith, hope and compassion in the healing process can never be over looked.”6

Does psychiatry need spirituality?

Psychiatrists as a professional group are not particularly religiously inclined.4, 5

Psychiatry has a history of ignoring, being in conflict with

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and attacking religion,8 and dismissing spiritual experience as ‘universal obsessional neurosis’, ego regression, 9,10 pathological thinking in need of modification, and a sign of emotional imbalance.11

To understand whether psychiatry needs spirituality or not we will have to examine what we mean by the term mental health? It is not mere absence of disease, it is a state of harmony within the individual and harmony between the individual and the environment out side, and this means we are talking in spiritual terms.

Health benefits of spirituality

The extensive research work of people such as Harold Koenig and David Larson is indicative of their being a positive association between religion, spirituality and mental health.7, 12, 34 Its health benefits include:

• Extended life expectancy.
• Lower blood pressure.
• Lower rates of death from coronary artery disease.
• Reduction in myocardial infarction.
• Increased success in heart transplants.
• Reduced serum cholesterol levels.
• Reduced levels of pain in cancer sufferers.
• Reduced mortality among those who attend church and

worship services.
• Increased longevity among the elderly.

• Protection against depression and anxiety. • Reduced mortality after cardiac surgery.

Spirituality reframes mental health problems potentially in positive ways. On the basis of current knowledge, we might consider that religious and spiritual beliefs may affect patient’s

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wellbeing in the following ways: 5,7,12

· Enhances coping by offering such things as hope, value, meaning and purpose.

· Facilitates social integration and support by linking religious patients with specific forms of caring communities.

· Provides systems of meaning and existential coherence.

· Establishes a perceived relationship with a divine other, i.e. persons can extend their circle of social support by drawing in religious and spiritual figures.

· Promotes participation in specific patterns of religious organization and lifestyle which may offer support and protection from, anxiety and depression. This reframing is not always positive, but it is certainly not always negative.

The above findings suggest that psychiatrists should take spirituality seriously.

I will now discuss about a great epic and its value in mental health not only for a particular religious group but for the whole mankind.33

The Bhagvad-Gita is universally renowned as the jewel of India’s spiritual wisdom spoken by Lord Shri Krishna, the supreme personality of godhead, to his intimate devotee Arjuna. The Gita’s eighteen chapters comprising of seven hundred verses provide a definitive guide to the science of self-realization. Indeed no work compares in its revelations of man’s essential nature, his environment and, ultimately his relation with supreme soul.14

What they say about Bhagavad- Gita

Many philosophers, saints and knowledgeable personalities of the world have commented about the Bhagavad-Gita. Few of them are mentioned below.

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“When doubts haunt me, when disappointments stare me in the face, and I see not one ray of hope on the horizon, I turn to Bhagavad-Gita and find a verse to comfort me; and I immediately begin to smile in the overwhelming sorrow. Those who meditate on the Gita will derive fresh joy and new meanings from it everyday”

– Mahatma Gandhi

“I owed a magnificent day to Bhagavad-Gita. It was the first of books; it was as if an empire spoke to us, nothing small or unworthy, but large, serene, consistent, the voice of an old intelligence which is another age and climate and pondered and thus disposed of the same questions that exercise us”

– Ralph Waldo Emerson

Bhagavad-Gita teaches us the Science of Life and the Art of Living

The Bhagavad-Gita means the song celestial. If you imbibe the message of the Bhagavad-Gita, it will bring about the music of life. Well the question is, in today’s world which notes of music are guiding or shaping our life? It is discordant notes, meaning there are so much of conflict, discord, stress and strain within the individual as well as in the society. So the word ‘song celestial’ means to bring out the exquisite music of life so that you enjoy every beat of life.

The problem is, there is no real cheer and enthusiasm to go out and perform our day-to-day activities. We look forward for getting away from our activities, e.g. we look forward for Saturday afternoon rather than Monday morning. Many people have wrong notion that they get peace and rest by getting away from

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occupation. But according to the Vedanta intense work is rest. If you can not find rest in dynamic activities, you cannot find rest in taking off from work. The art of taking rest is by performing activities. This is the law of life. While performing our daily routine we often feel boredom, are tired and fatigued, which is not because of activities or actions but because of our wrong mental attitude and negative mental disposition towards work.

Why we experience stress and strain, worries and anxiety, or any kind of mental agitations? Gita preaches that the problem is not in the outside world but in our attitude, our approach to the world. We get terribly attached, obsessed with our own body, mind, intellect and ego, which causes sufferings. When we get attached or obsessed with anything that belongs to us, what ever happens to that object also happens to us. This is the law of life. We get so obsessed with the body and bodily objects, mind and its emotions, intellect and ideology that cause the psychological disturbances. What is necessary is to keep a distance and continue to do our duties, rather than running away. This is the message of the Bhagavad-Gita.

Bhagavad-Gita: The book of Psychotherapy.

The Bhagavad Gita is the conversation between Lord Krishna and Arjuna in the battlefield of Kurukshetra. The Kauravas and Pandavas were the two rival forces. The Pandavas were the righteous lot, the good lot. The Kauravas were the unrighteous lot. Arjuna the commander-in-chief of Pandavas having his friend and mentor Krishna as charioteer, is faced with an intense psychological turmoil when placed in predicament of having to kill his own kith and kin in the opposite camp- an immoral act according to him. He was overwhelmed with emotions and told Krishna,

“Seeing my friends and relatives present before me in such a fighting spirit, I feel the limbs of my body quivering and my mouth

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drying up, my whole body is trembling; my hair is standing on end, my bow ‘Gandiva’ is slipping from my hand and my skin is burning. He pleads that he is incompetent to face the challenge and seeks to avoid it. By saying, I don’t want to fight, I want to run away from the battlefield”.14

Thus we have here an example of faulty coping strategy in the face of stress. The message of Bhagavad-Gita is to awaken Arjuna to perform his Sahaj Dharma of being a Kshatriya i.e., duty of a warrior to destroy the evil forces and to re-establish the Rule of Law (Dharma Rajya). In the metaphysical sense the human mind is the Kurukshetra where there is a constant struggle to choose the righteous actions over the unrighteous ones or to attain transient happiness by fulfillment of desires over the attainment of the Supreme Bliss by practising working toward selfless action (Tyag).

Cognitive Model of
Arjuna in the battle field of Kurukshetra

Situation : War – placed in the predicament of having to kill his own kith and kin in the opposite camp.

Automatic thoughts :

Cognitive appraisal of self : He is a righteous and valiant warrior.

Threat : He is doing an immoral act.

Anticipation : of outcome – negative.

Emotions : Anxious, tense, sad.

Physiological reactions : His limbs quivering, mouth drying up, body trembling and hair standing on end, bow ‘Gandiva’

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slipping, skin burning, unable to stand, forgetting himself and feeling mind-reeling.

Behaviour : Inaction, “I want to get away from the battle field, I don’t want to fight”.

Who is Arjuna in today’s context?

Each one of us, a dynamic individual, a corporate executive, doctor, chartered accountant, professionals, business personnel, exam-going student, person appearing for interview, player playing important match, in short, all those who have to face great challenges.

This whole world is a battlefield like Kurukshetra. People like Kauravas and a few like Pandavas are fighting till this day in this world. People like Kauravas are fighting to establish egoism and selfishness as well as people like Pandavas are fighting to establish righteousness or Dharam. Egoism or selfishness is Adharma or wrong. It is wrong because all crimes originate from egoism. Man becomes criminal on account of his selfishness or egoism. The root reason of all struggle for which mental peace is lost, is Egoism. Hence struggle between Dharam and Adharma – between right and wrong – between good and evil is the eternal struggle.

In order to maintain peace of mind and peace of world, the main thing which is essential is Tyaga or sacrifice. What is to be sacrificed? The ‘egoness’. How it is possible? It would be possible if work were done without any self expectation, only for the benefit of people and for the benefit of the society or the world. So Lord Krishna advises that work should be done without any expectation, as it causes pain. This advice of the Lord is applicable not only to Arjuna but also to the entire world.

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Krishna as a Cognitive Therapist

For one whole chapter and 10 verses, Arjuna ventilated his inner turmoil, guilt, for doing immoral and sinful acts of killing his guru and relatives. Krishna gave him enough time to express his grief and conflicts, just to set the psychology of the sufferer and make him receptive for suggestions. The sermon of the Bhagavad Gita came only after Arjuna completely surrenders to him. Krishna observed basic principle of counseling to create a therapeutic alliance.

Krishna resorted to correct his cognitive inadequacy by providing a new framework for the coping behaviour, where the task performance is made independent of the anticipation of outcome. He focused Arjuna’s attention on the value of his perception of himself in his role-status and of the objective environment. He taught that non-anticipation does not necessarily mean inaction. Thus it was not proper for Arjuna, to abstain from fighting against enemies on accounts of doubt of result.

In Bhagavad Gita there are no dos and don’ts. Krishna says at the end in 18th chapter –

Yatha ichhasi tatha kuru” (You do whatever you want). “I have explained to you the reality of life. There is no compulsion”. Krishna never forced Arjuna; he only exposed him to the reality of life. The law of life is that anything that is forced cannot be forceful. The real creativity is expressed under freedom. Excessive compulsion has a rebellious effect.

Steps for cognitive restructuring as described in Bhagavad-Gita; ‘Jyana’, ‘Karma’, ‘Bhakti’ and ‘Dhyana’

‘Jnyna’The path of knowledge or Cognitive appraisal The first task in facing any situation is Jyana or

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accurate cognitive appraisal

Krishna explained to Arjuna that “You are mourning for what is not worthy for grief. Those, who are wise, lament neither for living nor for the dead.15. Man is spiritual in nature and his spirit/ soul or ‘Atman’ does not come under the category of any substance, attribute or even an action. Krishna, further appraises Arjuna that the soul passes through childhood, youth and old age and also in to another body just as an old cloth is replaced by new one16 By killing, you will destroy the physical body no one is able to destroy the imperishable soul.17 For the soul there is neither birth nor death any time.18 The soul can never be cut to pieces by any weapon, nor burned by fire nor moistened by water, nor withered by the wind.19 By killing the physical body you are not committing any sin or immoral act because you are attached to their soul and not the physical body which is just a vehicle.

The Bhagavad-Gita concept of Jnyna in a wider sense i.e. understanding of the universal nature of the spiritual self in contrast to the individual ego experiencing pleasure and pain, can be definitely helpful in reducing the impact of life events as personal stressors. The Bhagavad-Gita’s concepts of immortality of the soul is especially soothing for one who is grief-stricken with a loss of loved one. Similarly, the emotional disturbances associated with the advent of adolescence and old age become more tolerable in light of Bhagavad-Gita’s concept of these inevitable phases of the life cycle.

‘Karma’ – The path of action

Karma’ or appropriate action is the path for ‘Yogi’ to face the problems. Krishna explains to Arjuna, “considering your specific duty as a ‘Kshatriya’, you should know that there is no better engagement for you than fighting on religious principles; and so there is no need for hesitation.20 Fight for the sake of fighting, without considering happiness or distress, loss or gain, victory

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or defeat – and by doing so you will never incur sin”.

Krishna emphasizes the importance of unattached action. If action is performed with attachment to the result one becomes either enjoyer or sufferer. Non-participation or inaction is also another side of attachment. Any attachment, positive, or negative is cause for bondage. Inaction is sinful therefore fighting as a matter of duty was the only auspicious path of salvation for Arjuna.22

Every human being has to perform his obligatory duty, because action is superior to inaction. One cannot maintain one’s physical body without work.23 Therefore, without being attached to the fruits of activities, one should act as a matter of duty, because by working without attachment one attains the Supreme, that is, self-realization.24

Elaborating the need for action, Krishna clarifies, “whatever action a great man performs, common men follow and whatever standards he sets by exemplary acts, all the world pesues.”25

Krishna further clarifies that not inaction but action without attachment will lead to actionlessness. For that, let us look at the anatomy of action:

Vasna (passion) – manifest as- thoughts- manifest as – desire- manifest as action- further creates your habits- creates your character-creates your destiny.

You are what you are because of your action.

Now let us examine how you can eradicate action : Action performed with selfish desires will create more selfish desires.

Action performed with unselfish desires will remove the selfish desires but create unselfish desires. Action performed

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with selfless desire will eradicate the desire.

Once the desire is eradicated, action will automatically be eradicated leading to ‘actionlessness’. Krishna has given logic and reason, intellectual appeal, emotional appeal, devotional persuasion, flattery, in a personal appeal for action.

One should therefore,

1. Derive one’s gratification from doing his duty and not from its outcome Viz. “Nishkam Karma

2. Perform his task perfectly viz. ‘Karmashu kaushalam’

3. Dedicate actions for society’s welfare viz. ‘Yagnarthat Karma’

These three aspects of action are technically termed as ‘Karmayog’ in Bhagvad-Gita

So Krishna advises Arjuna to overcome his improper refusal of his duty to fight which has come to him by his birth (warrior class), upbringing and temperament. This is his appropriate role, directed by ‘Dharma’- the code of conduct, which protects the interest not only of the individual, but of the society at large. It’s true that Arjuna was killing his guru, kith and kin as a part of his duty of the physical body, but his mind was not on killing, it was on a higher ideal that he was doing this to rescue the country from the clutches of the Kauravas. When the intentions are noble one may go through a negative action that does not matter. A soldier in the army is constantly killing, he does not have desire to kill but to save his country.

The principles of ‘Nishkamkarma’ is appropriate for anxiety states related to action with uncertain outcome, and helps the person to function effectively in this achievement oriented world, where rewards may not be always certain.

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‘Bhakti’- The path of faith

Faith in God and dissolving the egocentricities, thereby identifying with a universal soul or personal God is a unique step to salvation from problems. Bhagavad-Gita’s explanation on ‘Bhakti’ gives prominence to the identification of the individual soul with the Supreme soul through complete dedication and surrender. Infact, the active religious life of common Hindus today is grounded in ‘Bhakti’ and thus, the various rituals such as ‘Japa’. ‘Homa’, ‘Archana’, ‘Seva’, and ‘Vandana’ can be developed as therapeutic tools, in the Indian society.

‘Dhyana Yoga’ – The path of peace, tranquility self-realization by yoga and meditation

In ‘Dhyana Yoga’, Krishna explains the process of eight fold Yoga system as a means to control mind and senses. Krishna emphasizes that the mind can be the best friend or worst enemy of living beings. The eight-fold yoga controls the mind in order to make it a friend in discharging the human mission. As long as one’s mind remains unconquered, its enemy within is driving oneself towards lust, anger, avarice and illusions. If the mind is conquered one reaches ‘Param Atman’ situated within himself. Such a man reaches the super soul and attains tranquility. For him happiness and distress, heat and cold, honor and dishonor are all the same.28

In one instance Krishna advises Arjuna to be a man with positive mental health which is required to face problems in the real life. When asked, Krishna defined a man with positive mental health, whom he termed ‘Sthitapragna’— A man who can act effectively in conflict-free way, he is one who is unruffled by grief, desire or anger alike, who is free from any kind of attachment, has control over his senses and whose happiness wells up from within, being non-contingent upon external gratification26. This definition of a man with positive mental health is holistic

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as compared to the normal personality described by the modern experts.

The Bhagavad-Gita also refers to other important approaches for better positive mental health. This includes ‘Pranayama’ or deep breathing exercise. The technique of the ‘Pranayama’ suggested by Krishna is as follows :

“Shutting out all external sense objects, keeping the eyes and vision concentrated between the two eyebrows, suspending the inwards and outwards breathe within the nostrils, and thus controlling the mind, senses and intelligence. The transcendentalist aiming at liberation becomes free from desires, fear and anger. One who is always in this state is certainly liberated.27”

Krishna also emphasizes that for positive mental health, ‘Pariprashna’ or discussion, ‘Shraddha’ or devotion.31 ‘Ekgramana’ or meditation30 ‘Yuktahara Vihara’29 or good nutrition and relaxation are most essential ingredients.

Apart from providing conceptual framework conductive to freedom from psychological conflicts, the Bhagavad-Gita also provides a cookbook approach to positive mental health, using the principles of Yoga, the steps of self-disciplining in food and habit and the code of conduct (Yuktaahara Vihara) physical training through postures (Asanas), autonomic training through deep breathing exercises (Pranayama) and the various stages of meditation (Ekgramana).They constitute the truly effective approach to integration of the mind and body.

After intense cognitive restructuring by 18 chapters and 700 verses of Bhagvad-Gita, in the eighteenth chapter Krishna finally tells Arjuna, “I have revealed to you this profound knowledge about The Self. You now do whatever you like.” Arjuna said,” my illusions

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are destroyed, as I have gained my confidence, mental capacity, and dutifulness through your preaching I am firm; my doubts are gone. I will do according to your words.” At the end of Mahabharata, he conquers the battlefield of Kurukshetra, the victory of righteous forces over unrighteous, positive thoughts & attitudes over negative.

Conclusions

How spirituality of Bhagavad- Gita can be complimentary in our clinical practice?

To sum up in a nutshell, the Bhagavad Gita introduces your self to your self. It begins with the word Dharma i.e. your nature and ends with the word Ma..Mam i.e. mine. So the message of Gita is what is my essential nature, who am I? The Bhagvad Gita is the manual to restructure your personality and to attain perfection in whichever field you are engaged. This can be achieved by regularly reading and living Bhagavad Gita in day-to- day life.

There is an urgent need for a more holistic approach to mental healthcare which is sadly lacking at present. The World Psychiatric Association and the World Health Organization have both called for more attention to be given to spirituality and religious beliefs. The modern civilization’s ‘loss of soul’ may cause a wide range of symptoms from obsessions, addictions, violence and loss of meaning. Dehumanization of medical care is a trend in all specialties. Psychiatrists should provide credible and humane role models to medical fraternity. We must practise and preach the fact that psychiatrists are physicians to the soul as well as the body. If the challenge is real, then psychiatry first has to reinstate the soul, the soul that our profession has lost. To reclaim psychiatry’s soul, to reinstate the origin of ‘psyche’ into psychiatry demands that we return to learn about the ‘anatomy’, ‘biochemistry’, ‘physiology’,’spirituality’ and ‘dynamics’ of the soul13. Let us accept the fact that spirituality is complimentary to

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psychiatry and psychiatry should take advantage of the complementing role of spirituality rather than contradicting it.

From the above, it is apparent that the Bhagavad-Gita is replete with concepts relevance to psychotherapy in the present day psychiatric context, but these concepts must be viewed with reservation. Obviously, the severely-depressed, the confused, demented or the hallucinating person with schizophrenia may not reap much benefit from the Bhagavad-Gita. The message of the Bhagavad-Gita, however, appeals to the vast multitude of less severely-disturbed people, plunged in competition, frustration and meaninglessness.

For the therapist in his busy task of catering to the needs of the emotionally disturbed, to deploy these principles, certain pre- requisites are to be borne in mind. The therapist has to cherish the value system of Bhagavad-Gita himself, thus maintaining congruence in his therapeutic relation to the patient. Secondly, the belief and value system of the patient must be considered and the therapist must not impose his values upon the patient.

Krishna’s model of cognitive therapy can definitely help us reinstate the soul, lost by our profession.

Read, digest and discuss principles of Bhagavad-Gita. Reinstate the origin of ‘psyche’ into psychiatry.

References:

1. Culliford,L. (2002) Spirituality and Clinical Care. British Medical Journal. 325:1434-5.

2. Swinton, J. ‘Why Psychiatry Needs Spirituality’, paper presented to the Royal College of Psychiatrists AGM in Edinburgh 22/6/05.

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3. D’Souza R, Heady A, Rich D. Spiritual needs in psychiatric practice. In: Proceedings of the 36th RANZCP Congress. Book of Abstracts. Canberra: RANZCP, 2001.

4. Neeleman J.,& King., M. B. (1993). ‘Psychiatrists religious attitudes in relation to their clinical practice: a survey of 231 psychiatrists.’ Acta Psychiatrica Scandinavica. 88:420-424.

5. Swinton, J. (2001) Spirituality and Mental Health Care: Rediscovering a “forgotten” dimension. London: Jessica Kingsley Publishers.

6. World Health Organisation WHOQUOL and Spirituality, Religiousness and Personal Beliefs: Report on WHO consultation Geneva: WHO, 1998.

7. KoenigHK,McCulloughME,LarsonDB.(2001)Handbook of Religion and Health Oxford: Oxford University Press.

8. Kung, H. (1990) Freud and the Problem of God. New Haven: Yale University Press.

9. Freud, S. (1959) Civilization and its discontents. In: Stachey J, Ed. The Standard Edition of the Complete Psychological Works of Sigmund Freud,Vol. 1. London: Hogarth.

10. Lruba, J.H. (1929) Psychology of Religious Mysticism. New York: Harcourt Brace.

11. King, M.B. (1998) The spiritual variable in psychiatric research. Psychological Medicine ; 28: 1259–1262.

12. Larson, D.B., Swyers, J. P. & McCullough, M. (1997) Scientific Research on Spirituality and Health: a consensus report. National Institute for Healthcare Research.

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13. Andreasen, N. C. (1996) Body and soul (Editorial). American Journal of Psychiatry 153: 589–590.

14. Bhaktivedanta Swami Prabhupada. Bhagvad-Gita as it is. International Society for Krishna Consciousness. Mumbai: Bhaktivedanta Book Trust.

15. Chapter-1, text-28, 29,30, pp 56 16. Chapter 2 verse 11, pp 235.
17. Chapter 2 verse 13 pp91
18. Chapter 2 Verse 17 pp 96

19. Chapter 2 Verse 20. pp101
20. Chapter 2 Verse 23. pp 106
21. Chapter 2 verse 31 pp 115
22. Chapter 2 verse 38. pp 121
23. Chapter 2 verse 47 pp 134
24. Chapter 2 Verses 53-59 pp 141-146 25. Chapter 3 verse 8 pp 171

26. Chapter 3 verse 19. pp 184
27. Chapter 3 verse 21 pp 186
28. Chapter 5 verse 27-28 pp 302-303. 29. Chapter 6 verse 4-8 pp 278-281 30. Chapter 6 verse 17,pp 325.
31. Chapter 6 verse 19 pp 329
32. Chapter 6 verse 47 pp 359.
33. Chapter 4 verse 34 pp 26216.

34. Satyananda, D. (1992) Dynamic Psychology of the Gita of Hinduism, London, Oxford and IBH.

35. Venkoba Rao, A. & Parvathidevi, S. (1974) The Bhagavad Gita treats body and mind. Indian J. Hist. Med, 19: 35-44

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Dr. Usha Sundaram

Dr.Usha Sundaram has worked for many years as a Psychiatrist at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, India. She began searching for additional ways to help people, and decided to apply her many years of training in yoga after finding that yoga was a practical and effective approach to reintegrating the body, mind and spirit.

Dr. Sundaram has travelled extensively all over India, teaching yoga at schools, colleges, temples, churches, corporate groups and to individuals. She was a Visiting Professor at Youngstown State University in Ohio in 1988-89. She has since been going every year to the United States, teaching at Ohio, Texas, Indianapolis, Mineapolis, Los Angeles and Illinois. She has published articles in journals and has authored a book on “Mantra”.

She is a Visiting Faculty at the Bihar Yoga Bharati, Munger, Bihar, and teaches Indian Psychology, Yoga and Mental Health at the Richmond Fellowship College of PsychoSocial Rehabilitation, Bangalore. Dr. Sundaram practises under the name of Swami Dharamkeerti Saraswati as initiated by her Guru Paramahams Sri Swami Satyananda Saraswati, founder of the Bihar School of Yoga.

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YOGA, MIND AND MENTAL HEALTH

Usha Sundaram

Over the last 5000 years, in India, there has been a collection of documented experiences that flowed from intense research into the behaviour of the body, mind and Supermind by seers and their disciples. They were accumulated over many generations by scientists, physicians, administrators, kings, merchants, men and women from every walk of life in uninterrupted Guru-disciple traditions. These systems of thoughts were not of an abstract or speculative nature. They were born of stringent well thought out methodologies, meticulously documented perceptions in the minutest details, debates and discussions by competent teachers who had walked the path at specific conferences hosted by the wealthy, powerful and wise people of those times in a passionate desire to transcend perceived human limitations that were seen to cause suffering. As a consequence, there were six main schools of Philosophy called Darshanas and their writings run into volumes.

These are Mimamsa, Vedanta, Nyaya, Vaisesika, Sankhya and Yoga. However, the techniques as well as practical methods of the yogic school were adopted by other schools. Because these schools existed side by side over thousands of years, qualities of tolerance and respect for each others’ traditions or other ways of perceiving Reality became interwoven into the psyche of the Indians. As a consequence, they contained concepts, which when followed sincerely contributed to life-styles that maximized health and happiness, recommended by enlightened people and were not organised religions by any stretch of imagination.

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Yoga

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Yoga is the Science of Consciousness which, while dealing with the evolution of the human personality, leads to the awakening

of the dormant energy sources within the individual mind.

There are two main traditions of Yoga – The Vedic tradition and the Tantric tradition. They deal with practical, moral, social, ecological, metaphysical and spiritual dimensions of life in the universe. At the individual level, there are treatises which deal with body, mind, emotions, expressions, behaviour, predispositions and perceptions which go beyond the reach of these realms of body and mind as we know today. They contain a rich body of practical techniques to help each individual experience and transform the deeper dimensions of his/her psyche in meaningful and joyful way.

Mind

The concept of Mind in the Yogic tradition is a combination of consciousness and Energy. The mind is divided into :

Pure : A luminous state of Being totally fulfilled in itself, craving neither for stimulation or experience for its joyful sense of completion.

Impure : Subject to cravings, desires, ambitions, it seeks fulfillment from the ever changing world of sensory stimulation and sensory objects and not finding satisfaction, remains disturbed and incomplete.

It should be noticed here that Pure and Impure do not allude to morality or societal concepts of ‘virtue’ and ‘vice’ but to purely its holistic or limited functioning. All suffering is due to perceiving this Impure mind as being Pure and identifying with its gratification of cravings as genuine solutions to the problem of distress. The Impure or Incompletely Perceiving Mind is made up of :

Manas : The rational analytical mind or the intellect. [Approximating the left brain functions as we know today]. It is a

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quality of the ‘manifest’ mind.

Buddhi : The intuitive mind which is synthetic in nature or the principle of intelligence. It receives stores, compares, brings appropriate information to the surface and is a balance between the left and right hemispheres of the brain.

Chitta : The subconscious, unconscious and the ‘collective conscious’ dimensions that contain all past impressions and conditioning which are part of the genetic, cultural and personal past.

Ahamkar :The specific identity or Ego aspect of the individual.

These four go by the name of Antahkarana.

Six dimensions of consciousness:

A dimension or a body of consciousness is called ‘shariram’.

1. Sthula shariram : The physical and physiological dimension. Here we are talking of the Consciousness, the intelligence in the very cells themselves which make the body a coordinated organism where every cell has the wherewithal to nourish, defend, destroy and recreate itself.

2. Sukshma shariram : The emotional body or the Subconscious mind. This also involves the vital energy or prana which forms the bridge between body and mind.

3. Karana shariram : The Unconscious collection of genetic, cultural and distant collective past which influences many of our behaviour patterns which are not underderstood today. These impressions are called ‘vasanas’ or in terms of modern psychology are archetypes.

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with the Collective consciousness of the Present. This is the perfect mind, but not the complete mind.

5. Atma shariram : A state of pure awareness not limited by body as we know them. This dimension is the witness of all that happens in the above four dimensions.

6. Brahma shariram : Super consciousness or the ‘cosmic mind’.

Sakshi bhava – awareness

According to Yogic tradition, there is only one continuum of perception or experience called ‘chetana’. Chetana is consciousness and is constant, endless and is changeless. It encompasses all the above dimensions which in their totality include the experience of the waking state or ‘jagrat’; the dream state or ‘swapna’; the deep sleep state or ‘sushupti’. For most people there is at any time only a fragmentary and partial awareness of even one of these states and that too of the waking state. Sakshi Bhava or witnessing, in yogic terminology refers to an aspect of the Buddhi, a nonjudgmental seeing of the whole which happens when the Buddhi starts to function. Awareness changes according to our circumstances. If we take just one sense organ e.g. the vision, our vision changes between our looking at an object through the medium of a magnifying glass, a smoky glass, smoke itself, tears, water, or through a smoggy sky.

The eyes and the Buddhi are the same, but the medium through which we look creates different states of experience. This is at the physical level alone, notwithstanding problems in the eye itself. Add to these a million years of conditioning where anything ‘unfamiliar and strange’ is seen as dangerous and a threat to happiness. This refers to seeing objects on the outside. What happens when the object is a part of our own inner shadow – our fears, our jealousies, or rages, or even our greed? We do

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not see them because they are threatening to our emotional survival. What is unpleasant is denied and in the denial further vasanas are newly built reinforcing the past or merely strengthening already existing ones. These vasanas are like dust on a mirror. The techniques of yoga clean the dust and we see life with authenticity.

The aim therefore of Yogic practices is to become fully aware of every dimension of consciousness simultaneously and all techniques are geared towards this end. The impure mind which sees only partially creates suffering. Therefore, techniques to raise the awareness so the mind perceives the whole are called as Chitta Shuddhi — purifying of the Chitta or removing the past conditioning that prevents us from seeing the Whole either due to an infatuation with something that reinforces the past or a fear that creates a repulsion which again reinforces past behaviour. This attraction and repulsion are called ‘raga’ and ‘dwesha’ and lead to ignorance of the Reality or avidya and this causes distress in life. The more expansive our awareness, the less threatened we feel and therefore more relaxed. We find solutions taking the larger perspectives into consideration. We suffer less and are more compassionate in our behaviour than when we see only a part of the problem. It has often been said during yogic training that “the Manas solves problems but the buddhi dissolves them.”

The word buddhi comes from the root ‘bodh’ meaning “to know” or “to be aware of”. To be a fully functioning buddhi is to be a witness to life as it is and meditations are called ‘vidyas’ because they transcend the state of avidya or ignorance. It is a cleaning of the mirror of vasanas and seeing everything as it is. Awareness, absence of awareness, expansion of awareness can be experienced through yogic techniques. During the waking state, awareness takes one form, during dream, another and during deep sleep yet another. However there can be moments when awareness or sakshi bhava is a combination of all three states

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with equal intensity all through as one homogenous experience state of perception. This is the state of the Super Conscious mind or the state of Samadhi.

Imbalance and suffering

The therapists, as well as the patient both have the body, emotions, intelligence, intuition, psychic qualities and the capacity to witness the totality. The therapist, therefore, to be really effective has to be able to go into all these various dimensions. In confronting his own inner turmoil and channeling them positively, he would be working on two levels – his own individual liberation from limitation and that of contributing to the wellbeing of the Collective consciousness of which he is a part.

Every emotional, psychic, pranic disturbance is mirrored in the body too. When the therapist feels hostility, frustration, anger, rejection or confusion within a therapeutic relationship, not only is it reflected as body language but it has an impact on the nervous system, hormones, immune system of both and the community at large through the collective consciousness or deva shariram.

There is an imbalance and imbalance creates suffering.

Broadly speaking, imbalances can be encountered in
1. Sthula Shariram : Physical and hormonal reasons
2. Sukshma Shariram : Lowered intelligence, lethargy,

confusion, dullness
3. Karana shariram : Disturbances creating delusions,

hallucinations and even psychotic states
4. PranicimbalancesPrana:NotextonYogaiscomplete

without an understanding of the term ‘Prana’. According to Yoga, there are two aspects of man’s existence – Prana and consciousness. Prana is the bioplasmic or vital energy that is universal in nature. It is the life force of the Universe while

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consciousness is knowledge. Prana is the active and Consciousness the dormant part of our existence.

On a higher level prana and consciousness are one and the same. Prana is the energy of Consciousness. However at the ordinary level they are related and interact with each other. The cosmic manifestation of prana in the individual body is called ‘kundalini’. The entire cosmic experience from creation to dissolution is embedded within the folds of kundalini hence it is known as ‘atma shakti’”, says Swami Satyananda Saraswati in his book on Kundalini Tantra. Only the full force of Kundalini Shakti {maha prana shakti or atma shakti} can awaken all conscious and vital functions. When the prana expresses itself as the mental world of thoughts emotions etc., it is called chit shakti and when it expresses itself as life forces of a physical nature, it is called as prana shakti.

The easiest way to the understanding of prana is to study and realize its functioning in the different dimensions of consciousness starting with its expression in the physical body through yogic techniques. Since Prana is the force both within the breath and the body, practices of pranayama and Prana Vidya help in its study.

The word prana is a combination of two words Praand Naand denotes a force in constant motion. Pranayama is a process through which the quantity of prana and its intensity of vibration is increased to a higher frequency. Pranic flows are called nadis [from the word ‘nad’ to flow. The passage of flow of prana shakti is called ‘pingala’ and the passage of flow of chit shakti is called ida. Wherever two nadis or two flows cross there is a whirlpool of energy called a chakra. Different chakras have different frequencies of vibration. The body and mind share the same prana which expresses itself in three ways – inertia, movement and harmony respectively called tamas, rajas and sattwa :

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a. When prana is low or stagnant, in other words tamasic, the individual is low in motivation, exhausted, dull, lazy, and depressed. His /her relationships are disturbed and violent, his career stagnates, and the immune system is lowered. The individual exhibits a sense of great demoralization at all levels and can be quite rigid and inflexible in mind.

b. When prana is too high or too active, in other words Rajasic, then the individual is restless, can have hyperactivity, mood swings, irritability.

c. When there is an imbalance between ida and pingala flows, there can be temperature variations, mind body incoherence, mental and physical growth retardation, difficulty with concentration and memory and sleep disturbances.

d. Energy blocks can cause excess functioning in one area and lack in another area.

5. Psychic imbalances

a. Experiences of extra sensory kind without preparation, control or knowledge

b. Blocks and obstacles in the path of sadhana, higher experiences or evolution.

c. Acquiring extra sensory skills like ‘clairvoyance’ etc., and demonstration for self-promotion. These are transient and yoga is very clear in saying that these are to be witnessed as sign posts along the way and not craved for or clung to because if a practitioner places great emphasis upon them, then when the energy is depleted in overusing them, a great depression settles.

6. Kundalini Experiences

If Kundalini experiences occur in an uncontrolled unsupervisedsetting, theindividualwillnotbeabletocopewith the qualitative change in perception, with altered states of

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Consciousness unfamiliar to him, or with looking at the contents of the Unconscious mind when it comes spilling into the conscious state. This alone can lead to a breakdown of psychotic proportions or into great depression, mania and paranoia.

However, it must be noted here that the science of yoga has its own inbuilt safety mechanisms. If yogic practices are done systematically under supervision, then when the person is not ready for experiences that he/she cannot handle, nature puts obstacles in the way.

Yogic practices to handle risks and imbalances – Karma Yoga

A person who is hypersensitive, introverted,, timid, dependent, credulous one who has difficulty in communication, who lives in a fantasy world should not experiment with techniques like meditation that bring up the unconscious mind because it can be alarming and dangerous. Such individuals should practice karma yoga which is to make a willing commitment to working physically as a means for inner development, and allowing various possibilities to unfold within themselves such as confidence and self-worth. Work, however big or small is a privilege and an opportunity for self expression and inner growth e.g. gardening is not just planting and watering, it is also a way of receiving prana from the soil, water and plant as well as nurturing and nourishing life. When a normal individual practicesmeditativetechniques,itis againimperativetocontinue with the karma yoga as a way of balancing the mental and physical dimensions otherwise one can become introverted because of constant exposure to one’s own inner mind alone.

Hatha yoga

Strictly speaking, hatha yoga is a series of cleansing practices or shatkarmas like, neti, shankaprakshalana, nauli, dhauti, and

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trataka. However, some people also add the practices of asanas as comprising hatha yoga. Whether one is tamasic, rajasic or sattvic, the practices of hatha yoga must be taken up first. The tamasic person uses it to get the stagnancy moving, the rajasic to balance the ida and pingala and the sattvic person uses it in his quest for his own inner awakening .

Asana

These are body postures and movements that work deep in the body, regulating the endocrine and autonomic nervous systems. Asanas that are maintained in a still posture are called static-ones and can be practiced by people who are not distressed.Asanasinvolvingmovementarecalleddynamic and are better for people who are distressed like depressives or psychotic patients. Strong or threatening emotions like fear and anger can be grounded through the practice of these postures. Dynamic asanas are simple movements repeated rhythmically many times. They set in motion stagnant energy, physical and psychic converting Tamas to Rajas. Some examples of static asanas are bhujangasana, siddhasana, halasana while those of movement asanas are pawan muktasana, tadasana, tiryaka tadasana, katti chakrasana and surya namaskar.

Pranayama

The practice of dynamic asanas is linked with breathing techniques like Nadi Shodana Pranayama which balances the physical and mental energies in the individual, Brahmari Pranayama relaxes and soothes the emotions apart from its uses in physical ailments of psychosomatic nature like asthma, hypertension etc. Bhastrika Pranayama is useful in raising sluggish energy levels. Through the practice of simple breathing techniques, turbulent emotions can be soothed. A sense of optimism and wellbeing is induced which deals with a low morale. The breath is a powerful tool in focusing the mind and temporarily

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breaking negative cycles of thinking. Conscious rhythmic breathing helps in enhancing energies and providing mental clarity. The individual now becomes not just active but a man of action because productive action proceeds from centeredness.

Dhyana

The practice of meditation or ‘dhyana’ is not used for deeply disturbed or unstable personalities. It can however help a therapist gain greater inner clarity. It becomes an essential part of his/her repertoire to remove deep seated attitudes and complexes that are not amenable to other techniques and are responsible for negative patterns of reaction. Needless to say, these techniques should not be learnt from books but learnt from a mature teacher who can support the individual through the anguish of watching his/her own inner storms as a prelude to energy transformation.

Kriya yoga

Unlike various practices that demand mental control, Kriya Yoga is a part of tantra where the techniques help in transforming a dissipated or negative mind into a transformed energy without any suppression. Mind is energy. Through kriya yoga, one harnesses the energies of the mind. The premise here is that suppression causes explosion and the greater the suppression, the greater the explosion. There are many kriya yoga practices, but a combination of 20 is said to be very powerful and is to be taken up only after asana and pranayama practice for a period of time and to be learnt only under supervision.

Bhakti yoga

The capacity for faith, devotion, or ability to surrender is a result of an openness of mind and spirit and a sense of being non-threatened. The ability to let go is in each of us. This aspect of ourselves has to be acknowledged as strength and not as weakness. In the science of yoga, vulnerability with awareness

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is strength. A soft heart is a human heart. There are practices that help a person to open themselves up to life without fear. These are the practices of bhakti yoga.

Everyone faces difficulties

It is not realistic to expect that therapists have no problems, no negative emotions, and will never face a crisis. What is important is to have a technique and a philosophy that will help weather a storm when it arises.Yoga fulfills this necessity. It helps us see disrupting patterns and work out healthy ways to coming to terms with limitations and aspirations. It helps us make contact with goal of the inner spirit – of being authentically human instead of deceiving ourselves with false images of being super men or super women and suffering as a result.

Being an authentic human being is the state of Total Mental Health, an exploration of which is rewarded by the discovery of a fulfilled whole person within. This is the promise of Yoga.

References :

H. Motoyama (1979); Yoga and Oriental Medicine. Research for Religion and Parapsychology, 5 [i]

Swami Niranjanananda Saraswati Prana: (2002); Pranayama, PranaVidya.Yoga Publications Trust, Munger, Bihar, India.

Swami Satyananda Saraswati Kundalini Tantra: Bihar School of Yoga publication.

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Dr. R.Srinivasa Murthy,

Prof. Murthy completed his postgraduate degree in Psychiatry (M.D.) in 1975 and has been a Postgraduate Teacher of Psychiatry from 1975.

Prof. Murthy was Professor of Psychiatry at the National Institute of Mental Health and Neurosciences, Bangalore, India, from 1987-2003. He was Head of the Department of Psychiatry, from January 1988 to February 1997 (9 years) with over 50 postgraduates and 40 academic staff.

Prof. Murthy has worked with the WHO extensively. He functioned as Editor in Chief of the World Health Report 2001 during 2000-2001. The report focused on Mental Health. Following retirement in 2004, he worked with the World Health Organisation at the Eastern Mediterranean Regional Offices of Cairo and Amman. The last two years 2006-2007 of work was as mental health officer of WHO-Iraq.

His research contributions have been mainly in the areas related to community mental health. He has published extensively in national and international journals (over 200 publications).

Currently, working (for two days a week) in Bangalore with a voluntary agency for mental handicap (ASSOCIATION FOR MENTALLY CHALLENGED, http://www.amcin.org ) to develop a community based care programme for persons and families with mental handicap. Contact: murthy_srinivasar@yahoo.co.in

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CONTEMPORARY RELEVANCE OF HINDUISM TO MENTAL HEALTH

R.Srinivasa Murthy

.

Hinduism is one of the ancient religions of the world. Wig (1990, 1999) has pointed out the difficulties in any generalization about the Indian mind as being very difficult, and many concepts described by some as ‘typically’ Indian is likely to be contradicted by others. The chief reason for this is that the Indian civilization is one of the oldest continuing civilizations, with thousands of years of history. During its existence it has assimilated many influences, which have shaped modern Indian thought. Unlike many others, however, Indian civilization has thoroughly absorbed the previous cultures into the new ones without making a clean break, with the past cultural values. For this reason, in modern Indian religious thought, one can easily pick out the strands of old Aryan and Buddhist teachings, along with the influence of latter day Hinduism, medieval Islam, and modern European thinking. Of the many aspects of Hinduism, mental health is a very important one. The following sections present the contemporary relevance and applicability of the key contributions of Hinduism to Mental health. The chapter presents a brief overview of Hinduism, followed by five contributions to mental health.

The Hindu religion is an ocean of spiritual teachings about all aspects of life and consciousness. It is the world’s oldest religion, going back to the very dawn of history. It sees its origin in the cosmic mind itself. Yet Hinduism is perhaps the world’s

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teachers and allows for correction and evolution over time. Hinduism is the most diverse religious tradition in the world. It could be said that there are probably more religions inside of Hinduism than outside of it. It has numerous saints, sages and yogis, both male and female, from ancient to modern times. Hinduism is the world’s largest Biblical tradition, with nearly a billion followers worldwide. It could be called the world’s largest non-organised religion as it emphasises individual spiritual experience, the realisation of the higher self over any religious institution, book, dogma or saviour. Hinduism is the world’s largest pluralistic tradition, recognising One truth- an eternal reality of Being –Consciousness Bliss in all beings- but also many paths to realise it. Hinduism has probably the world’s largest literature of spirituality, mysticism, and yoga. It provides complete spiritual culture including art, dance, sculpture, medicine, and science, with all these subjects explained according to a science of consciousness (Johnsen, 2002).

Hinduism appears to many as a jigsaw puzzle but if one knows where to put the pieces, not only is the puzzle easily solved, but also gives rise to a beautiful picture. Hinduism is a religion because it accepts the existence of God and posits him as the final goal of our life. It places before us many paths that suit persons of different temperaments, but leading to the same beatific experience of that God. Hinduism gives the moral and ethical disciplines that help a human being to purify himself and become fit for the pursuit of God. It provides enough scope and opportunity for its adherents to get emotional satisfaction through its rituals and festivals. It recognizes the shortcomings of the powers of the human intellect in matters spiritual and experiential, and hence gives due recognition to the revealed word of God, the Vedas. Following the maxim that the same cap can not fit everybody, it gives different modes and methods of sadhanas or spiritual disciplines to aspirants of different temperaments.

Hinduism as a philosophy, gives through rational analysis, and in a convincing manner, a knowledge about the ultimate truths

 

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behind man and the universe, as also the final goal and the path. It has given freedom of thinking and expression to all schools and subschools of thought, though they may not agree among themselves. Differences of opinions are respected whereas the spiritual seekers are given the full liberty to opt for any one of them. Hinduism is a culture, because it encourages all aspects of culture like music, dancing, drawing, sculpturing and other arts, but as reflecting the glory of the divine and also as aids to spiritual evolution, if the right attitude is adopted. Further, Hinduism is both ancient and modern, in that ancient in its eternal value-system, but modern in that it is always open to new ideas and ever ready to replenish its treasure-house of knowledge, wisdom and virtues. Hinduism has survived the vicissitudes of history and onslaughts of time, exactly because of the various factors mentioned above.

There are many unique aspects of Hinduism and the contribution of Hinduism to humanity. I would like to refer to two of them in this essay.

The first is the way Hinduism looks at religion as a way of life unlike that of other religions. This is well illustrated by the following quote from Radhakrishnan, who quotes Arnold Toynbee as follows:

“As I have gone on, Religion has come to take a more and more prominent place, till in the end it is in the centre of the picture… I have come back to a belief that Religion holds the key to the mystery of existence; but I have not come back to the belief that this key is in the hands of my ancestral Religion exclusively….The Indian religions are not exclusive minded. They are ready to allow that there may be alternative approaches to the mystery. I feel sure that in this they are right, and this catholic- minded Indian religious spirit is the way of salvation for all religions in an age in which we have to learn to live as a single family if we are not to destroy ourselves”(Radhakrishnan, 1968; 49)

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The second most important contribution of Hinduism is in the area of health in general and mental health in particular.

Ayurveda

In India and the neighboring countries, like Nepal, Bangladesh and Sri Lanka, a highly developed and elaborate system of medicine has flourished for nearly three thousand years (Varma, 1965; Dube et al, 1978, 1983, 1985; Narayana Reddy et al., 1987; Balodhi, 1987; Knipe, 1989; Wig, 1990, 1999; Frawley, 1998; Valiathan, 2003; Harshanand, 2008). It is generally known by the name of Ayurveda (the science of life). There are many medical texts dating back to the first and second century A.D which describe in detail the principles of Ayurveda. The two best known medical works are by the Ayurvedic physicians Charaka and Shusruta. These books were originally compiled sometime between the third century BC and the third century A.D. The principles of Ayurvedic medicine, like in other Indian philosophical systems, were probably well developed by the third century BC.

In Ayurveda the fundamental principle of health is the proper balance between five elements (Bhutas) and three humours (Dosas). The balance occurs at different levels: physical, physiological, psychological and finally spiritual- the state of bliss in which the ultimate goal is tranquility. The human being is considered an integral part of the nature and is made up of the same five elements (Bhutas) that constitute the universe; water, air, fire, earth and sky. The three humours or Dosas recognized in Ayurvedic medicine are Kaph (phlegm), pitta (bile) and Vata (wind). People in India who describe the states of health and disease still popularly use these terms for the three Dosas. Another concept that is very central to Ayurvedic medicine and Indian philosophy is the Tri-guna or the theory of three inherent qualities or modes of nature. These three gunas are, Sattva (variously translated as light, goodness or purity), Rajas (action, energy,

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passion) and Tamas (darkness, inertia). In the medical and religious texts, the theory of three gunas is used repeatedly to describe different types of personalities, food, action, etc.

All the major Ayurvedic texts like Charak Samhita and Shusruta Simhata have a separate section dealing with insanity (unmada) (Frawley, 1998; Valiathan, 2003). In addition, there are chapters on spirit possession (bhutonmada) and epilepsy (apasmara). Different types of convulsions, paralysis, fainting, and intoxications are also well described. There is detailed description of different types of spirit possessions. Twenty-one sub-types based on three groups of sattava, rajas, and tamas are described. Though at times the descriptions appear artificial, some of them have clear resemblance to some modern descriptions of personality disorders, psychosis, and mental retardation. The chapters on unmada (insanity) are very well written, both in Charaka Samhita and Shusruta Samhita. Six types of mental disorders are well recognized: vatonmad caused by vata dosa; kaphonmad caused by kapha dosa; pittonmad caused by pitta dosa; sampattonmad caused by combined dosas; vishaja unmad caused by intoxications and poisons and shokaja unmad caused by excessive grief.

The symbiotic relationship between ‘psyche’ and ‘soma’ was recognised in Ayurveda, attributing the highest importance to psychic energy as the propulsive power of creation-the original force. The main therapies are (i) suggestion, auto-suggestion, hypnotism, assurance, persuasion, and ritualistic therapy; (ii) transferring of symptoms; (iii) confession, penance, and sacrifice; (iv) use of natural elements; (v) medicine and endocrine therapies; and (vi) tantric and yogic practices (Dube et al., 1978, 1983, 1985).

The aspects of mental health in Ayurveda in terms of understanding of personality, the causes of mental disorders, the classification of mental disorders, the treatment of mental disorders and training of mental health professionals are

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considered in detail elsewhere (Srinivasa Murthy, 2009).

I can identify four important aspects of Hinduism relevant to mental health, both in the understanding of mental health and mental disorders and in the treatment of mental disorders. These are (i) wholistic approach to health; (ii) yoga and meditation; (iii) Bhagavadgita and (iv) theory of life stages. These four aspects of Hinduism address the understanding of health and disease, the physical and psychological measures to address health and the way to negotiate life cycle. The following section covers the contemporary relevance of Hinduism to mental health.

1. Wholistic approach to health

Hinduism recognises the unity of the body-mind relationship. Much of western science has been influenced by the Cartesian mind-matter dualism. Varma (2008) describes this as follows :

“Mind is what perceives the matter and matter is what is perceived by the mind. That mind must also be part of matter is not realised. On the other hand, the mind-matter dualism is not accepted in most approaches of Indian science. The observer is not separate from the observed. There is an ongoing interaction between the two. With the observer – observed dichotomy in western science, objectivity assumes great importance. Most of the Indian philosophies refute the mind-matter dualism. Of the 12 major schools of philosophy, only the sankhya philosophy admits of a doer purusha and an object prakriti. Largely speaking, there is a constant, ongoing interaction between the observer and the observed. Identification of the seer with the instrument of seeing, namely the sense of perception and organs of action, intelligence and ego is berated as asmita or egoism. The purpose of the conjunction of the seer with the seen is for the unfolding of the inherent powers of the nature and the spirit so that the seer discovers his own true nature”.

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It is only in the recent times that the unity of mind-body has come to be accepted in the Western medicine. This recognition is a major development in modern medicine. It is important to recognise that in Ayurveda the division of the body and mind was not there. This is a matter of some pride for the followers of Hinduism. However, there is more to this story than wisdom of Hinduism. It will be very tempting to overemphasise this, and glorify it.

However, the developing understanding of mind-body medicine is more complex, and is the result of a wide variety of forces. For example, Harrigton (2008) in her excellent recent book reports on these changes:

“In March 2007, I conducted an internet search on Amazon.com using several key words. Amazon showed me 2438 books that were about the ‘mind-body connection’ and 1081books that were about ‘mind-body medicine’. It also showed me 1992 books about psychoneuroimmunology; 1638 books about social support and health;1717 books about the health effects of meditation; 5913 books about the placebo effect;11724 titles concerned with stress and health; and a whopping 14075 titles concerned with positive thinking. When I searched for the keyword- ‘genomics’, 15138 titles turned up. Genetics is important in our culture-we knew that-but mind-body medicine appears to be holding its own”. (p.243)

Harrington further presents these changes in the historical perspective as follows:

“Today’s mind-body medicine offers resources for proponents of doctor led rituals who may also be skeptical of patients’ own abilities to control and make sense of their own experiences (the Power of Suggestion); for those who believe in the healing power

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of the examined life (the Body that Speaks); for advocates of patient-initiated practices and those most skeptical of medicine’s arrogance (the Power of Positive Thinking); for those most committed to the power of modern laboratory science to crack the secrets of the mind –body connection (Broken by modern Life); and those who are drawn to both the more folksy and homegrown (Healing Ties); and the more exotic and romantic (Eastward Journeys) forms of medical, social and moral redemption”.

In Ayurveda, the unity of body, mind and environment is reflected in the way promotion of health, prevention of health problems, and treatment of illnesses include changes in the diet/ fasting, use of medicines, psychological interventions like prayer, and restrictions on daily activities.

Against this way of looking at the growing understanding of mind-body medicine, it will be prudent to view the contribution of this aspect of Hinduism as not ‘static’ knowledge but a guide to understanding the field. It would be beneficial to mankind, if we were to examine the 3000 year old knowledge in this area with modern methods of science and other means of enquiry. It can be expected that there will be greater attention to Hinduism’s concept of mind-body relationship in the coming years.

2. Yoga and meditation

A very important therapeutic contribution of Hinduism is the science of yoga. Yoga has become so widely accepted by astronauts, leading sports persons, celebrities and the lay population. This can be considered the greatest export from India to the world. This wide acceptance has sometimes created controversies like the recent call for negative sanctions from some religious groups like the fatwa in Malayasia. Abdul Shukor Husin, Chairman of Malayasia’s Islamic Council, recently issued a fatwa against yoga because of its Hindu roots and its “blasphemous”

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meditative chants and said “there are other ways to get exercise and a peace of mind…eat less fatty food” (Newsweek, 2008). Leaving these controversies aside, yoga offers a practical and easy way of regulating body and mind.

Yoga is a discipline, a system that has evolved in India over several thousand years to facilitate the evolution of consciousness. It offers a worldview, a lifestyle and a series of techniques by which changes in human awareness can be brought about. The basic aim of yoga is growth, development and evolution of the mind. The yogic techniques, when practiced correctly, give rise to certain types of reactions within the person, so that there are qualitative and quantitative changes in awareness. There are various systems of yoga. All point towards the same end i.e bringing about altered states of consciousness, which is variously known as the cosmic consciousness, transcendental illumination or samadhi (Varma, 1985; Nayar, 2008).Yoga and meditation are probably the most visible aspects of Hinduism in non-Hindu populations, and have received wide acceptance all over the world.

Patanjali yoga gives a complete, comprehensive overview, integrating and placing the various types of yoga in their place in the development of the human experience.

The eight steps of Patanjali Yoga are follows

1) Yama-universal moral commandments; 2) Niyama- selfpurification by discipline; 3) Asanas-postures of the body; 4) Pranayam-rhythmic control of breath; 5) Prathyahar-withdrawl and emancipation of the mind from the senses and exterior objects; 6) Dharana-beginning of concentration; 7) Dhyana-an uninterrupted flow of concentration; and 8) Samadhi-a state of super consciousness brought by profound meditation and concentration in which the individual becomes one with the object of meditation.

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Yamas and Niyamas control the passions and emotions and keep a person in harmony with his fellowmen. Asanas keep the body healthy and strong. Pranayama stills the restless mind. These four constitute the ‘outward practices’ of yoga. Pratyahar, Dharana, Dhyana, and Samadhi take the person within himself. They keep in harmony with himself and his maker. These are the ‘inner practices’ of yoga (Nayar, 2008).

There are two aspects of yoga that can be commented upon. Firstly, the growing popularity of yoga in the general population and secondly, the recent focus on scientific studies.

A very striking aspect of the current application of mental health concepts and practices of Hinduism is the large popular use of the techniques among the general population. These have ranged from books addressing the Eastern approach to understanding mind-body relationships (Chopra, 1991). The new age gurus have been marketing the methods to achieve nirvana specially addressed to the urban stressed populations. Unlike the gurus of the past, the current plethora of gurus are trendy, urbane and presenting the ancient practices in a modern way, sometimes referred to as “providing a user friendly designer manual for modern living” (Gautier, 2002; Chopra, 2003; Vasudev, 2003).

In recent years, the practice of yoga and its benefits have come under scientific scrutiny. Scientific studies have focussed on three groups of effects. The first set of studies focus on the changes among the normal healthy volunteers practicing yoga. These studies point to the positive physical and mental health. The second group of studies describes the physiological and biochemical changes after yoga practice. Many studies in this category point to enhanced physical and mental functioning following regular practice of yoga. The third sets of studies examine the therapeutic application of yoga in a number of clinical

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conditions, pointing to its positive benefits.

Systematic research into yogic practices and their effect in different mental disorders has been a recent development during the second half of the twentieth century. There is a resurgence of academic interest in the effects of different types of yogic practices and the mental health effects of the Bhagavad Gita. For example, during February 2006, there was a World Conference on “expanding paradigms: science, consciousness and spirituality’ at the All India Institute of Medical sciences, New Delhi. In March 2007, a national seminar on ‘Yoga therapy for psychiatric and neurological disorders’ was organised at Delhi and Bangalore. In September 2008, a two day conference at Bangalore examined the mental health aspects of Bhagavad Gita. All of this leads one to conclude that there will be greater examination of the impact of yoga and meditation in the coming years, using a wide variety of physiological and psychological tools. Following is a brief review of the research efforts.

Initial research reports of use of yoga and meditation were with a wide range of mental disorders (Deb Sikdar, 1961; Vahia et al., 1966, 1973, 1975; Sethi et al., 1982; Varma, 1985). In addition, the special relationship between the patient and the therapist in the Indian context and its advantages were explored (Neki, 1973, 1977). This was followed by comparison of standard treatment with yoga in psychoneuroses: anxiety (Sahasi et al., 1989; Kohli et al., 2001), drug addiction (Vedamruthachar et al., 2006), psychogenic headache (Sethi et al., 1981; Prabhakar et al., 1991). There were also a number of studies on the various aspects of TM and its physiological effects (Wallace et al., 1982; Alexander and O’Connel, 1984; Singh, 1984; Khandelwal and Deb, 2008).

The more recent studies have examined the effectiveness of specific treatments based on Sudarshan Kriya Yoga (SKY) in

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dysthymia (Janakiramaiah et al., 2000), depression (Murthy et al., 1998), schizophrenia (Duraiswamy et al., 2007) and drug and alcohol dependence (Vedamruthachat et al., 2006). The increased interest in eastern therapies and the availability of measures to study the effects should result in more sophisticated studies of effectiveness of the different therapies in different mental disorders. There is also reexamination of the ancient Indian wisdom to modern mental health practice (Shamsunder, 2008; Varma and Gupta, 2008).

It can be expected that with greater scientific study of yoga in ordinary life and in disease states there will be better understanding and enhanced support for its use in different health conditions including the mental disorders.

3. Bhagavadgita

The Bhagavadgita, popularly known as the Gita, is one of the outstanding religious classics of the world. It is also one of the most translated religious texts of the world. Hindus, irrespective of their sects and denominations, cherish great reverence for this book.

A good example of the importance of the Bhagavadgita is the place of Gita in the life of Mahatma Gandhi, Father of Nation. No book was more central to Gandhi’s life and thought than the Bhagavadgita, which he referred to as his “spiritual dictionary”. Mahatma Gandhi expressed his love for Gita in these words (Gandhi, 2000) :

“I find a solace in the Bhagavadgita that I miss even in the Sermon on the Mount. When disappointment stares me in the face and all alone I see not one ray of light, I go back to Bhagavadgita. I find a verse here and a verse there and I immediately begin to smile in the midst of overwhelming tragedies- and my life has been full of external tragedies- and if

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they have left no visible, no indelible scar on me, I owe it all to the teachings of Bhagavadgita.”

The book (dated by modern historians as varying from 1424 B.C to 525 B.C) forms an integral part of a much bigger epic, the Mahabharata. The core of the Gita is a poetic work in the form of a dialogue between Lord Krishna and Arjuna, on the battlefield of Kurukshetra. The setting of the battlefield contributes a dramatic element to the book and relates religion to the realities of life. (Harshanand, p.255, Vol 1). The setting of Kurukshetra is the battlefield, in which two groups of cousins are at war over the kingdom. Arjuna is torn between his responsibility as a warrior and the emotions of killing his teachers and his cousins. Arjuna despairs and refuses to fight. He is paralysed by fear and guilt. He tells Lord Krishna that he cannot fight. Overwhelmed by his condition, he asks Lord Krishna to help him. Across eighteen chapters, a dialogue ensues between Krishna and Arjuna that leads to the resolution of Arjuna’s crisis and his existential transformation.

Arjuna’s position is typical of the human situation, easily liable and upset or confused during periods of crisis. The questions that he raises and the solutions that Lord Krishna offers are relevant to current situation. Many scholars consider the dialogue an excellent illustration of psychotherapy (Aurobindo, 1922; Venokba Rao, 1978, 1997; Wig, 1990; Gandhi, 2000; Vinoba Bhave, 2007).

The central message by
Lord Krishna in the Bhagavadgita is

“Your entitlement is only to the rite, not ever to its fruits. Be not motivated by the fruits of the acts, but also do not purposely seek to avoid acting. Abandon self-interest, Dhananjaya, and perform the acts while applying single mindedness. Remain equable in success and failure-this equableness is called the application, for the act as such is far inferior to the application of

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singleness of purpose to it” (Gita, p. 48-49).

Krishna further states

“For him, who has conquered the mind, the mind is the best of friends; but for one who has failed to do so, his mind will remain the greatest enemy” …“For one who has conquered the mind, and the Supersoul is already reached, for he has attained tranquillity. To such a man happiness and distress, heat and cold, honour and dishonour are the same” (Harshanand, 2008; p.204)

Reddy (2002) relates Gita with psychoanalysis as follows. In the Gita, Krishna functions as Arjuna’s teacher and psychoanalyst. Krishna’s analytic (therapeutic) function is not interpretative per se but more as an object that facilitates Arjuna’s ego (psychic) development and maturation. Specifically, it is Krishna allowing Arjuna to use him as a transformational object….from a psychoanalytic viewpoint, the cardinal techniques of abstinence, anonymity, and neutrality are both observed and violated by Krishna. The pivotal and transformative violation of anonymity, by Krishna’s self-disclosure promotes the therapeutic regression and psychic reorganisation that leads to Arjuna’s existential transformation.

Sri Aurobindo (1922) summarises the importance of Gita to mankind as follows

“The arugument of the Gita resolves itself into three great steps by which action rises out of the human into the divine plane leaving the bondage of the lower for the liberty of a higher law. First, by the renunciation of desire, works have to be done as a sacrifice by man as the doer, a sacrifice to the deity who is the supreme. This also means a sacrifice to the Self, though by him it is not yet realised in his own being. This is the initial step. Secondly, not only the desire of the fruit, but the claim to be the doer of works has to be renounced in the realisation of the Self.

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The immutable principle works as simply the operation of the universal Force, of the Nature-soul, Prakriti, the unequal, active, mutable power. Lastly, the Supreme Self has to be seen as the supreme Purusha governing this Prakriti, of whom the soul in Nature is a partial manifestation, by whom all works are directed, in perfect transcendence, through Nature. To him love and adoration and the sacrifice of works have to be offered; the whole being has to be surrendered to Him and the whole consciousness rose up to dwell in this divine consciousness. This is so that the human soul may share His divine transcendence of Nature, and of His works, and act in perfect spiritual liberty”. (Aurobindo, p.37)

4. The concept of Ashramas

One of important contributions of Hinduism is the concept of the four stages of life or four ashramas (Wig, 2006; Harshaanand, 2008). These ashramas are (i) brahmacharya or studentship; (ii) grahast or householder; (iii) vaanaprastha or forest dweller and (iv) sanyas or ascetic. The ethical code of the four ashramas was was well established a thousand years ago in India and it was seriously pursued as an ideal way of life till recently. The essence of the four stages of life is the regulation of the life of individuals. These four stages provide a systematic and timely guidance for life at the different ages of an individual.

Wig (2006) argues that this is relevant even in modern life, specifically the vaanaprashtha ashram. He considers this an important concept of the Indian way of life. The basis or central theme of Hinduism is the idea of tyaga or renunciation. In practical terms, facing old age is to gradually prepare for the changes associated with ageing and to handle it gracefully with peace of mind. In practical terms, ultimate happiness and peace of mind can not come by only changing the environment, but by changing oneself. Specifically, facing old age can be successfully approached by (i) voluntarily withdrawing oneself from the routine rush of life and live life close to nature; (ii) deliberately choose to

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live a simple life by not increasing resources to meet the needs but reduce the needs to meet the resources available; (iii) give back to the society through service for the welfare of the society; and (iv) pursuit of the spiritual path.

Conclusion

Hinduism is a rich source of wisdom relevant to mental health. The current relevance of Hinduism is described by Avdesh Sharma (2008) as follows :

“The ancient Indian wisdom has a lot to teach us. It has vastly elaborate systems of functioning of body, mind and consciousness (soul) in health and disease as applicable to the individual and the society he/she inhabits. In some ways, it has foretold of the maladies and their manifestations that plague us today. We only need to curl within ourselves to rediscover what once was not only a way of living but a way of being. Our ability to quickly comprehend, blend, modify, and apply the thoughts , philosophy, wisdom in the modern day context may not only decide how well we live, but how well we survive” (p. 4)

Venkoba Rao (1997) outlines beautifully the needs for the further development of the mental health concepts of Hinduism:

“India is an ancient and great cultural, spiritual and anthropological laboratory. She has been the nursery of saints and sages, scientists and founders of world’s major religions and promulgators of profound philosophy. Nevertheless, to be satisfied with the glory of the past is to turn into a fossil; but to interpret the old from a new point of view is to revitalize the past and bring in a current of fresh air into the monotonous present” (p.1).

This is the challenge and opportunity for the mental health professionals of India and the world.

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Acknowledgements

My sincere thanks to Prof.N.N.Wig and Prof. G.N.Narayana Reddy for their critical suggestions and their support in writing this chapter.

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Vinoba Bhave (2007) Talks on Gita. Paradham Prakasan, Pavnar.

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Wig N.N. (1990) Indian concepts of mental health and their impact on care of the mentally ill. International Journal of Mental Health. 18:71-80.

Wig N.N. (1999) Mental health and spiritual values. A view from the East. International Review of Psychiatry 11, 92-96.

Wig, N.N.(2006) The Joy of Mental health. Servants of the

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People Society, Chandigarh.

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Dr. Afzal Javed

Dr.Muhammad Afzal Javed, MBBS,
MCPS, D.PSYCH ( LONDON), BOARD
CERT.PSYCH (UK), F.R.C.Psych. (UK),
M.PHIL (EDINBURGH), FRCP (Ireand) is a
Consultant Psychiatrist at Coventry & Warwickshire NHS Partnership Trust at Nuneaton. He is also an Honorary Clinical Associate Professor at Warwick Medical School, University of Warwick, UK.

He graduated from King Edward Medical College, Lahore, Pakistan and received higher specialised training in Psychiatry at Pakistan, Royal Edinburgh Hospital, University of Edinburgh, Institute of Psychiatry & Maudsley Hospital, London, UK.

His role in international psychiatry is highlighted by his involvement as committee member with World Psychiatric Association, World Association for Psychosocial Rehabilitation, South Asian Forum, Asian Federation of Psychiatric Associations and many other regional and international organisations.

He has served the Royal College of Psychiatrists as Deputy Registrar & the lead College office bearer for SAS doctors. He is the current Chairman of West Midlands Division of the College & a member of its Central Executive Committee.

His areas of special interest are Social and Transcultural Psychiatry, Psychosocial Rehabilitation and Psychiatric Research. His academic skills have been invaluable when publishing more than 80 scientific papers and being author of six books/monographs on different topics of psychiatry.

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ISLAM AND MENTAL HEALTH

Afzal Javed

Mental Health and Mental well-being are getting a significant importance in terms of general health needs. It is becoming well recognised that for a healthy body we need a healthy mind and when we talk about Mental Health we are not only referring to the mental illnesses, but, also talking about a positive and stress free mental health. In addition to the belief that many mental illnesses are caused by “chemical imbalances” in the brain, recent research emphasize a lot to the importance to the socio-cultural factors. It is now becoming clear to most mental health professionals that mental disorders need to be defined in a holistic manner that includes the interaction of the environments and other biological factors including genetic and non-genetic predispositions.

Religion forms the basis of many cultural norms, as man’s faith in religion is as old as humankind itself. The relationship of religious beliefs and various types of sufferings dates back to the start of many civilizations across the world. The impact of religious faith has always been acknowledged as an important factor in the well being of individuals and its need to be a greater force for survival is considered as old as humankind itself. The links of religion with mental health are equally fascinating as ideas of possession and evil forces have dominated the aetiology of many mental disorders. The dual role of priest-physician in managing such conditions has also been mentioned in the literature and as a result mental illnesses have been cared and managed by the priests, shamans and religious leaders in the past.

This relationship has however been fluctuating. Until the 15th century, medicine and the priesthood worked together. This was followed by waves of secularisation and ‘scientification’ of medicine which led to the two professions going their separate

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ways. The establishment of exclusive places for the mentally ill and physical methods of treatment in psychiatry provided further gaps between these two disciplines. With the innovation and advent of scientific theories, the mysteries of mental disturbances were explained to a large extent on the basis of underlying structural and biochemical disturbances in brain. Whereas formally the mentally ill were seen by the priest as possessed by devils and spirits, their odd behaviour was subsequently explained by mental health professionals as disturbances of mind.

Although the 20th century has witnessed a significant shift of beliefs and spirituality, the interaction between religious and mental health still continued to be viewed as mutually beneficial and helpful in understanding and managing a number of psychiatric disorders. It is true that religion, its psychological aspects, and its practice all affect mental health. Similarly beliefs about mental illnesses and their treatment are closely tied to beliefs about sins and sufferings in many societies and views that mental illnesses may result from some kind of separation from the divine, or even possession by evil still prevails in many cultures. If we look at the interaction of psychiatry and religion, a number of factors appear playing an important role. Beliefs of the patient, beliefs of the mental health professionals, cultural influences and attitudes and beliefs about treatment of the mental illnesses, all have variable influences in this regard.

Islam is one of the leading religions in the world & is getting more importance as some of the conflicts in the international scenario are being attributed to the practice of Islam. Islam literally means submission and this signifies that the Muslims are submitting themselves to God for leading and practicing a preferred way of life. There are over a billion Muslims in the World and with 50 Muslim nations more than 10 million Muslims are living in the western countries. Unfortunately, a lot of misconceptions about Islam and Muslims are prevalent in the

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western world and is creating more conflicts & difficulties in understanding the view points of Muslims.

Islam in its true sense is not simply a religion but is also a way of life and gives a number of directions about leading life and sorting out the day-to-day problems. There are five pillars of Islam i.e., faith in oneness of Allah and prophet Muhammed being the last prophet, prayers five times a day, fasting in the month of Ramadam, Zakat (Alms) and Pilgrimage to Mecca at least once a life if one can afford it. These are the basic pillars and every Muslim has to believe and practice on these principles. In addition to the pillars of Islam the Code of Conduct to lead day-to-day life has been explained in the religion with some approvals and disapprovals. The basic philosophy of Islam is adherence to a group and acting on an improved code of attitudes and behavioural norms. Similarly, the concept of after death life is very important and an understanding of events which would otherwise be non- understandable on the basis of knowledge makes the Islamic philosophy more intact & helpful.

In terms of the community living Islam offers a vision of self realisation and self respect. Belonging to this religion and following socially conditioned approaches make it more fascinating as the positive re-enforcements are mediated through the social approvals and social support and similarly positive extinction is governed by social disapproval and legal disapprovals.

Mental illnesses are also recognised as disease entities and emphasis has been made about the care and the rights of the mentally ill. Islamic doctoring has dealt with a number of psychosocial issues including marital relationships, child rearing, family care, adoption, orphanage, women’s rights, love, mercy, dutifulness, justice, modesty, as well as topics that include well defined guiding principles for normal and civic duties.

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In terms of religious practices clergy or priests have no mediation function between man and God. Their only function is to guide the people to the code of conduct. In terms of day-to- day living, quoting of right (halal) and wrong (haram) forms the basis of principles of daily life. If we look from a psychological point of view, the concept of ego and super ego along with consciousness & sub-consciousness are imbedded in such coding of life. The development of ego or self is governed by the pillars of Islam and the super ego is strengthened by the acceptance of behaviour by the social norms of the society. Similarly internalisation of socially shared religious criteria forms the basis of group ego and this is how the integration of self and society is determined in terms of healthy functioning.

The Islamic religion like many other religions has a belief system and a code of approved conduct. The Islamic code of conduct includes details of personal and inter-personal relationship and constitutes goodness and fairness that leads to rewards in the afterlife. This obedience of the basic rules of conduct by wrong doings leads to punishment in later life.

An understanding of some of the basic beliefs of Islamic religion and ritual practices may be of interest for the mental health professionals who are not following this religion. In terms of psychopathology, delusions and hallucinations relating to the religious beliefs needs to be evaluated keeping with the Muslim religious background. Similarly following the rituals may need to be distinguished from obsessional acts and any inappropriate behaviour that may be falsely conceived. In terms of using the principles of religion in dealing with complex mental health issues like suicide, stress, abuse of drugs and conflict resolution there are a number of good points that can help the mental health professionals in their day-to-day practice.

Let us take the example of suicide. Islam advocates

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preservation of life. Suicide or harming oneself is prohibited. There have been a number of reports that confirm that suicidal acts are less common in severely Muslim depressed patients. They may be having the suicidal thoughts equal to non-Muslim patients, but, when it comes to ending life, the frequency of suicidal acts or rituals decrease significantly. The religion thus provides a shield and this is an important aspect of Islamic religion that can be used successfully in dealing with the suicidal problems and complications.

Drug abuse and intoxication is prohibited in Islam and if one explains about gambling, alcohol, intoxication and other related problems with special reference to the religion a lot of support can be extended to these growing mental health problems.

Stress, another common presentation in Mental Health, can also be managed in terms of Islamic perspectives. Stress is considered as a test of endurance and patience. It is accepted as God’s will, calling for patience and then appealing to God to relieve stress. This is a very interesting concept as here there is no hopelessness, but, there is a hope and one approaches God to get guidance and help to overcome the stress. Looking from the religious perspectives, stress also elicits the support of others, limits personal responsibility towards events and is based on forgiveness and generosity.

Guilt, an important psychopathology is also explained in a more favourable prognostic way in the Islamic religion. The concept is that no one is expected to do more than what could be done by an individual and one is not responsible for the sufferings or the wrongs of others. Attributing all wrongs beyond ones own control and asking for forgiveness by God’s mercy helps to alleviate the guilt through the religious concepts.

Coming to anxiety and anger management, teachings of

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Islam assure that you are going to control yourself at the times of being angry and irritable by thinking of God and you are exposing yourself to feared situations with a strong intent to get over it. Islam has very clearly stressed the importance of conflict resolution in all fields of life and it has been mentioned in Koran in different verses that Islam promotes and supports inter-personal conflict resolution. This is again an important approach while dealing with the day-to-day difficulties and conflicts.

Another psychological aspect of understanding and following Islamic religion is based on the role modelling. Islam supports modelling and the prophet Muhammed has been considered as the best model amongst the people. He was considered the most honest, reliable and trustworthy even before Islam and used to be called as “Muhammed the honest”. Through the role modelling, it is reinforced that Muslims have to follow their religious head and get guidance from his life. In terms of interpersonal approaches Islam supports the development of mature interpersonal roles and the formation of mature group relations in the society. This helps members of the society to relate to others and co-operates with fostering care for each other. Islam does support mature group social relations through support acceptance and group identification and stresses the importance of positive and constructive behaviour not only towards one’s own self but also towards others.

The status of women in Islam is considered as very important and highly respected. Their rights match with their duties and respect; love and affection are the main directions to deal with the women. They have got equal but may not be identical rights and contrary to the knowledge of many non Muslims, women do have share of inheritance and the right to be a witness in the court. In summary, Islam is a religion that brings healthy lifestyle, promotes stress free life and generates brotherhood providing better coping mechanisms. It does give a message of peace

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and advocates self realism and respect to others and emphasises the responsibility and duties of care for others. Islam is a religion promoting peace and never encourages violence, destruction or terrorism. This needs to be taken as a code of life that sets direction for helping people to overcome their day-to-day psychosocial problems. Looking at the current conflicts and misconceptions about Islam, it is the need of the time that we examine Islamic religion and practices with an open mind. This will certainly need more work both at clinical and research levels.

For further reading

Bourguignon,E. (1992) Religion as a mediating factor in culture change. In. J.F.Schumaker (ed.) Religion and Mental Health. New York: Oxford University Press.

Crossley,D. (1995) Religious experience within mental illness. British Journal of Psychiatry.166: 284-286.

Dols,M.W. (1992) Majnun:The Madness in Medieval Islamic Society. Oxford: Clarendon Press.

Ellison,C.G. (1991) Religious involvement & subjective well- being. Journal of Health & Social Behaviour, 32(1): 80-99.

Greenberg,D. & Witztum,E. (1991) Problems in the treatment of religious patients.

American Journal of Psychiatry.45: 554-565.

Husain,S.A. (1998) Religion and mental health from the muslim perspective. Handbook of Religion and Mental Health. Academic Press, New York. pp. 279-290.

Javed, M.A. (1998) Contributitions of Muslims in the uplift of Mental Health Services in Indian Subcontinent. Paper presented at Intenational Conference on History of Islamic

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Medicine.Birmingham,UK.

Javed, M.A. (1996) Suicidal symptoms in depressed Pakistani patients. Journal of the Pakistan Medical Association .46(4): 69-70.

Koenig, H.G., George, L.K.& Peterson, B.L. (1998) Religiosity and remission of depression in medically ill older patients. American Journal of Psychiatry, 155: 536-542.

Kroll, J. & Sheehan,W. (1989) Religious beliefs and practices among 52 psychiatric inpatients in Minnesota. American Journal of Psychiatry, 146: 67-72.

Kroll, J. (1998) Religion and psychiatry. Current Opinion in Psychiatry.11:559-562.

Larson,D.B.,Pattison,M.,Blazer,D.G.,et al (1986) Systemic analysis of research on religious variables in four major Psychiatric Journals 1978-1982. American Journal of Psychiatry.143: 329-334.

Shaver, P.Lenauer,M.& Sadd,S. (1980) Religiousness, conversion and subject well-being: The ‘healthy-minded’ religion of modern American women. American Journal of Psychiatry, 137(12): 1563-8.

Sims, A. (1994) Psyche-spirit as well as mind? British Journal of Psychiatry, 165: 441-446.

Weiss, F.S. (1991) Pastoral care planning:a process oriented approach to mental health.

Journal of Pastoral Care. XLV (3): 268-278.

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Dr. R. M. Chokhani

Dr. Rajendraprasad Mannalal
Chokhani, Consultant Psychiatrist &
Counsellor, is the Chief of the Department
of Psychological Medicine and the Vipassana Counselling & Research Centre, at the Siddharth Municipal General Hospital.

He is a medical graduate (1976) from the Armed Forces Medical College, Pune and has specialized in Psychiatry (1981) from the TNM Medical College,Mumbai.

Dr. Chokhani is associated with the Vipassana mission for about 3 decades now and has conducted many courses and seminars, delivered talks and presented scientific papers on Vipassana at various fora.

He is a Vipassana ‘Acharya’ at the Vipassana International Academy in Igatpuri-Maharashtra, and Secretary of the Research Council, Vipassana Research Institute (VRI) in Mumbai.

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VIPASSANA MEDITATION
A Positive Mental Health Measure and

the Path to Spiritual Fulfillment
R. M. Chokhani

Abstract : Vipassana Meditation is considered to be the quintessence of the Buddha’s Teaching. It is a non-sectarian and scientific technique of self-observation and truth-realization leading to progressively better insight, personal growth and autonomy (positive mental health attributes), as also, inculcation of universal human values like love and goodwill, tolerance and compassion, peace and harmony, etc. (spirituality). Its psychotherapeutic potential and benefits, as also, its practical applications in various human spheres are discussed in this article.

Key Words : adhyatma, altruism, awareness, bhavana, Buddha, Dhamma, equanimity, meditation, nibbana, panna, positive mental health, sankhara, self-actualization, spirituality, tanha, vedana, Vipassana.

Introduction

Meditation as a practice of self-liberation (moksha, nibbana) was developed in all cultures by and for members of religious groups in the context of their cosmology (Kutz et al, 1985). Evincing interest in the reported beneficial psychological effects of meditation, primarily, anecdotal case reports, many health personnel have conducted scientific studies on the impact of meditation and found variable yet significant amelioration in various clinical conditions namely, neurotic disorders like anxiety, phobia, depression, etc.; psycho-physiological disorders like headache, migraine, peptic ulcer syndrome, colitis, asthma, hypertension, eczema, psoriasis, pain, etc.; personality disorders, addictions,

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and so on. Meditation has been thus discussed both as a self- regulation strategy for specific psychotherapeutic and psycho- physiological aims and as a discipline and way of life for deep self-exploration and transformation (Shapiro & Walsh, 1984).

Meditation (dhyana) is usually defined as the intentional regulation of one’s attention – ‘concentration’ leading to tranquility (samadhi). The objects of attention (alambana) could be verbal – mantra or chants, name of a god/goddess, etc.; visual – picture/ statue of a god/goddess, a living saint/guru etc.; even imaginary. Accordingly, a variety of meditation practices are in vogue. Changes brought about in the meditator are both psychological – various perceptual, cognitive and affective changes (altered states of consciousness), as also, physiological – reduced oxygen consumption, breathing rate, heart rate, blood pressure; reduced serum lactic acid levels, increased skin resistance, etc., collectively termed ‘the Relaxation Response’ (Benson H, 1975).

Vipassana Meditation, also known as Insight Meditation, is a scientific technique of introspection (ajhatta, adhyatma) and self- exploration: a system of self-transformation by self-observation. One explores and realizes, by direct experience, within the framework of one’s own mind and body, the reality pertaining to mind (nama) and body (rupa) – the mental and material phenomena, how they interact and influence each other, how out of ignorance (avijja) one keeps on multiplying one’s own misery, how with wisdom (panna) one can eradicate one’s misery and live a healthy and happy life.

Historical Background

Vipassana is a very ancient meditation technique of India, laudatory references to which are found even in Rig Veda, the oldest of four Vedas – the earliest repository of the ancient Indian cultural heritage and wisdom, which says, “Yo visvabhih vipasyati

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bhuvanah, sanca pasyati na parsadati dvisah” meaning that one who practices Vipassana in a perfect way, comes out of all aversion and anger; the mind becomes pure. The same refrain and exhortation reverberates across the millennia. A verse from the Bhagavad Gita says, “Vimudha nanupasyanti pasyanti jnanacaksusa” – the ignorant (oblivious of the truth) cannot see whereas the wise do see since they practice the truth (Vipassana). Bhagvan Mahavira says, “Ayata cakkhu loka vipassi” – one who practices Vipassana gains wisdom. Guru Nanak also says, “Adi saca, jugadi saca, hai bhi saca, Nanaka hosi bhi saca” – start with the truth and when every step is with the truth, one will reach the ultimate truth. “Know Thyself” is thus the eternal message of all the saints, the rishis, the munis, the sthitaprajnas, the arihants and the buddhas (Goenka SN, 1994).

The systematic training and practice of Vipassana, however, was long lost to humanity till about twenty-six centuries ago, when in 589 BC, it was rediscovered by Prince Siddhattha Gotama, through practicing which he became Buddha, the Enlightened One. The Buddha never taught ‘Buddhism’; what he taught was Dhamma – the universal and scientific laws of nature, that are applicable to everyone, everywhere, at all times; the word ‘Buddhism’ was not even in vogue during the Buddha’s time and till about 500 years later (Goenka SN, 1998). Although Vipassana contains the core of what later has been called Buddhism, it is not an organized religion, requires no conversion, and is open to students of any faith, nationality, colour or background (Fleischman PR, 1991). Formal training in Vipassana is imparted in 10-day residential courses world over by the renowned Meditation Master S.N. Goenka and Vipassana teachers trained and authorized by him.

Mechanism & Psychological Effects

‘Vipassana’ is a Pali word meaning insight, to see things as they really are, in their true nature, whereas ‘bhavana’ means

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mental development; thus, ‘Vipassana Bhavana’ means self- development leading to self-actualization with the practice of Vipassana.

One introspects, observing objectively like a scientist, how one’s mind functions; how the mind and body influence each other at the level of body sensations – ‘vedana’; how ‘vedana’ is the interface between the six sense-doors (five physical & the sixth-mind) and their objects, namely, eyes – vision; ears – sound; nose – smell; tongue – taste; body – touch and mind – thoughts, memories, emotions; how all mental states have their confluence in ‘vedana’ and how through ‘vedana’ alone are all phenomena actually experienced.

One realizes how one’s mind keeps feeling these body sensations (vedana) continuously and keeps on reacting with ‘raga’ – craving for the pleasant sensations, and ‘dosha’ – aversion for the unpleasant ones, and how this ‘tanha’ (raga, dosha) – attachment, is the root cause of one’s conditionings and negativities – ‘sankhara’, the real cause of one’s misery and suffering. Vipassana aims at the total eradication of these ‘sankhara’ to achieve real peace of mind and lead a healthy and happy life.

With the practice of Vipassana, one realizes that these body sensations (vedana) keep arising and passing away, keep changing and that they are all impermanent – ‘anicca’; one thus realizes the futility of this ingrained conditional reflex of mental reaction and learns to eradicate it by a choiceless observation of ‘vedana’, whether pleasant or unpleasant, cultivating awareness of its transient nature (anicca) and with this ‘panna’ (experiential wisdom) developing equanimity (non-reactivity) with the result that no new conditionings (sankhara) are now produced and a progressive elimination of the old ones is facilitated (Vipassana Research Institute, 1990-b).

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The mind is de-conditioned with Vipassana, altering the process of conditioning per se, so that it is no longer a prime determinant of future acts (Goleman D., 1977). A refinement of awareness occurs and one responds consciously to life situations thereby becoming free from limitations, which were forged by mere reactions to them. One’s life becomes characterized by increased awareness, reality-orientation, non-delusion, self- control and peace (Fleischman PR, 1986), which in turn facilitate quick decisions, correct and sound judgements and concerted efforts – mental capabilities vital to one’s success in contemporary life, whatever be one’s vocation (Thray Sithu Sayagyi U Ba Khin, 1962). The benefits that accrue with the practice of Vipassana are potential in the technique; each student starts at a different place and progresses individually (Fleischman PR, 1999).

“Know Thyself”, all wise persons have advised since suffering springs from ignorance of one’s true nature; insight, truth – experiential truth, alone frees one (Fleischman PR, 1991). Vipassana enables one to examine the reality of one’s own mind and body, to uncover and solve whatever problems that lie hidden there, to develop unused potential and to channel it for one’s own good and for the good of others (Hart W., 1987).

People from various religious denominations, even their religious teachers, have been participating in Vipassana courses without any reservation since the technique touches the heart and meets the bottom line of all religions, namely ‘spirituality’, defined as purifying one’s mind and inculcating basic, universal human values like love and goodwill, peace and harmony, compassion and service – altruism. (Fleischman PR, 1997; Goenka SN, 1990; Vipassana Research Institute, 1996). Vipassana is verily the path of all-healing, including self-healing and other-healing, relevant to all spheres of human endeavour be it health, education, organization, management or social concerns like stress and strife, poverty and exploitation, corruption and crime, etc.

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Mental Health Implications

Considerable data is available documenting the multifarious bio-psycho-social health benefits that accrue with the practice of Vipassana meditation (Vipassana Research Institute, 1986, 1990- a, 1990-c, 1995 & 2005). However, it needs to be emphasized that healing is not disease cure. The essential healing of human suffering is the purpose of Vipassana. With its practice, one’s entire being gets suffused with infinite love, compassion, sympathetic joy and equanimity; one’s approach to life is totally transformed, enabling one to face all the vicissitudes including disease, even death, with serenity and fortitude (Chokhani RM, 1997). Health professionals, hailing from various disciplines like yoga, ayurveda, homoeopathy, allopathy, naturopathy, etc., have all readily accepted Vipassana as it is free from dogma, experientially based and focused on human suffering and relief (Fleischman PR, 1991).

Everybody needs healing, even the healers. “Physician Heal Thyself”, is a well-known phrase. Freud and Jung insisted that analysts be analyzed. The practice of medicine is a confluence of the twin streams of science and art. A healer needs not only the learned skills of diagnosis and treatment but human understanding too, with love and compassion for the suffering. Besides, the constant exposure to human suffering may lead to professional burnout unless the healer consistently endeavors to deepen one’s own autonomy and self-knowledge, and augments one’s ability to be a professional anchor to others in the tumult of their lives (Fleischman PR, 1991).

Chandiramini K. (1991), Dwivedi KN (1977)) and Fleischman PR (1986, 1991 & 1999) have pointed out some links between the ideas and practice of Vipassana and those of Psychiatry, as also, the differences in their terms of reference and value systems. Vipassana is not advocated for treatment purposes; besides, the formal ten-day training programme in Vipassana is an intense

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experience that entails the participant’s total compliance with its rules, regulations, guidelines and instructions, the capacity for which, however, may be impaired in persons with mental disorders. The latter, therefore, ought to exercise discretion and make an intelligent choice in consultation with their therapist; waiting, choosing the proper time or forbearing from formal training are all part of the equation of choice.

The clinical utility of Vipassana is thus considered to be more in terms of providing a general psychological pattern of positive mental states rather than as a response to any particular presenting problem, which makes it a perfect tool for self- actualization and realization, a positive mental health measure indeed (Ayyar & Chokhani, 1992; Chokhani RM, 1986, 1995 & 1997; Khosla R., 1990; Vipassana Research Institute, 1986, 1990-a, 1990-c, 1995 & 2005). The primary focus of research, therefore, is on studying its psychological benefits, in terms of transformation in one’s personality and attitude; one’s coping patterns in the face of life-stressors; one’s performance and adjustment at home, study and work; in short, the “Quality of Life’” (Chokhani RM, 1997).

Conclusion

Considering the alarming growth in mental disorders world over, it is apparent that some urgent measures are required to promote positive mental health instead of just augmenting the treatment facilities. Current psychiatric research needs to study various methods – ancient and contemporary, which enhance one’s sense of psychological well-being. All these measures taken together alone shall help prevent mental disorders, as also, help improve the ‘Quality of Life’. Vipassana meditation is a powerful tool for self-exploration, personal growth and spiritual fulfillment, which offers a rich therapeutic potential as well.

In the words of Gautama, the Buddha, called ‘Maha Bhisakko155

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– the Great Physician (Narada T., 1963):

“Arogyo parama labha; Santutthi paramam dhanam; Vissasa parama nati; Nibbanam paramam sukham”

Health is the highest gain; Contentment is the greatest wealth; The Trustworthy are the best kinsmen; Nibbana is the highest bliss.

References :

Ayyar K.S. & Chokhani R.M. (1992): A Review of Literature & Research on the Therapeutic Actions of Vipassana Meditation, Paper presented at the 23rd Annual Conference of the Indian Psychiatric Society-West Zone, Baroda.

Benson H. (1975): The Relaxation Response, William Morrow, New York.

Chandiramani K. (1991), Vipassana Meditation: A Mirror to the Mind, Indian J. Psychiat., 33 (4): 293-296.

Chokhani R.M. (1986), Vipassana in Psychiatry, Paper presented at the 38th Annual Conference of the Indian Psychiatric Society, Jaipur.

Chokhani R.M. (1995), Vipassana Meditation and Positive Mental Health, Bombay Psychologist, XII, No.1 & 2: 43-47.

Chokhani R.M. (1997); Vipassana, Health, Healers. In Vipassana Pagoda Souvenir, Global Vipassana Foundation, Mumbai: 77.

Dwivedi K.N. (1977); Vipassana and Psychiatry, The Maha Bodhi Journal, 85: 254-256.

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Fleischman P.R. (1986); The Therapeutic Action Of Vipassana and Why I Sit, Buddhist Publication Society, Kandy, Sri Lanka.

Fleischman P.R. (1991); Vipassana Meditation: Healing the Healer and The Experience of Impermanence, Vipassana Research Institute, Igatpuri.

Fleischman P.R. (1997); Cultivating Inner Peace. Putnam, New York.

Fleischman P.R. (1999), Vipassana: A Unique Contribution to Mental Health. In Fleischman P.R.: (ed.) Karma and Chaos. Vipassana Research Publications, Seattle, Washington: pp. 57-85.

Goenka S.N. (1990); Altruism: Quintessence of Religion. In: (Eds): Vas C.J. & de Souza E.J. Issues of Biomedical Ethics: Proceedings of the Festival of Life International Congress, Dec.1988, Bombay; Macmillan India Ltd., New Delhi: pp. 95-102.

Goenka S.N. (1994); The Gracious Flow of Dhamma, Vipassana Research Institute, Igatpuri.

Goenka S.N. (1998), Keynote Address delivered at the Seminar on “World Unity on Buddha’s Tri-Ratna”, Bauddha Mahotsav (November 1998), Sarnath; Vipassana Research Institute, Igatpuri.

Goleman D. (1977); Meditation and Consciousness: An Asian Approach to Mental Health, American Journal of Psychotherapy, 30: 41-54.

Hart W. (1987); The Art of Living: Vipassana Meditation as taught by S.N. Goenka. Harper & Row, New York.

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Khosla R. (1990), Psychological Benefits of Vipassana Meditation, M.D. (Psychiatry) Thesis, University of Poona, Pune.

Kutz I., Borysenko J.Z. & Benson H. (1985), Meditation & Psychotherapy: A Rationale for the Integration of Dynamic Psychotherapy, The Relaxation Response and Mindfulness Meditation. American Journl of Psychiary, 42: 1-8.

Narada Thera (1963), (Ed): The Dhammapada, Vajirarama, Colombo, Sri Lanka.

Shapiro D.H. & Walsh R.N. (1984); Meditation: Classic and Contemporary Perspectives, Aldine, New York.

Thray Sithu Sayagyi U Ba Khin (1962), The Real Values of True Buddhist Meditation, Buddha Sasana Council, Yegu, Rangoon, Burma.

Vipassana Research Institute (1986); A Reader: International Seminar on ‘Vipassana Meditation’, December 1986, Vipassana International Academy, Igatpuri.

Vipassana Research Institute (1990-a), A Reader: Seminar on ‘Vipassana Meditation, Relief from Addictions, Better Health’, November 1989, Vipassana International Academy, Igatpuri.

Vipassana Research Institute (1990-b); A Reader: International Seminar on ‘Vipassana Meditation: The Importance of Vedana & Sampajanna’, February 1990, Vipassana International Academy, Igatpuri.

Vipassana Research Institute (1990-c); Abstracts of Scientific Papers: International Seminar on ‘Vipassana Meditation and Health’, November 1990, Vipassana International Academy, Igatpuri.

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Vipassana Research Institute (1995); A Reader: International Seminar on ‘Vipassana: Its Relevance to the Present World’, April 1994, Indian Institute of Technology, New Delhi.

Vipassana Research Institute (1996); A Reader: International Seminar on ‘Dharma – Its True Nature’, May 1995, Vipassana International Academy, Igatpuri.

Vipassana Research Institute (2005); A Reader: Seminar on ‘Vipassana & Ayurveda’, October 2005, Vipassana International Academy, Igatpuri.

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Dr. Manaswi Gautam

He is Director & Consultant Psychiatrist at the Gautam Hospital & ResearchCenter; Consultant Psychiatrist, Shekhavati Hospital; Honorary Secretary, Mental Health Foundation, Jaipur.

He is Member of the Indian Psychiatric Society, Indian Association Of Private Psychiatry, and the Indian Association Of Geriatric Psychiatry

He has a Diploma in Naturopathy, Diploma in Yoga and various Certificates in International Clinical Research Meetings.

He has received the ‘Amit Bohra Memorial Young Scientist Award’ for Paper presented and has presented many papers at National conferences.

He has worked with various NGO’S in medical camps and workshops and participated as faculty in training programs for General Physicians at different places in Rajasthan.

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PREKSHA DHYAN

Manaswi Gautam

Introduction to Preksha Meditation

Meditation : Meditation is a cognitive experience wherein a person sits in silence and concentrates over either an inner or an external object (virtual / real, or a name or a set of words i.e. Mantra)

Scientific meditation consists of two types of exercises: 1. Perceptive-PrekshaMeditation
2. Contemplative – Therapeutic Thinking

Perceptive: Preksha Meditation

The word ‘Preksha’ means ‘to perceive carefully and profoundly’. Preksha Meditation is the system of meditation engaging one’s mind fully in the perception of subtle internal and innate phenomena of consciousness. The technique begins with the perception of one’s breath, followed by the body, and the psychic centers. This process not only stops the ever restless mind from wandering, but also relaxes the body and prepares it for the subsequent step of concentration of thought or contemplation, where the conscious mind is encouraged to concentrate on a particular thought.

Regular practice of Preksha Meditation reportedly enhances one’s physical, nervous, emotional and aural (spiritual) energies.

Contemplative: Therapeutic thinking

The practice of concentration of thought or contemplation is two-fold :

· Intuitive Contemplation: This involves contemplation and reflection of eternal truths such as transitoriness of all worldly associations, solitariness of soul, etc., and

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· Discursive Contemplation: This involves application of one’s reasoning mind for acquiring desirable virtues and eradicating psychological distortions via vivid visualization of the goal coupled with auto suggestions. This technique is called ‘Therapeutic Thinking’.

Jain Yoga and Meditation

According to the literature available at Jain Vishva Bharti a centre for Jain studies founded by Gurudev Tulsi and further researched and propounded by Acharya Mahapragya, the word Preksha is used with the meaning of ‘Perception’. It is derived from the root Iksha, which means ‘to see’. When the prefix ‘Pra’ is added, it becomes Pra + Iksha=Preksha which stands for ‘perceiving carefully and profoundly’.1

The mind never relaxes even when we sleep. Through Preksha the mind is given auto-suggestion to relax. It is true that breaking the thought process is extremely, difficult however it is not impossible. When the mind is constantly studied it becomes all the more restless. In Preksha Dhyana no thought is forcefully stopped. Instead the art of merely observing the thought process without forming any reaction or attaching the self to it is developed. By doing so, thoughts themselves cease to come. So the technique of Preksha is a practical way and a powerful instrument for establishing the restless mind.

Preksha Dhyana is the technique of meditation for bringing about a change in behaviour, modifying and bringing about an integrated development of personality. It is based on the wisdom of ancient philosophy and has been formulated in terms of modern scientific concept.2

The term ‘vipashyana’ is synonymous to it. Both the terms have been commonly used in Jain literature. The term Preksha has been chosen for this system as the term ‘vipashyana’ is

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already being used in the current Buddhist system.1

Preksha – 7 Therapeutic strategies

Only when the physical, mental and emotional health of the individual is achieved can it give rise to social health. All the four are inter-dependent and constitute a whole. Following are the seven strategies of Preksha :

1.Yogic Physical Exercise : To give exercise to all muscles limbs and other external organs.

2. Yogic Asanas : To give exercise to deep-seated organs and control their activity.

3. Pranayam : Conscious control and regulation of breath is pranayam. This will result in increase of will power and benefit the autonomous nervous system.

4. Kayotsarg : In kayotsarg total relaxation is practiced with awareness and detachment through auto-suggestion. All tensions are drained out and the cellular structure of the body is revitalized and rejuvenated.

5. Dhyan : Practice of self-observation unravels the mysteries of the unconscious mind and brings about catharsis.

6. Anupreksha : Practice of contemplation concentration and determination is known as Anupreksha.One reaches the deep unconscious mind to bring about capacity and ability to change attitudes and behaviour.

7. Leshya Dhyan : Concentrated perception of specific colors are used to weaken the forces of malevolent leshyas and strengthening those of benevolent leshyas. Leshya Dhyan

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results in eradication of psychological distortions of cruelty, lust, hate, etc.

Relevance to Psyche

It is postulated that Preksha Dhyan acts via altering activities of nervous system and endocrine system. It has been proved by many authors that meditation produces a state of wakeful hypo- metabolism stage and hence gives rest to all the organs of the body. This state produced by Preksha is different from sleep, as we have seen in Transcendental Meditation (TM) technique Wellace (1960). In Transcendental Meditation (TM) technique EEG changes recorded during various TM activities show significantly more alpha activity than control group indicating that there is significant psycho-physiological de-excitation meaning a state of restful alertness. Transcendental Meditation (TM) technique produces restful alertness of mind, reduces oxygen consumption, carbon dioxide elimination and reduces arterial lactate concentrations and decrease in cardiac output by 25%.

As Preksha Dhyan involves meditation (dhyana) along with asanas and exercises Hence it can be postulated that Preksha Dhyana has direct effect on the nervous system similar to TM probably using the similar mechanism of action on nervous system with interplay of neuro chemicals due to modulation of neuro endocrino pituitary axis due to dhyana, yogic exercises and asanas as in TM, since meditation component is common in both Preksha and TM. Although there have been no studies (control group / parallel group/comparative) done on Preksha as on TM. Hence the evidence is limited.

Studies have also explored the effect of composite therapeutic packages, i.e., medical treatment and therapies used in clinical setting (counselling, CBT and RT) along with traditional Indian psychological methods, like Pranayam and Sudershan kriya, to foster better mental health with a view to alleviate negative

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emotions, enhance academic performance and overall personality development. Findings indicated that Indian traditional psychological methods improve the quality of life by combating stress and strain. Pranayam, Sudershan Kriya and other yogic methods like Preksha meditation have a positive impact on the behaviour of the subjects suffering from depression and anxiety and have a synergistic effect when combined with other forms of therapy, including allopathic medicines.3

Yogasana is a self-help system for curing and preventing illness, stress and enhancing physical, mental, emotional and spiritual health. Its key concept is to increase vital energy. The energy is then circulated into health, vitality, balanced emotions, creative and spiritual expression. Illness is caused by a blockage of energy. Too much or too little energy in one part of the body results in disease to the part and stresses the entire body. Stress or injury to one organ, gland or system weakens the entire body. The body is also self-regulatory and will naturally move towards balance if one is regular in practice. Western medical doctors have only recently discovered the disastrous effects on health of stressful living, and their methods of coping with stress are still in their infancy. Asana and meditation lead a man to transfer the stress and negative emotions into creativity, learning, healing and peak experience.4

Evidence (Research/studies to support)

A study of 25 patients with uncomplicated benign essential hypertension was conducted by Dr. Bimal Chhajer, Cardiologist, at the All India Institute of Medical Sciences, Delhi. All the patients were given the training of Preksha. The period of study included the onset of training and each individual used to perform meditation for half an hour per day. Results were studied after 6 months and were quite encouraging. Before meditation systolic BP and diastolic BP was 150+17 mm Hg & 94+9mm Hg respectively and after meditation it was measured to be 140+11

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mm Hg and 88+7mm Hg respectively. The lowered BP was independent of whether subjects were taking antihypertensive drugs or not.

25 patients with documented Angina Pectoris were on the drugs in addition to performing Preksha Dhyana. TMT was repeated after 4 months and 6 months. All patients continued Preksha Meditation and there were no dropouts. The mean increase in duration of exercise after meditation program is 1.02 minutes. The onset of ST segment depression was delayed by 55 seconds or 16%, which is quite significant. In addition patients on Preksha Dhyana reported less anxiety, less need of tranquilizers, and improved personal inter-relationships.

In another study done to investigate the effect of Preksha Meditation on the mental health of prisoners (Sharma et.al, 2004), a sample of 100 male prisoners (50 for experimental and 50 for control group), equivalent in all respects, was drawn from Central Jail, Jaipur (Rajasthan). Prior to commencement of their respective treatments ‘Mental Health Checklist’ of P.Kumar was administered on the subjects of both the groups. The subjects of experimental group were initiated to the training of Preksha Meditation and the group practiced meditation for one hour, daily, for four months regularly, while the subjects of control group were not assigned any special treatment or activity, rather they were

 

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indulged in their daily routine activities, as usual. Mental Health Checklist was re-administered on the subjects of both the groups at two stages of the experiment, i.e., at the end of two and four months of their respective treatments.

The subjects of both the groups were found homogeneous in all the 11 areas of mental health at the initial stage of the study. But after two months of Preksha Meditation practice the subjects of experimental group differed significantly from those of control group as their level of mental health (measured by the checklist) improved in nine out of 11areas of viz; anxiety (p< .025), restlessness (p< .005), despair (p< .10), anger (p< .05), headache (p< .05), fatigue (p< .025), sleeplessness (p< .025), constipation (p< .025) and acidity (p< .01). The subjects of experimental group further improved highly significantly (p< .005) on all the 11 areas of mental health after four months of Preksha Meditation practice in comparison to the control group. Further as compared to their pre-experimental stage the subjects of experimental group were found significantly better in their Mental Health at the end of two months of Preksha Meditation practice as they improved significantly on all the eleven areas of mental health viz. anxiety (p< .01), restlessness (p< .0005), nervousness (p< .01), loneliness (p< .0005), despair (p< .0005), anger (p< .0005), headache (p< .0005), fatigue (p< .0005), sleeplessness (p< .01), constipation (p< .005) and acidity (p< .01). The mental health was further strengthened highly significantly (p< .0005) on all the 11 areas by the end of four months Preksha Meditation practice. Thus the findings of the study endorse that Preksha Mediation worked as a treatment modality for improving the mental health of prisoners in the period of two and four months.5

A study at work based on a survey of randomly selected representative sample of 150 managers with 50 managers each belonging to Public Sector, Private Sector and Government Departments working in their respective organizations located in

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and around Bangalore was done. (Arun et.al 2007)6. The work profile of the selected sample subjects consisted mainly of the mental efforts involved in the processes of planning, decision- making, monitoring and controlling. The instruments employed were a pilot study verified, 4-point, 5-dimension and 21-item scale designed based on Likert’s principle to obtain responses pertaining to the subtle principles of yoga and a semi-structured personal interview schedule which helped to obtain a holistic picture about the behaviours of the respondents. The results revealed that in the workplace based on Western management practices the synthesis of Eastern thoughts at the workplace still happens through the application of subtle principles of yoga. The results further revealed that in the overall application of subtle concepts of yoga, while executing one’s work at the workplace in an organization structure based on the western management practices, the nature of the organization does not have any significant levels of influence on individuals. However, the private sector managers were significantly better placed in the dimensions of ‘structural tension’ and ‘short-term transmission of enthusiasm’ where as in the dimension of ‘long-term transmission of enthusiasm’ the managers of Government departments were significantly better placed than the others.6

A pilot study (Gaur, Shah, Jain & Ashar, 2004) investigates the effect of Preksha Meditation on management of stress in teenage students. A sample of 24 boys and girls were the subjects with mean age of 14 years, drawn from various parts of Mumbai. The Bisht Battery of Stress Scale was administered on the subjects prior to commencement of Preksha Meditation training. The subjects underwent Preksha Meditation practice for 16 days, three times a day. The subjects were re-tested on the aforesaid psychological test at the termination of treatment. The training of Preksha Meditation was imparted by trained instructors of Preksha Meditation. The results obtained reveal that due to the practice of Preksha Meditation for 16 days, the subjects

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experienced a reduction in stress in the areas of academics, family and achievement. They became more self-assured and confident. In the area of academics there was a reduction in their frustration level (p< .05); conflict (p< .05) and pressure experienced (p< .02). Further there was a reduction in the level of family frustration (p< .01) and family anxiety (p< .01). Their achievement frustration and anxiety were also reduced (.05 and .01 level of confidence), as well as the existential pressure (p< .01), due to Preksha Meditation practice.7

A study (Mishra, 2007), was done to explore the influences of pranic healing (prana therapy) on the blood pressure and alpha EEG waves in human volunteers. Twenty five subjects were selected by incidental sampling. Pre and post test of Alpha EEG and Blood Pressure was done. The systolic Blood Pressure pre- test mean score was 138.96 ± 11.50 mm Hg and post-test mean score was 128.4 ±6.89 mm Hg. This shows systolic B.P. was reduced by one session of pranic healing. Secondly, diastolic Blood Pressure pre-test score mean was 93.92 ± 10.27 mm Hg and post-test score mean was 85.84 ± 7.06 mm Hg this showed that diastolic B.P. was reduced by one pranic healing session. Each session was of 20 minutes duration. To heal hypertension, the solar plexus and meng mein chakra (energy centers a (explained in glossary)) must first be cleansed thoroughly and then inhibited by using light blue prana. The brain and the nervous system are controlled and energized by the ‘crown chakra’ and ‘forehead charkra’. It was found in the study that there were some significant relationship between pranic healing and blood pressure and alpha waves.8

Implications in psychiatric patients & general population

Preksha Meditation Can Help : Reduce physical stress and strengthen the immune system, Improve mental and emotional health, Develop personality, Change harmful habits, and treat phobias, Enhance mental abilities, concentration and

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operational efficiency, Enhance creativity and develop career skills, Prevention and cure of psychosomatic diseasesn, Balance between activity and rest,: Relaxation, Keeping purity and peace of mind, Increases will-power; Achieve goals, and much more.

Every man chooses his field of activity. Working and working efficiently are two different things. Today thousands of professionals are working as doctors, engineers, professors and scientists. There is a wide variety of fields of activity. One person works efficiently and gets success in his work. Another does not work efficiently and courts failure although both possess similar professional skills. Preksha helps in working efficiently.9

Practice of Preksha Meditation (dhyana) can enhance person’s efficiency of working by :

Increasing self- confidence Strengthening decisiveness Development of concentration Development of memory Effective emotional balance Increasing tolerance power Developing the strength of work Development of creativity etc.

On a spiritual level, a firm control of the reasoning mind, regulation and transformation of blood chemistry through proper blending of the neuron-endocrinal secretions and production of dispassionate internal vibrations lead to attain infinite compassion, equanimity, bliss and happiness.

Preksha Meditation has been found to be useful in treatment of psychiatric disorders as well through some of the Preksha Techniques :

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Insomnia

Asana Matsyasana, Sarvangasana, Taadasan-Techniques Relaxation.

Pranayama Ujjayi Pranayama, Shitli Pranayama, Shitkari Pranayama, Suryabhedi Pranayama.

Weak Memory

Asana Matsyasana, Relaxation, Yoga Mudra, Sarvangasana. Pranayama Anuloma-viloma Pranayama-5 minutes.10

Preksha Meditation is especially recommended for people with heart problems. In most cases an operation (by-pass) can be avoided.11

Scope of future research

To further evaluate the efficacy of Preksha Meditation in various psychiatric problems : Research has been done to study the significance and effect of Preksha Meditation on mental health and other aspects of a person. Yet, they can be studied further and be useful as a new non-pharmacological approach to a healthy life. As many researches are preliminary studies in this field, it needs to be replicated with larger samples.

It has been acknowledged that religious and complementary therapies are commonly used in community settings in India. The human magnet through its vital energy can be affected and get affected by others. Noted psychologist Prof. Victor E. Kromar has investigated the role of mental power (will power) in controlling and utilizing the bio magnetic power of the human body.

There is an increasing interest in non-pharmacological and complimentary treatments.

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Concluding remarks

Preksha means different things to different people because it contributes to increase physical, nervous as well as spiritual energies. It has profound influence upon mental states and forming positive behavioural patterns of an individual. On the physical level it helps each cell to revitalize itself, it facilitates digestion, it makes respiration more efficient, and improves circulation and quality of blood. On the mental level it becomes a methodology to train the mind for better concentration, purification and relaxation. It offers a way to treat serious psychosomatic illness without drugs. It is an efficient exercise in self-discipline leading to the end of addiction and other bad habits. It leads to what lies beyond the conscious mind. On the emotional level the active functioning of the reasoning mind controls reactions to environmental conditions, situations and behaviour of others. It helps to harmonize the functioning of nervous and endocrine systems. This leads to control and ultimate eradication of fear, hatred, jealousy, anger, lust and sexual perversion.

Glossary

The body is said to be consisting of the pathways of energy (nadis), which converge at different spots in the energy body to form the energy centers or chakras. These centers (chakras) act like traffic lights and govern the flow of energy and the health of the physical organs associated with them.

Acknowledgement

Author acknowledges the timely help of Nitya Saraf and Anuja Bhardwaj Trainee Psychologists at GHRC in preparing this manuscript and literature search.

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References :
1.
Acharya Mahapragya, Preksha Dhyana: Basic Principles,

p. 1, Jain Vishva Bharti. Ladnun (Raj.).

2. WWW.jainworld.com,Preksha Dhyan, Preksha meditation and health, from the works of Acharya Mahapragya, Compiled by Mrs. Vidya Jain.

3. Sujata Satapathy, Sidhartha Satapathy & Dilbagh Kaur, (2002),Combined effect of Art of Living, counselling & medical treatment on specific mental disorders- some interventional case studies: Paper presented at the National conference on Yoga & Indian approaches to Psychology, Pondicherry, India.

4. MuniKishanlal,ShubkaranSurana,(2003),JeevanVigyan course book. Jeevan vigyan academy publication: J.V.B. Ladnun, Rajasthan.

5. Sharma, A & Gaur, B.P. (2004); Preksha meditation as a treatment modality for mental health – a pilot study. Paper presented at the National Seminar on ‘Indian Psychology- Theories & models’, Bangalore.

6. ArunB.K.&Upinder,D.(2007);Theinvisiblesynthesisof eastern and western managerial thoughts through subtle principles of yoga-an empirical study. Paper presented at the National Seminar on ‘Indian Psychology- Theories & models’, Bangalore, 2007

7. Gaur B.P., Shah R.B., Jain, M. , & Ashar, H.K. (2004); Effect of Preksha Meditation on management of stress in teenagers. Paper presented at the National Conference on ‘Indian Psychology- Yoga & Consciousness’, Pondicherry,(India) Dec 2004

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8. Mishra,G.(2007)Astudyofeffectofpranichealing(prana therapy) on blood pressure and alpha EEG. Paper presented at the National Seminar on ‘Indian Psychology- Theories & Models’, Bangalore, 2007.

9. AcharyaMahapragya,efficiencyofworking,jeevanvigyan (science of living),Jaindhram.com

10. Acharya Mahapragya, Preksha therapy, towards inner harmony- Preksha meditation comprehend the soul transform your life.

11. How to transform fear into love-preksha meditation-hatha kriya yoga center, info@hathakriyayoga.com

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Dr. T.S. Sathyanarayana Rao

Dr. T.S. Sathyanarayana Rao holds
degrees of MD, DPM and is the Prof. and
Head of Dept. of Psychiatry in JSS Medical College, Mysore since 1987. He is also the editor of Indian Journal of Psychiatry. His first article on Religion and Mental Health was published as early as 1992. He has conducted 9 major conferences of Indian Psychiatric Society, including ANCIPS in 2004.

He has 4 books and more than 70 articles to his credit. He has served as the editor of Indian Journal of Psychological Medicine published by IPS South Zone and he is the editorial member of many prestigious journals so also regular columnist for popular publications. He started the multi-speciality sexual clinic at JSS Hospital in 1995 and his keen interest is in the area of sexual medicine, its research, education and practice.

He is a fellow of council on sex education and parenthood international and many related associations. He is also a member of World Association of Sexology, Asia Oceania Federation of

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Sexology and Human Sexuality Division of World Psychiatric Association.

Dr. M.R. Asha

She is Ph.D, and a specialist of
Nutrition & Sensory sciences based in
Mysore. She has been actively practising Reiki and is recognized trainer being qualified as Usui Reiki Master and Karuna Reiki Master.

She is also a poet and freelance writer on various aspects of bio-chemistry, health and complementary medicine. Her book “CREATE YOUR LIFE CONSCIOUSLY” is due for release early next year. Her areas of interest include Energy medicine, Neurolinguistic programming (NLP), counseling and Psychotherapy, Epigenetics, Neuroscience, Receptor Molecular biology and Consciousness Research

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SEXUALITY AND SPIRITUALITY

T.S. Sathyanarayana Rao M.R. Asha

“A total orgasm of the body and mind might be described as a showering of nectar from the head, running down your insides like a springtime shower. It is unmistakable, a wave of subtle chi energy that opens up hidden powers of feeling. You feel like a newborn baby, only adult and conscious”.

– Mantak Chia

Apparently diametrically opposite and appearing poles apart, sexuality and spirituality are two facets of the same energy that have been driving mankind incessantly. They are not only comparable and compatible, but also complementary. Both are fountains of creativity urging a a person to explore, to know, to become aware of, to experience, to search for meaning. Both require sensitive honoring of body, mind and soul with enhanced awareness for best results. Sex does not sabotage spirit but it can be a stepping stone to spiritual progress. Sex is an integral part and an eloquent expression of spirit. Sex can be evolved into a sacrament and a tool for enlightenment. When the truly sacred nature of sex is understood, a deeper connection with oneself, one’s lover and the divine spirit can be established, cultivating an ecstatic freedom within. Instead of debating which stems from base instinct and which leads to highest peaks of ecstasy, it’s time to transcend the polarity and integrate these two vital aspects of human consciousness for enriched and meaningful living.

One of the elegant ways of divine manifestation is paradox. What appears to be the end may really be new beginning. What seems to be the riskiest path may be unfolding for our highest good in the long run. What looks like a reservoir of carnal pleasure may contain seeds of innate spirituality. What seem to be transient flashes of love initially, may eventually lead one to eternal bliss.

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The only transformer And alchemist That turns everything Into gold is love.

Sigmund Freud, the founder of psychoanalysis, made a theoretical dissection of human psyche and postulated the presence of ‘unconscious’ and ‘conscious’ mind. He argued that one of the instincts of the id, ‘eros’ is libido or sexual energy which is a life integrating force. Libido refers to any energy drive which supposedly has erotogenic stimulations arising within the soma (body), as its source, irrespective of its manifestations. The fact that the libidinal energy primarily originates in sexual sphere does not necessarily mean that all its aim lies in sexual union. The libidinal energy which is initially dischargeable only through the act of sex can also be discharged in gratifiable ways even in non- sexual objects. When this libidinal energy is not channelised in healthy ways, when it is suppressed or repressed, the resultant frustration may ultimately lead to adoption by individuals of various ego defenses such as reaction formation, repression etc. The commonly associated (with sex) emotions of guilt and shame, when carried to extremes, can adversely affect the mental health of an individual. Unless resolved completely, these can become pathological, interfering with the normal sexual life of individuals, significantly diminishing the quality and distorting the meaning of life.

Ancient Hindu scriptures such as Vedas and Upanishads revered the human body with all its innate qualities. Many Indian authors, including Vatsyayana, celebrated the ‘Art of Loving’. In his classic work ‘Kamasutra’ (Aphorisms of love) Vatsyayana includes the three pillars of the Hindu religion Dharma, Artha and Kama representing religious duty, worldly welfare and sexual

– Anais Nin

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aspects of life respectively. The main theme here appears to be the expression of Indian attitude towards sex as a central and natural component of Indian psyche and life [1]. Love is in the true nature of humans and sex is a form its expression, bringing two people together overcoming the feeling of ‘separatedness’ and fulfilling the deep seated need for affection and belongingness. When within the framework of Dharma, love remains balanced and in harmony. Indian society in the ancient times was a sexually liberal one where women had an equal say in what they wanted and enjoyed in bed. Lord Krishna has been quoted to have said in Bhagavadgita that He is omnipresent but takes the form of desire, especially sexual desire, in the human body. Kalyanamalla, (the author of ‘Ananga Ranga’, a famous Sanskrit work) is said to have said that “all of you who read this book shall know how delicious an instrument is woman, who is capable of giving the divinist pleasures”.

“The inner woman, entering the ‘royal road’, takes rest at intervals in the secret centers. Finally she embraces the supreme Lord in the lotus of the head. From that union there flows an exquisite nectar that floods and permeated the body; then the Ineffable Bliss is experienced”.

– Anandagiri

Hinduism has been the home for another paradox – asceticism -as in Buddhism and Jainism renouncing all sensual pleasure and eroticism- embracing sex in all its splendor as in Tantric sex. Both ultimately lead to the same goal – the rebirth of the practitioner to a new existence on each level of consciousness. The implications are clear – the libidinal energy can be transmuted to highest form of spiritual energy. The cosmic energy contained in human sexuality could be released into the consciousness, but only after completely surrendering and worshipping as the sacred, primal power ‘Shakti’.

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Indian mythology depicts the communion of male and female parts of human consciousness as represented by ‘Shiva’ and Shakti [2] When Shakti unites with Shiva, the whole world is created in a sexual dance of bliss.

In The Tao of Love and Sex: The ancient Chinese way to ecstasy, specific concepts in the Taoist approach to eroticism have been described in detail. A strong emphasis on female satisfaction is a key feature of the Tao of loving, achieved only through a proper balance and harmony of the forces of Yin (female) and Yang (male), the opposites in the cosmic scheme of the universe. As expounded by Chang, the Tao of loving is an explanation of the advice extended by various authorities in classical works on Taoism that considered love making as part of the natural order of life [3]. When partners surrender fully to each other, they are said to connect with the source of the universe. The link between spirituality and sex is what the modern day sex therapists and frustrated lovers are struggling to understand, and rediscover, which the Tantriks of ancient India and Taoists of China knew and practiced well.

“By practice, even without understanding, it will be made plain; your body will understand it long before your mind puts words into it. No amount of understanding without practice will work. It is not necessary that knowledge precedes experience. Performance will produce knowledge”.

– Shiva Sutra

Our body is a mass of vibrating energy. Ecstasy results when energy flows freely and expands. Viewing sex as only physical robs the deeper meaning and beauty inherent in this passionate and mystical union of two energy bodies, of male and female forces of nature. One moment it is like wild thunder and the next, exquisitely tender. It is not mere genital contact but a sacred

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contract. This shared intimacy is meant to create long lasting energy bonds between the partners, in the afterglow of this glorious bliss. When bodies of lovers are treated as temples, love making becomes an act of worship, of experiencing heaven on earth. Conscious love making reconnects us with our spiritual origins. The expansion of sexual energy is not just the secret of good sex and love, but it is the secret of life.

“Your genitals and spine are like a water wheel that draws the energy up your spine and then pours it into your head to replenish your brain. From there it flows down like a waterfall into your abdomen, where it can be stored in a life-giving reservoir of energy. The Taoists knew there is nothing more powerful than water and nothing more powerful in our body than our sexual energy”.

– Mantak chia

Miranda Shah, an American tantric scholar, adds that the energy of the heart has to be released in order to attain ‘Nirvana’ or enlightenment. She reports that some of the tantric pioneers perceived that a celibate life style symbolized repression and denial of one’s own sexuality, far from representing mastery over it [2].

According to Margot Anand, author of The Art of Sexual Ecstasy and The Art of Sexual Magic, tantra activates all our energies. The pinnacle of tantric practice described by her as ‘orgasm of the brain’, linking the right and left hemisphere [2]. Tantric teachers regard body as an instrument through which the cosmic power (Kundalini shakti) manifests itself. Visualised as a coiled serpent at the base of the spine or ‘Mooladhara’ (Root charka), the Kundalini shakti is believed to transform the body and mind when aroused through elaborate ritualistic steps [4]. A frequently encountered symbol of spirit is ‘light’ or ‘fire’ represented

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as ‘Agni’ in Hindu mythology. The Vedic description of ‘Agni’ as ‘Hiranyagarbhi’ meaning ‘Golden germ’, is compared to ‘lightning’ and to the flash of orgasm. ‘A perpetual fire’ is a symbol of immortality and indestructible soul [5].

“He who realizes the truth of the body can then come to know the truth of the universe”.

– Rat Nas Tantra

In his bestselling book, ‘From Sex to Superconsciousness’, Osho stated that orgasm is a transient state of ‘Samadhi’ where the mind becomes empty of thoughts akin to peaks of meditational ecstasy reaching the state of ‘Timeless nothingness’ [2]. Both peak experiences, according to Daniel G. Amen, religious ecstasy and sexual pleasure, appear to be primarily processed in the right hemisphere of the brain, particularly the right temporal lobe and prefrontal cortex. This implies that enhancing the experience of one may favorably influence the other [6].

“It is a pleasure of the bee to gather honey of the flower, but it is also the pleasure of the flower to yield its honey to the bee. For to the bee a flower is a fountain of life and to the flower a bee is a messenger of love, and to both, bee and flower, the giving and the receiving of pleasure is a need and an ecstasy”.

– Khalil Gibran

Emphasising the value of ‘Samyama’ (conscious abstinence), Swami Chidananda comments that celibacy is the deliberate conservation of precious energy which can be transmuted to different forms creating miracles. There have been numerous spiritual leaders who insist on conscious celibacy always upholding abstinence, rather than indulgence. Major world religions have emphasized taming the carnal desires by effectively

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manipulating human behaviour through the concept of ‘sin’ based on guilt and shame stemming from the ‘superego’, the moralistic manager.

Religion and ethics provide the framework and guidelines for practicing human sexuality. They may be hedonistic or ascetic or legalistic or situational [7]. Neurotheosphy is an emerging science – a blend of Neuroscience and Theosophy, with a focus on bringing the best of human spirit in conjunction with the works of God.

A mention of Interfaith Sexual Trauma Institute (ISTI) at St. John’s Abbey and University, Collegeville, Minnesota, USA, would be appropriate at this juncture. This organization is dedicated to promote the prevention of sexual abuse, exploitation and harassment through publication, education and research. ISTI has the vision of facilitating the building of safe, healthy and trustworthy communities of faith, thereby providing a soothing balm of spirituality to sexual trauma victims [8].

The only true need anyone has is to be seen as real.

– Deepak Chopra

Possibilities of using meditation and other spiritual practices for therapeutic and preventive purposes in sexual dysfunction hold a great promise as natural therapy, as these practices have the potential to bring deep rooted, regressed issues buried in the unconscious, bubbling up to the surface. This facilitates dealing with those issues in the present and resolving them, fostering healing and leading to enjoyable sexual life. Many sex therapists recommend Yoga asanas (to facilitate harmony of body and mind) to their clients to free them from the mental blocks that inhibit sexuality [9].

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Chakra system, invariably detailed in most of the Indian traditional books on Energy system, has been given a unique erotic touch by Michelle Pauli in her book ‘Spiritual Sex’ [10]. It is a symbolic map of the body’s energy web. These are the centres of dynamic interplay between consciousness and energy. Awakened by love making, as the sexual energy flows through the body, the chakras spin freely, attracting, containing and directing the sexual charge. When energy flows freely, the act encompasses the heart and spirit, no longer confined to physical body. It is at this moment that the simple physical union is transformed into oneness with the universe. She states that in Tantra, the ‘yoni’ (the Sanskrit word for the female sex organs, meaning ‘sacred space’) is worshipped as the sacred door to direct experience of the divine. One of the ancient sexual images is ‘the cosmic yoni’, worshipped by many cultures throughout history. The penis is called ‘lingam’ meaning ‘wand of light’. It is the symbol of Shiva, the male energy of consciousness. The lingam has been worshipped as an emblem of fertility, universally.

Look at these worlds spinning out of nothingness. That is your power.

– Rumi

An interesting question to pose at this juncture would be whether sex can be spiritually liberating or whether spirituality can liberate us from the throngs of sex? Perhaps it is more of an individual perspective and choice where the answers can be found within one’s self.

“Having seen one’s partner as a god or goddess, one naturally feels a sense of devotion. At this point, there is no need for elaborate instructions, as love play spontaneously becomes the sport of deities. Every gesture becomes an act of worship,

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every sigh and word of love becomes a prayer, and gazing into the lover’s eyes becomes a one-pointed meditation”.

– Miranda Shaw

Sex and the human spirit have been closely linked with man’s quest for meaning and fulfillment. Sexuality is destructive or valuable to the extent that it does not express or does express love. A truly spirited life does not deny or repress sexuality but puts it in the proper perspective. Sexuality and spirituality are different means of worshipping the divine temple i.e. the soma where the soul is housed in the brief sojourn on planet earth. Bridging the apparent chasm between sexuality and spirituality is possible through a healthy balancing of ‘Eroticism’ and ‘Asceticism’, not necessarily compromising either of the two. Merging with the cosmic dance of this primal force, an individual loses his/her self only to find new elements in him/her self hitherto unknown and unexpressed, nevertheless profoundly alive and inherently dormant.

Love, enjoyed by the ignorant, Becomes bondage.
That very same love,
Tasted by one with understanding, Brings Liberation.
Enjoy all the pleasures of love fearlessly, For the sake of liberation.

– Cittavisuddhaprakarana

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References :
1.
TheKamasutraofVatsyayana:TranslatedbySirRichard

Burton and F.F. Arbuthnot, New York: Putnam 1984, 223 p.

2. The Tao of Love and Sex : The Ancient Chinese way to Ecstasy. Foreword and Postscript by Joseph Needham, New York: Dutton, 1977, p.136

3. Parveen Chopra. (2004) Spirituality. Life positive.April 2000. 4th Anniversary special. Pp. 64-75.

4. ArvindandShantaKale.(2003)TantratheSecretofSex. Jaico Publishing House, Mumbai.

5. CliffordBishop.(1996)SexandSpiritualiy:Ecstasy,ritual and taboo. Duncan Baird publishers. London.

6. Daniel G. Amen. (2007) Sex and the brain: 12 lessons to enhance your Love Life. Harmony Book, New York.

7. Janet Shibly Hyde/John Delamater. Understanding Human Sexuality.

8. http://www.csbsju.edu/isti
9. Kanhaiah, B, Bhanutej N, Devika V., Somnath, B. (2000)

Sex and spirituality. The Week. Nov.5, pp. 36-46.

10. Michelle Pauli. (2002) Spiritual sex. MQ Publications Limited, London.

11. Quotes quoted in Parveen Chopra. (2004) Sex & Spirituality. Life Positive :4th Anniversary special. April, 5(1), 64 – 75.

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Prof Sanjeev Jain

Prof Sanjeev Jain did his medical
studies at the Maulana Azad Medical
College and Associated LNJPN and GB
Pant Hospitals, New Delhi, India; and his
post-graduate studies in psychiatry at the
National Institute of Mental Health and Neurosciences, Bangalore, India. He joined the faculty of NIMHANS in 1986 and has been an active researcher in various aspects of mental health and neurosciences, with a major research emphasis on genetic aspects of psychiatric and neurological syndromes, molecular biology and also the history of psychiatry. He has been a Commonwealth Medical Fellow at the University of Cambridge, UK; a Visiting Faculty, Department of Psychiatry, University of Washington at St. Louis School of Medicine, St. Louis, Missouri, USA; and also a Visiting Fellow, Wellcome Institute of History of Medicine, London, UK.

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SPIRITUALITY: BIOLOGY OF THE SOUL

Sanjeev Jain

The notion of the mental world as being distinct from the physical word, and thus having mystical, religious or spiritual qualities that are unfathomable by the laws of the natural world has an ancient history, perhaps as long as human acculturation. In its essence, this mental world is populated by ideas of permanence, giving rise to a moral universe that is supposed to guide human behaviour across time and space, in the temporal sense. Thus all religions and other creations of the human mind have been constructed as ideal forms of existence.

The ‘evolutionary biology’ of spiritualism

The human brain with its capacity for language and reflective self-awareness is perhaps one of the rare occurrences in biology. In the previous millennium, it was often commented that between Galileo/Copernicus and Darwin (and self-proclaimed by Freud), the idea of man as being the centre of the universe was successfully eroded. Man, instead of being the unique creation of a divine being, became one of the accidents of the physics and chemistry of matter, and only one of the millions of biological variations of DNA structure. Perhaps humans were always aware of their ‘true’ nothingness in the vastness of space and time. Thus, as the developments in rationality and reason progressed in the last 500 years, their success was accompanied by a loss of faith. This has been a continuous tug-of-war between them, and carries on even now. To quote a contemporary spiritual song, the ideal state often sought for by humans seems to be “Got Me No Reason; Got Me No Doubt”.

The cognitive systems of life forms were created to allow for a meaningful engagement with the physical world around them.

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Human beings, given the overwhelming nature of the complexity around, developed explanatory models that could help them tidy it up with rules. Human beings after all have an inherent propensity for rules and symmetry, as suggested in the evolutionary origins of obsessive-compulsive disorder. As we see in that syndrome, yielding to the obsession/compulsion is accompanied by a decrease in anxiety.

More pertinently, contemporary humans evolved as a social organism, and after Homo Sapiens success in overcoming all other large predators, the only anxiety provoking situation was other humans, natural disasters and infections. It soon became apparent that shared rules and co-operative behaviour within a human society reduced anxiety, and allowed the impact of the other two dangers to be reduced. So, in another more complex way, linguistic, cultural and religious affiliations created the conditions by which these rules became a part of the human condition.

However, these rules (formal religions, ideologies, all- explanatory psychological models) could never successfully explain the bewilderment and wonder that humans felt about the world around them. Though they were empirically successful, they could never provide all the answers to the human condition. However, spiritual experience performs an extremely useful and primal discursive function. The primary orgins of many religions andmythsarisefromsuchexperience. Inmanysocieties,tribal elders “call” (call upon) the deity through sacrifice, prayer and ritual, but first of all through naming; (as is seen in various shrines where the chanting and the naming makes the spiritual experience powerful and therapeutic) and it is crucial to get the name right (somewhat similar to the Jap or the Mantra). This reference can yield either referential success or referential failure, but when it fails, what’s at issue is not a fit between world and word, but rather a fit between self-reflective existence and possibility (the

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transcendence of what could be) which is mediated by the word being employed. (Seiple 2004)

The Religious Connection

Modern psychiatry is alleged to begun in Europe during the Renaissance, when following the secularization of the human mind, the passions and follies of the soul could be attributed to natural rather than divine causes. This reaction against organized religion however occurred in many parts of the world. Even in Europe, the rapid advances in the understanding of the ‘scientific’ basis of life and the universe, and the apparent inability of religion to offer equally valid explanations, resulted in a moral vacuum, wherein several spiritual movements came to the fore. Many of the predecessors of the various schools of psychology that are practiced today appeared in their early forms in the 17-18th century in the form of pietists, and other religious movements that talked of a direct communication with the Divine, and thus succour, rather than through the established theological and political powers. It has even been alleged that the burning of witches and the later development of psychological models was thus a response to the alternate spirituality as practised by the alleged witches.

Here in SouthAsia, the orthodox religions of Hinduism and Islam went through similar movements. In their range and extent, these religions attempt to provide a road-map for the entire life cycle of a human being. However, due to their close relationship with worldly power, and the various iniquities that were practiced, questions were raised about their validity and alternative models often emerged. These have actually been a more powerful and prominent part of daily life here. Thus, the various Bhakti movements (e.g. Tulsidas, Kabir, Tuka Ram, Akka Mahadevi, Chandidas, Vidyapati) from all corners of the country, the Sufi movements exemplified in the shrines and practices all over, the reformist Sikh religion, and the popularity of the many Christian

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practices that emphasize a direct communication with a higher order have served to offer an alternate model for guiding humans. The very popularity of these methods forces to try and understand the validity and usefulness of these.

The ‘social’ connection

As described above, a primary dissatisfaction with the bureaucracy of religions often provided the initial impetus for spiritual approaches. As Williams (1985) points out in the ‘Anatomy of Madness’, the emphasis on materialism and scientific naturalism in the 19th century had lead to a crisis of faith and a certain acceptance of spiritual ideas. The appeal of spiritualism was diverse. Women otherwise denied a role in the power structure of contemporary society, could become mediums and acquire a certain status. Similarly, working class spiritualists could avoid submission to a dominant culture and control their own religion and culture and education.

The specific anti-authority potential in India was obvious, and the residues of that can still be felt in the various religious fundamentalisms that persist. However, the typical Indian medical professionals, trained in medical colleges in India and Britain, became a part of the local power elite that identified itself closely with the British power elite, and post-Independence with the ruling political classes. They were perhaps influenced strongly by the Victorian (and later Marxist) emphasis on naturalistic (and by extension, materialism), rather than the ‘spiritualistic’ views regarding psychological phenomena. Faith healing, whether by fakirs in Calcutta, or at seances in London, was both worthy of contemptuous dismissal by medical authorities (Jain and Sarin, 2000).

In subsequent years, the progress of physiological and medical science, in our field, was reflected by a preoccupation with ‘biological psychiatry’. The inner psychological space of the

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patient remained neglected by doctors. This scepticism regarding psychological, religious and at one level ethical and moral issues, both western and ‘native’, however, became a part of the Indian psychiatric establishment, which has tried to preserve itself as a ‘purely clinical’ service provision.

However, the development of ‘spiritual therapies’ in India were contemporaneous with Charcot and Breur in Europe, where Freud would soon take the field of subjective psychology to dizzying heights, and herald a dramatic change in notions of psychopathology. Thus, the early European practitioners, e.g Honigberger in Punjab and Esdaille in Calcutta specifically point out the essential similarity between Mesmerism and the folk healing practices of various Fakirs and Pirs. In one of the earliest known demonstrations of trans-cultural psychiatry, Esdaille held a joint session of therapy/hypnotism with a Fakir in Calcutta to show that the idea of Mesmerism (from Europe) was the same as practiced here.

The Indian doctors, coming out of the Presidency medical colleges, were well aware of this link. One of the earliest references one could find is a case report by a ‘native’ doctor of treating patients with ‘hysteria’ by Pandurang in 1869, criticising the theoretical basis of prevailing ideas (discomfort with the Charcot type ideas already coming to India), and others like Chetan Shah who pointed out the use of ‘faith’ in successful treatment in 1888. However, the growth of the ‘biological approaches’ for treating hysteria is best described by Gupta in 1900, and included being ‘pinched, pricked, burnt with a match, employed a battery, ether, pilocarpine, caffeine citras, carbolic acid intra-muscular .. with no improvement’. Perhaps most of us are still familiar with the similar response of the medical services to someone who has ‘functional or ‘supra-cortical’ symptoms even now. Note also all the ‘Western’ methods, from the electric battery to the drugs. Both the drugs and the attitudes became fixed to a certain notion

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of psychological symptoms.

The typical medical practitioner thus feels instinctively uncomfortable when confronted by spiritual issues.

The physiological issues

Last year, Oliver Sacks (2008) wrote an editorial to accompany the article by Harris et al (2007) in the Annals of Neurology that explored the basis of faith, using an fMRI. Harris et al showed that assent, dissent and uncertainty, whether in terms of mathematical possibility or propositional inaccuracy, were accompanied by activation of ventro-medial frontal cortex. Sacks, in his commentary, wondered if these experiments could ultimately lead us to the answer- to whether the biology of spiritual truth is as hard-wired as that for mathematical truth. Of course, it could be that all of it is ‘maya’ but that is a separate question! The basic premise that the human brain likes to resolve uncertainty is now getting closer. These findings have had support from many others. The work of Zeki and Romaya (2008) on the MRI of the contrasting emotion of hate also identifies the frontal pole, along with amygdala and insula as structures that show inactivation/ activation patterns, somewhat similar to those seen in OCD and also with ‘romantic love’. Other recent work by Weich et al (2006) demonstrates that perception of pain can be altered by ‘faith’. They showed that practicing Catholics had decreased experience of pain compared to controls, and the areas involved in this were the VLPFC. Studies using fMRI on schizophrenia subjects with widespread delusions (including religious) suggest that attribution/ misattribution of internal psychic states to external objects (real or imaginary) may underlie certain aspects of the delusional process and according to the authors of the review (Taber and Hurley 2007), may share some properties with religious beliefs.

This flurry of activity in the recent past demonstrates that the capacity of belief systems (religious or ‘psychotic’) will have

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an interface with the perceived world in the minds of humans, and alter their responses of pain, dysphoria and depression. Thus, the biological correlates and consequences of the spiritual experience need to be looked at, even by biologists.

There are some caveats to all this. Eccles and Popper (1984) in their discussion about the nature of the Self, postulated that there are three conceptual worlds. The world of physical matter (world 1), the world of emergent biology (the cognate systems that interact with the world 1; called world 2) and lastly the world of ideas (world 3) that can interact with both the worlds in a complex manner. What we try and do, as humans, is to try and develop laws of the world of ideas (world 3), using methods that develop by our understanding of world 1 and 2. The implication is that with successful application of science, the High Priestess of Reason, this would be possible. Would that be a good idea? Would we still Know who we are, when we Conclude who we are?

This was a possibility that troubled Karl Jaspers (1984). As he points out in his biographical essay,

“As a physician and psychiatrist, I saw the precarious foundation of so many statements and actions and beheld the reign of imagined insights, e.g. the causation of all mental illnesses by brain processes (I called all this talk about the brain, as it was fashionable then, brain mythology; it was succeeded later by the mythology of psychoanalysis), and realised with horror how, in our expert opinions, we based ourselves on positions which were far from certain, because we had always to come to a conclusion even when we did not know, in order that science might provide a cover, however unproved, for decisions the state found necessary.”

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Summary

It thus becomes evident that the application of faith, and a spiritual experience, can be extremely useful in reducing the anxieties humans face, in time of uncertainty (most of modernity!) and equally, when faced by real trauma and torment. To understand this better, we will need to extend our methods in many directions. We will need to understand the evolution, development and variations of the brain, the evolutionary and neurophysiological drive towards reducing ambiguity, the social processes that consolidate this and ultimately the drive towards being a self-fulfilling human being that everyone possesses. These reference points are often critical for mental health. The intentionality of consciousness is very highly valued and most humans will strive to achieve this freedom at every level. Spiritual practice thus performs a very useful function in providing this meaning. The how and why of this can be a subject of constant enquiry, as we try and explore who we are.

References :

1. Harris S, Sheth SA, Cohen MS. (2007) Functional neuroimaging of belief, disbelief and uncertainty. Ann Neurol, 63:141-147.

2. Jain S., & Sarin A. (2000) Some reflections on the development of Psychiatry in India. National Medical Journal of India 13 (6) 329-330

3. Jaspers, K (1984) On my Philosophy; In Existentialism from Dostoyevsky to Sartre, (ed) W. Kaufman; Peter Smith Publisher

4. Popper K.R., Eccles, J. C. (1984) The Self and Its Brain: An Argument for Interactionism; Routledge,

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5. Sacks O, Hirsch J. (2008) A neurology of belief. Ann Neurol. 63(2):129-30.

6. Seiple.D. (2004) Karl Jaspers and Ontological Reference; The Karl Jaspers Society, Annual Meeting of the American Philosophical Association (Central Division): Chicago, April 24, 2004

7. Taber KH, Hurley RA. (2007) Neuroimaging in schizophrenia: misattributions and religious delusions. J Neuropsychiatry Clin Neurosci. 19(1):iv-4.

8. Wiech K, Kalisch R, Weiskopf N, Pleger B, Stephan KE, Dolan RJ. (2006) Anterolateral prefrontal cortex mediates the analgesic effect of expected and perceived control over pain. J Neurosci. 26(44):11501-9

9. Williams JP (1985) Psychical Research and Psychiatry; The Anatomy of Madness, Vol1, People and Ideas, (ed). WF Bynum,RoyPorter,MShepherd.Tavistock Publications,London and New York. p233-254

10. Zeki S, Romaya JP. (2008) Neural correlates of hate. PLoS ONE. 3(10):e3556. Epub Oct 29.

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Planning Committee Members

Dr. Gupta Satish Kumar, Shantivan, Abu Road Dr. Gupta M. D., Delhi Shakti Nagar
Dr. Gupta Mohit, Delhi Shakti Nagar
Dr. Mehta B.C., BSES MG Hospital, Mumbai Dr. Mittal Shyam Kumar, Pilkhua (UP)
Dr. Parab Sachin, Vikroli, Mumbai

Dr. Rathod Ratan, Vashi, New Mumbai Dr. Sharma Avdesh, Delhi
Dr. Shah Kokila, Ahmedabad, Mahadevnagar B.K.Upadhye Rupa, GHRC, Mount Abu

 

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Section (II) : Applications in the Present

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Dr. NIKHIL PATEL

A medical Graduate (MBBS) from
GMC, Surat, South Gujarat University,
India. DPM & MD Psychiatry from GMC,
Surat (Year 1990-91), he is Life Fellow of
Indian Psychiatric Society (IPS).He is the
recipient of award from IPS for community service in psychiatry (Year 2006).

He has actively participated in and organized National & International conferences. He is examiner for MD / DPM in various Universities featured on National / International Television/Radio Programmes and is a firm Believer & practitioner of holistic health including non-pharmacological therapies like meditation.

He has presented / published papers in various conferences andjournals. HeisMemberofAmericanPsychiatricAssociation, Consultant & Head – Department of Neuropsychiatry & De- addiction in Global Hospital & Research Centre, Mt. Abu (India) since 1993.

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SOUL MIND BODY MEDICINE

Nikhil Patel

Traditionally, India is considered to be a Guru of the world as far as the field of spirituality is concerned. It claims to have the oldest and the richest culture, civilization and spiritual traditions. The core principles of spirituality and its practices which transcend the conventional religiosity probably originated from India and were acknowledged across the globe. In the advent of immense scientific developments in the field of Medical Science in general and in the field of Neuropsychiatry in particular, the role of spiritual aspects of health and disease cannot be overlooked. At times, the novel research findings lead us to an unimaginable height of awesome and unexplored revelations where the margins of scientific field and spiritual/metaphysical field become increasingly merged with each other. The vast evidence of published research studies on spirituality and medical practice has prompted the clinicians to seemingly a new and probably a missing dimension of spirituality

This has led to have specialty committees / annual workshops being formed / organized in various psychiatric societies that include the American Psychiatric Association and the Royal college of Psychiatry but not the Indian Psychiatric Society. Despite India being a Guru, the Indian Psychiatric Society lacked a committee / task force on spirituality and mental health even after six decades of its existence, till it was formed a few years back.. I am indeed thankful to Indian Psychiatric Society and especially Dr. Avdesh Sharma, Chairperson of the task force on spirituality and mental health for assigning me an instrumental role of Convener of the task force. From Convener’s Desk, I do not intend to pen down an exhaustive review of literature or a large data of meta-analysis on spirituality. Instead, I wish to pen down practical and relevant issues of spirituality in our practice.

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At the outset, let me mention a word about spirituality as a Convener of the task force. I have no doubt in my mind regarding the fact that spirituality per se transcends all boundaries of gross religious practices. To me, religion is an external identity of an individual accompanied by some gross rituals to pray / worship God. Spirituality is not synonymous with religion as some believe. Most of the concepts and principles of all religions match with each other. The belief in the Almighty God and the concept of universal brotherhood remain the very essence of all major religions and their scriptures.

There are plenty of retrospective / prospective, single / double blind studies published in medical journals related to role of spirituality in different psychiatric / psychosomatic illnesses. This has probably led to the World Health Organization (WHO) and various national / international psychiatric bodies across the globe to acknowledge and further explore the spiritual dimension of health. We, the practicing psychiatrists should categorically discern between the dogmatic, delusional / religious thinking which leads to marked social and occupational impairment and the mature belief systems / core spiritual values that enhance the overall growth and development. We the professionals should also be wise enough not to compartmentalize various religions / faith and instead try to extract and implement the core conceptual aspects of spirituality which makes a continuum of holistic health. We should look at the complimentary role of spirituality in our clinical practice and scientific research. Our task force envisages to have a constructive and creative role of spirituality for the well- being of the patients and to certainly reject the confrontational and controversial practices of gross pathological religiosity.

Importantly, one cannot completely avoid / reject spiritual beliefs held not only by the patients and the patient’s relatives but also held by the clinicians, which ultimately impact the outcome of psychiatric treatment. The task force would

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particularly attempt to investigate and implement the core eternal values of spirituality practiced in India and would also endeavor in general to incorporate the health benefits of spirituality in day to day practice.

It is appropriate to mention here that research studies on consciousness in the field of psychiatry and other specialties like parapsychology, neurology, cardiology, and neuroquantology (Quantum Physics) have revealed some stupendous phenomena like Near-Death Experiences (NDE)1,2,3,4,5,6, Out of Body Experiences (OBE)7,8,9,10, Past Life Revelations (PLR), Hypnotic Regression (HR) etc.. Does it make a medical scientist wonder and probably question oneself whether she/he studies and explores reproducible science or mystical spirituality or both? One also needs to ask oneself whether spirituality and neurosciences are the two sides of the same coin or whether they are two different ways of reaching the ultimate truth regarding the purpose and meaning of life and beyond? Can we bridge the gap between the two seemingly opposite fields so that we can answer some of the unanswered questions? The IPS task force on spirituality and mental health would provide common platform for both the believers and skeptics of spirituality alike. It would encourage further discussion at various stages in this overlapping field of neuroscience and spirituality.

It is very pertinent for the psychiatrists to have a wider view of the model of existing healthcare i.e. Bio-Psycho-Social Spiritual model of health. An increasing number of evidence like changes in one’s personality and world-view after having Near-Death Experiences, healing effects following hypnotic regression, dramatic transformation in the perception of the self following Out of Body Experiences, significant reduction in symptoms of anxiety / depression following spiritual practices, enhanced coping mechanisms to deal with stressors following meditation make us believe that spiritual dimension of holistic health cannot

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be overlooked. There is a need for Soul-Mind-Body Medicine type of modern medical practice in contrast to Mind-Body Medicine type of concept prevalent about three decades ago when Hans Selye first studied the effect of stress on autonomic nervous system. A plethora of relaxation techniques following relaxation response propagated by Hans Selye were initiated leading to pioneering work in the field of Mind-Body Medicine. The subsequent research work by Raymond Moody, Ian Stevenson, Elizabeth Kubler-Ross and others on NDEs and health benefits ensuing meditation techniques revolutionized the concept of Soul- Mind-Body Medicine.

The field of psychosomatic medicine is progressing and expanding at a rapid pace. The effect of acute or severe stress or the effect of chronic enduring stress is undoubtedly a key factor to consider for triggering, maintaining or aggravating different psychosomatic illnesses. The field of psychoneuroimmunology has conclusively proven the role of stress in reducing overall immunity of an individual and thereby making an individual susceptible to various physical conditions. The psychological factors affecting medical conditions have become one of the important reasons for referrals by the physicians to the practicing psychiatrists. The list of psychosomatic illnesses is ever-expanding and includes common physical illnesses like common cold, hypertension and the uncommon illnesses like HIV. The issues related to unhealthy lifestyle and associated maladaptive behaviours also play a role in management of various psychosomatic illnesses. The overall management of psychosomatic illnesses not only engages the practicing family physicians but many a times it also includes consultation liaison with the practicing psychiatrists. The practicing psychiatrists are expected to provide holistic therapies not only to the patients but also to the patient’s family as a whole. The cultural and religious issues of the patient and the patient’s family come in the way during the process of family therapy which

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at times brings about conflicts and succeeding resolution by the therapist. The interplay of the beliefs related to spiritual issues between the client and the therapist becomes not only interesting but frequently a focus for a successful therapeutic outcome. Therefore the therapists across the globe barring caste and religion need to be sensitized towards the basic knowledge and the skills to resolve such issues arising out of therapeutic process. The spiritual beliefs and values held by a therapist are also reflected in a therapeutic process of counter-transference. The psychiatrist cannot and should not replace the exclusive role of a spiritualist but she/he can definitely be a bridge to fill in a gap that exists in treating the patient as a whole.

Over the decades, there is an explosion of various meditation and yoga techniques world-wide that claim to have varying degrees of therapeutic benefits. Can a psychiatrist prescribe a particular type of meditation to a patient as a sole or an adjuvant therapy? There are some yoga / meditation techniques that recommend only restraint over unhealthy behaviours like Vipasana meditation and there are other yoga techniques that advocate only certain physical / physiological postures / processes like Patanjali meditation. There are some other meditation techniques that teach changes in thinking, cognition and belief system like Brahma Kumaris Rajyoga meditation and Transcendental Meditation. In other words, these techniques claim to have therapeutic effect by changing the psyche and the personality of an individual.

Is there a standardized universal technique of meditation that can be recommended to a patient across all cultures and countries? Is a particular meditation technique superior to the others? Do different psychosomatic / psychiatric illnesses warrant different meditation techniques? Can a meditation technique be prescribed to bring about only healthy behavioural changes in the lifestyle of a patient? Can meditation be used

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only to promote mental health? Can meditation be used as a primary or secondary prevention for psychiatric illnesses? Can psychiatrists reduce the mental suffering of patients caused by dogmatic religiosity? Do we psychiatrists need to improve our own spiritual well-being? Should the psychiatrists practice yoga / meditation themselves? Is it a call of time for the psychiatrists to introspect within and improve their spiritual health? Can psychiatrists come together on a single platform and develop some consensus practice guidelines on spirituality? Can psychiatrists unite together as a single family and oppose vehemently the pathological / pervert religiosity and foster true spirituality filled with altruistic love, compassion, asceticism and universal brotherhood that transcends all mundane boundaries of caste, creed and external religion? Do some patients need spiritual psychotherapy particularly in Indian setting? Can we develop our identity at a level of consciousness that transcends all physical identities and take a thoroughly professional stand on spirituality as a professional body? Can we stand together as a single society that recommends the policy makers as to how they should conceptualize and chart the road ahead to improve the standard of holistic healthcare? The answers to all these questions are probably not straight-forward.

This inaugural book of the task-force is a small and humble beginning to address these questions. There is ample evidence to suggest that yoga/meditation techniques have therapeutic effect in different psychiatric conditions except psychosis. Therefore, the task force on spirituality and mental health would invite constructive suggestions from researchers as well as the practitioners and would in turn like to have practice guidelines on spiritual practices including yoga / meditation techniques.

To end this article, I exhort my academic and practicing colleagues to contemplate over these very important issues on spirituality because it is probably the need of the hour in today’s

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contemporary world plagued by mindless violence and intolerance. I also look forward to have lively interaction with one and all at different forum in the days to come.

References :

1. Greyson,B.(1985).Atypologyofnear-deathexperiences. American Journal of Psychiatry, 142, 967-969. (VF Near-Death Experiences No. 1153)

2. Greyson,B.,&Stevenson,I.(1980).Thephenomenology of near-death experiences. American Journal of Psychiatry, 137, 1193-1196. (VF Near-Death Experiences No.1148) Irwin, H. J. (1993). The near-death experience as a dissociative phenomenon: An empirical assessment. Journal of Near-Death Studies, 12, 95-103.

3. Owens, J. E., Cook, E. W., & Stevenson, I. (1990). Features of near-death experience in relation to whether or not patients were Near-Death. Lancet, 336, 1175-1177. (VF Near- Death ExperiencesNo.1156)

4. Pasricha, S., & Stevenson, I. (1986). Near-death experiences in India: A preliminary report. Journal of Nervous and Mental Disease, 174, 165-170. (VF Near-Death Experiences No. 1154)

5. Roberts & Owen (1988) The Near-Death Experience, British Journal of psychiatry, 153: 607-617.

6. Alvarado, C. S., & Zingrone, N. L. (1999). Out-of-body experiences among readers of a Spanish New Age magazine. Journal of the Society for Psychical Research, 63, 65-85.

7. Blackmore, S. J. (1984). A postal survey of OBEs and 211

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other experiences. Journal of the Society for Psychical Research, 52, 225-244.

8. Irwin,H.J.(1996).Childhoodantecedentsofout-of-body and déjà vu experiences. Journal of the American Society for Psychical Research, 90, 157-173.

9. Morris, R.L., Harary, S.B., Janis, Hartwell, J., & Roll,W.G. (1978). Studies of communication During out-of-body experiences. Journal of the American Society for Psychical Research, 72, 1-21.

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B.K.NIRWAIR

He is the Secretary-General ,Prajapita Brahma Kumaris Ishwariya Vishwa Vidyalaya; MANAGING TRUSTEE,Global Hospital & Research Centre, Mt. Abu & VICE-PRESIDENT, Janki Foundation for Global Health-Care, London.

B.K Nirwair was born in Punjab and served in the Indian Navy for nine years, where he trained as an Electronics Engineer. A seeker of truth, he became a student of the Prajapita Brahma Kumaris Ishwariya Vishwa Vidyalaya (PBKIVV) at the young age of 20.

In 1982, he represented the Brahma Kumaris at the Second Special Session on Disarmament (SSOD) held at the United Nations HQ, the International Headquarters in Mount Abu have hosted a number of such conferences over the years on the themes of “Universal Peace”, “Global Co-operation for a Better World”, “Universal Harmony”, “Spiritual Response to Changing Times”, “Our Efforts for a Value-Based Society” etc. Apart from carrying out the role of Secretary-General, he has visited all the five continents to propagate the teachings and principles of the BKWSU.

He is the Chief Editor of an English Monthly spiritual magazine,“TheWorldRenewal”. Hehaswrittenseveralarticles on spirituality in Hindi and English. Being an eloquent orator, he has delivered several lectures on the practical techniques of adopting spirituality in daily life, a number of which has been compiled in the following books: “Spiritual Treasures” and “Insights of a Rajyogi”.

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Over the years, his selfless service to humanity has made him recipient of the following awards :

– ‘Rising Personalities of India Award’ by International Penguin Publishing House, in 1999.

– ‘Morarji Desai Peace Education International Award for Year 2001’ under Gujarat Gaurav Awards, by the Governor of Gujarat, in 2001.

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RAJ YOGA – POWER OF SILENCE FOR POSITIVE MENTAL HEALTH

B.K.Nirwair

The practice of Raj Yoga Meditation calls for the need to first understand that this is the most subtle but scientific practice based on the life-long query of ‘Who am I?” A bit of reflection on this aspect inspires us to withdraw from the external objects, away from the sensual and materialistic forms to focus our thoughts on a higher level of consciousness. Raj Yoga differs from other systems or schools of meditation from the onset as it starts with understanding the self (the ‘I’) and focusing one’s conscious attention on the source of inner higher powers to be developed and experienced.

Raj Yoga Meditation cannot be practiced without a clear understanding of the form and nature of the self and the source of all powers. A little thoughtful reflection takes us beyond our existence of the physical that is names and forms or even abilities, qualities, professional qualifications and worldly relations. A very clear concept of the self of being a spiritual being, a being of external divine light encompassing the power of thought, treasure of emotions, and ability to judge between right and wrong, as well as originally bestowed with completely positive personality traits which glorify the Creator. The original true nature of the self continues to ignite our consciousness and motivates us to go within and explore the treasures of positivity, peace and real happiness.

Whenever the human mind becomes influenced by negative forces, the true nature of the self will always help us avoid such thoughts and actions that are contrary to our true nature or real nature. In Raj Yoga practices, the practitioner accepts that he, the soul, was eternally created in the image of the Eternal Creator, who happens to be the Ocean of Love, Peace, Purity, Truth and

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Wisdom. Once we accept ourselves to be the heir-apparents of the eternal Supreme Being, we become more and more enlightened and attuned to our higher selves.

For this inner subtle development, there is need to realise that we hardly identify ourselves with our true nature and form and instead are always conscious of our physical image, and continue to identify with blood relations or professional status etc. In fact we need to remember what Shakespeare said, “This world is a stage and we are all actors”. Unlike us, those actors would not identify themselves with their costumes in which they play their roles. Now is the time to bring about a shift in our awareness.

With Godly teachings and meditation practice, it becomes clear that we belong to the Supreme Being (Shiva – Allah – Waheguru – Jehovah) and dwell with Him in the Supreme Abode or Paramdham or World of Eternal Light before descending to play our respective roles on this stage (Mother Earth). This clear understanding about the self and Supreme Being empowers us to experience higher levels of consciousness. This leads us to realise our long cherished dreams of ‘Self-Realisation’ and ‘Experiencing God’s Love and Power’ wherein we can restore ourselves to our most powerful consciousness of being a living divine energy full of love, peace, purity, happiness and bliss.

Importance of meditation in silence

For centuries, it had been known that when we explore the depths of our inner being to re-empower ourselves, due reflection and silence form a very important part of meditation practice. Examples of great yogis, scientists, reformers, and statesmen are proof beyond doubt that meditative silence carried out with a definite, conscious aim reflecting our natural pure selves in a light state of closeness and belonging with the Supreme Being, like a constellation of shining stars, slowly becomes an experience

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of real peace and tranquillity.

During these moments, appreciation for God’s blessings being showered on us would retain these wonderful experiences and enhance the power of our positive being. Our own virtues and spiritual awareness become more and more powerful and make us more determined to renounce all negativities from within, which otherwise steal away our inner happiness and peace. As the consciousness becomes more and more positive, so does one’s character in practical life of action and reaction. Regular Raj Yoga Meditation practice in silence would empower the practitioner to :

a) conquer all negativities in thought, word, speech and action bringing immediate fruit of tranquility and happiness in life.

b) absolve the past karma resulting in victory over subtle negativities in thoughts and dreams.

c) inculcate spiritual virtues thereby reassuring divinity in life and Angel or Deity Status in the future.

Power of silence in Rajyoga meditation

Regular daily morning practice of meditative silence unleashes the realisation of the self as a King or Master of one’s own thoughts, emotions and actions. The longer the practice (at least 45 minutes) regularly every morning, the deeper is the cleansing of the self and gradual removal of inner weakness. In the spiritual company of the All-Powerful One (Almighty Father) in silence, the self or one’s soul gets coloured and becomes mighty like the Father. This realisation and further reflection helps a Raj Yogi to spread the light of love, peace and power and help other human souls to recognise themselves and reclaim their Godly birthright. These meditators create very positive vibrations around the entire globe that act as a catalyst to return the five

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elements of nature to their own original nature of serving humanity (providing comfort) rather than playing havoc from time to time.

In short, the power of silence through Raj Yoga meditation if understood in the right perspective can transform human consciousness to the highest levels and enable the practitioner to enjoy the beauty of positive mental health. Then alone can every human being regain an ever-healthy and ever-happy life and constantly smile like the deities or Gods and Goddesses worshipped in the temples.

OM SHANTI

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DR. USHA KIRAN

Dr. Usha Kiran is the Professor and
Head of the Department of Cardiac
Anaesthesia in Cardiothoracic Center of All
India Institute of Medical Sciences. She has
been the Chairperson of the Board of Examination for DM, cardiac Anaesthesia for four batches

Dr Kiran also takes interest in teaching stress management especially to patients who have to undergo heart and major vascular surgery as well as to their relations and attendants. Dr. Usha Kiran is providing pain therapy with Rajyoga Meditation technique, acupressure and acupuncture.. She has participated in 58 ‘Holistic health Mela’ and delivered more than 500 community lectures.

She has conducted research and presented her papers in USA, UK, Australia and Russia. and all over India. Dr Kiran has written two Educational Books, more than 150 scientific papers are published in National and International journals on her name. Dr. Usha Kiran has received 3 International and 13 National Award for these researches. She received ‘Rashtriya Gaurav Award’ in 2007.

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HEALING HEAD AND HEART

Usha Kiran

Let us first start thinking about the ‘Heart’, which is full of emotions and feelings, but there is no limit to them. Anything that crosses limits or boundaries is like floods in the river. The water which is necessary for life when plays havoc destroys the soil for years and makes life miserable to live. If we all the time listen to the voice of heart, keep fulfilling its demand, we create chaos like floods. In place of water being useful to all, water become a source of destruction. Similar is the result of disharmony in heart and head.

Head represents wisdom, but all the time if Head is thinking all the time and cross questioning, it becomes a big headache. If one becomes high headed, one thinks that I know everything, I am everything. The high headed person has reduced listening capacity and excessive speaking capacity. He starts desiring that every body should agree with him/her. No body should reply back. He/she is always right adopting an egoistic behaviour. “I am right, My thinking is right, My life style is right, My way of working is right, My idea is always right, Everyone should say yes to me!”

Living with his/her own ideas, a high headed person will get furious if some body doesn’t pay attention to him/her. He/she always demands respect and makes fun of others. He doesn’t respect others feeling or other’s emotions. Acquiring a short temperament he/she looses temper on small matters. Life is miserable for himself as well as for others staying with him/her in the house, neighbors or office/colleagues. He/she has justification for all their activities, labeling others as wrong, tries to prove he/she is right. These are the kind of people who have frequent fights in life, get angry frequently, and have feeling of annoyance with relatives. These are the people who are prone

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for hypertension and coronary artery disease at a younger age.

The people with dominating emotional factors, i.e. heart, show too much care and concern for their own feelings and not for others’ feeling. They think too much and cry for small matters. They are no doubt very emotional personalities and unable to control the emotions with the Head (wisdom). These people become too sensitive and not sensible enough to take right decision at the right time. They even lose the common sense and the logical sense resulting in trusting wrong people and losing wisdom at the time required. These are the people who are prone to depression and suspicion. They would not like to talk. They will not open up to some body, but they keep suppressing themselves. Furthermore they stop trusting anybody. They develop the feeling they are not worthy of anything. They stop valuing themselves and underestimate themselves and develop low esteem. They may have thoughts like:

I am useless
I don’t know why GOD created me I am a problem for everybody No body likes me
I am a burden on others

They feel very lonely and sometimes to divert their mind, they adopt habits like eating more frequently or trying to involve themselves in shopping. So, emotions need to be controlled in a sensible way. One needs to have respect for others emotional needs also. By spirituality through Rajyoga, one understands that:

I am a peaceful soul I am a loveful soul I am a blissful soul I am a pure soul

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I am a happy soul
I am a knowledgeable soul I am a powerful soul

Who am I? The ego boosts up as we come to know that our real form is peaceful, loveful, blissful, powerful, pure and full of happiness. These thoughts create a balance between emotion and wisdom. Living with soul conscious state of mind is the first lesson of Rajyoga. This creates a divine personality in human beings. Charging our battery or self by a loveful communion with Supreme Being, through the medium of thought power enables a human being strengthen his inner self and improve relationship with others and be able to handle difficult situations and different kinds of people. He or she starts absorbing the good qualities and discarding the negative from their head and heart and start vibrating with peace, love, happiness, bliss, power and purity and become good leaders in their field. The most powerful force for winning anybody’s heart is pure love.

What do we mean by love? Philosopher Milton Mayer brilliant book ‘On Caring’ states, “ Love is the selfless promotion of growth of others, when you help others grow to become the best people that they can be, you are being loving – and as a result you grow”. In the professional life, pure love is the act of intelligently and sensibly sharing your knowledge, networks and compassion with your business partners. The secret to being a high impact leader and the essence of individual and corporate success is: Learn as much as you can as quickly so that you can share your knowledge aggressively, expand your network of people who share your values and connect as many of them with each other as possible.

All these questions are answered when we learn Rajyoga from Brahma Kumaris World Spiritual University. When we live a Rajyogi life style, as per their philosophy, the self is transformed

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to its true identity of purity, peace, happiness, love. Empowering self from the Supreme Being is a must. The more we understand the pure inner consciousness, the more we become successful in professional, personal and social aspects of our life. We can’t make intelligent decisions many times as we are not sure what will happen tomorrow. Rajyoga teachings of Brahma Kumaris clearly describe all the three aspects of time making human being highly intelligent.

So, wisdom makes sense if the heart’s needs of every individual of the society are the concern. With the kind of wisdom being applied till now, we have reached a stage of global economic crises all over the world. Healing head and heart through the practice of Rajyoga and living a Rajyogi life style will result in accurate decision as per the need of hour.

Talking about healing- Healing is the biomechanical influencing of the body’s systems by direct attempts to fix, correct and restore a system to its version of normal functioning. “Healing”, as per the first chapter of famous book Baily and Love’s Text book of Surgery “is not possible in a body if not alive.” Healing needs harmony between head and heart. People in conflict frequently carry a battle between head and heart. Head signifies values and conscience while heart means emotions. The innumerable thoughts generated in the mind because of the conflict between head and heart is usually negative and confusing. The pressure of negative and absurd thought affects the healing process of body affecting the resistance of body (body’s internal defense).

A study was conducted at the All India Institute of Medical Sciences- Delhi’s Cardiothoracic Centre, on relieving anxiety and fear of heart surgery by Rajyoga meditation. It was noted that 82% of patients were discharged from hospital on seventh post operative day in those who received preoperative training in

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relaxation therapy through Rajyoga practice while those who were not given training in positive thinking and relaxation therapy through Rajyoga, only 68% were discharged .Just 3 lessons of Rajyoga meditation before coronary artery bypass surgery could initiate positive thinking in those who made an effort to do so. Out of 50 patients to whom lessons were given, before initiating, about 90% said it is difficult to think positively in this scenario and after 3 sittings of Rajyoga training , most of them said they could think positively.

Another study conducted at AIIMS by the author herself has shown imbalance of heart and head, resulting in anger and depression which were noted to be one of the commonly associated symptoms in patients of chronic headache. The chronic headache patients, majority of who were categorized as chronic tension headache had anger and depression as commonest associated features. Three months treatment with Rajyoga meditation, initially 8 lessens on alternate days and 20 min. of meditation every day morning/evening was highly successful in treating more than 550 patients. Headache as well as the associated temperamental behaviour, irritable mood, depression could be relieved in 94% of patients. The study was objectified by measuring blood cortisol levels before initiating treatment as well as at 6 weeks and 12 weeks of treatment. Blood cortisol levels were found to be significantly low in those patients suffering with headache for more than 5 years. Practice of Rajyoga meditation along with appropriate medicine could significantly optimize the blood cortisol levels in addition to relieving symptoms of headache, depression and anger.

The study conducted in collaboration with Department of Science and Technology also revealed the link of chronic headache with hypothalamo-pituitary axis and endogenous opioid system. Rajyoga meditation training in the hospital setup was successful in optimizing beta-endorphin and serotonin levels.

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Melatonin, the secretion of pineal gland was also suboptimal in patients with chronic headache, resulting in disturbed sleep leading to headache or chronic headache for years ultimately resulted in sleep disturbance. Sleep disturbance as well as headache were treated within 3 months of Rajyoga teaching and regular practice of meditation, in addition to appropriate medicine. The melatonin levels in blood were also optimized within three months. Rajyoga meditation improves healing through balance of head and heart. It also improves optimal ways of thinking, rationalizing, positive emotion, connectively with Supreme Being and proper diet especially including fruit and vegetables in dietary habits and adequate physical exercises.

It is highly essential today to have a balance between head, heart and hands. The inner conflicts and external scenarios are likely to result in the kind of diseases like hypertension, diabetes, and stress related disease occurring at younger ages. It is thus important to heal both head and heart which can be done through Rajyoga meditation. Balancing Head and Heart there should be mandatory curriculum of spirituality and Rajyoga meditation, right from the schools. This will ensure good physical, mental, and social health from the childhood which will result in long, healthy, happy living.

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Dr Mohit Dayal Gupta

Dr Mohit D Gupta D.M.,M.D.
(Cardiology), currently working as assistant
professor of cardiology in GB Pant Hospital.
Youngest member of the faculty, Dr Gupta has a distinct achievement of getting more than 18 gold medals and 5 silver medals in his medical career and was honored by the hospital for outstanding services to the patients for the year 2005. In October 2006, he has been awarded ‘Young scientist of the year’ by the Association of Physicians of India.

He has more than 30 publications in journals of national and international repute and more than 130 abstracts. Besides intervention cardiology, he has extensive interest in genetic research and is carrying various projects with institutions of repute. Strong advocator of spirituality, Dr Gupta has been associated with Brahma Kumaris’ World Spiritual University from his childhood and practices Rajyoga meditation daily. He believes that practicing spirituality with correct and scientific understanding is key to leading a balanced life.

He has given more than 500 lectures and conducted symposia all over the world (In USA, UK, Europe and universities like Oxford and Cambridge University). Besides this, he is actively involved in various community and media activities. Various institutions like Seimens, Tata consultancy services, IMT, MDT, Amul group, PNB, HEPA, HUDA, various other management institutes, Cipla, Aventis, Unichem group, etc have benefited from his experience as have more than 30 IMA’s of different cities.

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BLENDING SCIENCE AND SPIRITUALITY

Mohit Gupta

“Science without religion is lame, religion without science is blind”.

– Albert Einstein

The saying is so old yet so true. Spirituality and Science is seen by many as two separate things. What we normally call Science is that which we can measure, see and prove. From that perspective, Spirit maybe is the last thing to find in any microscope. The science of Spirituality maybe not so easily measured from the parameters used in normal science.

The conjugality of science and spirituality is very exciting and we will further see how both can be blended into a ‘Oneness festival’. This is a festival where both science and spirituality work, complementing each other.

Where has science led us today?

What would this world look like if science wasn’t there? It is unimaginable to dream of a life without science. Today, practically every aspect of our life has something or other governed by laws of science or inventions based on it. Right from the start of our day, the time we go to work, communicate with each other, travel, and entertain and so on and so forth, we can see science playing an important role. So the progress in science is directly linked to progress in our life too. It is deeply linked and inseparable.

But, where is the gap? Today man has developed new medicines, research techniques and treatments, but he has failed to develop a magic treatment to control or transform the human

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emotions. Today he has reached beyond earth and reached the moon and other planets, but has failed to go into the depths of his own mind and discover the treasures within. Today we have build some of the most exotic and beautiful buildings in this world but we have failed miserably in building a value based human being. So much so that we have even lost the value of the values we talk about. This has created a feeling of emptiness in our life and everyone is yearning to fill this gap: to fulfill the desire of love, care, harmony, peace and bliss in our life and lives of others.

Is Spirituality Really Opposed to Science?

Our technical and scientific capabilities are increasing at an enormous and unprecedented rate. In contrast our spirituality and values are developing much more slowly. This has created a perilous time and often empty culture. We need a broadly accepted spirituality that gives purpose and meaning beyond the necessities of daily existence. Our scientific understanding has undermined many conventional approaches to spirituality at the very time we most need to strengthen these capacities. The problem today is that we believe in science because it works and we can see it. But if we put forth a question to ourselves that how many of us have made spirituality work for us? Most of us just talk about spirituality; forget about being spiritual. Spirituality is something that will bring immense sacredness in our life. Until and unless we are truly spiritual, we can never make spirituality work for us. So the power of spirituality is not yet explored by us. We therefore fail to appreciate what wonders it can create in our life. Faith, as embodied in spirituality, and reason as embodied in science are often but erroneously thought of as being in opposition to each other. Science is not an enemy of spirituality, only of superstition. Both science and religion are engaged in the search for truth, the main difference lies in the methodologies used.

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Integrating science and spirituality : Towards objective spirituality

A group of disciples went to a saint and asked him that when should we turn to GOD. The saint said, “Turn to God one day before your death.” His disciples asked, “How can a man know the day of his death?” The Saint replied, “Then you should turn to God today; perhaps you’ll die tomorrow; thus everyday will be employed in returning to God.”

Approach to objective spirituality is not different from what we have in science.

a) Spirituality also needs a substrate to work: Just as science needs a substrate to work, similarly spirituality needs some substrate to work too. The substrate here is the soul. Soul more commonly known as psyche, consciousness, the energy, is the driving force residing inside this body. Just as the beauty of a car comes with the driver, in similar way, the beauty of this body comes when the driver i.e. the soul enters in the body. Today several evidences are available to prove the existence of soul. Some of these are :

– Logic
– Stories of birth and re-birth
– Out of body experiences
– Near end of life experiences
– Scientific experiments and electrode studies: in which loci

of soul has been located to be in front of hypothalamo- hypophysial fossa. Scientists often name this area to be God spot.

(i) Logic:Weallcallourselvesashumanbeings.Human beings stands for; Human i.e. Humus (body) and Beings i.e. self or soul. Naturally we just keep on remembering and considering ourselves as a body and we forget the ‘being’ within us. As a

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doctor, I remember my days of training in anatomy, when we used to do dissections on human body cadavers. I used to ask my professor that this dead body has intact heart but it does not beat. It has eyes but he is unable to see. It has legs and hands but they don’t work. It has a brain but it does not think? Why is this so? What is missing that makes it non-functional.? I did not get my answers. It was only when I realized that human beings can be compared to a car. The beauty of a car comes with a driver. Only when the driver sits in a car, it starts functioning. The moment driver leaves the car; it’s no more than a non-functional object. Similarly, the beauty of this human body comes with the being in it, i.e. the soul. When soul enters the body, it becomes functional.

(ii) Stories of Birth and rebirth : There are numerous stories of birth and rebirth published in various books and news papers where a young child is able to recollect his or her experiences of the past. They are able to identify their parents of previous birth, their belongings and even identify the place. This suggests that it is the body that dies and soul never dies. It only changes its costume in the next birth.

(iii)Near End-of-Life and Out-of-Body Experiences :

There are numerous incidents and experiences where patients narrate their experiences at the time of resuscitation. They are able to recollect and vividly describe how they were resuscitated by the doctor and how the operation was carried out. This suggests that consciousness or soul is an entity that can function outside the body.

(iv)Scientific experiments : Numerous experiments have been carried out in the west that has shown the loci of the soul to be in front of the hypothalamo-hypophysial fossa. Scientists have labeled this as God Spot. They have used elimination technique to outline this area.

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All this makes it very clear that body and soul are two different entities that make up human beings. This makes it very clear that we have today learnt to live our life in such a way where we just see this body, decorate this body, diagnose illness of this body and when this body dies, we destroy this body. We identify ourselves with features that just define this body. In fact, we are today living our life in a ‘body conscious’ way where our every action is governed and related to our body.

The art of living life in a ‘soul conscious’ way is such that peace, love and purity inform every action. The functional anatomy of soul includes the mind, intellect and resolves which interplay to govern every thought and action that we perform.

b) Laws of spirituality : Just as science is governed by laws, spirituality is also governed by certain laws. The most important law that governs our life is the law of Karma. In simple way, it is defined as: to each and every action, there is equal and opposite reaction. To understand it spiritually, it states that whatever we are facing today, whether it’s good or bad, it is because of either our karmas of this birth or of previous births. Understanding it makes it very clear that whatever may be the situation, my karmas should always be positive and filled with spiritual energy and in accordance with God. We must understand that this life is like a boomerang which has a natural way of coming back. Similarly, whatever we do, it will come back to me.

c) Remembering Supreme Soul : Once I understand that I am a soul, and then it’s natural and easy for me to remember my father i.e. Supreme soul. It’s so logical that we always talk about supreme soul and never supreme body. So if God is known as Supreme soul, then we, his children, are naturally not this body, but soul. The easiest and most acceptable description of the Supreme soul is point of light and might. This form is the

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most acceptable form of God to all religions too. God is ocean of love, peace, happiness, purity, bliss, power and so on and so forth. We can share every relation with God depending upon what we want to experience. But we must ask ourselves that is our remembrance with God — need based or love based? Which one is better? The answer is so obvious!

d) Meditation : The ultimate experience – Meditation is often thought of by so many people to be difficult and requiring long practice. In fact, meditation is by far the deepest and most direct route to relaxation. It is not by chance that for over two thousand years almost every ‘wisdom path’ has featured meditation as the core practice to achieve everything, from relaxation to inner peace, to mystical states of enlightenment. The purpose of learning meditation is to introduce ourselves to the deepest form of relaxation – the relaxation of the spirit. The most profound calm and serenity lie at the core of our own being; we have simply lost awareness of its presence. As we had earlier examined, spirit is what we are, sometimes referred to as soul. We each radiate energy in the form of spiritual light. That light emanates from the core of our being, and is entirely invisible. The quality of our thoughts and feelings will be according to the quality of that light.

The true and original nature of each and every soul is peaceful and loving. However, our peace has become disturbed and distorted by our attachments, wrong beliefs and misperceptions, all learned on the journey of this life, and possibly several previous lives. Meditation is the deepest and most effective way to ‘let go’ of the attachments which distort our energy and heal the spiritual wounds of the past. Meditation is the easiest way to see and transcend our old beliefs, gain a true insight into eternal truths, and dissolve the blocks that have stopped us from experiencing our inner peace. However, practice and perseverance is required!

The practice of meditation does not require any previous

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experience, the shaving of heads, the chanting of mantras, complex postures or the burning of incense sticks. All we need to get started is a quiet space at home, a comfortable chair (not too comfortable) and the intention to get to know ourself. If one is just beginning, then ten minutes in the morning and again in the evening is about just right. We will naturally increase this at our own pace.

Ultimately meditation is not something that we do, but a way by which we discover and understand how to consciously create our state of being. We are not accustomed to inward focus, but are more inclined to pay attention to outer noises and events. So as we begin, many external sounds may interrupt, or our body may feel uncomfortable and distract us. But in time, with practice and patience, we will easily learn to be beyond anything ‘coming in’ through your physical senses. Meditation will help us to master our senses, maintain our focus of inner attention and therefore remain undisturbed by external events. In fact, word meditation is a derived from a Latin word “medere” which means “to heal”. Meditation is a healing process of the soul. Spiritually, the communion of soul with Supreme soul is known as meditation. It is a loveful and intellectual communion. Simple steps to do meditation include:

– Internalization – Channelization – Visualization
– Realization

This experience of meditation gives us happiness beyond senses i.e. a blissful experience. This super sensuous joy is indescribable. This changes our lives forever and fills our life with so much spiritual power that each moment we live is memorable because its filled with love and blessings of our Spiritual Father.

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Conclusion : It is said that “Wars are born in the mind of men”. In fact, it would be apt to say, not only wars, but everything is born in the minds of man. Mind power is the biggest power that we human beings have. One of the ‘mental laws’ that can be found working in the world is referred to as the law of correspondence which states that “as without, so within”. If our desk or our bedrooms are in chaos, it means our mind can be chaotic, and we probably find it hard to order our thoughts. A precursor to this mental law is a spiritual law which says, “as above, so below”. Just imagine staring at the night sky and we find ourself staring into infinity with a sense of awe and wonderment? Try it! Find a quiet spot and simply look out into the vastness of outer space. Several poets, down through the ages, have been inspired to record the profound feelings and inner awareness this contemplation upon the unlimited seems toinvoke. Whyisthis?Aswestareintotheboundariless,infinite space, with no limit or end in sight, it is simply reminding you of your own inner space. Blending of science and spirituality is one such exercise. They were, they are, and will remain complementary to each other.

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Dr Sarah Eagger

Dr Sarah Eagger is an honorary senior
lecturer and consultant psychiatrist for the
elderly at the Division of Neuroscience and Psychological Medicine, Imperial College School of Medicine, London. She is chair of the Spirituality and Psychiatry Special Interest Group of the Royal College of Psychiatrists.

She chairs the Spirituality and Faith Committee in her Mental Health Trust and is a trustee of the National Forum for Spirituality and Mental Health. Her particular interests include training doctors in assessing patients’ spiritual needs. She is the co-ordinating editor of a facilitators’ manual for healthcare professionals, Values in Healthcare: a spiritual approach published in 2004.

Dr Eagger is particularly interested in the spiritual aspect of the holistic model, has practised and taught meditation in various NHS settings for many years and has also spoken on aspects of consciousness and spirituality at national and international conferences.

Arnold Desser

He holds degrees of BA (Hons), CAc
(China), MBAcC, FHEA, MAcME. Arnold
Desser is a Senior Lecturer at the School
of Integrated Health, University of
Westminster. He is a Fellow of the Higher
Education Academy and a member of the
Academy of Medical Educators. He is a
course leader on the ‘Training the Trainers’ course for primary care physicians organised by the London Deanery. As an

 

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Educational Consultant to the London Deanery (a confederation of the National Health Service, the Royal Colleges of Medicine and the University of London, responsible for all post-graduate medical training of doctors in London) he trains hospital consultants and primary care doctors in consultation, teaching, and supervision skills. Arnold is a member of the core team that produced Values in Healthcare and is one of the Scientific and Medical Advisers to the Janki Foundation. He also practises traditional Chinese medicine in the National Health Service.

Dr Craig Brown

He holds the degrees of MB,ChB,
MRCGP. Dr Craig Brown is a Trustee and
Scientific and Medical Advisor for the Janki
Foundation. He has been a full time National
Health Service general practitioner in West
Sussex, UK, for 30 years. He has a
longstanding interest in holistic medicine
and is a trustee of the British Holistic
Medical Association. He trained as a
healer, and was President of the National
Federation of Spiritual healers from 1997 – 2001. He is author of ‘Optimum Healing’, which outlines a practical spiritual approach for patients. He has extensive experience of facilitating the workshops for a variety of health care practitioners at undergraduate and postgraduate level.

 

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VALUES IN HEALTHCARE: A SPIRITUAL APPROACH FOR MENTAL HEALTH

PRACTITIONERS.

Sarah Eagger Arnold Desser Craig Brown

Summary : Values in healthcare: a spiritual approach addresses the issues of teaching spirituality in healthcare.1 It is a personal and team development programme supporting the personal wellbeing of practitioners through the identification and expression of their core values. The authors describe the background, inspiration and underlying principles of the programme, and how it has been used in medical education in the UK and other countries.

Introduction : Spirituality and spiritual care is increasingly seen as being an integral part of healthcare. It is a challenge as to how it may be integrated into medical education. Sometimes it is merely reduced to a discussion about different religions or medical ethical issues. For many, however, spirituality is something that transcends cultural and religious boundaries with opportunities to offer spiritual care in healthcare settings. A spiritual approach to learning about values and how they can be taught to healthcare practitioners is described in detail in this chapter.

Background : During the winter months of 2000/2001 a group of 10 colleagues from various backgrounds in healthcare, medical education, and organisational consulting and training met to share ideas about the issues facing the healthcare professions. A question that concerned us all was how the spiritual dimension of ‘whole person’ medicine could be integrated into

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current healthcare provision and into the training and education of healthcare workers. We wanted to develop an educational programme that would provide space and time for practitioners to explore these issues for themselves before, then thinking about how they might bring these ideas into their work.

Inspiration : We were much inspired by certain contemporary approaches to healthcare and education. Among these were Living values : an educational programme, created by Diane Tillman and others.2, 3 Published in the USA in 2000, andwinneroftheprestigious2002Teacher’sChoiceAward,Living values is a guide for teachers, community workers, parents and students. It explores human values in depth and includes educational activities that promote self-esteem, emotional intelligence and creative expression in people of all ages. Guided by this approach, we began to develop the structure and content of our programme, which became aptly entitled Values in healthcare. In our discussions of the current concerns facing healthcare organisations and practitioners, we thought of the importance of taking a positive approach, and so adopted the term ‘positivity’ to reflect this in the material we produced. We turned to the ‘Appreciative Inquiry’, a process building on what works well in organisations and individuals’ practices, rather than taking a critical approach.4, 5 We chose exercises that we knew worked well for a broad range of participants, structured questions to be appreciative, and kept the language positive.

We spent many hours discussing and meditating on the meaning of spirituality and agreed that it involved using inner resources of peace, love, positivity and compassion for the benefit and healing of others and ourselves. We felt deeply that spirituality could be expressed through thoughts, feelings, attitudes and actions. Apart from our own experience in this area, we drew on relevant work from nursing care, hospice work, chaplaincy, and mental health.6-11 Finally, the group’s various

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concerns and enthusiasms gave voice to an abundance of ideas drawn from each of our individual approaches to clinical practice, learning and teaching. We were inspired by each other and the process. We modelled our meetings on the type of programme we were producing and from this went on to develop a method of teaching that we called the ‘spiritual approach’. This includes deep reflection, periods of silence, visualisation, listening, appreciation, as well as being creative and playful.

Underlying principles : In 2002, as we began writing and designing the Values in healthcare programme, three underlying principles became evident:

1. Physician heal thyself : Working within a framework of values is hardly a new idea. The Hippocratic Oath, for example, is one of the earliest and best-known statements of values. All medical/professional organisations have statements that refer to values in their codes of practice. Interestingly, in 1994 the British Medical Association (BMA) hosted a conference, Core values for the medical profession, to examine the future of the practice of medicine.12 Since this conference, there has been ongoing discussion in the medical profession concerning the importance of core values and the need to reaffirm them.13,14 These values were based on caring, compassion, integrity, competence, confidentiality, responsibility, advocacy and the spirit of enquiry. They were seen as the profession’s greatest asset, greater even than scientific knowledge and technology, which seemed to have been sidelined in the training of healthcare workers. We shared these ideals, but also had the fundamental belief that healthcare practitioners cannot aim to heal others before nurturing and healing themselves. We also felt that any educational programme should aim to support and develop the personal wellbeing of healthcare practitioners, rather than specifically focus on improving their clinical skills. In our own collective experience, the benefit of healthy practitioners to patient

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care in terms of raised morale and renewed sense of purpose was immeasurable.

The theme of ‘Healthy doctors – healthy practice’ was a lead editorial in a recent British Medical Journal and introduced four linked studies looking at doctors’ health. There is growing concern over doctors’ health and the BMA has hosted an international conference on the subject of doctors’ health reporting high incidences of depression, drug addiction and suicide rates amongst physicians.15,16

2. Learning through experience : In the healthcare professions, many different methods are used to teach the skills and art of each discipline. Traditionally formal lectures, personal study, tutorials and practical experience are used alongside apprenticeship learning. Very little is done, however, to enhance and strengthen the qualities of calmness and compassion that is expected of healthcare professionals. Paradoxically, these may actually (though unintentionally) be trained out of us. We believed that values could best be understood and explored through direct, ‘inner’ experience, so we planned the programme to provide facilitated, small-group experiential learning, rather than didactic instruction. By allowing time in a supportive environment for silence, reflection, meditation and sharing, we hoped to encourage the discovery of personal values and insights.

3. Relevance to work : Finally, we felt the learning experience – with an emphasis on reflection, action planning, review, evaluation and a commitment to ongoing learning – should be relevant to participants’ work and lives. Much has been written about the high levels of stress experienced by health professionals, the effect it has on practice, why so many doctors and nurses are unhappy and what can be done to promote well- being.17–20 Indeed, all healthcare professionals have been worn out by work at times; much of the day-in and day-out business of

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taking care of people who are ill is, after all, inherently distressing. But changes (and the rate of change) in society, organisational structures, medical and information technology, and patients’ expectations have imposed an additional burden that can lead to a state of chronic tiredness and demoralisation.

Pines and Maslach, among others, have described this exhaustion arising from involvement in situations that are emotionally and physically exhausting as ‘burnout’.21,22 Stress and its consequences can be addressed by working with our values as a way of preventing burnout and ill health.23 It seems self-evident that healthy practitioners will provide enhanced quality of care for patients. Organisations, too, would benefit from a clear, values-based statement that staff at all levels can identify with. Institutions encouraging a culture of care can contribute significantly towards creating a healing environment for staff as well as patients. Such an environment can also go some way towards protecting patients from practitioners acting out their own needs in the healthcare setting (ie the desire for power, control, to be liked, needed and cared for). These needs can be more healthily addressed in an atmosphere of good staff support, an optimum environment in which to deliver high quality care and a place where people are well supported when caring for those who are distressed or suffering.

The pack

Four years later, after hundreds of hours of thinking, discussing, outlining, structuring, writing, reflecting on what had been done and what needed doing, changing, editing, testing ideas at conferences, and real-world piloting, the words, voices and aspirations were committed to the 500 pages of text which form the pack the programme is published in. The pack contains detailed guidance and all the necessary materials to run the seven modules, packaged into a ring binder with CDs (see box).

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The seven modules

Values : By identifying values in ourselves and at work, we can identify and apply core values in healthcare. This includes ways in which we could remind ourselves of the values which motivated and guided us at the outset of our careers, how to bring new vitality to our practice by reflecting on these values and assist others to rediscover their own personal values through a series of structured exercises, activities and meditations

Peace : Peace is introduced as our natural state; that within all of us there is an innate core of calm and tranquillity. The programme uses simple yet powerful ways to rediscover this inner peace. By practising peacefulness, participants can access their positive qualities which help to build self respect and contentment. Peacefulness is the medicine for ‘burnout’.

Positivity : Positivity is seen as an antidote to the critical thinking that healthcare professionals often do out of habit. The programme helps participants recognise unhelpful patterns of thinking and change them into more positive ones.

Compassion : Compassion is the expression of our innate qualities of patience, generosity and kindness, yet there are often personal barriers to its expression – anger, anxiety, guilt and attachments. The programme helps participants to acknowledge the barriers and to view compassion as a value they can consciously express throughout their practice.

Co-operation : This enables participants to gain an understanding of the thoughts, attitudes, feelings and behaviours which enable successful co-operation. This allows them to build team spirit in non-competitive ways, so that tasks become enjoyable and creative.

Valuing the self : Valuing the self requires that we recognise 244

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our own worth and, in doing so, better acknowledge the intrinsic worth of others. Participants explore ways they currently look after themselves and consider what sources of personal support they have available to them. Self-confidence will grow as they develop their self-respect. This can help them to bring mutual respect and harmony into their relationships, to the benefit of themselves, their patients and colleagues.

Spirituality in healthcare

Spirituality is a vital concept in furthering the ideals of holistic health and in meeting the spiritual needs of patients and practitioners alike. The programme invites participants to clarify concepts of health and healing, spirit and spirituality, in order to further develop their values-based practice.

Each module consists of a full day session, containing a mix of group learning activities, guided by a facilitator. The modules can be run as stand-alone workshops, incorporated into wider development programmes, or run in sequence. The materials can also be effectively used for self study. Each module begins with an introduction to the theme and optional warm-ups, followed by a structured programme of activities, some active, some reflective. Time is then spent on summarising, action planning, evaluation and closure. The morning and afternoon sessions allow for a progression from personal exploration through to application of learning to work-based situations and issues. The programme pack sets out to address the spiritual needs of healthcare practitioners through all seven of its modules, helping them in identifying their personal values, being peaceful, being positive, practising compassion, co-operating with colleagues, practising self-care and developing self-esteem.

Conclusion

The Values in healthcare training has been well received in

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the UK and has been used at undergraduate and postgraduate level for doctors, nurses and other healthcare professionals. The flexibility of the training pack means it can be used for short 1-3 hour sessions, or teaching one module over a day. All seven modules, spaced out over 1 month intervals, have been used for staff at a London mental health hospital. It has been adapted for courses for medical students, general practice registrars, occupational therapists and nurses in hospices. Since 2004 it has been used in many countries for training health care professionals at various levels. The interesting observation is that values are the universal language of spirituality; participants identify their core values and consider ways of integrating them into practice. Although different countries have their own subtle emphasis on the values that they consider are important in their own cultures, we find that the core values are the same in all countries that we have taught in. This is immensely encouraging to realise that we all have the same values, as we can co-operate to make a better life for ourselves, and at our place of work.

The training pack has been translated into Italian and Portuguese and translations are underway in German, Icelandic and Mandarin. Over 300 facilitators have been trained worldwide in countries including India, Thailand, Philippines, Sardinia, South Africa, Argentina, Brazil, China, North America and the UK.

The Values in healthcare programme started with a seed of an idea and now is a vibrant young plant. It is rooted in spirituality and nourished by the participants who use it. The facilitators are the gardeners that sustain that growth and are respectful of the elements that influence it. As the plant matures and strengthens, new branches are developing all around the world.

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For further details about the Values in Healthcare programme, contact

How to Contact VIHASA in India?
Dr. Ashok Mehta – Ambassador,
BSES Hospital, Mumbai, Tel. 022-66487500 ghrc.vihasa@gmail.com

Sr. Mathilde Sergeant – National Co-ordinator Global Hospital & Research Centre, Mt Abu ghrcabu@gmail.com; ghrc.vihasa@gmail.com Tel. 02974-238347/48/49

How to Contact VIHASA in U.K?
Joy Rendell
The Janki Foundation for Global Health Care 449/451 High Road, London NW10 2JJ, UK Tel: 44+ (0)20 8459 1400 http://www.jankifoundation.org

BOX 1

Values in healthcare
Part 1: Introduction to the pack
Part 2 : Guidance for facilitators
Part 3 : The modules – there are seven modules providing: · background information
· timings
· aims and learning outcomes
· step-by-step facilitiation guide
· exercises/feedback
· review
· action planning
· handouts
Part 4 : Spiritual tools
· details on the ‘tools’ or learning principles used:
· meditation, visualisation, reflection, listening,

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· appreciation, creativity and play
Part 5 : Additional resources
· warm-up exercises
· movement exercises and closure exercises · learning logs

· action planning and evaluation pro formas
· references and resources for follow-up reading and · exploration
· texts of meditations and visualisations on CD
· CD of meditations: spoken commentaries,
· visualisations and music

Acknowledgements

Our thanks to our co-creators: Jan Alcoe, Astrid Bendomir, Maureen Goodman, Anne Kilcoyne, Linda Lee, Kala Mistry, Anne Radford and Joy Rendell.

References :
1.
Journal of Holistic Healthcare, 2004, 1 (3).

2. Gill-KozulC,KirpalaniJ,PanjabiM.(1995)Livingvalues: a guidebook. London: Brahma Kumaris World Spiritual University.

3. Tillman D. (2000) Living values: an educational program (series). Deerfield Beach: Health Communications Inc, (For further details on LVEP, see http://www.livingvalues.net)

4. CooperriderD,SorensenJ,WhitneyD,YaegerT.(2000) Appreciative inquiry: rethinking human organization toward a positive theory of change. Champaign: Stipes Publishing.

5. Cooperrider D, Whitney D, Stavros, J. (2003) Appreciative inquiry (AI) handbook. Bedford Heights: Lakeshore Communications Inc,.

6. BradshawA.(1997)Teachingspiritualcaretonurses:an 248

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alternative approach. International Journal of Palliative Nursing, 3 (1): 51–57.

7. Draper P, McSherry W. (2002) A critical review of spirituality and spiritual assessment. Journal of Advanced Nursing; 39 (1): 1–2.

8. PetersonEA,NelsonK.(1987)Howtomeetyourclients’ spiritual needs. Journal of Psychosocial Nursing; 25: 34–39.

9. KellehearA.(2000)Spiritualityandpalliativecare:amodel of needs. Palliative Medicine; 14: 149–155.

10. Department of Health. (2003) NHS chaplaincy: meeting the religious and spiritual needs of patients and staff. London: Department of Health.

11. Swinton J. (2001) Spirituality and mental health care. London: Jessica Kingsley.

12. Department of Health. (1994) Core values for the medical profession in the 21st century. (Published report). London: British Medical Association.

13. Hawes Clever L. (1999) A call to renew. British Medical Journal; 319: 1587–1588.

14. Hawes Clever L. (1999) A call to renew. British Medical Journal; 319: 1587–1588.

15. Firth-Cozens J. (1999). Stress in health professionals: psychological and organizational causes and interventions. London: Wiley.

16. Brewster J M (2008) Doctors health BMJ, 15 Nov 2008, 249

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p1121-1122.

17. BMA, International Conference on Doctors’ health matters –finding the balance, 17-19th Nov 2008 London. http/ http://www.bma.org.uk/doctorshealthmatters

18. Appleton K, House A, Dowell, A. (1998) A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds. British Journal of General Practice, 48: 1059–63.

19. Smith R. Why are doctors so unhappy? 2001) Editorial. British Medical Journal, 322: 1073–1074.

20. Yamey G. Promoting well being among doctors. (2001) Editorial. British Medical Journal 252: 232–253.

21. Pines A, Aronson E. (1988) Career burnout: causes and cure. New York: The Free Press,

22. Maslach C. Burnout: a multidimensional perspective. (1993) In: W Schaufeli, C Maslach and T Marek (Eds). Professional burnout: recent developments in theory and research. New York: Taylor & Francis,

23. Brown CK. (2003) Low morale and burnout: is the solution to teach a values based approach? Complementary Therapies in Nursing and Midwifery; 9 (2): 57–61.

First published in Journal of Holistic Healthcare, Volume 2 Issue 3 August 2005. Reproduced with permission of the British Holistic Medical Association. Modified and updated 5.12.08

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B.K. Mathilde Sergeant

She was born in Holland & presently is the Nursing Educator & Teacher -Positive thinking at GHRC, Mount Abu. She worked as a Nursing Tutor & Principal in various countries in Europe and in Africa as a missionary/nurse.

Her Publications include various articles concerning supervision of students in hospitals and in community healthcare. She is the author of a text book for nurses on Obstetrics and Gynaecology “Stepping Stones for Nursing Care”, 1985 Amsterdam..She has taken national & international lectures on various nursing specialties.

She is organizing Committee member of International nursing conferences and an external inspector for specialized courses in nursing.

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SPIRITUALITY IN ACTION, GLOBAL HOSPITAL EXPERIENCE

B.K. Sister Mathilde

The Global Hospital & Research Centre Trust, a registered charity with the Charity Commissioner of the Greater Mumbai Region, established and managed its flagship health services unit J Watumull Global Hospital & Research Centre, a 102-bed multidisciplinary hospital located at Mount Abu, Rajasthan, India, in 1991.

Global Hospital, as it is popularly known, serves the community through its out-patient clinics, diagnostic facilities, indoor treatment services, operating rooms and community outreach programmes. The hospital has out-patient clinics in the disciplines of dentistry, dermatology, ENT, gynaecology, medicine, neuropsychiatry, obstetrics, ophthalmology, orthopedics, pediatrics, physiotherapy and surgery. Diagnostics units include a well-equipped pathology laboratory offering biochemistry, clinical pathology, cytology, hematology, histopathology, microbiology and serology. Imaging facilities comprising color Doppler, CT scan, mammography, orthopantomogram, ultrasonography and x-ray.

Global Hospital also houses the Global Hospital Blood Bank, and three operating rooms housed in a centrally air-conditioned modern operating complex. Our community outreach programmes include :

· Village outreach programme that has adopted 17 villages that are visited on a twice-weekly basis. 3 out post clinics are functioning in the tribal area which have telemedicne(ISRO) communication with Global Hospital.Nutritional projects are running in 6 of these 17 adopted village primary schools.

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· Community ophthalmology programme, which involves screening villagers for the presence of blindness causing cataract or glaucoma and free surgical treatment for selected cases at the base hospital.

· Community service project, a daily service to remote villages and their village schools through a revolving mobile clinic staffed by a doctor and paramedic.

· Cleft lip and cleft palate reconstructive surgery conducted under the Smile Train programme.

Since 1991, the Trust has expanded its operations to include these units (in order of establishment) :

· Brigadier Vora Clinic & Jyoti Bindu Diagnostic Centre, Baroda

· G. V. Modi Rural Health Care Centre & Eye Hospital, Abu Road.

· BSES MG Hospital, Mumbai
· Global Hospital Institute of Ophthalmology, Abu Road
· P C Parmar Foundation Global Hospital Eye Care Centre,

Abu Road
· Radha Mohan Mehrotra Global Hospital Trauma Centre,

Abu Road.

Most important, the Hospital works in a spiritual atmosphere and has Ayurveda, Homeopathy and Energy Healing units.

The experience in The Global Hospital at Mount Abu (Rajasthan)

The Global Hospital and Research Centre is a very special place and since 15 years I have the honour to work here and help in establishing the various areas related to nursing. I have great pleasure in writing about my experience as a nursing tutor,

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teacher positive thinking and infection control nurse. I have worked in hospitals all over the world for a span of 50 years and have even done missionary time in Africa. How different this hospital is from all the hospitals I worked in, all over the world for 50 years.

In Global hospital, we are combining spirituality and healthcare in such a way that it can find a niche in every religion. Let me begin by saying, with great love from the heart, “Om Shanti”. This literally means ‘I the soul am peaceful’. This is an expression that the Brahma Kumaris (a spiritual organisation closely linked to Global Hospital) use to greet others. It is a greeting of peace which, when said with understanding and pure feeling, creates a beautiful exchange of happiness. In just a few moments, a feeling of closeness, of belonging, and of knowing each other very well is generated. This greeting is used almost by all the staff members in the hospital. It is used to greet the patients as well. I teach the student nurses to give this spiritual injection of a smile to each patient when they start their nursing procedures; hence the healing process is instant. An honest heart and true feelings are those which connect us to our divinity, our innermost highest truth.

In the Global Hospital I have been able to find the balance between the Mind and the Heart. I am always careful not to burden my brain too much, my feelings are my main focus. I always make sure that they are pure and honest, because I know that if my feelings are true then whatever the brain thinks will be accurate. You could understand this to be a different kind of intelligence, based on a completely novel way of using the mind. When feelings are pure, the brain automatically begins to think right thoughts, based on those feelings. For me this experience in Global Hospital has become a spiritual journey.

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Spirituality in practice

The positive thinking course : (The i instead of I denotes egolessness)

– to make spirituality a practical part of my life and that of others around me i know that i should stay positive at all times.

– to have good wishes and pure feelings for all students, staff, patients and family. to keep this level of positivity

– i started to meditate regularly not only at certain times but while i was moving along and interacting with people.

– i also practice to keep the link with the Divine Being: the ocean of positivity and love. i taught myself to care about everyone in an unlimited way, bestowing always yet staying in spiritual terms : detached and loving.

– i do not need to judge what someone is like, i am only there to play my role. there is no need also to listen to gossip and waste talk about someone unless it is of professional interest.

– i started to give classes on positive thinking.

– the start of the course is : look inside the mirror of your mind, just as you can see yourself sitting, you can also see the computer of your mindscreen. When you think of the posture of your body in which you are sitting, you can ask yourself: am i relaxed? Do i feel any stress in any part of my body, any tension? Then look at your mind and ask yourself what type of thoughts do i have. Are they positive or negative? Do these thoughts give me energy or is there a leakage in my energy in terms of waste thoughts?

– First i strive to make patients and students aware of themselves. then we start ‘deleting’ the thoughts which we do

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not need or want.
– This is a training anyone can learn and practice: delete old

useless thoughts and put them in the waste paper bin. When these thoughts come back, keep on deleting them until they are not a part of your past or better still transform them into positive thoughts. This is not only beneficial for your mind but also for your body.

– Remember that all the atoms/molecules of my body respond to positive thoughts in a positive way. Even plants grow better in an atmosphere of positive thoughts. similarly meals cooked and served with love gives a lot of positive energy. therefore, this is a way of helping to heal the body as well as the mind.

– Positive thinking is independent thinking based on higher principles and values. It is not a reaction to seemingly external events nor is it dependent on my expectations from people, places or things.

– Positive thinking originates in self respect. this implies that one is aware of the essential truth about oneself and knows on a deep level that any negativity within oneself is acquired and not original. this means to become detached and loving for yourself as well.

– i have observed that when patients, students or anyone goes through this short training, it leads to enormous benefit to the self. The responses are overwhelming. every day for a short period of time, the mind and body gets an experience of generating a stream of positive thoughts which bring about a positive inner experience of love peace and an inner joy.

– Meditation is an essential spiritual tool at every session of the positive thinking course. Meditation trains the mind to become

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stable and elevated, then the soul can connect to the higher spiritual dimension and enjoy the bliss of communion with god, the Supreme Divine Being and restore the spiritual powers of wisdom, virtues and healing power.

Spirituality in practice

Values in Healthcare: A Spiritual approach : This is a programme for both team development as well as on a personal level. The essence of the programme is a rejuvination of healthcare workers. A value based approach to patient care is researched and expressed in well planned out workshops.

In Global Hospital we have used these workshops for the staff and nursing students. Values such as compassion, cooperation, peace, positivity are practically emerged on deep levels of experience by using spiritual tools such as meditation, visualisation, and appreciative inquiry, the art of listening, creativity, reflection and play. The general outcomes of these workshops which we conduct on a monthly basis in our hospital here as well as in other hospitals are that of closeness and connectivity with the group. There is an appreciation of every individual and their values. Doctors and nurses create their own beautiful workplace by visualising it in a practical way. For example, putting up a new value on the notice board every day and reminding each other of that at the workplace; creating a ‘silence’ room for practicing meditation; Reminding each other at meetings to be a good listener. The workplace becomes more congenial by simply having had a workshop together; when you value yourself, you become more confident. There is respect for the self and others. The nursing students start their first week with values. This is a wonderful subject to start nursing studies with. This is also repeated throughout the studies as part of their curriculum. The Values in Healthcare programmes are now being conducted in many health care settings all over the world.

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Spirituality in practice

Experiences of patients : In taking care of those involved in giving care, we are automatically serving the patients. When the health care workers have a pleasant appearance and manner, the surrounding environment will be injected with this feeling. One such person who learnt how to smile! She expressed the following

“It was my first visit to the Global Hospital. There were so many amazing things and adventures happened during my holiday in Mount Abu. I was enjoying the peaceful atmosphere in this spiritual place when I was called to attend to a sick friend who had to be operated at the Global Hospital. Previously I had very bad experiences in hospitals in Russia. I was petrified by the very name ‘hospital’. Since my friend was not allowed to stay alone, I had to go to the Global Hospital with her and look after her. I was so sad and nervous because I was not ready for this psychological test. But since I had no choice, I had to go along with it and overcome my battle with fear.

At Global Hospital, after the operation, my friend slept all the time and I just sat near her bed all night. But all the time this room was full (some other patients were also there). Some doctors, nurses and foreign volunteers were constantly monitoring the patients. Every one who was coming was smiling, caring and greeted us with kind words specially ‘Om Shanti’. This created a positive atmosphere. I also smiled and my fear gradually vanished. I carried this inner happiness with me on the bus whilst returning and from this time onwards, smiling became a part of me. I don’t know about miracles but God taught me how to smile, here in Global Hospital. It was His blessing for me .As a result of this sweet experience at Global Hospital I won’t say I have love for hospitals and clinics, but Global Hospital for me is the place where I found my LOST SMILE.”

Patients who are referred to our ‘Positive Thinking’ course,

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which includes meditation, are surprised that this basic understanding of one’s true identity has been forgotten. As you meditate, the soul takes in the divine power. Through this process, the innate qualities of the soul, that of love, peace and happiness emerge and the mind is positively focused. Often depressed patients say that this course has helped them more than the medicine they have been taking.

Travelers especially back packers who come to the Global Hospital are offered the positive thinking course and meditation. They thoroughly enjoy the peacefulness of the meditation rooms and the yoga therapy. Many return asking for further spiritual experiences.

The Global Hospital has successfully developed a research programme for patients with coronary artery diseases (CAD patients). Some patients who had to undergo a second bypass operation in major hospitals were almost all helped by the following treatment/rehabilitation programme: Meditation and Positive Thinking course, lifestyle changes, healthy diet and exercises. This treatment is ongoing and patients are admitted for seven days at the time. This study has evoked an international interest. The changes which the patients experience are heartwarming. The expression on their faces changed from anxiety to composure and an inner pleasantness. Many have become regular meditators.

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Dr. Andrew Powell

Dr. Andrew Powell MA., MB., MRCP.,
FRCPsych. specialised in psychiatry and
psychotherapy at the Maudsley Hospital,
London and was Consultant and Senior
Lecturer at St. George’s Hospital, London
before moving to Oxford, where he continued to work in the National Health Service until 2000.

He is Founding Chair of the Spirituality and Psychiatry Special Interest Group of the Royal College of Psychiatrists, UK, which has a current membership of around 2000 psychiatrists (www.rcpsych.ac.uk/spirit).

He is co-author with Dr. Bisong Guo, of ‘Listen to your Body – the Wisdom of the Dao (University of Hawaii Press) and his recent publications on spirituality and health can be found at http://www.rcpsych.ac.uk/college/sig/spirit/publications/index.htm

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FURTHERING THE SPIRITUAL DIMENSION OF PSYCHIATRY IN THE

UNITED KINGDOM
Andrew Powell

Introduction : In this paper, I shall be focusing, quite narrowly, on spirituality in psychiatry, as opposed to the wider compass of mental healthcare, and steering well clear of the schisms that arise from religious differences. However, I first want to distinguish between spirituality and religion:

Religion : an organised system of beliefs, practices, rituals, and symbols designed to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality).

Spirituality : the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship with the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community.

(Koenig, H. K., McCullough, M. E. & Larson, D. B. (2001) Handbook of Religion and Health. OUP)

A further definition of spirituality is given on the website of the Royal College of Psychiatrists’ Spirituality and Psychiatry Special Interest Group :

‘Spirituality can be as broad as ‘the essentially human, personal and interpersonal dimension, which integrates and transcends the cultural, religious, psychological, social and emotional aspects of the person’ or more specifically concerned with ‘soul’ or ‘spirit’’.

http://www.rcpsych.ac.uk/spirit

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Lastly, in this age of high-technology medicine, a welcome reminder from the World Health Organisation concerning the broader context of healthcare :

Health is ‘a state of complete physical, mental and social well-being, not merely the absence of disease’

and

… ‘the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and to faith – in healing, in the physician and in the doctor-patient relationship. This reductionism or mechanistic view of patients as being only a material body is no longer satisfactory. Patients and physicians have begun to realise the value of elements such as faith, hope and compassion in the healing processes’.

Psychiatry and scientific realism

In order to see where psychiatry has been heading, it helps to understand something of its history. Current mental health science is largely dismissive of pre-scientific reality as ‘primitive’ and ‘animistic’. For instance, the shamanic view of ‘spirit’, which has informed cultures as far apart as Northern Asia, Mongolia, the Inuit, North American Indians, the tribes of the Amazon Basin, the aboriginal culture and in Europe, the Celts, is these days of interest only to medical anthropologists. Yet contemporary psychiatry shows the same indifference towards the major faith traditions of today. This becomes more intelligible in the light of Gallup surveys which show that while 80 – 90% of the general population believes in God, or a higher presence, only some 30% psychiatrists and psychologists do so. I shall be looking at some of the consequences of this discrepancy for mental health services.

Metaphysical beliefs of Western Antiquity

Every culture has a tendency to regard itself as pre-eminent.

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The culture of Western science is no different, regarding its interpretation of the nature of ‘reality’ as indisputably true, while treating metaphysical reality is nothing more than ‘imagination’. Yet this conceptualisation is just a few hundred years old, and entirely derived from instruments which themselves are comprised of that which they measure.

Let me begin, therefore, by situating Western science against the backdrop of earlier civilisations which, though ‘pre-scientific’, nevertheless advanced their own traditions of scholarship, wisdom and truth. All of these held there to be an animating principle of life – the Egyptians called it ka, the Greeks called it psyche, meaning ‘soul’, and the Romans spiritus (from ‘breath’).

In this discussion, I shall be using the word ‘soul’, (Old English: Sawol) to mean the unique and irreducible essence of each person, and ‘spirit’ for the more general animating principle behind matter. The Greeks saw science and soul as going hand in hand. Pythagorus (6th Century BC) remembered an earlier incarnation as Euphorbus, a warrior in the Trojan War. Later, Socrates was to assert the immortality of the soul, and Plato (4th/3rd Century BC) believed that by virtuous living, the soul is purified and regains its original perfection, while moral dereliction leads to Tarturus (Hell). As to the true nature of reality, Plato used his famous allegory of the cave to liken our perception of reality to mistaking the shadow thrown on the wall of the cave for its source. Jewish mysticism (Kabbalah), too, has a long and ancient history. ‘Hidden teachings’ were revealed by angels to Adam and handed down to Noah and Moses. According to The Zohar, souls must reincarnate until the germ planted in them grows to perfection, when they return to the Absolute. Islam, too, has its own mystical tradition in Sufism.

Eastern metaphysics

Turning to the East, we find the same intuited truth in Hinduism, rooted in the Vedas that go back 3500 years. The

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eternal soul (Atman) is caught in the cycle of birth and death until freed of its sanskaras (past impressions) by purification through yoga. Daoism, which was refined in the 6th century BC in China, teaches of ‘The Way’, the path of perfect balance in harmony with cosmic law. The soul is in two parts, kwei (yin), which is terrestrial and impermanent, and shen (yang), which is celestial and immortal. The third great Eastern tradition is Buddhism, which originated in India in the 5th century BC India and spread to China two hundred years later. Karma and re- birth are central to the Buddha’s teachings on the nature of suffering, its cause, its cessation and how it may be avoided (the ‘noble eightfold path’).

The early Christian Church – reincarnation denied

The early Gnostics texts – the gospels of Thomas and Philip and the Pistis Sophia – all refer to re-incarnation, while the four synoptic gospels offer no more than hints. In fact, reincarnation was first undermined by the emperor Constantine at the Council of Nicea in 325 AD, when Jesus Christ was declared the only son of God (the Nicene Creed). At a stroke, the human race was set apart and made subordinate to the Church, requiring the priest to intercede for the sins of humanity. In 543 AD, at the 5th General Council of Churches convened by the emperor Justinian, the doctrine of reincarnation was anathematised. Gnosis (direct revelation of the Divine) was viewed as potentially subversive and instead, faith, and adherence to the teachings of the Church were given prominence.

Following the fall of the Roman Empire, mediaeval Europe was dominated by Christianity, fuelled by the 11th Century schism between Roman Catholic and Eastern Orthodox Churches. Religious intolerance, as evidenced by the Crusades, and persecution of heretics, was now an established feature of the Christian church. Despite the power politics of Christianity throughout history, the mystical tradition has nevertheless been

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upheld by individuals who trusted their personal relationship with God more than obedience to the established order – Hildegard of Bingen, Francis of Assisi, Meister Eckhart, Julian of Norwich, St. John of the Cross, Jakob Boehme, Blaise Pascal, Emanuel Swedenborg, Pierre Teilhard de Chardin and Thomas Merton, to name but a few. It is the mystical tradition about which we psychiatrists particularly need to know, for our patients are liable to bring to the consulting room not the catechism or the liturgy, but direct experience of God and, not infrequently, the Devil too.

The scourge of evil and the fate of the mentally ill

The prospect was not good for those suffering from serious mental disorder in mediaeval Britain. In 1401, the first Act of Parliament against witchcraft was passed. The water test was usually decisive; the accused was thrown into a pond, bound hand and foot. Those who sank were declared innocent and survived, if they were lucky enough to be pulled out of the water before drowning, while those who floated were found guilty and burned at the stake.

A further Act of Parliament followed in 1604, which determined ‘Death without benefit of clergy to anyone who invoked evil spirits or communed with familiar spirits’. Around 1000 people, mostly women, were put to death in the UK and some 40,000 in Europe prior to the 1735 Witchcraft Act of George III, when hanging was replaced with imprisonment. Incidentally, the last prosecution took place in 1944 when the Medium, Helen Duncan, was imprisoned for nine months under the Act for ‘betraying details of the D-Day preparations via pretended contacts with the spirit world’. The Witchcraft Act of 1735 was finally repealed in 1951.

The Renaissance: a two-edged sword

The hegemony of the Church in Europe was broken by the Renaissance. At the turn of the 15th Century, Copernicus

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challenged the geocentric worldview of Catholicism and Galileo was sentenced to life imprisonment for subsequently demonstrating that the solar system to be heliocentric. The force for change, however, was inexorable. Renee Descartes (1596 – 1650) claimed that ‘nothing is held to be true until one is absolutely certain of it’. ‘Cogito, ergo sum’. Yet since the one thing Descartes could not doubt was his own existence, in doing so he gave primacy of mind over matter. Descartes also said: “To be capable of so perfect an idea as God means that such an idea could not have been caused by anything less perfect than God. Therefore both classes of substance body (res extensa) and mind (res cogitans), are created by God”

Isaac Newton (1642 -1727), who published the laws of gravitation and motion in his historic work Principia Mathematica, was also a deeply religious man. Newton held the universe to have been created by God, stating that “Truth is the offspring of silent, unbroken meditation”. The profound discoveries of Descartes and Newton set in motion a revolution that by the 18th Century had led to the ‘Age of Enlightenment’, with the flowering of individualism in the arts, in political and social reform, and with extraordinary progress in science, medicine and technology.

At the same time fateful seeds were sown, for Descartes’ dictum, ill-used, served to put Man in the place of God and Newton’s physics were misused to relegate God to a Heaven that had no substance except in faith. The result was the birth of material realism, which has taken humankind down a path of alienation from both the spiritual universe and from the wisdom of nature, leaving us, three hundred years on, facing a planetary crisis of survival.

Pioneering the humanitarian care of the mentally ill

Until the 18th century, those mentally ill but not deemed to

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be witches or possessed by the devil were incarcerated. The Bethlem Royal Hospital, where inmates were put in chains and publicly ridiculed, had been founded as early as 1247 and was popularly known as Bedlam. A small number of influential reformers finally broke this mould. In Paris, Phillipe Pinell (1745 -1826) instigated ‘moral treatment’, first at Bicetre Hospital and then at the Hospice de la Salpetriere. Pinell stopped purging, blistering and bleeding, preferring to talk with his patients. Independently, in this country, William Tuke (1732 -1822), a Quaker, founded The Retreat in York, caring for the afflicted with humanity and concern. John Conolly (1746 – 1866), who became the superintendent of Hanwell Asylum, published a ground- breaking book in 1856 entitled ‘Treatment of the Insane without Mechanical Restraints’. Conolly advocated providing patients with both occupational and recreational activities, and that they should be treated with kindness.

Care of the mentally ill in the 19th Century

Mental illness was now seen as a medical problem and the treatment given was, for the most part, humane. However, an experiment in social engineering had been taking place through the large scale building of mental asylums that segregated and isolated the patient population. By 1930, over 140,000 patients were residing in such institutions. Some patients benefited; those too disturbed to care for themselves could become part of a community, working on the estate, and taking part in the asylum’s organised recreational life. Many others suffered greatly, having been inappropriately diagnosed in the first place, or sent there for spurious social reasons, sometimes with the diagnosis of ‘moral degeneracy’ and large numbers of patients were effectively subjected to life imprisonment without trial or appeal.

The establishment of psychiatry: theories of biological causation

By the end of the 19th century, the medicalisation of mental

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disorder had been firmly established. This was based on the identification of a range of pathologies, including infections (neurosyphilis), physical lesions (tumours and head injuries), biochemical disorders (porphyria), vitamin deficiency (thiamine and B 12) and many others being shown to cause damage to the brain resulting in mental changes. Emil Kraepelin, the ‘father of psychiatry’, classified severe mental illness into two main categories, schizophrenia and manic-depressive disorder, and psychiatrists optimistically looked forward to discovering the underlying physical causes. Over a hundred years later, in most cases no physical cause has yet been identified.

The development of mainstream psychiatric treatments in the 20th Century

Early 20th century treatments were limited to medication with opiates, bromides and barbiturates. However, from the ‘30s onwards, lobotomy was widely performed (40,000 in the USA, 17,000 in the UK). The procedure could be carried out in 10 minutes in a doctor’s consulting room, with a probe inserted over the eyeball and shoved into the frontal lobes of the brain. Insulin Coma Therapy was also popular, another intervention that destroyed brain tissue, this time from oxygen starvation. Both treatments wrecked countless lives.

Electroconvulsive therapy (ECT) turned out to be the other mainstay of treatment, and this continues to be used, 12,000 treatments per year currently being carried out in the UK. This is because ECT can relieve intractable depression and is, on occasions, life-saving. During the ‘50s, antipsychotic drugs became available (for instance, Largactil), tricyclic antidepressants came on the market (Tryptizol), the benzodiazepines (Valium), and the first mood stabiliser (Lithium). In the ‘60s, a new class of antidepressants was discovered, known as MAOIs (Nardil) and since then, two further classes of antidepressants, the SSRIs (Prozac) and the SNRIs (Effexor),

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as well as a range of other medications.

In parallel with early physical methods of treatment, psychoanalysis had been the psychological therapy of the first half of the century. However, by the 60’s, psychoanalysis was fighting a losing battle, on the one hand with biological psychiatry (since physical treatments were much more useful in treating major mental disorder) and, on the other hand, with behavioural psychology, which was now proving effective in a wide range of conditions. Nevertheless, biological psychiatry, psychoanalysis and behavioural psychology were all united in one thing: none of them had any time for religion. A leading textbook of the ‘60s by Mayer-Gross, Slater and Roth contains just two references to religion, ‘Religiosity in deteriorated epileptic’ and ‘religious belief, neurotic search for’. This aversion to the spiritual can be better understood when some of the implicit assumptions of 20th Century science are listed.

· Subjective experience does not count. Reality is seen to be something ‘out there’.

· Events take place by chance and become only meaningful statistically when they can be shown to have significantly deviated from occurring by chance.

· Science is reductive/analytic so that a concept like wholeness has no heuristic status.

· Causation is ‘bottom up’ rather than ‘top down’; e.g. the 20th Century scientific view that consciousness must somehow be generated by the activity of brain cells.

· The value of altered states of consciousness, which require a different methodology, are discounted in favour of ‘consensus reality’.

· Despite advances in quantum physics, which show all ‘reality’ to be highly subjective, ‘objectivity’ remains the gold standard (the ‘Newtonian’ worldview).

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Besides biological psychiatry and secular psychotherapy, a third strand to contemporary mental healthcare is beginning to make its mark. Although the impact on mainstream psychiatry has, to date, been small, I believe this third strand holds the key to crucial future developments. This is transpersonal or soul- centred healthcare. Its origins as a psychological theory lie in the analytical psychology of Carl Jung, while no less drawing on the great religious and mystical traditions for spiritual illumination.

In the United Kingdom, analytical psychology has influenced mainstream healthcare to a certain extent, for there are a small number of consultant psychotherapists in the Health Service with a Jungian background. But the Jungian approach is less concerned with symptom resolution than with ‘individuation’, the development of the ‘whole person’ during the second half of life. It is therefore out of step with the focused short-term treatments that are funded and available in the Health Service.

Soul-centred approaches, however, can be highly focused. The willingness of the patient to work with ‘soul’ can be elicited when taking a spiritual history – to which I shall be referring later – and then the appropriate intervention made. The main influences on psychiatry today can be summarised on the flowchart shown below, with relative influence depicted by the arrow size.

The increasing burden of mental illness

Mental disorder has now assumed epidemic proportions. One in ten adults (450 million worldwide) is affected by mental illness, accounting for over 12% of the global burden of disease and rising, according to the WHO. In Europe and the Americas, the burden of mental illness is over 40% of the total burden of disability. 25% women and 12% men will suffer a major depressive disorder during their lifetime and 35% of people seriously medically ill are clinically depressed. In just the first 5 years of Prozac coming on the market, over 10 million prescriptions were issued.

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We need to ask ourselves what is going wrong. Is the human race suffering from some kind of biological melt-down? This seems unlikely. More probable, in my view, is that too many of us are living lives estranged from our spiritual birthright, with its innate values of goodness, beauty and truth. The consequent lack of meaning and purpose is inflicting a terrible price on our health. Let us look at a few of the modern myths which surround the privileged ‘First World’ in which we live. They are mainly characterised a substitutive addiction to excitement, power and fear.

·  Birth is down to chance – a random event

·  The way life goes is also largely a matter of luck

·  Death is final

·  There is no ultimate purpose in life

·  Love is selfish – based merely on self-survival

·  Get to the top of the heap, make a lot of money and buy
pleasure

·  Blur the emptiness of life with drugs / alcohol
· Aggression, fear, risk-taking, gambling, make you feel alive · Sex is a great antidepressant. Have more – thanks to Viagra
Small wonder that the stage is set for breakdown, driven by an underlying spiritual crisis which may not be evident at first sight.
The ‘spiritual emergency’ in psychiatry
Those easiest to help are patients who can recognise how their symptoms relate to the loss of meaning and purpose in life and who welcome a spiritually-informed therapeutic approach. A second group will come with a range of emotional or somatic symptoms, which on exploration have their roots in the spiritual arena. Here, it is important that the psychiatrist does not misdiagnose depression, for instance, and treat as such. This can happen if the patient is not encouraged to express his/her

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spiritual concerns. The most difficult situation to evaluate is when a patient presents with ‘psychotic’ symptoms that have a strong religious or spiritual significance, or with Kundalini phenomena. There is no diagnostic entry in ICD-10 (World Health Organisation International Classification of Diseases) for ‘spiritual emergency’. There is, however, an entry for ‘acute and transient psychotic disorders’ (ATPDs) in ICD-10 (F23) including ‘acute polymorphic psychotic disorder without symptoms of schizophrenia’ (F23.0)

‘Hallucinations, delusions and perceptual disturbances are obvious but markedly variable, changing form day to day or even from hour to hour. Emotional turmoil, with intense transient feelings of happiness and ecstasy or anxieties and irritability is also frequently present. This disorder is likely to have an abrupt onset and rapid resolution of symptoms; in a large proportion of cases there is no obvious precipitating cause’.

People suffering from ATPDs recover, by definition, from the episode of illness. However, they do show a relapse rate of up to two thirds and around 40% will eventually be diagnosed as having schizophrenia.

Because most psychiatrists are not attuned to the spiritual dimension, we simply do not know how many of these patients are breaking down because of a spiritual crisis, and neither do we know how a psychospiritual intervention might influence the outcome. One problem is that intense spiritual preoccupations are often regarded by the psychiatrist as a feature of illness, to be minimised when the acute phase passes. Yet sooner or later, the embattled archetypes of good and evil will need addressing, for when the inner struggle is left to continue unaided, it is sure to erupt again. The skill lies in finding a creative way to help the patient work with his/her spiritual concerns that may protect against further breakdown.

Mediumistic phenomena

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Another issue at the interface of spirituality and psychiatry concerns trance and spirit communications. Here, ICD 10 acknowledges a problem, not least because of the need to recognise widely varying cultural traditions.

Under F44.3, ‘Trance and Possession Disorders’, we find : Disorders in which ‘there is a temporary loss of both the sense of personal identity and full awareness of the surroundings; in some instances the individual acts as if taken over by another personality, spirit, deity or ‘force’. Attention and awareness may be limited to, or concentrated upon only one or two aspects of the immediate environment, and there is often a limited but repeated set of movements, postures and utterances’.

and

Only trance disorders that are involuntary or unwanted, and which intrude into ordinary activities by occurring outside (or being a prolongation of) religious or other culturally accepted situations should be included here.

The bad news for all those who believe in the actuality of ‘spirit’ lies in the ‘as if’, for Western science does not countenance the possibility of the survival of human consciousness that can communicate across the bounds of space-time. The good news is that Mediums can be reassured that they will not be diagnosed with a mental disorder unless, of course, they happen also to have fallen ill.

The need for a Spirituality and Psychiatry Special Interest Group (SIG)

During the latter years of my consultant work in the Health Service, when my interest in soul-centred psychotherapy was deepening, I became increasingly aware of a number of issues that could usefully be addressed:

· Many psychiatrists unhappy with ‘scientific realism’ but no

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forum for debate without risking censure
· Spirituality largely ignored by mainstream psychotherapy · Psychiatrists not encouraged or trained to explore religious/

spiritual concerns and consequently reluctant to engage with topic in clinical practice

· Research by Mental Health Foundation showing over half of patients turn to their spirituality/religion when in crisis but cannot discuss with the psychiatrist

· Need for accurate diagnosis when distinguishing mental illness from spiritual crisis, especially when archetypal spiritual/ religious themes are central

· Unsure as to what status/credibility to give to ‘paranormal’ phenomena

· Soul-centred therapies largely unavailable within NHS

· Ignorance of research correlating spirituality and positive mental health

It seemed, therefore, a propitious time to form a Special Interest Group, one which would align psychiatry with its intended meaning of ‘psyche’ soul, and ‘iatros’, doctor. Colleagues were canvassed, a proposal was put forward to the Royal College of Psychiatrists and a working group was established. Our inaugural meeting was held in September 1999 and the first programme of the SIG took place in January 2000. Since then, the membership of the group has grown to more than 1,500 psychiatrists.

The role of the Spirituality and Psychiatry Special Interest Group, Royal College of Psychiatrists UK

The proposal put forward to the College stated that the SIG would be a discussion forum for psychiatrists (having no religious bias and respectful of differences) in order to explore :

· Fundamental concerns intrinsic to good mental healthcare such as the purpose and meaning of life, and the problem of

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good and evil

· The need for an integrative approach (mind/body/spirit)

· Specific experiences invested with spiritual meaning, including birth, death and near-death, mystical and trance states, ‘paranormal’ phenomena, the ‘spiritual emergency’, and to distinguish between normal and pathological human experience in the field of mental health

· How best to develop and provide educational input to the Royal College for the training of psychiatrists (professional competencies curriculum, with explicit knowledge, attitude and skills)

· The relationship between illness, health and spirituality, and the growing evidence base associating spirituality with positive mental health (the protective effect against depression and outcome research in the treatment of alcohol and substance abuse, to name just two).

The work of the Spirituality and Psychiatry Special Interest Group

The SIG has been concerned to influence the training that is provided for psychiatrists. We have submitted extensive proposals for the introduction of spirituality into the curriculum for trainees and are awaiting the response of the College. The aims and objectives of what we believe spiritually informed psychiatry should be able to offer are summarised below:

The psychiatrist should be aware of, and responsive to, spiritual aspects of psychiatry arising from :

· The need to find a sense of meaning and purpose in life
· The personal search for answers to deeper questions

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concerning birth, life and death
· The difference between spirituality and religion, and their

inter-relatedness
· The relationship of spirituality to the development and

expression of individual human values
· How spirituality informs concepts of good and evil

The psychiatrist should have knowledge of

· Spiritual crises, meditation, prayer and altered states of consciousness, including the Near Death Experience

· The spiritual significance of anxiety, doubt, guilt and shame

· The spiritual importance of love, altruism and forgiveness, and their relation to mental health

· The influence of materialistic goals on personal identity and self-esteem

· The reciprocal relationship between culture and spiritual / religious beliefs and practices, and the consequences for psychiatric practice

· How the presence or absence of spiritual/religious beliefs and practices in mental healthcare workers may influence clinical decision-making

· The role in clinical management of spiritual / religious support networks, including chaplaincy and pastoral care departments as well as those in the community

The psychiatrist should be familiar with research on

· The application of both quantitative and qualitative research to the field of spirituality and psychiatric practice

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· The findings of epidemiological studies relating spirituality to mental health variables

· The introduction of spiritual values in the design and execution of research validated instruments for measuring spiritual and religious beliefs

· The contribution of research to understanding the neurophysiology and efficacy of prayer, meditation, forgiveness and love

Good psychiatric practice should be informed by

· Awareness that medical practice is founded on values which include discernment, compassion, generosity, tolerance, patience, honesty, humility and wisdom

· Awareness of how his/her own value systems may impact on others

· Sensitivity to, and tolerance of, the value systems of others

· An understanding of the concept of spiritual development as part of personal growth

The psychiatrist should be skilled in

· Taking a spiritual history

· Being able to stay mentally focused in the present, remaining alert and attentive with equanimity

· Developing the capacity to witness and endure distress while sustaining an attitude of hope

· The recognition of his/her own emotional responses to spiritual disclosures

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· Honest self-appraisal, in the interests of continuing personal development

· Maintaining personal well-being in the interests of patient care

Taking a spiritual history should include enquiring

· What is the patient’s spiritual / religious background?

· What role did spirituality / religion play in childhood, and how does the patient feel about that?

· Is spirituality / religion important now in the patient’s life?

· If so, are such beliefs supportive, or anxiety provoking and punitive?

· Is spirituality / religion drawn upon to cope with stress? In what ways?

· Is the patient a member of any spiritual / religious community? Is it supportive?

· What is the patient’s relationship with their clergy like?

· Are there any spiritual / religious issues the patient would like to discuss in therapy?

· Do the patient’s spiritual / religious beliefs influence the type of therapy he or she would be most at ease with?

· Do those beliefs influence how the person feels about taking medication?

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Further activities of the Spirituality and Psychiatry Group

The website http://www.rcpsych.ac.uk/spirit is in the public domain. The SIG Newsletter is published regularly, with notice of meetings held and details of programmes, which have included:

What do we mean by spirituality and its relation to psychiatry? Fear and faith – the quandary of the psyche under threat Avenues to peace of mind
Forgiveness and reconciliation

Engaging the spiritual mind; the healing power of love Good and Evil – the challenge for psychiatry
Integrating mind and body: psycho-spiritual therapeutics. Pathways to peace – East meets West

Invited or not, God is here: spiritual aspects of the therapeutic encounter
Minds within minds: the case for spirit release therapy Spiritual issues in child psychiatry

Prayer in the service of mental health
A fatal wound. Who and what does suicide destroy?
What inspires the psychiatrist? Personal beliefs, attitudes and values
Special needs, special gifts – learning disability and spirituality Spirituality and religion in later life
Psychosis, psychedelics and the transpersonal Journey Sanity, sex and the sacred: exploring intersecting realms Suffering – what is the point of it all?
Body and spirit
Spirituality and psychopathology
Researching spirituality: paradigms and empirical findings

Public conferences include :

The place of spirituality in psychiatry
Beyond death – does consciousness survive?
Healing from within: the therapeutic power of altered states Psychotic episode or spiritual emergency? The

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transformative potential of psychosis in recovery

The wide range of papers presented at meetings given can be downloaded from the SIG website publications archive. The SIG promotes links with other bodies, such as The Janki Foundation ‘Values in Healthcare Programme’, The Scientific and Medical Network and The National Institute for Mental Health in England.

An important publication has been the leaflet ‘Spirituality and Mental Health’, formally approved by The Royal College and available for download from the College website homepage ‘topics’ menu (www.rcpsych.ac.uk)

A textbook ‘Spirituality and Psychiatry’ has also been commissioned by the Royal College from the SIG, due for publication in 2009.

Where do we go from here?

My belief is that if we are significantly to promote the development of spirituality in psychiatry, our work needs to develop in a number of areas. We must raise awareness in the profession to paradigm change within science (quantum physics, advances in cosmology, the non-local nature of consciousness, the significance of the near death experience etc.). More research is needed into the effectiveness of the psycho-spiritual therapies. Training in psychospiritual therapy should be more widely available. (Provided these therapies can be shown to work, they will find acceptance, even if the mechanism of change is regarded as entirely psychological).

We will continue to advocate a holistic approach – not ‘either/ or’ but ‘both/and’. Physical treatments, appropriately and thoughtfully given, especially for severe mental illness can be life-saving; but for healing to take place, it helps to enlist the soul.

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In our clinical work, we need to engage with the spiritual reality of the patient and seek to elicit the wisdom he/she already holds. The solution always lies in the problem, which invariably has been perfectly ‘arranged’ to provide the spur to change and growth.

Science need not stand in the way of the Golden Rule: ‘do unto others as you would have them do unto you’. Doctor and patient are merely roles – each needs the other! We are all travelling along the path of learning, one which ultimately takes us to the same destination. We can remain optimistic in the most apparently hopeless cases since, from the point of view of soul, there is no such thing as a bad experience.

Last but not least, we should never forget that the healing power of love remains the best medicine known to humankind.

Paper given to the 1st British Congress on Medicine and Spirituality London 30th June/1st July 2007

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Dr Russell D’Souza

Dr Russell D’Souza, is currently the
Director of Clinical Trials Research &
Bipolar, Northern Psychiatry Research
Centre, the Department of Psychiatry of
The Melbourne University. He is also a
Senior Lecturer at the Department of Psychiatry, The Melbourne University and Honorary Senior Lecturer at the Department of Psychological Medicine, Monash University, Melbourne.

He is a Visiting Professor at Fountain House Psychiatric Centre, Lahore, Pakistan and Medical College, Chennai, India. He has appointments in the USA and UK. He is Disaster Committee member of the World Psychiatric Association, secretary of the Tsunami Task force on psychosocial support and rehabilitation.

He has presented and run workshops at several national and international venues including USA, The Maudsley UK. Canada, Egypt, Colombo, India and Pakistan. His work on the SACBT was filmed and screened on the ABC National Compass program ‘Psyche & Soul’ receiving very good critiques and rescreening of the program twice due to public demand. Dr D’Souza has been the guest of several Radio programs in Australia and UK discussing this dimension. He has published several papers on this area.

He is the Secretary of the Australian national special interest group on Spirituality, Religion and Mental Health.

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FOSTERING SPIRITUALITY AND WELL-BEING IN CLINICAL PRACTICE

Russell D’Souza

Health professionals and patients are increasingly aware of the basic need of all human beings for a source of meaning that is greater than one’s self. The growth in awareness is driven by professional’s practical goal of reducing disability from mental disorders and by the wishes of the patients for their therapists to recognise the need for self transcendence. As a result mental health professionals and the general public are growing in awareness of the need to foster spirituality and well-being in clinical practice. There is now a groundswell of professional work that suggest from evidence that this domain has an important role in caring for patients. In fact the word psychiatry is derived from Greek and literally means “the healing of the psyche” The “psyche” is the Greek word for soul or spirit, which is the immaterial but intelligent aspect of the consciousness of a human being. The great mystery of neurosciences is that the human consciousness cannot be explained or reduced to materialistic process. I will work through this important area which will be addressed in two parts, part one will discuss spirituality, religion and psychiatry and its application to Clinical practice and the second part will describe the evidence based Spiritually Augmented Cognitive Behaviour Therapy.

PART – I

Spirituality, Religion and Psychiatry: Its Application to Clinical Practice

‘Nothing in life is more wonderful than faith- the one great moving force which we can neither weigh in the balance nor test in the crucible…Faith has always been an essential factor in the practice of medicine…Not a psychologist but an ordinary clinical

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physician concerned in making strong the weak in mind and body, the whole subject is of interest to me’’.

– William Osler1 What is spirituality/religiosity?

Spirituality is a globally acknowledged concept2. However, attempts to reach a consensus regarding its nature have not been met with success3. In discussing spirituality, one is fundamentally discussing the ways in which people fulfill what they consider to comprise the purpose of their lives. Therefore, it is possible to see why many different definitions of spirituality have been proposed.

Human beings are considered to have two realms of existence, the outer and inner realms 4. The outer realm consists of a person’s interaction with the world, whereas the inner realm has been defined as the individual’s interaction with the transcendental. This may be a divine being or ideals hinted at through experiences such as beauty, awe, and love4. These realms may arise from different contexts. For example, in the monotheistic faiths one acts justly to know God, whereas in Buddhism one acts justly to be released from suffering5. In addition, some patients may define their problems as spiritual rather than religious. By ‘spiritual’ they generally mean a transcendent relationship between the person and the higher being – ‘a quality that goes beyond a specific religious affiliation’6. By contrast, the term religion refers to adherence to and beliefs and practices of an organised church or religious institution7.

Spirituality in psychiatry

It has long been agreed that the mind, body, and spirit are integrally connected8. Western medicine has dichotomised the mind, body, and spirit/soul in comparison to the Eastern system8. Traditionally, psychiatrists and psychologists have

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underemphasised religious issues in their work. Religion is often regarded by mental health professionals in Western societies as irrational, outdated, and dependency forming. This view is derived from Freud who saw religion as a ‘universal obsessional neurosis’6.

Historically, it has been acknowledged that psychiatry has had three revolutions. The first of which was the middle ages, when mental illness was accepted as an illness, rather than the earlier held belief that it was a curse of God. Subsequently, mental illness moved from the realms of religion to medicine. This period was also known as the ‘age of enlightenment’. The second revolution was the ‘age of psychoanalysis’. The fear of a return to the dark ages may explain partly the stance that Freud took towards religion. The third revolution is considered the ‘age of deinstitutionalisation’, which was heralded by the advent of the neuroleptic Chlorpromazine. From this flowed the end of the paternalistic model that was the realm of management for patients with mental illness. It is now believed that we are heralding the fourth revolution, the ‘age of empowerment of the consumer’. This has been a force that is currently seeing the need for re-evaluating and changing our practices.

An area of importance is the consideration and validation of the spiritual dimension of the patient, and the need for ‘whole person therapy’. Recent attempts at empirical assessments of the relationships between religion, spirituality and mental health have suggested that religion may promote better mental health6. To date, medical training in the Western world has been strongly concerned with the more easily measured physical aspects. Therefore, education surrounding the spiritual aspects of medical care has not typically been included in the medical school or college curriculum. However, the accumulating evidence suggests that it is emerging as something that our patients want and expect as part of our caring for them.

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Several Australian studies9,28 have validated these findings, and have replicated results of similar studies in the United States of America and New Zealand10. Importantly, in a patients’ interaction with clinicians/psychiatrists they do not cease to be human beings with deep and wide ranging needs. Indeed, in times of illness, questions surrounding life and death may loom all the more strongly within a patient’s consciousness and subsequently spiritual issues are likely to come to the fore of human awareness for both patients and professionals. Therefore, recognising patients’ spiritual concerns may be viewed as an essential part of ‘patient-centred medicine’, increasingly seen as crucial to high-quality patient care11. Additionally, studies have shown that religious individuals are less satisfied with a non- religious clinician than with a religious one12. There are signs that things may be slowly changing. Numerous authors are beginning to underscore the importance of mental health professionals taking into account patients’ religious and spiritual lives during the psychiatric consultation6.

Are doctors, psychiatrists and clinicians healers?

Doctors, Psychiatrists and Clinicians are healers primarily through the caring relationships they form with patients. Caring includes calling on an individual’s inner strengths. These strengths amongst others include spiritual resources, which support integration or wholeness of body, mind, and spirit. By addressing the spiritual and religious dimensions in patient care, clinicians can truly be holistic – the need of the day. Thus, it appears that spiritual and/or religious care that is ethical and sensitive is an invaluable dimension of total patient care. Attending to the spiritual dimensions of the patient can provide the physician with a more in-depth understanding of the patient and his or her needs. Therefore, it makes sense that clinicians use a variety of spiritually informed therapeutic tools to facilitate the patient’s coping ability, thus enhancing well-being and recovery.

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Clinicians’ own religious or spiritual practices, or non- practices, may impact upon their ability to function effectively in this area of clinical practice. Thus, this is an area we must take cognisance of. As doctors, we have been trained to be objective and to keep our beliefs and practices out of therapy. Unfortunately, we have also over time strayed into keeping our patients’ spiritual beliefs, needs, and supports out of clinical practice. We have thus potentially ignored an important aspect of their lives that might be integral to their ability to cope, which is vital not only for recovery but also for their ‘well being’. This is the objective of medical practice.

Spirituality and religiosity for the patient

The World Health Organisation defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Patients want to be seen and treated as whole persons, not as diseases. A whole person is someone who has physical, emotional, social, and spiritual dimensions. Ignoring any of these aspects of humanity leaves the patient feeling incomplete and may even interfere with healing. For many patients spirituality is an important part of wholeness and when addressing psychosocial aspects in psychiatry this dimension of their personhood cannot be ignored.

There is evidence to suggest that many seriously ill patients use religious beliefs to cope with their illness13. Religious and/or spiritual involvement is a widespread practice that predicts successful coping with physical illness14. Numerous studies by Koenig13-16 suggest that high intrinsic religiousness predicts more rapid remission in depression, an association that is particularly strong in patients whose physical function is not improving15. A meta-analysis16 examining the relationship between religious involvement and various aspects of mental health found that the majority of people experience better mental health and adapt more successfully to stress if they are religious. Another

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meta-analysis examining religious involvement and health found that compared to non-religious individuals, religious people are physically healthier, lead healthier life styles, and require fewer health services17.

Despite the above mentioned evidence, it is important that religious practices do not replace psychiatric treatments. While many people find that illness spurs them to metaphysical questions and helps them rediscover religion, thus far no studies have shown that people who become religious only in anticipation of health benefits experience better health.

Addressing patients’ spiritual needs

Patients’ spiritual needs can be addressed at a variety of levels including research, training, and practice. In academia, relatively little attention has been paid to spirituality (a search of the Medline 1966 database, in February 2000 yielded 19301 out of 10074921 articles, less than 0.2%). Given the importance of spiritual considerations for patients, this is remarkable. There is a need for future research to examine the prevalence and clinical presentations of major mental disorders and their relationship to religious and spiritual problems. With regards to training, with the exception of texts on palliative care18 and ethics courses, spirituality is not directly considered in medical teaching, even though spiritual considerations will be present whenever patients’ rights and needs are discussed. Doctors and clinicians should be required to learn about the ways in which religion and culture can influence a patient’s needs.

What does this mean for clinical practice?

The first and foremost step is for doctors to acknowledge the importance of spirituality and religious beliefs in the lives of their patients. Therefore, all medical students and graduates should be trained to take a spiritual history as part of history

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taking. Knowledge of a patient’s spiritual history is as important, and should come as naturally as asking patients about their inter- personal relationships, marital history, hobbies, and interests. Cox19 argues that ‘if mental health services in a multicultural society are to become more sensitive to user needs then eliciting religious history with any linked spiritual meanings should be a routine component of a psychiatric assessment, and of preparing a more culturally sensitive care plan’. It may therefore, be beneficial to adapt existing therapies to the patient’s spiritual perspective.

There is evidence that cognitive therapies may be more effective if they take a patient’s religious beliefs into account20,29. Spiritually Augmented Cognitive Behaviour Therapy, developed by our team, has shown efficacy in randomised controlled studies in patients who rated spirituality as important or very important in the patients’ spiritual needs survey21,22,23,29. Spiritually Augmented Cognitive Behaviour Therapy has been shown to be associated with improved treatment adherence and higher satisfaction, than the control arm, in patients with schizophrenia who had recovered from psychosis24. Furthermore, patient centred approaches, as a whole, help to maintain patient dignity and ensure that the interventions offered are appropriate. This has resulted in positive outcomes including compliance with medication, a major barrier to outcomes in psychiatry, and greater patient overall satisfaction25.

We have included some thoughts in these regards, based on clinical experience, outcome studies, and common sense.

What doctors and clinicians should not do

Doctors should not ‘prescribe’ religious beliefs or activities for health reasons. In addition, doctors should not impose their own religious or spiritual beliefs on patients. Furthermore initiation of prayer without knowledge of the patient’s religious background

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and the likely appreciation of such activity is strongly discouraged. Psychiatrists should not provide in-depth religious counselling to patients, something that is best done by trained clergy.

What doctors and clinicians should do

Doctors should acknowledge and respect the spiritual lives of patients and always keep interventions patient-centred. Acknowledging the spiritual dimensions of patients involves taking a spiritual history 26. A consensus panel of the American College of Physicians have suggested four simple questions that physicians may ask ill or seriously ill patients27: (i) “Is faith (religion, spirituality) important to you?”, (ii) “Has faith been important to you at other times in your life?” (iii) “Do you have someone to talk to about religious matters?”, and (iv) “Would you like to explore religious, spiritual matters with someone?”. Taking a spiritual history is often a powerful intervention in itself25. The doctor may then consider whether supporting the patients’ spiritual religious beliefs will aid in coping. It is acknowledged that religious and spiritual patients’, whose beliefs often form the core of their system of meaning, almost always appreciate the doctor’s sensitivity to these issues. The doctor can thus send an important message that he or she is concerned with the whole person, a message that enhances the patient-physician relationship, the corner stone in medical care, which may increase the therapeutic impact of the intervention.

At times it may be necessary to enlist the help of a religious professional such as a chaplain or someone influential in a religious organisation6. Chaplains are increasingly becoming a pivotal part of the multi-disciplinary team in the United Kingdom, justified on the basis that religious and spiritual needs are prevalent among patients with acute and chronic mental illness. Religious professionals may be the first ‘port of call’ for those with mental health problems, and there is a need for collaboration between religious and mental health professionals6.

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Our calling as physicians and clinicians is to cure sometimes, relieve often, and comfort always. The comfort conveyed when a psychiatrist or mental health clinician supports the core that gives the patient’s life meaning and hope is what many patients miss in their encounters with mental health professionals. Finally, considering these issues and approaching questions of spirituality and religiosity of patients will not only improve patient care and the patient-doctor relationship, but in time may well come to be seen as the salvation of biomedicine.

References :
1.
Osler W. The faith that heals. British Medical Journal 1910;

1: 1470-1472.

2. Narayanaswamy A. A review of spirituality as applicable to nursing. International Journal of Nursing Studies 1999; 36: 117-125.

3. Dyson J, Cobb M, Forman B. The meaning of spirituality: A literature review. Journal of Advanced Nursing 1997; 26: 1183-1188.

4. Yawar A. Journal of Research and Social Medicine 2001; 94: 529-532.

5. Lamotte E. The Buddha, his teachings and his Sangha. In: Bechert H, Gombrich R, eds. The World of Buddhism. London: Thames & Hudson, 1984:41-58.

6. Dein S. Working with patients with religious beliefs. Advances in Psychiatric Treatment 2004; 10: 287–295.

7. Shafranske E, Malony HM Clinical Psychologists’ religious 295

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and spiritual orientations and their practice of psychotherapy. Psychotherapy 1990; 27: 72–78.

8. Wig NN. Mental health and spiritual values: A view from the east. International Review of Psychiatry 1999; 11: 92-96.

9. D’Souza RF. Do patients expect psychiatrists to be interested in spiritual issues? Australasian Psychiatry 2002; 10: 09-22.

10. De Beer WA. “The Religiosity Gap”: A New Zealand Perspective. Proceedings of the Royal Australian and New Zealand College of Psychiatrists 35th Annual Congress; 2000 April 27-30.

11. May C, Mead N. Patient-centeredness: a history. In: Dowrick C, Firth L, eds. General Practice and Ethics Uncertainty and responsibility. London: Routledge, 1999; 76-90.

12. Keating AM, Fretz BR. Christians’ anticipations about counsellors in response to counsellors descriptions. Journal of Counselling Psychology 1990; 37: 293-296.

13. Koenig HG, McCullough M, Larson D. Handbook of Religion and Health. New York: Oxford University Press, 2000; 7-14.

14. Koenig HG, Cohen H, Blazer D, Pieper C, Meador K, Shelp F. Religious coping and depression in elderly hospitalised medically ill men. American Journal of Psychiatry 1992; 149: 1693-1700.

15. Koenig HG, George L, Peterson B. Religiosity and remission from depression in medically ill older patients. American Journal of Psychiatry 1998; 155: 536-542.

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16. Koenig HG. Spirituality, religiosity and medicine: Its application to clinical practises. Journal of the American Medical Association 2000; 284: 1708-1709.

17. Hummer R, Rogers R, Nam C, Ellison C. Religious involvement and US adult mortality. Demography 1999; 36: 273-285.

18. Twycross R. Introducing Palliative Care, 3rd edn. Oxford: Radcliffe Medical Press, 1999.

19. Cox J. Psychiatry and Religion: A general psychiatrist’s perspective. In: Bhugra A, eds. Psychiatry and Religion: Context, Consensus and Controversy. London: Routledge, 1996; 158.

20. Qureshi B. Transcultural Medicine, 2nd edn. Lancaster: Kluwer Academic, 1994.

21. D’Souza RF, Rich D, Diamond I, Godfery K, Gleeson D. An open randomised controlled trial of a spiritually augmented cognitive behaviour therapy in patients with depression and hopelessness. Australian and New Zealand Journal of Psychiatry 2002; 36: A9.

22. D’Souza RF, Heady A, Rich D. Spiritual needs in psychiatric practice. Proceedings of the 36th Royal Australian and New Zealand College of Psychiatrists Annual Congress, Canberra, 21st-24th 2001.

23. D’Souza RF, Rodrigo A, Keks N, Tonso M, Tabone K. An open randomised control study of an add-on spiritually augmented cognitive behaviour therapy in a cohort of patients with depression and hopelessness. Proceedings of the 28th Royal Australian and New Zealand College of Psychiatrists Annual Congress, Hobart, 12th-15th May 2003.

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24. D’Souza RF, Rich D, Diamond I, Godfery K. An open randomised control study using a spiritually augmented cognitive behaviour therapy for demoralisation and treatment adherence in patients with schizophrenia. Australian and New Zealand Journal of Psychiatry 2002; 36: A9.

25. Kinnersley P, Stott N, Peters TJ. The patient-centredness of consultation and outcome in primary care. British Journal of General Practice 1999; 49: 711-716.

26. D’Souza RF. Incorporating a spiritual history into a psychiatric assessment. Australasian Psychiatry 2003; 11: 12-15.

27. Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Annals of Internal Medicine. 1999; 130: 744-749.

28. Mathai J, North A. Spiritual history of parents of children attending a child and adolescent mental health service. Australasian Psychiatry 2003; 11: 172-175.

29. D’Souza RF, Rodrigo A. Spiritually augmented cognitive behavioural therapy. Australasian Psychiatry 2004; 12: 148-152.

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PART II
The Spiritually Augmented Cognitive Behaviour Therapy

– A meaning therapy for sustaining mental health and functional recovery.

Introduction

Most of the world is becoming a truly post-modern society, a place where we are learning to incorporate uncertainty in our view of the world. The absolute is giving way to the relative; objectivity to subjectivity; function to form. In the modern view of the 20th century, seeing was believing; in the post-modern world of the turn of the century, believing is seeing. Conviction yields to speculation; prejudice to a new open-mindedness; religious dogma to a more intuitive, inclusive spirituality. Even the concept of God receives a changed emphasis, from the materialist’s ‘out- there’ being, to a spirit that is more intimately part of us1.

The historical split between ‘facts’ and ‘values’, science and religion is being reconsidered. There has been the recent shift away from dichotomies such as therapy/spirituality, science/ religion towards a both/and syntheses in the ‘New Science’ and spirituality. The ‘Cartesian anxiety’ and dualism that has dominated western thought in the last 300 years is now less apparent, and science is more inclusive of different paradigms2.

Background

Spirituality is a concept globally acknowledged. However, attempts to reach a consensus regarding its nature have not met with success. In discussing spirituality, one is really discussing the ways in which people fulfill what they hold to be the purpose of their lives. Spirituality can encompass belief in a higher being, the search for meaning and a sense of purpose and connectedness. There can also be a wide over lap between religiosity and spirituality.

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There is now awareness across multiple disciplines of the importance that spirituality and religiosity has for many patients. This has lead to suggestions and research in relation to validating the incorporation of aspects of spirituality and religiosity into multi- disciplinary assessments and interventions for patients with psychological and physical illness3. In an Australian survey a large majority of patients wanted their therapist to be aware of their spiritual beliefs and needs. About two thirds (68.7%) of respondents believed that their spiritual beliefs helped them to cope with psychological pain4.

Demoralisation, originally described by Jerome Frank,5 is the experience under stressful circumstances of being unable to cope, characterised by feelings of distress, apprehension, helplessness, subjective incompetence, hopelessness, diminished esteem and confidence, isolation and alienation, and a loss of personal meaning and purpose in life5, 6. Frank explicitly described psychotherapy as the treatment for demoralisation, effective across different cultures. This is particularly important in the medically ill, where the treatment of depression with antidepressants, while effective, is complicated by drug interactions and adverse effects7.

Folkman and Greer8 elaborated the idea of meaning based coping. In their therapy there is an emphasis on exploring meaning and purpose and identifying meaningful and realistic goals within whatever limitations life and illness brings. Further work by Breitbart et al9 looked at a group therapy intervention explicitly looking at existential issues based on the work of Victor Frankl’s work and Existential therapy. Earlier work by Moorey and Greer10 using an ‘Adjuvant Psychological Therapy’ based predominantly on “techniques of cognitive restructuring which included reality testing, challenging negative automatic thoughts and assumptions”, demonstrated in a randomised controlled trial that it was able to diminish levels of hopelessness11.

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A study by Cole and Brenda12 testing the efficacy of a spiritually focused therapy group (SFT) and a no treatment centred group of people confronting cancer, where the SFT was formulated around four existential themes relevant to this population: control, meaning, identity and relationships. The results suggested that the SFT group tended to improve in functioning, while the control group tended to decrease in functioning across almost all of the dependent variables. The treatment group’s level of depression reduced across time while the control group’s level of depression increased. Specifically, surrendering control was predictive of lower levels of depression, anxiety and pain severity. The same group compared a CBT without spiritual issues and resources and SFT. The results suggested that the CBT was superior to the SFT in decreasing anxiety but not in its effect on other dependent variables. Propst et al13 studied the comparative efficacy of a religious CBT (RCBT) and non religious CBT (NRCBT) in a cohort of 59 patients who considered religious and spiritual issues important or very important, and who met Research Diagnostic Criteria (RDC) for non-psychotic, non-bipolar depression, and were treated with18-20 one hour sessions over three months. The RCBT patients reported significantly lower post treatment depression and adjustment scores than did the NRCBT group. Pargament, Koenig & Perez25 completed a study assessing the full range of religious coping methods, including potential helpful and harmful religious expressions. Results of regression analyses showed that religious coping accounted for significant unique variance in measures of adjustment (stress-related growth, religious outcome, physical health, mental health and emotional distress) after controlling for the effects of demographics and global religious measures.

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Description of the
Spiritually Augmented Cognitive Behaviour Therapy

Background : The Spiritually Augmented Cognitive Behaviour Therapy was developed and tested for efficacy and effectiveness at the Sydney University’s Centre for Excellence in Remote and Rural Psychological Medicine, Broken Hill. A multidisciplinary team of professionals, including members of the hospital pastoral team and the indigenous elder under the leadership of the psychiatrist, took part in developing and testing this therapeutic intervention. This is a meaning therapy that has been found to be significantly beneficial over control groups in a number of outcome measures. These benefits were demonstrated in three randomised controlled trials in patients with depression and or demoralisation.

Principles : This psychotherapeutic intervention uses the principles of Cognitive Behaviour Therapy with an added focus on existential issues, using techniques to find meaning that incorporates and validates the individual’s belief system into the treatment. Thus the use of meditation, prayer/ritual together with monitoring the effects of these beliefs and or rituals on their symptoms, and their acceptance of treatment including medications, form the behavioural components of this therapy.

Method : The therapy and method of execution and supervision is informed by our previous work; D’Souza et al14,15,16,17,23, and that of Moorey & Greer10, and Breitbart et al9. It is semi-structured and explores a range of issues and the use of a range of therapeutic techniques. The techniques emphasised are empathic listening, facilitation of emotional expression, problem solving, emphasising self-efficacy, exploring meaning and purpose and ultimately enabling self-therapy. Exploring meaning includes the specific meaning of the situation – the appraisal of the current situation and its significance for the future, and where relevant, global meaning. Finding meaning by the use

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of approaches such as experiential values- by experiencing something, or someone we value, creative values –‘doing a deed’ providing oneself with meaning by becoming involved in the project of one’s life18, and attitudinal values- which include such virtues as compassion, bravery, a good sense of humour, and even achieving meaning, as Frankl suggested, in one’s suffering19. When there is much negativity and cognitive distortions, cognitive restructuring is employed together with the conventional principles and techniques of Cognitive Behavioural Therapy.

In this intervention there is an important emphasis on the respect for, and maintenance of patient autonomy and empowerment. Thus the16 sessions might not aim to achieve radical change to personality or the instilling of values never held, but the rekindling of values and resilience perhaps forgotten or lost in illness, and set backs in the form of trauma, and loss of meaningfulness that was never fully expressed before – thus we would aim to encourage a purposeful engagement with the dimensions that life has to offer.

This intervention is semi structured, used in a manualised form, and is end focused with the end directions being patient as self-therapist, empowerment and coping enhancement. It is bi- directional in that lists of useful catalogues of issues are offered for work with, and the patient returns with possible solutions. The therapist initially takes on the role of Captain – offering direction and leadership but then moves sidewards during therapy to the role of a Coach – offering support from the side. Thus a gradual positive shift takes place. It is expected that the objective of empowerment with the patient becoming the self-therapist, will be achieved.

New issues in this therapy

What is new in the therapy is its focus on meaning, purpose, and sense of connectedness in the context of the patient’s belief

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system. Thus validating and appropriately including their belief and rituals that often might be the core that gives the patient and his /her family’s life meaning and hope. This aspect of this therapy offers to the patient comfort in the clinician supporting this core area of possible importance to them and their families, an area that many patients miss in their encounters with care-givers20.

In this therapy, attention is focussed in the meaning of illness, of relationships, of one’s self and one’s role, even of suffering, the purpose of life and of everyday activities. In loss, meaning is created by searching and finding the redeeming value21. This area may not be dealt with or may even be avoided in the traditional cognitive behaviour therapy. The use of problem solving is important to reduce existential anxiety and to increase mastery. The encouragement of social connectedness, an aspect of spirituality, can help reduce isolation and anxiety and give meaning that is associated with being part of a family and community.

Practical issues

The therapy is given individually at the bedside or in a room that has a healing environment, such as the quiet room, a non- denominational prayer room or the chapel. The SACBT manual uses a bridging session worksheet, which lets the patient prepare for each session, and helps with returning to areas to be focused on in the therapy session. These include areas that are found to be difficult to contend with and other areas that bring wholeness and satisfaction. An opportunity to disclose reasons for not being able to complete the homework, including the daily and/or weekly meditation, and prayer/ritual monitoring forms, is made available in this bridging worksheet, thus reducing the drop out from patients who have not completed the homework.

The cognitive focus takes place in four key areas, those being: Acceptance, Hope, Achieving meaning and purpose, and the Dimensions of forgiveness. The behavioural focus is on

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Relaxation, Medication and Prayer/Ritual exercises, together with record keeping soon after these exercises. This is achieved by reflecting on the benefits of these exercises (meditation and prayer) on the patient’s symptoms and dysfunction domain. These would include the impact of the exercises of meditation, prayer and ritual in bringing hope, extinguishing helplessness and existential despair, accepting of medication, and reduction of side-effects if these are being experienced. There is the validation of the belief in a force greater than the self, be it the supernatural or for some ‘God’. This serves in part to achieve dereflection- a technique in achieving meaning by moving beyond and away from the self on to others and for some, a supernatural18.

The patient reflects and then records the effects of these exercises (meditation, rituals – including prayer) on improving sleep, appetite, energy, function and positive well-being. The patient marks a score of1 to 5 for each of these areas on the daily worksheet. After Day 7 the patient is encouraged to spend a short period reviewing the daily record sheet, and then fill in a weekly score for each of the domains on the weekly monitoring record sheet. Based on the evidence that the patient has from these work sheets, together with the subjective experience, they are encouraged to write a comment in the weekly record sheet that reflects the true situation. This is discussed and examined during therapy sessions. The intersession of self-therapy sessions can be planned as early as the 3rd week to take place in-between therapy sessions.

Each of the four cognitive areas of Acceptance, Hope, Meaning and Purpose, and Forgiveness are considered from the catalogue of issues, surrounding each of the areas from the manual. Reflection on developmental history, and life experiences that have contributed to, or negatively impacted on each of these areas are considered and dealt with in the sessions.

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Achieving meaning and purpose

The area of meaning and purpose takes an important focus. There are five phases through which the patient is guided to work through towards achieving meaning and purpose. This starts with confronting the inevitabilities of life such as birth and death – confronting and desensitising oneself with mortality then moving to the phase – the letting go of fear and turmoil in one’s life. Exercises around achieving the letting go of fear and turmoil are built in, with the aim of mastery accomplishment in this phase. The next phase encourages examining one’s lifestyle – centring on lifestyle areas that avoid confronting mortality, and perpetuate fear and turmoil. Lifestyle changes are planned that will be adaptive to achieving desensitisation of one’s mortality together with the realistic removal of fear and turmoil in one’s life. Moving to the next phase involves focuses on seeking divine purpose, after examining and accepting one’s journey in life between the two inevitabilities of birth and death. Finally meaning is sought by seeking meaning for each day. This is achieved by identifying meaningful and realistic goals within whatever limitation life and illness brings. The use of experiential values, creative values and attitudinal values discussed earlier can be drawn on in helping the patient achieve meaning.

Structure of sessions

Generally the therapy takes place over 10 to 16 sessions for about 60 minutes duration, with flexibility to allow for between 45 to 70 minutes. The initial two weeks might allow for two sessions per week, if necessary and where possible. This will aid engagement and is appropriate to the level of distress patients generally are experiencing. Further, this could positively influence the building of trust and therapeutic alliance – a key component in achieving successful outcomes in most psychological interventions. Thereafter sessions follow on a weekly basis. The assessment of termination needs and relapse prevention needs

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in the form of scheduling booster sessions must start early in the therapy. This ensures the place in predicting and planning for the patient’s needs later in therapy and further down. For ethical reasons the therapy may continue past the 10 to 16 sessions if the patient desires this and there is mutual agreement with the patient and therapist with regards to this need.

Efficacy, Effectiveness and Efficiency

Three randomised controlled trials comparing SACBT and case management, SACBT and supportive therapy, and SACBT and equal clinical contacts have been completed. The results have not only shown significant benefits over controls in reducing hopelessness, despair, depression and improving quality of life15,16 but importantly has achieved significantly better treatment adherence, lower adverse effects of treatment and lower relapses compared to controls followed for 12 months17,23.

Conclusion

This meaning based therapy that incorporates appropriately a person belief system, which often might be the core that helps the patient and family cope, is an adjunct therapy that has been shown to improve function and quality of life. This is an important part of caring for the whole person, an area that has been found wanting in the bio-medical model22.

The results of trials17,23 have shown a reduction in relapse and re-hospitalisation in the group of patients that received this therapy. There is also evidence, that reducing relapses and increasing time to next relapse in psychiatric illness, will offer benefits in psychosocial functioning such as work and relationships, including the marital relationship24. Thus this adjunct therapy has an important and useful role in enhancing functional recovery and whole person care – an area that has had less attention given to in conventional psychiatric treatment.

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References :

1. Mackay. Postmodernity. Christian Identity in a Fragmented Age. Minneapolis: Fortress Press, 1997.

2. Adam N. Australian New Zealand Journal of Family Therapy 1995; 4: 201-8.

3. D’Souza R. Incorporating a spiritual history into a psychiatric assessment. Australasian Psychiatry 2003; 11.

4. D’Souza R. Do patients expect psychiatrists to be interested in spiritual issues? Australasian Psychiatry 2002; 10.

5. Frank JD. Psychotherapy: the restoration of morale. American Journal of Psychiatry 1974; 131: 271-274

6. Kissane DW, Clarke DM, Street AF. Demoralisation syndrome: a relevant psychiatric diagnosis for palliative care. Journal of palliative care 2001; 17; 12-21.

7. Koenig HG, Breitner JCS. Use of antidepressants in medically ill older patients. Psychosomatics 1990; 31: 22-32

8. Folkman S, and Greer S. Promoting psychological well- being in the face of serious illness: when theory, research and practice inform each other. Psycho-Oncology 2000; 9: 11-19.

9. Breitbart W. Spirituality and meaning in supportive care: Spirituality- and meaning-centred group psychotherapy interventions in advanced cancer. Supportive Care in Cancer 2002; 10: 272-280.

10. Moorey S, Greer S. Psychological therapy for patients with cancer. London: Heinemann Medical Books.

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11. Greer, S et al Adjuvant psychological therapy for patients with cancer. A prospective randomised trial.British Medical Journal 1992; 304: 3.

12. Cole BS. The integration of spirituality and psychotherapy for people confronting cancer: An outcome study. Dissertation Abstracts International: Section B: the Sciences & Engineering 2000; 61: 1075.

13. Prospt RL, Ostrom R, Watkins P, Dean T. Comparative efficacy of religious and nonreligious cognitive-behavioural therapy for the treatment of clinical depression in religious individuals. Journal of Consulting and Clinical Psychology 1992; 60: 94-103.

14. D’Souza R. Proceedings of the 36th Royal Australian and New Zealand College of Psychiatrists Annual Congress, Canberra, May 2001.

15. D’Souza R, Rich D, Diamond I, Godfery K, Gleeson D. An open randomised control trial of a spiritually augmented cognitive behaviour therapy in patients with depression and hopelessness. Australian and New Zealand Journal of Psychiatry 2002; 36: A9

16. D’Souza R, Rich D, Diamond I, Godfery K. An open randomised control study using a spiritually augmented cognitive behaviour therapy for demoralisation and improving treatment adherence in patients with schizophrenia. Australian and New Zealand Journal of Psychiatry 2002; 36: A9

17. D’Souza R, Keks N, Rich D, Godfery K. An open randomised control study using the spiritually augmented cognitive behaviour therapy for demoralization and treatment adherence in patients with schizophrenia. Proceedings of the 38th Royal Australian and New Zealand College of Psychiatrists

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Annual Congress, Hobart, 12-15th May 2003.

18. Frankl VE. The Unconscious God: Psychology and Theology. New York: Simon and Schuster, 1975.

19. Frankl VE. Man’s search for meaning: An Introduction to logotherapy. New York: Washington Square Press, 1963.

20. Koenig H. Religion, Spirituality and Medicine: Application to clinical practice. The Journal of the American Medical Association 2000; 284: 1708.

21. Park CL & Folkman S. Meaning in the context of stress and coping. Review of General Psychology 1997; 2: 115-144.

22. Astin JA. Why patients use alternative medicine: results of a national study. The Journal of the American Medical Association 1998; 279:1548-53.

23. D’Souza R, Rodrigo A, Keks N, Tonso M, Tabone K. An open randomised control study of an add on spiritually augmented cognitive behaviour therapy in a cohort of patients with depression and hopelessness. Proceedings of 38th Royal Australian and New Zealand College of Psychiatrists Annual Congress, Hobart, 12th –15th May 2003.

24. Coryell W, Turvey C, Endicott J, Leon AC, Mueller T, Solomon D, Keller M. Bipolar 1 affective disorder: predictors of outcome after 15 years. Journal of Affective Disorders 1998; 50: 109-116.

25. Pargament KI, Koenig HG & Perez LM. The many methods of religious coping: development and initial validation of the RCOPE. Journal of Clinical Psychology 2000; 56: 519-543.

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PROF. P. C. SHASTRI

He holds the degrees of M.D.(PSY), D.P.M., FIPS., MAPA(USA), M.W.P.A, Diploma International Culture.

He is Honorary President: Indian
Psychiatric Society (2008-09),President: SAARC Psychiatric Federation (2008),Chairman: Child Psychiatry section – Indian Association of Private Psychiatry (2005-09).

He is Chairperson : World Psychiatric Association (WPA): Section on Developing Countries- Chairman: Child & Adolescent Mental Health : (2008 – 2011), Chairman: Shrimati Motibai Thackersey Institute of Research in the Field of Mental Retardation-1975-2009, Sairam Autism Centre (1997-2009),.

He is recognized for being a prolific contributor and a leader in Indian Psychiatry, a stalwart in child & adolescent psychiatry for nearly four decades. He is a researcher with over 110 publications and contribution to 17 books to his credit.

He is a consultant : Adolescent Education Program – WHO, UNODC (United Nation Office of Drug & Crime), UNFPA (United Nations Population Fund), Ministry of Human Resource & Development, Government of India Kendriya Vidyalaya Sangathan, Central Board of Secondary Education, Navodaya Vidyalaya Committee, Delhi Public School & Expressions India.

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SPIRITUALITY AND CHILD MENTAL HEALTH

P. C. Shastri

WHO defines health as physical, mental, social, moral and spiritual well-being. The definition encompasses promotional and preventive aspects of mental health.

Last two dimensions of health viz. moral and spiritual wellbeing have been included primarily to prevent large number of disorders and promote positive mental health. It is a known fact that majority of behaviour patterns are due to deterioration of moral and spiritual values. For e.g. High risk behavior like unprotected sex and its consequences (HIV, teenage pregnancy), alcohol related problems are just few interlinked issues that can best be prevented by proper moral foundation, right at the beginning of life. Moral and spiritual development is hence a vital dimension in a child’s development. It is well known that family plays vital role in moral development. Appropriate guidance and attention in ensuring proper moral & spiritual development in early childhood surely translates into them having a sound and quality mental health as adults.

In India, the concept of ‘Garbh-Sanskar’ i.e. intrauterine learning has been well documented and practiced by large number of families as part of their culture and upbringing. Even in our mythological stories, we find ample evidence of intrauterine learning. As depicted in Indian epic Mahabharata – Abhimanyu learnt about war tactics including handling strategic moves to combat complicated war situations described as ‘Chakravyuha’ while he was in the womb. When he grew up he effectively used his leanings during the war of Mahabharata.

It is common in our culture that during pregnancy, women indulge in religious and spiritual programmes, read books that

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present better values and positive, high thinking in new arrival in the family. Emotional well-being is associated with moral and spiritual well-being. Another example from our mythology is that of Ramayana where Sita brought up Luv and Kush – from early pregnancy days to adolescence. Their upbringing gave them confidence and power to fight for their rights and excellent handling of war like Ashwamedh Yagna with their father Lord Rama. They had confidence to stand through valiant fight and achieve victory to bring back the respect and deserving status to them as well as their mother. Being born and brought up in spiritual environment had given them moral strength and high self-esteem.

All religions recommend spiritual leanings as part of environment during pregnancy. Most of our families also believe in exposure to pure thoughts and words as part of intrauterine life. The aim behind spiritual development is to channelize their mind, thoughts and feelings in positive direction. Modern science also has enough evidence to substantiate that fetus learns during intrauterine life – a classical example being voice recognition of father and mother soon after birth. These learning also transcend from child to adult phase.

Development of conscience and moral standards occurs during preschool years. Middle childhood years represents critical period during which conscience develops at rapid rate. As child begins to involve the development of more generalized abstract standards, it becomes less exclusively determined by external rewards and punishments and more by internal sanctions; it begins to involve not only the avoidance of prohibitions but also the pursuit of what one should do.

Story telling and moral lessons of story are important to development of sense of equity in moral judgment between the age of five to twelve years. Some excellent examples of these teachings are our very own childhood story literature like Jataka

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Tales, Panchatantra etc. Later on, group and peers influence the judgment. However, a sound early moral judgment base from family is less likely to be influenced by peer group at later age.

Murphy says, “Moral realism yields gradually during childhood to an ethics of reciprocity; what is right is now defined not in terms of self-evident and inherent necessity but in terms of a sense of balance or justice. Rightness is a matter of the mutual consideration of needs.”

Unless a reasonable degree of conscience development takes place during the middle childhood years-that is, unless standards of right and wrong are established-the child and later, the adult is apt to yield to the asocial temptations offered by others or to his own urges of aggressive, sexual and regressive behaviour. Obviously, mature conscience development requires cognitive maturation as well as a number of complex psychological processes based on learning.

What is spirituality and why is it of value to children. Spirituality doesn’t mean the rules and dogma of any organized religion, nor the value system of a culture. A definition from Webster best describes Spirituality; it means “showing much refinement of thought and feeling”. According to Peggy Jenkins, the “thought and feeling” is awareness that we are multidimensional beings, living in a spiritual universe, governed by spiritual laws.

Spirituality is important to children because, like us, they are spiritual beings having a physical experience. The fresher they are from the spirit world, the more expanded their awareness. They know our thoughts and feelings, see into other dimensions, and remember where they came from. It is important that these natural gifts be supported, not denied or made fun of.4

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According to Peggy Jenkins, a spirituality based upon true identity can build children’s self-esteem. “An understanding of spiritual laws that can be counted on in all situations gives children a sense of security and control over their lives. In age appropriate ways, they can be taught the creative power of their thought. Principles such as “what you focus on expands” or “where your attention goes, there energy flows,” put them in charge of their life.”

Another way that spiritual understanding aids children is that they come to see this world as an ordered place run by higher laws, a classroom where they are totally supported in learning what they need to learn. In this context, the world is seen as a benevolent place, not chaotic, haphazard or dangerous.4

Until about twelve, the family traditions and their observations of family faith are the motivations for children’s spiritual thinking. This is the age, from about six to twelve, that family values of Right Action and moral behavior have the most profound influence on spiritual values. That is why it is so difficult for children from dysfunctional homes or broken marriages to craft their adult belief systems easily. By the teenage years, spirituality has been established. For those from well grounded homes, spirituality is evident, through both words and behaviors. But many teens that are not subject to daily demonstrations of faith do, never the less, manage to evolve as spiritual beings. It is, after all, an inherent legacy in us all.1

According to Stuart Malkin, “Empowering children with Spirit is an adult quest to which we should all aspire. It means recognizing that children at an early age, when they are only able to think in concrete terms, be empowered with the real visions that they can comprehend. It means answering questions and allowing them to express their ideas. It means encouraging good thoughts and discouraging mean spirited ideas and actions.”

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We can use practical ways to show our children, using nature or everyday objects, about the natural or spiritual laws. Many people these days call themselves as ‘spiritual seekers’ but do not see themselves as religious or want to talk to their children about God. But one can add lot of value and quality in mental framework by teaching lessons on things like:2

· An introduction to Gratitude. · An introduction to Spirit.
· An introduction to Oneness.

According to Becca Glouzstein, “We are all made up of spirit with divine qualities, such as peace, joy, clarity, love, health, order, wisdom, power. No matter how others look and act, we all have the same qualities within if we look close enough. Spirituality in growing years can show your children in a gentle way exactly who they are and what they can be. Spiritual lessons are so simple and visual that the mental image of them will guide them through many of life’s challenges.”

As parents, we can follow simple principles for ‘Spiritual Parenting’. According to psychologists Mimi Doe and Marsha Walch in their book ‘10 Principles for Spiritual Parenting’: “We know more about nutrition than did past generations. We’ve identified learning disorders and new educational techniques. We give our children every advantage we can afford, and some wecannot. Weorganize,direct,enroll,coachandtransportour children to and from lessons, games, practices, social events, doctor’s appointments, and schools. We are trying to be good parents and give our children all they need to develop into well- rounded and successful adults. We may, however, be missing the very core of our children’s being: their spirituality.”

We presume that children are ready and suited for certain kind of exposure or lessons keeping their age in mind. We wonder

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if children are capable of an inner spiritual life. After all we adults often have difficulty understanding the meaning of life and what is right for us and we are on a perpetual spiritual journey.

Traditionally, pre-adolescent children have been thought to be too self-centered and not able to process abstract concepts. They just absorb values and beliefs from their parents. But more recent research is showing that by the age of 4 or 5, children are intensely interested in the metaphysical –

right and wrong, good and evil. The foundation of moral, ethical and spiritual development is in first years of life, i.e. preschool years. Children are involved in what they call meaning-making- making sense of their world – from the time they become conscious of the distinction between themselves and their environment.

According to Robert Coles, “Children have insights and experiences that leave them with a remarkable sense of certainty regarding human nature, morality and spiritual reality. This knowledge is unrelated to and often inconsistent with what they were taught and left lasting influences that shaped their lives. What do we want for our children and how do we help them to achieveit? Spiritualdevelopmentisnotonlyafaithresponsibility but also a secular one because it is so closely connected to theirmoral,socialandculturaldevelopment. Thiscanhelpthem to experience a feeling of transcendence, to search for a purpose in life, to develop knowledge of oneself and to examine one’s own experiences and those of others. By supporting their development of a spiritual consciousness, we are giving our children a message that helps them to relate in a loving way to the world so that they become the good stewards of the future world.”

How do we do that? Parents can actively expose children to nature because when done in their early years, it can have a

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profound effect on their spiritual development. From nature, children learn that all life is connected. When children trust that all life is connected, they respect and appreciate themselves and the people around them. Kindness, empathy, compassion, and love grow from appreciation and respect. However, the materialism of our culture makes it difficult for us and our children to maintain our connection to the natural universe. One can see this happening as children get older and their time becomes full of school, friends, lessons, TV, video games.3

“There are number of ideas to reinforce a child’s connection to nature viz. – planting gardens, taking care of a pet, taking walksinthewoods. Keepchildrenawareofthechangingofthe seasonsandtherhythmsofnature. Incorporateregularnature- celebrating rituals into your life. Encourage quiet focused times with your children so they may hear birds singing and the wind blowing through trees”, observes Robert Coles.

Children have to be exposed to various teachings and practices in first 6 years of life. Faith, trust, love, security have potential to strengthen their roots in their six years. Later years of teaching and preaching never helps in development of these traits.

Out of a feeling of connection evolves service to others. As children develop empathy and compassion for all in the universe, responsibility and service to others is the next natural step. This can be built by making children work for others in the community and making community service as part of curriculums. It is a natural human impulse that unfortunately a lot of us lose in the family,andintheschools. Welearntoelbowourwaytothetop; ignoring people to the right and left of us all the time – this in the nameofeducation. WebecomepeoplewhogetallA’sbutflunk ordinary living.3

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Finding adequate words to describe and express the spiritual isimpossibleevenforadults. Intheirinnocence,youngchildren may try to communicate, but if they are not heard and honored, they soon begin to guard these feelings against the laughter of the world. By the age of 10, children knew it was taboo to refer to spiritual subjects in public because of the ridicule they were be subjected to by peers.3 Infact, children with strong spiritual development will not get influenced by the mindset and perception of their peers.

“By sharing with your child, they learn to feel safe and to be open. Also, it is essential to affirm child’s imagination and sense of wonder. Imagination is a vital tool for inner development. You should make sure and praise and give importance to your children’sfantasyandimaginativeplay. Childrenespeciallylike secret places (tents, snow forts, tree houses), secret boxes and imaginary friends. They may be ways for children to try out different personas and find ways to express powerful feelings”, suggests Robert Coles.

Creativity is also a good medium to bring a child closer to sense of divine and power. The creative arts can be – listening to and composing music, dancing, create artwork of all kinds as well as creative writing. This is also excellent way where children can express feelings and thoughts that are inexpressible in words.

It is important to maintain regular rituals at home even if you do not embrace a formal religion. These rituals will be the meaningful expressions of spirituality that encourage your child’s expressions. Rituals can be as simple as lighting candles & diyas or blessing the food during meal. These family rituals and celebrations turn the ordinary into the extraordinary. Celebrating the ordinary is a way of doing this.

A simple thing that appeals to children is to make a regular

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ritual of acknowledging and applauding each other. Some religions have a ritual of blessing their homes when they move in – you could compose a home blessing ceremony with your children. Burn candles, select a special rock, read something special, burn sage to clear out negative energy, play music and invite friends.

You can encourage your child to share his or her dreams with you. If you show a genuine interest in your child’s dreams, he or she will learn to value them. This will help build their self- confidence and create an optimistic approach to life and builds their self-confidence. Our encouragement helps give children the assurance they need to remain persistent and get through setbacks. If children’s dreams, wishes and hopes are accepted and encouraged, they will share them and eventually believe in the possibility of achieving them.3

There are a number of reasons why a faith community has an important role to play in building spiritual foundation in a child. As children evolve as spiritual beings, the faith community givesthemsupport,structureandasacredspace. Itprovidesa loving group to explore thoughts with, share moments of compassion and delight with, and to celebrate with. A religious community also provides support for parents. It helps them to clarify and articulate their own beliefs so they are better able to express them to their children. e.g At religious community gatherings children get exposed to relationships with different generations and different types of people and hopefully new challenges.3

Nurturing your child’s spirituality by listening to them, exposing them to nature, helping them expand their imagination, encouraging their dreams and celebrating with them is a gift you cangivethemthatwilllasttheirentirelives. Infact,thiscouldbe the most precious legacy we leave our children. We must

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embody the consciousness that we want for our children because, as the saying goes, “more is caught than taught”. Are WE choosing to live in a “safe” world that responds to our dominant thoughts and feelings?

According to Peggy Joy Jenkins, “As important as our modeling is, it is still not enough, however. Children need to be told that spiritual laws and principles exist. And these need to be discussed and demonstrated. As an analogy, consider virtues education. A parent valuing the universal virtues would be leading a life that embodies most of those virtues. However, many children don’t “get it” just from that! They need to have the virtues named (i.e. perseverance, compassion, orderliness, self- discipline, loyalty, humility, purposefulness, courtesy, courage, etc.). Then these need to be explained, observed, and become part of the language of the family. It is the same with spiritual principles and laws.”

As brain research shows, 83% of what we learn is through seeing and doing. The ancient Chinese said, “I hear and I forget, I see and I remember, I do and I understand.” Such visual analogy lessons work wonderfully for the parent who is juggling a job, home chores and car pools because they take only 5 to 10 minutes, and some can even be done in the car.

In a survey, two American psychologists asked a simple question: “What do you want for your children?” More than 10,000 adults in 48 countries across six continents responded overwhelmingly with one answer: “for their children to be happy”. While hardly a surprising answer, it underscored the fact that academics knew virtually nothing about what makes children happy.

Spirituality is a major contributor to children’s overall happiness. Spirituality — defined as an inner belief system —

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accounted for eight to 17 per cent of the average child’s sense of happiness, as per one study conducted by psychologist Mark Holder. By contrast, money, the marital status of parents and the child’s gender didn’t even register one per cent. The children were also asked to rate the importance of statements such as “I believe a higher power watches over me” and “developing meaning in my life.” Spirituality could be playing a larger role for several reasons. It produces a sense of hope and meaning and often involves socializing, which is important to children’s happiness. Spirituality is not the same thing as religion. For some people, spirituality (in children) is simply a way in which they’re more grounded internally and less dependent on external factors for their well-being.5 This is significant because once we find these (happiness) predictors, then we can give kids a coping mechanism when they’re going through difficult times.5

Spirituality helps children find in themselves a human strength, striving every once in a while to break the confines of self, of society, of time and space, even of faith. As researchers have observed, the phenomenon of children’s spirituality eludes the traditional conceptual and methodological apparatus of psychology or theology. Spiritual concerns, i.e., questions pertaining to life, death, birth, rebirth, and the universe in all its immensity do not directly depend on cognitive and verbal development.

Indeed, it is possible to trace the development of children’s religious consciousness by noting how, for example, as children mature, their prayers shift from being self-centered to altruistic. “Spirituality, undefinable as a process, defies the theoretical strictures of child development. In other words, there is something timeless about children’s spirituality. Children have the ability to tackle difficult philosophical and theological questions almost unknowingly, focusing on the idea itself, while sidestepping the logical sequences prescribed by rational discourse. Whatever

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the parents attitude toward their child’s spiritual aspirations, spirituality is an unavoidable issue in every family: the question of his or her origin, which every child asks, essentially pertains to spirituality”, notes Zoran Minderowic.

According to Erik Erikson, trust “born of care is, in fact, the touchstone of the actuality of a given religion.” Erikson uses the term “religion”, but his insight about care and trust can easily apply to spirituality in general. While there is no formula for a healthy spiritual life, caring parents will, by inspiring a fundamental sense of trust and by respecting the spiritual aspects of birth, enable their children to freely develop a sense of spirituality and manifest it through a passionate and fulfilling involvement in life. “Declaring that spirituality affirms children’s humanity and enhances their ability to understand life’s mysteries”, Robert Coles advises parents to encourage a child’s natural sense of wonderment and curiosity about spiritual issues. By their nature, children ask probing questions, and this desire to know, Coles affirms, “is also part of the moral development of children—a way for them to find a set of beliefs and ideals to guide their daily lives, a way for them to gain command of their behavior.”

To reinforce the message, one must understand and value importance of making moral and spiritual wellbeing as integral part of child’s upbringing. Their existence play vital role in prevention of large number of disorders and promotion of positive mental health.

References :

1. From Birth to Teen, Spirituality in Children By Stuart Malkin- /Parenting – Article Source: http://EzineArticles.com/ expert=Stuart_Malkin. Abstracted from the book “Empowering Children.”

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2. Wednesday, November 12, 2008 – Book Review – ‘NurturingSpiritualityinChildren’,by PeggyJenkins,reviewby Becca Glouzstein. http:www.inspirationformothers.com

3. Nurturing Spirituality in Children, – Robert Coles commentary on the net.

4. Nurturing Spirituality In Children – Peggy Joy Jenkins, Ph.D. joyful@joy4u.org

5. Spiritualitybigfactorinchildren’shappiness–study:Lena Sin, Vancouver Province; Canwest News Service – Published: Friday, March 14

6. Spirituality in Children – Encyclopedia of Childhood and Adolescence by Zoran Minderovic – Thomson Gale , Detroit, Gale Encyclopedia of Childhood and Adolescence, 1998

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Dr. Jitendra Nagpal

He is the Programme Director- “Expressions India”– The Life Skills Education & School Wellness Programme

He is the Secretary General of Indian Association for Child & Adolescent Mental Health (IACAM) and member of American Psychiatric Association. Worked in advisory capacity for technical inputs of the comprehensive school health policy for CBSE and the school health manuals. He has assisted the Technical Coordination of National Adolescence Education Programme and also been Incharge of Technical Resource Team for monitoring theAEP.

He worked with the WHO to generate teacher training packages for advocacy and awareness in child abuse. He was recently member of the Special Committee appointed by CBSE to look into the age of nursery admissions. He has been a member of various committees in assisting guidelines for child protection and promotion of mental health of children and adolescents

He is the Director of the Youth Wing – World Academy of Science & Spirituality (WASS). He is Consultant Psychiatrist – VIMHANS and Moolchand Medcity, New Delhi.

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SPIRITUALITY – A JOURNEY WITHIN THE BLOSSOMING YOUTH

Jitendra Nagpal

Interest in youth religious and spiritual development has risen sharply in recent years, positioning spiritual- religious domain as a development resource that lessens risk behaviour and enhances positive outcomes. Today’s youth is far more developed than the youth of yesteryears. Young ones have more freedom to express their thoughts and ideas and have widespread knowledge. If they are to compete on a global scale, they are armed with all the reasons and responsibility to become knowledgeable, aware and empowered.

The route people take to adulthood has become much more complicated with the pressure for achieving academic excellence. Most distressing states such as anxiety, depression and self-harm too have shown significant increases, but the general emotional experience of adolescents is less likely to reach the point of needing professional intervention. The findings are likely to fuel debates about how we are raising our children and whether they reflect parenting in early years or are linked to our education system with its emphasis on academic achievement, and poor record of out of school activities.

Spiritual Youth-The need and discovery of a nation

The spiritual component of health is now considered to be an important, integral part of well being. What is the impact of spirituality on the lives of young people? How does a young person’s spiritual heritage shape his or her view on moral and political issues? Does spiritual engagement make young people happier? And what exactly do young people believe in when they say that they have spiritual beliefs?

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Youth health indicators show that religious beliefs have a strong influence on adolescent girls and a minor effect on the behaviour of the boys. Studies argue that a religious and spiritual commitment in life is associated with lower rates of crime, drug use and other high risk behaviours.

What is Spirituality and the context to youth?

The essence of spirituality is the search to know our true selves, to discover the real nature of consciousness. This quest has been the foundation of all the great spiritual teachings, and the goal of all the great mystics.

There is often confusion between spirituality and religion. Thus, definitions are needed. Religion refers to a formal structured way individuals in groups gather to worship God. Whereas, spirituality is an individual’s personal relationship to God’ it can be marked by skepticism, belief, denial, any or all of which can be expected to affect one’s overall relationship to the world. Another definition of spirituality is, “the personal quest for understanding answers to ultimate questions about life, about meaning and about relationship to the sacred or transcendent, which may or may not lead to or arise from the development of religious rituals and the formation of community.”

Throughout the history of humanity it has been said that the self we know – the individual ego – is a very limited form of identity. Ignorant of our true selves we derive a false sense of identity from what we have, or what we do – from our possessions, our role in the world, how others see us, etc. Because the world on which it is based is continually changing, this derived sense of identity is always under threat, and our attempts to maintain it are responsible for much of our “self-centered” behaviour.

Behind this identity is a deeper identity, what is often called the “true self”. This can be thought of as the essence of

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consciousness. Although our thoughts, feelings and personality may vary considerably, the essence of mind remains the same. We are very different now than we were twenty years ago, but still we feel the same sense of “I”. This sense of “I” is the same for everyone, and in that respect is something universal that we all share.

How can spirituality facilitate?

There are many benefits of spirituality in its emerging scientific vision :

· Focus on personal goals. Cultivating your spirituality may help uncover what’s most meaningful in your life. By clarifying what’s important to you, you can eliminate stress by focusing less on the unimportant things that can sometimes seem to consume you.

· Connect to the world. The more you feel you have a purpose in the world, the less solitary you feel – even when you’re alone. This can lead to an inner peace during difficult times.

· Release control. When you feel part of a greater whole, you realize that you aren’t responsible for everything that happens in life. You can share the burden of tough times as well as the joys of life’s blessings with those around you.

· Expand your support network. Whether you find spirituality in a church, mosque, temple or synagogue, in your family, or in walks with a friend through nature, this sharing of spiritual expression can help build relationships.

· Lead a healthier life. Some research seems to indicate that people who consider themselves spiritual are often better able to cope with stress and heal from illness or addiction.

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How do I get started on a spiritual journey of self discovery?

Spiritual awakening is a journey, and just as with literal travel, this metaphorical passage is different for everyone. Being willing to surrender into the unknown is a huge – and necessary – step, because one cannot “figure out” spirituality in a linear fashion. People often begin a spiritual exploration by reading widely about the world’s religions, or by sampling various types of spiritual services. Some seek out a teacher or guru. Some learn to meditate. Others go on retreat in the wilderness. There are as many ways to discover your spiritual truth, as there are people. A formal practice is not required, although this can be a useful way to “get out of your head” in the early stages.

Within each person is a spiritual energy that has the power to make us whole. It helps us to tap into our latent power. Once touched by this energy within, we undergo a profound transformation. We experience benefits for the body, mind, heart, and soul.

A lot of researches have been exploring the body-mind connection. It has become evident that when we undergo mental stress, emotional pain, or depression, our physical resistance to disease drops. We become more susceptible to contracting a disease because our ability to keep our immune system in top working order decreases. Science has pinpointed certain disease such as heart disease, digestive problems, breathing problems and migraine headaches to name a few to be sometimes stress- related. In a study, Dr. Ilan Kutz States: “As the ability to meditate develops, a hierarchy of sensation develops ranging from deep relaxation to marked emotional and cognitive alterations”

Moreover, it can play a predominant role in increasing one’s concentration. Concentration is important in many spheres of life, such as academic studies, sports performance, creating

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music, art or literature, participation in various hobbies, and job performance. By increasing our attention span, the by-product would be more productivity and efficiency in whatever tasks we engage.

Spirituality also provides a galore of emotional benefits in several ways. First, by spending time within we can see our lives from a clearer angle of vision. We begin to recognize the roots of our pains and can start to solve the problems. By raising our consciousness we become aware of the causes of some of our feelings. We can then pinpoint the area of our life in which we need to work.

Most importantly, it helps us to recognize ourselves and our true spiritual nature.

Spirituality, life skills and adolescents

Spirituality does encompass a dimension of human experience that brings the confluence with mental health and well being to a scientific understanding. It outlines the relevance of spirituality to mental health and mental healthcare delivery. It is not necessary to hold formal religious beliefs, or engage in religious practices, or belong to an established faith tradition, to experience the spiritual dimension of mental health.

The school, in current times has a crucial role in the development of cognitive, linguistic, social, emotional and moral functions and competencies in a child. However, in the contemporary system of education, there has been a marginalized and compromised atmosphere in guiding, regulating and promoting psychosocial competence of children. The growing minds have to cope with heavy syllabi and curricula, inadequate teaching facilities and highly competitive examinations. In addition, there is low priority in national planning, limitations of resources and commercialization of education.

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School education has indeed been a serious source of stress in many parts of the country, awakening the demand of holism and well being as science as well as spirituality.

The implementation of effective school mental health programme, including an environment supporting social and emotional well-being should become an integral part of the movement towards a new science and art of spirituality.

‘‘A small body of determied spirits fixed by unquenchable faith in their mission can alter the course of history.’’

– Mahatma Gandhi

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Dr.Mushtaq Ahmed Margoob

Professor Mushtaq Ahmad Margoob,
Professor and head, Post Graduate
Department of Psychiatry, Government Medical College and Honorary Director, Advanced Institute for Management of Stress related disorders and life style problems, Srinagar, Kashmir is an internationally recognized expert on disaster psychiatry. Dr.Margoob’s research work encompasses a wide range of topics ranging from seasonal mood disorders to drug use problems and stress coping mechanisms.

Over the past more than eighteen years, the focus of his work has been traumatic stress resulting from man-made and natural disasters in the developing world and its impact on the individuals as well as the community as a whole. Dr Margoob is currently on the Editorial board of two international and two national journals including the Indian Journal of Psychiatry. He is also among the founding executive members of Indian Association of Biological Psychiatry.

He is a member/fellow of more than dozen international professional bodies including the international member of American Psychiatric Association, International Society for study of traumatic stress, The International society for the investigation of stress, World Psychiatric Association, SAARC Psychiatric Federation, South Asian Federation International and Indian Psychiatric Society. Dr Margoob has been actively involved at the national level in the efforts to advance Medical Education, Research and Service Planning in Mental Health. He is also member of national Consultative Committee for the National mental health Program.

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Huda Mushtaq

She obtained 1st position in her Post
Graduation in Psychology from the
University in Kashmir and then
completed her M.Phil in Clinical
Psychology from the Institute of
Human Behaviour and Allied Sciences (IHBAS), New Delhi. She did her specialized training in Child and Adolescent Mental Health and also in Behavioural Medicine from the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore. She is currently working as a Consultant Clinical Psychologist in the Post Graduate Department of Psychiatry, Govt. Medical College, Srinagar and is actively involved in the efforts to advance education and research in mental health.

She has to her credit, several research publications and was the guest editor of the first supplement issue of an indexed journal of JK Practionter-An international journal of current medical sciences and practice/ Traumatic Stress: Source, Symptoms and Solutions : South-Asian Experience.

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THE ROLE OF SPRITUALITY IN DISASTER SITUATIONS: PIR,

FAQIR AND PSYCHOTHERAPIST; PSYCHOSOCIAL INTERVENTION OF TRAUMA

Huda Mushtaq and Mushtaq A. Margoob

Introduction : In spite of the advances made in various fields of medical science, traditional healing practices continue to be used widely all over the world, especially in Africa and South Asia where traditional faith healers are usually the first contact in the event of a mishap or sickness. The dawn of the new century has also seen a significant increase in realization in the West that spiritual factors are an integral part of health and well being1. Recent observations including a pilot study (2008) of meditation for mental health workers in America following Hurricane Katrina in New Orleans suggests that meditation is a feasible, acceptable, and effective intervention for the post disaster symptoms of PTSD, depression, and anxiety2. Given the potential effects of spiritual and religious beliefs on coping with traumatic events, the exploration into the role of spirituality in fostering resilience in trauma survivors may advance our understanding of human adaptation to trauma3.It is therefore important for mental health care professionals to be aware and sensitive to spiritual dimensions of mental health. Taking a lead from an article4 by Late Prof. E.M. Hoch, written some 30 years back on the subject of importance of traditional healing practices in an oriental society, the present text describes the change over the years and the role of spiritual healers (pirs, faqirs) in chronic mass trauma interventions in Kashmir. It is largely based on an earlier publication of the authors5.

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Before describing the modus operandi of Pir Faqir healing practices, a brief account of spirituality is inevitable because the essence of their intervention is assumed to be based on it. Recent years have witnessed a significant increase in coverage of spirituality in the media, work place, education and socio- political circles1. Spirituality has also become more visible in health care with increased realization in the west that spiritual factors are an integral part of health and wellbeing6. In fact, it has always been difficult to separate mental health from spirituality in oriental societies. The reference point for traumatic stress, therefore need not always revolve around western theories alone. A rich body of knowledge and wisdom is present in ancient texts of oriental societies. A major resource already exists in terms of people who practice or advocate it, and populations that believe in it and follow it.

A recent study assessing the implications of psychiatric pluralism for WHO research on mental health disorders examined patients in three forms of therapy for mental illness in south India: Ayurvedic (indigenous),allopathic (western) and religious healing, and reported that patients in all three therapeutic systems showed improvement after follow-up evaluation, and that several patients had radically divergent experiences with each of the three therapies – each therapy was helpful to some and ineffective for others1 .In view of the new insights gained through recent studies7,8, the WHO’s 1979 follow-up study results on severe mental disorders are being reinterpreted in view of containing very little description of local culture, and tendency to apply western common sense to the practices of developing countries. The study had lamented ignorance about the nature of mental illness and misconceptions and superstitious beliefs about mental illnesses which lead people to seek help from faith healers. Subsequently, however, WHO sponsored follow-up studies found better outcome for severe mental disorders in developing country centres as such places have a greater

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availability of diverse forms of therapy when compared with the developed countries.

Psychotherapy implies a change of perspective with the objective to understand emotional problems, change coping skills and to restructure the personality9. Application of the techniques of psychotherapy commonly practiced in the west may be difficult to employ in their absolute form in our patients. Regional notions and healing practices including religion10, 11, 12, 13, yoga14, 15, 16 and meditation17, 18 are reported to be helpful in managing a number of psychiatric problems, social and spiritual afflictions and are now being strongly recommended even at the advanced centres of the U.S.A. Recent surveys show that approximately 80% of Americans believe in the connection between healing and spirituality and there is a rekindling of interest in, and focus on the spiritual dimension in medical schools19.

Dr. Afzal Javed, the World Psychiatric Association’s present Secretary General for the developing world, during an International Congress on ‘Religion, spirituality and psychiatry” at Tuzla, Bosnia, explicitly stressed on the need to reconsider the place of religion and spirituality in psychiatry. He emphasised that “despite the secularizing influence of modern society, the presence of religiosity remains substantial and reports suggest the positive impact of religious beliefs and practices on day to day functioning and mental well being20 .Suggestions that spirituality and religion can be powerful tools to boost resilience, not only for man made stressors but even in the face of calamities and catastrophes, are getting strongly substantiated.

A more recent study on the inhabitants of three different population centres in Israel, including a suburb of Telaviv, a settlement in the Western Bank and a settlement cluster in the Gaza Strip exposed to various forms of violence clearly demonstrated that even under extreme conditions, deeply held

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belief systems influencing life impart significant resilience against developing stress related disorders. “Religiousness combined with common ideological convictions and social cohesion was associated with substantial resilience as compared to a secular metropolitan urban population”, conclude the researchers21.

Our team has also observed a similar phenomenon over the years as already been reported in a number of our earlier studies including the most recent one during Imtiyaz Mansoor’s doctoral thesis work on psychiatric morbidity among amputees resulting mostly from the present violent conditions prevailing in Kashmir. A sizable number of amputees had no post amputation psychiatric morbidity which they attributed to coping by way of strong faith in the religion which emphasises the essence of fate and Will of the Creator in all the events of one’s life. Spirituality, though often used interchangeably with religion, goes beyond a specific religious affiliation 22,23. Religion and spirituality both offer a sense of meaning and purpose in life but spirituality transcends organized institution of religion, in relationship between the person and a Higher Being22, 24.

In almost all of South Asia and Africa, traditional religious healing practices are widely prevalent and people consult indigenous spiritual therapists first in case of bad health 25. The spiritualism in these countries is recognized as a way of life with eternal joy and bliss beyond the realm of sensual pleasures26. In the fatalistic orient, faith is often the reason for resilience, for it fosters acceptance of the trauma as an act of providence. No wonder then that in case of an adverse situations or disasters the affected communities almost en mass resort to coping attempts through spiritual cognitive mechanisms as revealed also in earlier disasters like Bhopal Gas tragedy 27 and Latur earthquake28. The capacity to make sense of a traumatic life event with an approach that “fits” with one’s previous beliefs not only diminishes the likelihood of developing post disaster

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morbidity, it may even lead to psychological or spiritual growth29.

Based on similar spiritual principles, Sri Sri Ravi Shankar’s organisation ‘The Art of Living Foundation’ has also been offering programs for trauma relief to several regions of conflict and natural disaster around the world. Kashmir has been the favourite abode of mystics for hundreds of years. Sufi mystic and psychotherapist share in the community the experience of balance between inner and outer life. In view of the prevailing turbulent conditions in Kashmir, a reappraisal of the conventional/ psychotherapeutic methods practiced here during 1970’s (as earlier reported by the eminent expatriate European psychiatrist late Prof. E.M.Hoch30, the then Head of the Department of Psychiatry, Government. Medical College, Srinagar and Medical Superintendent of the Sole Psychiatric Diseases Hospital of Kashmir), would be a worthwhile exercise. The present study therefore reports on the previous practices of the local traditional healers (during 70’s), the common beliefs concerning the nature and origin of mental disorders in Kashmir and the change over past 30 years. This includes items relating to their family background, sociodemographic variables, personal history and characteristics; the training recommended and detailed account of their techniques for different types of health and other problems.

In Kashmir, the Muslim community forms majority of the population; some families have the hereditary status of being a Pir. The Pir, known as a respected wise man, prominent representative of religion and a spiritual guide who not only has power to drive out evil spirits and to cure physical and mental illnesses, but also to ‘divine’ the hidden causes of various misfortunes including litigation, theft, and the wisdom to give appropriate advice in crucial life situations. Although not all the men born in a Pir family actually function in their traditional role and are engaged in different professions, but they still enjoy a special respect. A person, who has served an apprenticeship

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under a recognized Pir can also attain the status of Pir and would then transmit it to his descendents. The training and initiation into the carefully guarded secrets of their practices is handed down from father to son or from teacher (Pir) to disciple (Murid). No intoxicants are used for achieving trance states. A Pir usually dresses in a sober, traditional way which earns respect. The techniques used by Pir are making passes, breathing air on to the patients, dispensing of Tawiz (amulets), Pills or Holy water.

In contrast to the Pir, a Faqir does not have any hereditary status, may belong to any religion, and is a self styled healer, often eccentrically dressed or rather undressed and adorned by bizarre attributes, and makes frequent use of intoxicants, especially cannabis in various forms. Fumigations, rhythmical singings, dancing to the tunes of drums sometimes accompany the healing sessions. Sometimes a pretender can take on the role of a Pir or Faqir. In some situations, a chronic mental disorder patient is taken as a Faqir and lot of people visit him for healing.

Trivedi and Sethi, about 25 years back in their study on 10 prominent faith healers of Lucknow reported that most of them belonged to lower economic class, were extroverted, less intelligent and more assertive. Most of them had undergone training but had not been asked to demonstrate their ability25. With a significant improvement in the awareness, education level and socioeconomic status like any other place over the past thirty years, the stigma attached to psychiatric disorders has decreased. The turmoil of past 20 years in Kashmir has led to a phenomenal increase in psychosocial problems. The increased psycho- education through media, government health services and NGOs has led to an increased demand for psychotherapeutic and medical treatment by mental health professionals on one hand, while on the other, continued death and destruction has reinforced the faith in God and coping with spirituality resulting in a massive rush to faith healers, shrines and other

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religious places.

There has been a steady change in the percentage of patients visiting faith-healers before they seek psychiatric help. In 1996, 73% of the total patients would visit a faith-healer before seeking psychiatric help and more-so in rural areas (87% in rural and 59% in urban area), while as in 2005, 68.5% (84% in rural and 53% in urban) of the patients seeking treatment visit faith-healers first. Because of these factors, the trends to compete and cooperate to certain extent between mental health professionals and the indigenous spiritual healers is continuing the same way as three decades back. In majority of cases, without any ill feeling on either side and in a spirit of peaceful co-existence, the traffic continues to run both ways. Patients under the treatment of mental health professionals, wishing to make use of the local resources, are hardly objected to except for instructions not to approach an imposter using unethical measures like branding etc., or discontinue the prescribed treatment. The indigenous healers in turn continue to refer difficult cases to mental health professionals. Although the referral of patients from faith-healers is not very large, it is still higher than the percentage of patients referred by medical professionals.

In 1996, from a sample of 912 patients seeking treatment at Psychiatric Disease Hospital, 81.6% were referred by old patients, 13.4% by faith healers and only 5% by medical practitioners. In 2005, from a sample of 1010 patients seeking treatment at the Hospital, 76.17% were referred by old patients or after media inputs, 14.12% by faith- healers and 9.7% by the other medical professionals. Though there is an increase in the number of patients referred by the other medical professionals, the number of patients referred from the faith healers shows no significant change. Another tendency, that has decreased considerably but still exists, is the one in which some chronic cases of mental disorders may receive high respect and

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veneration as ‘Faqir’ or ‘Darvish’ and get approved as healers, especially by community associates from the similar sociocultural background with a possible huge identification with such a healer. But then, a similar kind of situation can also arise when unqualified people indulge in psychotherapeutic interventions especially in crises or disaster situations. The process of unwarranted digging like debriefing even by qualified professionals during the immediate post disaster period has been shown to result in more harm than help.

The indigenous healer usually achieves his aim of intervention in a single session, except if the person becomes a regular devotee or apprentice, while the psychotherapist usually works for a longer period which 30 years back would probably mean many years. Even though Cognitive behaviour therapy and other recent techniques focus more on the present situation over a few sessions, the faith healer has always been using techniques so as to complete the intervention in a relatively much shorter period. The Pir and Faqir continue to perform his practice mostly in public, either in a family or in a wider gathering. Psychotherapy on the other hand continues to rely on seclusion of the therapist with his patients, discouraging contact of family members. The strategy of traditional healers is drawn on aspects of healing that are viable alternatives in societies where advanced technology and sophisticated understanding of disease is wanting. The traditional spiritual healers, many of whom are part of the clergy, are intimately involved with their patients and are highly respected in the community for their skills and sharing the results of their work. For many people, the first person they seek out during times of crisis and need is a Pir, or a Faqir, or some other religious/ clergy person31. The psychotherapeutic consequence of a pir’s advice among particular subgroups of populations in a disaster situation is also reflected here in the case of a snow storm survivor of a semi nomadic mountainous dweller community of south Kashmir.

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Case Report:

Ms. J, 52 yr old female, a housewife, like other members of this socioeconomically poor and marginalized community of snowstorm survivors, experienced psychological reactions in the immediate aftermath which included feelings of ‘shock’, extreme fear, helplessness, multiple somatic complaints and sleep disturbances with occasional outbursts of anger and increased hostility. Unlike many others whose complaints improved over time by reaching an understanding with and acceptance of their experience, Ms. J’s symptoms worsened in the setting of ruinous post disaster environment, as she struggled to survive. In the fourth month after disaster when seen at the outreach post, Ms. J presented with history of irritability, use of harsh language and loss of sleep.

As the history unfolded patient attributed her symptoms to the traumatic experiences of the disaster. More than three months back during the snowstorm, she along with her husband got trapped in a collapsed cowshed. When her 60 yr old husband after a great struggle managed to find his way out of the crumbled structure, she initially refused to accompany him with the argument that in view of the whole village including her family having apparently perished, they should also die. While labouring out of the storm struck village through the devastated structures, uprooted trees and heavy snow, she could feel her feet touching dead human body underneath. She vividly described how her husband and she managed to pull out an old man alive, who collapsed immediately afterwards due to extreme cold. Finally, after an ordeal of many hours, when they reached the neighbouring village, she desperately looked for her family members and relatives who were scattered throughout the locality in different houses. To her dismay and shock, out of a total number of nine family members, only her 10-yr old youngest son, besides her old husband was alive.

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After this, the patient had continued to be disturbed by frightening dreams of dead bodies scattered all around. Recollection of thoughts related to the deafening sounds at the time of disaster and the dead bodies touching her feet as well as palpitations and restlessness would recur. She would get markedly distressed and would try her utmost to avoid thoughts, feelings and conversation related to any aspect of the snowstorm. She would even try to avoid looking towards the mountains as they vividly reminded her of the whole sequence of traumatic events associated with the storm. Following continued inability to have a peaceful sleep, patient’s irritability and outbursts of anger had markedly increased. She would often quarrel with those living in the neighbouring tenements. Routine clouds or winds would frighten her extremely and she would feel haunted by an intense feeling of an impending catastrophe.

During the interview, patient kept on saying repeatedly “ I want to die; I want to go away; I had all hopes pinned on my children, whom I brought up in abject poverty; I was looking up to them as a source of comfort during my old age; I have lost my whole world”, expressing extreme hopelessness and helplessness. Since the process of encouraging the traumatized community to first rely on their inherent strengths and their existing support network had been going on for quite sometime now and keeping in view the ground reality as well as the patient’s condition and vulnerability (2 years prior to disaster, her 21-yr old son had died due to fall from a tree, only 3 days after his appointment for a Govt. job) ̧the treatment attempts through cognitive behavioural therapy and exposure therapy had to be shifted to pharmacological intervention supplemented with task support with the help of community volunteers but the patient did not show much response. However, a remarkable rather a dramatic change in the overall behaviour was noticed after the visit of their family’s pir. The pir after a detailed advice regarding the implications of her continued negative response to the deceased

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against the will of God made her to restart the house hold activities including preparing the next day only a sumptuous meal for the pir and his associates This was a clear example of Spiritual cognitive restructuring/reinforcing, continued over the next three months, when patient improved considerably and would visit the other fellow disaster victims to share their grief and sorrows.

The situation even in the most advanced places of the world, as was revealed also after the ‘Katrina’ hurricane in America, also presents similar examples of spiritual coping after a disaster. Now a days, many people, even in the West would seek help from the clergy than from mental health professionals and are often more satisfied with the assistance they receive from clergy. Present research has revealed that spiritual programmes can be very useful in the event of traumatic response32, particularly in a mass trauma or a disaster situation. Encouraging collaboration with traditional healers has been specifically stressed, as a working alliance between traditional healers and allopathic practitioners can help to overcome barriers to treatment acceptance and delivery33,34.

This has also been strongly stressed by Russell De Souza and Bruce Singh in the light of their experience of working within the disaster areas of Srilanka following the Tsunami, who concluded, “Thus, in these resource poor areas, the collaboration of medical and mental health professionals with appropriate traditional resources such as faith healers, pastoral care clergy and similar care is seen as an important and necessary engagement and an opportunity in terms of care, provision of meaning and general community support”35

This intervention, like most other management modalities warrants a caution about its limitations. Faith healing, for most of its practitioners is a source of earning their livelihood. There is always a strong possibility of exploitation and likelihood of the

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whole exercise getting converted into a brisk business or unbridled trade for faith healers, once it gets inadvertently patronized by a qualified mental health professional or a credible organization. A reference to a recent write-up on this topic by the writer, Aijaz-ul- Haque,in Kashmir’s most widely circulated newspaper The Greater Kashmir may not be out of context. He writes on this “Peer-Mureed duo makes an interesting combination in the Oriental folklore and Eastern literature. It’s been once revered as a sacred bond between the one in quest of truth and the other bearing torch. But, as the years rolled by, pure spiritual association got smeared with material interests and thus entered the element of exploitation which the famous Eastern poet, Iqbal, refers to in a small poem titled ‘Baaghi Mureed’ (rebellious disciple), strikes at the root of a relationship based on foul play and exploitation, which Mureed(disciple) can’t bear anymore (I can’t afford even a lamp of clay, but look how does the mansion of my priest dazzle with the light of luxury)”.

“Had spiritual knowledge not been manoeuvered for personal ends, who knows world would have been better off. Peer-Mureed alliance so nonchalantly toyed with by mavericks, would have been a reference point of respect had it retained the essence it once had. Though there may be a few examples around with the same nostalgic touch, but how many? By and large the company of guide and the disciple can easily be renamed as a queer partnership between a naïve follower and a shrewd instructor. Dynastic rule, theocracy, priesthood and all such fanatic expressions of a base desire played havoc. Suppression of ideas, blind following, unquestioning obedience of some fallible and may be iniquitous souls was wilfully accepted as the order of the day. The institutions of an emotional mind-wash got encouraged, where a disciple could not dare to put his oil lamp of clay against the flashlights of affluence his guide enjoys. Religion, we believe, has humanized and will always humanize the rawness of flesh and blood. But, let us not forget, faith has nothing to do with

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pedigree. Knowledge, spiritual or material, is an intellectual property not to be inherited or copyrighted but to be cultivated, something not to be bought and sold, but to be taught and learnt”36.

One more caution to be taken is against imposters in the name of spiritual faith healing, who indulge in various injurious and unethical practices including branding psychiatric patients with hot iron rods. To prevent such unacceptable activities, proper advance homework including preparation of well formulated psycho education material, in the form of pamphlets and handouts for disciples can be helpful .We feel that an appropriate way to end this discussion is to close it with the late Prof. E.M. Hoch’s enlightening words, quite relevant even today:

“In developing countries under the influence of rapid social and cultural transportation, one frequently finds confusion in this respect (of the fit between popular beliefs and attitudes with regard to mental illness, the symptomatology of mental disorders actually prevalent and the healing practices available for them).Old sick roles and healing practices have lost their meaning and attraction while at the same time, the Western methods already introduced may not be adequate as yet for level of emancipation and the still archaic symptomatology of those who try to make use of them. The therapist working in this situation is therefore forced to abandon all dogmatic rigidity and to find new approaches relying on that which is fundamental to all healing. This, however, is what he basically shares with his indigenous counterpart, whom then he will no longer consider as an outdated absurdity, nor as a dangerous rival, but as a respected colleague with whom he feels at one”.

References :
1.
Mersoikomer, C and De Craemer W. (2002) The sprituality

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of academic physician: An Ethnography of a criptora-based group in an academic centre. Academic Medicine 7716: 562-563.

2. Waelde C.L.,Uddo M.Marqueett., Ropelato M et al.,(2008); A pilot study of meditation for mental health workers following Hurricane Katrina. Journal of Traumatic Stress, 21(5): 497-5 500.

3. Peres F. P Julio , Almeida A M, Nasello A G and Koenig H G, (2007) Spirituality and Resilience in Trauma Victims Journal of Religion and Health, 46(3)

4. Hoch ER. (1973); Pir, Faqir and psychotherapist. The human context, pp. 668-677.

5. Huda M, Margoob MA.(2006) Pir, Faqir And Psychotherapist. JKPractitioner,13(Suppl1) 589-593.

6. Dossey, L. (2001). Healing beyond the body; medicine and the infinite research of the mind. Boston, Shambhale.

7. Levin JS, Larson DB, Puchalsk CM. (1997); Religion and spirituality in medicine: rescue and education. JAMA, 278: 792-3.

8. Desai .N.G, (2003) Responsibility of mental health professionals. Presidential address delivered at the 27th Annual Conference of Indian Psychiatric Society – North Zone Oct., 2002. Journal of Mental Health and Human Behaviour, 8(2): 4-16.

9. Craig TJ, Seigel C, Hopper K, Lin S & Sortorious N. (1997); Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive practitioning reanalysis of the WHO DOSMD data. British Journal of Psychiatry. 170: 229-233.

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10. De Jong J. TVM & Van Ommern M. (2002); Towards a culture – informed epidemiology Combining qualitative and quantitative research. Transcultural psychiatry, 9:422-433

11. Hallburton M. (2004) Finding a fit: psychiatric pluralism in South India and its implications for WHO studies on Mental disorders, 41(1): 80-89.

12. Hopper K andWanderling J.(2002); Revisting the developed versus developing country in course and outcome in schizophrenia: Result from ISOS, the WHO collaborative follow up project. Schizophrenia bulletin, 26(4); 835- 846.

13. Hussaine SA. (1983); An elementary study of the principles of individual and group psychotherapy in Islam. Indian Journal of Psychiatry, 25: 335-337.

14. Grover P,Verma VK, Pershad D,Verma SK.(1994); Role of yoga in the treatment of neurotic disorders: Current status and future directions Indian Journal of Psychiatry. 36: 153-162

15. A prelimenary report on research projects conducted during yoga based Tsunami relief programme at Andaman and Nicobar Jan. March 2005. Swami Vivekananda Yoga Research Foundation, Bangalore India.

16. Janakiramaiah et al., (1998); Therapeutic efficiency of Sundershan KiryaYoga, NIMHANS.Journal , 16, 21-28.

17. Andrade C. (1991); Meditation from an Indian perspective. Indian J. of Psy. 33, 323.

18. Bhaskaran K. (1991); Meditation from a mental health perspective. Indian J. Psy., 33, 323.

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19. Galenter M.(2002); Alcohol and drug abuse, healing through social and spiritual afflictions. Psychiatric Services, 53: 9, 1072-1074.

20. Javid M.A., (1999); Religion, spirituality and psychiatry 6th International Congress of the WIAMH, Tuzela Bosnia & Herzegovina pp. 13-15.

21. Kaplan Z, Mater MA, Karmir R, Sadan T and Cohen H. (2005); Stress related responses after 3 years of exposure to terror in Israel: Are ideological religious factors associated with resilence? Journal of Clin Psychiatry, 66: 1146-54.

22. Blugler D and Osbourne T. (2004); Spirituality and Psychiatry. Indian J. Psychiatry, 46(1): 5-6.

23. Peterson ER, Nelson K. (1987); How to meet your client’s spiritual needs. Journal of Psychosocial Nursing, 25, 34.

24. Lukof D, Lu FG and Turner R. (1995); Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatric Clinics of North America 18, 467-486.

25. Trivedi JK and Sethi BB. (1979); A psychiatric study of traditional healers in Lucknow city. Ind. J. Psy., 21, 133-137.

26. Golecha GR.(1996); Spirituality science and mental health, Presidential address. Ind J. Psy. 38(2): 57-61.

27. Sethi BB, Sharma M, Trivedi HK, Singh H. (1987); Psychiatric morbidity in patients attending clinics in gas affected areas in Bhopal. Ind J Med Res 86(suppl):45–50

28. Executive summary of final report of ICMR center for 352

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advanced research on health consequences of earthquake disaster (Marathwada 1993) Agashe M.et.al.MIMHPune.

29.Tku,K.,Calhoun,L.G.,Tedeschi,R.G.,Gil- Rivas.,Kilmer,R.P., (2007); Examining posttraumatic growth among Japanese University students. Anxiety, stress and coping, 20, 353-367.

30. Hoch ER. (1973); Pir, Faqir and psychotherapist. The human context, pp. 668-677.

31. Koenig H.G, (2001),Religion spirituality and medicine: how are they related and what does it do? Mayo Clinic Proceedings, 76 (12): 1189-1191.

32. Jain A. K., Kanazi, R. L., Aberson, C. L, Fegin L., (2002); A Cross sectional study of the psycho-social and spiritual impact of natural disaster. Int. J. GroupTension, 31:2, 175-183.

33. World Health Organisation, (2003) Mental Health in Emergencies

34. Somasundaram, D. J. and Putvan, D.E. (2006); Management of trauma in special populations, J. Clinical Psychistry, 67 (Suppl 2), 64-73.

35. D’ Souza, R. and Singh, B. (2005); The mental health challenges in Srilanka from working within the disaster area; World Psychiatry, , 4:2, 68

36. Aijaz-ul-Haque, (2006); Write Hand, ‘I Dare’Adefiant disciple stands up and questions. Why? Greater Kashmir, 19, No. 97: Srinagar.

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Dr. Lakshmi Vijayakumar

She has obtained M.B.B.S. from
Thanjavur Medical College, Madras
University (1978); Post Graduate Diploma
in Psychological Medicine, Institute of
Mental Health, Madras (1981) Ph.D.
(Psychiatry) (1996) from Dr. M.G.R. Medical University for the thesis “Risk factors for suicides in India – A case control study”.

She is Head, Department of Psychiatry, Voluntary Health Services, Chennai, a 500- bed multi specialty, government aided hospital; Consultant Psychiatrist in Public Health Centre, a community hospital, Chennai and the Founder Director of Anugraha Research & Rehabilitation Centre, Chennai.

She has won National Talent Award by the Government of India for the first hundred students in the State, Kalimuthu Gold Medal for standing first in Medicine in Thanjavur Medical College, Balfour Medal for standing first in Medicine in Madras University and Excellence Award from the Rotary Club (1998)

She is Founder Trustee of SNEHA, a voluntary centre for suicidepreventionwhichis affiliatedtoBefrienders’International.

She is Vice President of the International Association for Suicide Prevention; National Representative for India in International Association for Suicide Prevention (I.A.S.P.); Chairperson of Ringel Service Award committee of I.A.S.P.; Member of W.H.O.’s International Network for Suicide Research and Prevention

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RELIGION –
A PROTECTIVE FACTOR IN SUICIDE

Lakshmi Vijayakumar

Introduction : Capacity to think, capacity to commit suicide and religion are distinguishing differences between other forms of life and humankind. Therefore, it is not surprising that they are intricately intertwined. Suicide is a very personal individual act but it occurs in the context of a socio-cultural milieu. Religion is an important part of this milieu as it permeates thoughts, beliefs, behaviours and actions.

There are many ways in which religion acts as a protective factor both at the individual level and the societal level. Durkheim’s (1897 / 1951) seminal study on social integration and suicide was the forerunner for numerous studies which reveal that religion and religiosity act as a protective factor against suicidality (Stack 1983a, 1983b, Lester 1987). Three sociological theories, all related to Durkheim’s work have tried to explain the relationship between religion and suicide. Durkheim’s social integration theory is based on two dimensions of religion – the number of shared religious beliefs and practices. The greater the number of such beliefs and practices the greater the subordination of the individual to group life and lower the chances of alleged destructive individualism. The actual content of these beliefs were viewed as secondary. The theory of religious commitment holds that just a few core life saving religious beliefs, (eg. Prayer, after life) may be all that are necessary to lower suicide risk (Stack 1983a). The ‘Network Theory’ (Pescosolido & Georgianna 1990) argues that church structures that facilitate friendship ties and promote interaction amongst the members acts as important source of social support and social support in turn reduces suicide risk. The above theories of religion in reducing suicide risk have supporters and detractors.

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At the individual level also, religiosity reduces suicide risk. All the religions of the world emphasize on Hope. Hopelessness is an important predictor of suicide risk and so belief and hope reduce hopelessness and reduce suicidal behaviour. Suicidal persons are invariably angry, agitated and perturbed. Prayers, chanting, meditation, yoga etc. are all aimed at calming the mind and reducing anxiety and agitation and persons who have developed these skills are likely to use them when distressed and in crisis and are hence more able to cope. The extreme loneliness or alienation is also reduced when one believes that God is with them. Belief in Karma helps to accept the vicissitudes of life which are beyond a person’s control and makes one feel helpless. The belief in afterlife (or Heaven) helps to bear the brunt of human suffering with fortitude, as the present life with its problems is perceived as only temporary.

The recent figures from W.H.O . (Bertolote, 2001), reveal that the highest suicide rates are found in atheist countries (former communist countries and China) where religiosity is not favoured by the State. On the other hand, countries where religion plays a significant role as in Muslim countries, the suicide rates are the lowest. There is an inverse relationship between religiosity and suicide rate. Trovato (1992) found that the proportion of Canadian Provinces with no religious affiliation was strongly related to suicide rate in 1971 and 1981. For 261 Canadian census divisions, a 10% change in the proportion of population with no religious affiliation (a sign of low religious commitment) brought 3.2% increases in suicide rate (Hasselbach, et al 1991).

To die and become a solitary spirit with no one to depend on is against the Confucian emphasis on family solidarity. Suicide has a long history and ancient provenance in Chinese culture. It has been connected with changing dynasties, ardent loyalty and moral protest. In the modern ideology of Chinese communism, there is no major role for religion. China has a suicide rate of

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16.1 (WHO, 1999) with unique higher rate for females. The high suicide rate in China could be explained by the traditional Chinese culture which is ambiguous about suicide and the lack of the protective factor of religion.

Communities which believe in Great Spirit like American Indian (suicide rate 19) and Aboriginals in Australia have a high suicide rate. Jains are a sizable minority in India and abroad. They are strict believers in not taking any form of life. They do not eat even potatoes, carrots and onions as the plant dies in the process. Religious suicide is sanctioned in Jainism. The monks starve themselves to death and the process is called ‘sallekhana’.

A substantial body of research has been done on religiosity and suicidal ideas, attempts and attitude to suicide. This paper will focus on the relationship between religion and completed suicide.

Christianity : The Old Testament describes ten suicides in a factual manner without censure – the most familiar are Saul, Samson and Judas. The early centuries of common Era witnessed the development of religious condemnation of suicide and Saint Augustine was the most prominent and influential opponent of suicide. Majority of the work on religion and suicide has been carried out in Christian a country which is facilitated by the availability of extensive and reliable data. Catholic religion serves as a deterrant against suicide as it is considered a sin to take life and also by the Catholic belief in after-life. Further, religious ceremonies like Baptism, Communion etc are social events which strengthen bonds among family and friends. Catholic countries like Italy (8.1), Portugal (6.7), Brazil (3.5) and Argentina (6.6) have lower suicide rates than Protestant countries like Germany (15.6), France (20.6), U.K. (7.1), and New Zealand (24.1) (W.H.O. 1999).

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Durkheim’s argument that Catholicism should shield against suicide whereas Protestantism should aggravate it has received mixed support (Stack, 2000). There are studies which reveal that catholicism was related to low suicide rate (Burr Mc Call and Powell 1994) and studies which are marked by contradictory results (Pescosolido and Georgianna 1989). In the case of gender variations, the male female ratio is narrow in Catholic countries signifying that more Catholic women commit suicide. Recent research by Pritchard and Baldwin (2000) reveal that despite a strong prohibition of suicide by Catholic Church, elderly suicides (Over 75 years) rates are higher in Italy, Spain and Portugal than in U.K or Scandinavian countries, the exceptions being Orthodox Greece and Ireland. Hence one can surmise that in general, the Catholic countries have a lower suicide rate but the elderly and the women have a higher than expected rate. Congregations which had more network and ties like Lutheran, Methodist, Reformed churches, Southern Baptist and Seventh day Adventists percent in the population lowered the suicide rate. African Americans have traditionally had low suicide rates compared to White Americans and religiosity is perhaps the most important protective factor for them (Gibbs 1997).

An index of religious commitment is Church attendance. Fluctuations in Church attendance rates in 1970 paralleled the suicide rates of different subgroups – Whites, Blacks, Men and Women (Stack 1983b). Girard (1988) found that once a control is introduced for percent African Americans, the relationship between church memberships and suicide disappears in 50 American States. Over a twenty year period in Ireland, decrease in weekly church attendance and monthly Communion was associated with increasing suicide rates in Irish males.

Individual-level data on religion and suicide are very limited. Maris (1982) found that both suicide completers and attempters were less likely to have attended churches or been religiously

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involved than controls. Sorri (1996) investigated religiosity among suicide victims in the Finnish national psychological autopsy study. Though there were no direct specific questions on religiosity, information was gathered from case reports. Overt, active religiosity was found in 18% of suicide victims. Psychiatric in patient treatment, psychotic and depressive disorders were more common among religious suicides. The author suggests that a higher level of mental suffering is necessary among religious subjects before suicide occurs.

Islam : The Quran says “it is not for any soul to die save by God’s permission … Spend in the way of Allah and cast not yourself to perdition with your own hands” (IV 33) Mohammed refused to bury a suicide and his example has established a law to that effect in Islam. Islam maintains the position that suicide is an unforgivable sin. Islam is a religion that binds its adherents to a strict code of conduct and regimen of worship. Majority of Muslims have a strong faith in their religion. According to W.H.O. statistics (1999), Muslim countries like Egypt (0.1), Iran (0.2), Syria (0.1) and Kuwait (1.8) have the lowest suicide rates. Underreporting has to be expected because of religious taboos, legal implications and the formidable challenges in collecting reliable data. Daradkeh (1989) studied 219 suicides in Jordan (1980-1985) and found that the peak rate was found in the age group of 15-34 years and 60% had previous psychiatric treatment. Simpson and Conklin (1989) compared suicide rates of Christian and Islamic countries using a 71 nation cross national analysis. They showed that Islam had an independent effect in lowering suicide within many different nations. Turkey, one of the most secular Muslim countries has a low suicide rate of 2.37 which is attributed to its religion and close family ties (Sayil 1997). Muslims living in non-Muslim countries like Fiji, England and South Africa also have a lower suicide rate compared to people of other religions (Khan 1998). Even in multicultural, secular Singapore, Malays (majority Muslims) have the lowest suicide rate compared

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to Chinese and Hindus.

In Egypt (Okasha A 1981) and Sudan (Goldney et al 1998) higher suicidal ideation is not reflected in increased suicide rate. This could imply that though there are suicidal individuals in Muslim countries, because of religious strictures, suicides are not often committed.

Judaism : The code of Jewish law absolutely forbids suicides but the story of the mass suicide at Masada is often given as an example of Jewish thought. Jews around the world have a lower suicide rate. The suicide rate in Israel has been relatively stable from 1955 and is 5.4 in 1996 (W.H.O. 1999). Levav (1989) compared suicide rates between Israel and selected European and North American countries and found that suicide rate of Israel is generally lower. But Jews of East European origin had a higher suicide rate. Pescosolido (1990) found that the Judaism’s protective factor were bigger in North East U.S.A. but small in the South.

Buddhism : Suicide is both censored and condoned . Buddhism does not consider suicide as either sin or taboo. In Buddhism, suicide can sometimes be considered as the proof of bravery or honour. It is not surprising that Buddhist countries like Japan (19.3) and Sri Lanka (31) have a high suicide rate. (Various forms of suicide like Hara-kiri, Shinju and Junshi are well known in Japan). Thailand has a low suicide rate of 4.0. There is a popular saying among Thai that “if one takes one’s life, one will be condemned to hell for five hundred life times”.

Hinduism : The majority religion in India is Hinduism. Hindus are a sizable minority in countries like Malaysia, Fiji, South Africa and Singapore. According to Hinduism, the elemental goal of human kind is to break the bondage of worldly existence. The Upanishads and Vedas ,which are the essence of Hindu

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philosophy denounce suicide. According to Gita, “One should desire neither life nor death”. Though the scriptures did not support suicide, there are numerous instances in the Epics and Puranas where suicides have been glorified. In Dharmashastra (Book of Moral code and conduct) there is a separate chapter titled “Allowable suicides”. Some of the “allowed suicides” are as atonement for crimes like murder, incest etc. A religious person can start the Great Journey of Life (Mahaparasthana) which is essentially walking in the North East direction, subsisting only on water and air until the body sinks to rest). The practice of ‘sattee’ (widow self immolation) and Jauhar (immolation of every female of the family or even the whole tribe) were also rampant in India. Hinduism condemned individual suicides but condoned religious suicides. It is not surprising that the suicide rate of India is 11.3 / 100,000. Hindus in Malaysia (Maniam 1988), Fiji (Price and Karim 1975) and U.K. (Soni, Raleigh et al 1990) also have a high suicide rate.

The often debated question is, is it the social network offered by the religion or is it the individual faith that protects against suicide? In the Hindu religion, one does not belong to any particular temple. There are numerous Gods and Goddesses and anyone can go to any temple at any time or different temples at different times. There is no geographical or community delineation for a temple. The duty of the priest (Pujari) is to be in the temple and offer poojas to the deity. They do not look after the sick, preach or visit any families to offer support. In short they have very little social role in the community. Unlike Church based activities like Sunday School, Choir etc., there is little community based activities in temples. People go to temples whenever it is convenient for them. It can be reasonably presumed that in Hinduism, it is the individual faith that is crucial and not so much the social network in reducing suicidality.

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Conclusion

Religion is a strong protective shield against suicidality. Studies among the survivors reveal that religious beliefs help them to cope with their distressing loss. Majority in the community also seek help and support from religion during times of emotional turmoil. It is unfortunate that in the name of religion, suicides and suicide attacks are committed.

In the words of Dr. S. Radhakrishnan : “Toleration is the homage which the finite mind pays to the inexhaustibility of the Infinite”.

References :

Bertolote J. (2001); XXI Congress of IASP, Chennai 2001.

Burr J, McCall P, & Powell – Griner, E (1994). Catholic religion and suicide. Social Science Quarterly 75:300-318.

Daradhek T.K. (1989) Suicide in Jordan 1980-85. Acta Psychiatrica Scandinavica 79. No.3. 241-244.

Durkheim E (1897 / 1951); Suicide – A study in sociology (J.A. Spaulding and G. Simpson Trans) Glencoe II. Free Press (Original work 1987).

Figures and facts about suicide W.H.O., Geneva (1999).

Gibbs J.T. (1997) African American suicide: A cultural paradox. Suicide & Life Threatening Behaviour, 27(1) 68-79.

Girard C (1988) Church membership and suicide reconsidered comment on Breault: American Journal of Sociology 93, 1471-1479.

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Goldney R.D., Lillian Craig Harris, Alia Badri, Sara Michael and Laura Fisher. (1998) Suicidal ideation in Sudanese Women. Crisis, 19 (4) 154-158.

Hasselbach P., Lee K.J., Yang M., Nicole R and Wigle D (1991). The relationship of suicide rates to sociodemographic factors in Canadian census divisions. Canadian Journal of Psychiatry 36:655-659.

Khan M.M. (1998) Suicide and Attempted suicide in Pakistan. Crisis, 19 (4), 172-176.

Lester D (1987) Cross national correlation among religion, suicide and homicide. Sociology and Social research 71: 103-104.

Levav I., Aisenberg A (1989) The epidemiology of suicide in Israel International and Intranational comparisons. Suicide & Life Threatening Behaviour, 19(2) 184-200.

Maniam T. (1988) Suicide and Parasuicide in a hill resort in Malaysia. British Journal Psychiatry, 153, 222-225.

Maris R. (1982) Pathways to suicide. A survey of self destructive behaviour. Baltimore John Hopkins University Press.

Okasha A (1981) Proceedings of 11th Congress of I.A.S.P. Paris p.85-91.

Pescosolido B & Georgianna S. (1989) – Durkheim, suicide and religion. American Sociological Review 54, 33-48.

Pescosolido B.A. (1990) The social context of religious integration and suicide. The Sociological Quarterly ,31 (3), 337-357.

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Pilgrim JA, Mellors JD, Boothby HA and Mann AM. (1993) Inter rater and temporal reliability of the Standardized Assessment of Personality and the influence of important characteristics. Psychological Medicine 23:779-786.

Price J and Karim I (1975) Suicide in Fiji. A 2 year study. Acta Psychiatrica Scandinavica, 52 (3), 153-159.

Pritchard C and Baldwin D. (2000) Effect of age and gender on elderly suicide rate in Catholic and orthodox countries: an inadvertent neglect? International Journal of Geriatric Psychiatry 15:10, 904-910.

Sayil I. (1997) Review of suicide studies in Turkey. Crisis, 18 (3) 124-127.

Simpson ME and Conklin G.H. (1989) Socio economic development. Suicide and religion: A test of Durkheim’s theory of religion and suicide. Social forces, 67 (4), 945-964.

Soni Raleigh V. Bulusu L. Balarajan R. (1990) Suicide among immigrants from the Indian sub-continent. British Journal of Psychiatry, 156:46-50

Sorri M. Henricksson M, Lonnquist J. (1996) Religiosity and suicide. Findings from a Nationwide psychological autopsy study. Crisis, 17 No.3:123-127.

Spitzer R.L., Williams J.B.A., Gibbon M. and First M.D. (1992) The structured clinical interview for DSM III R (SC ID) Archives of General Psychiatry 49, 624-629

Stack S (1983a) The effect of decline in institutionalized religion on suicide 1954 and 1978. Journal for the Scientific study of religion, 22: 239-252.

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Stack S (1983b) the effect of religious commitment on suicide. A cross national analysis. Journal of health and social behaviour, 24:362-374.

Stack S (2000) Suicide: A 15-year review of the sociological literature part II Suicide & Life Threatening Behaviour,.30 (2), 163-176.

Trovato F (1992) A Durkheimian analysis of youth suicide in Canada 1971 and 1982 Suicide & Life Threatening Behaviour, 22: 413-427.

Vijayakumar L. and Rajkumar S. (1999) Are Risk Factors of suicide universal? A case-control study in India, Acta Psychiatrica Scandinavica, 99: 407-411.

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Dr. O.P. Sharma

He holds the Degrees of M.D. F.I.C.N. F.I.C.P. F.I.A.M.S. F.C.G.P. F.G.S.I. F.A.C.M., F.I.M.S.A. F.R.C.P (EDIN).

Dr. Om Prakash Sharma is a
Consultant Physician Geriatrician. He is Founder Fellow of API

He is a life member of 23 Scientific Bodies and fellowship like FICP, FICN, FCGP, FIAMS, FIACM, FGSI, FIMSA, FRCP. He is the National Professor on Geriatrics and Editor of Geriatric Care in India.

He was awarded Dr. B. C. Bansal – Dr. C. Prakash Oration, Dr. R. S. Tiwary Oration, Alembic Geriatric Oration, Bharatji Gulati Memorial Oration, Dr. A. K. Rai Chaudhary Oration, Unity International Award, Reckitts Geriatric Oration, Life Time Achievement Award RAJAPICON-2003-04 and Life Time Achievement Award, Geriatrics by Lt. Gov. of Delhi, 2004.

He has edited and produced three textbooks in Geriatrics which have been taken as textbooks in Indian Medical Colleges.

Dedicated to elderly care, he has enormous contribution in a Charitable Trust which is heading for the creation of a nodal Geriatric Centre in the country.

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SPIRITUALITY AND THE ELDERLY

O. P. Sharma

“Spirituality of Asia & Science of West if combined together will bring wonders to this world”.

– Swami Vivekananda The ancient perspective

The echoing of Swami Vivekananda’s words from the historical Chicago Conference was imbibed by the modern materialistic western world as the beginning of their exposure to spirituality. The Vedic culture of India1 has a philosophy of life based upon phases of life. In this order, it begins with innocent childhood, a phase of learning, karma for social life followed by detachment in the later part of the life. The innocent childhood was the period in which apart from love and affection of parents, the child cultivated consciously or unconsciously in one’s own nature and behavior, the traditions of family as well as the habits from the parents. Needless to say, the mother’s impression always over-shadowed all other exposures. This phase, that is, learning, continued in the ‘gurukuls’, which later on became the schools and other centers of learning.

The learning was influenced to a great extent by the caste, creed and the family profession, apart from the access to teaching institutions. This followed the karma phase, during which the person looked after his parents, earned the livelihood, entered into marital bondage and brought up his off springs. The obligations towards the society were also fulfilled during this phase. Having full filled his responsibilities during this phase which lasted up to 6th or 7th decade, the person moved to a state of detachment from the family and the society towards ‘vanaprastha’ and meditated most of the time. This phase was often mistaken as moving towards spirituality. Some of the people who did not

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marry and lived away from materialistic world were also clubbed in this group. This wrong understanding continued to the extent that it got embedded in a religious cover.

The concept of meditation is as old as civilization. Saints and seers had taken refuge in solitude and meditation to get peace of mind. Meditation opens up the awareness to infinite reservoir of energy, the creativity and intelligence that lies deep within everyone.2 Spirituality has been a way of life and has been in existence in India and Asia at large. This has been exposed to the Western world much later. For the present upsurge of spirituality, a lot of credit goes to doctors and scientists, for its understanding as a science and thereby increasing the awareness of it amongst the masses.

Population Demography

Elderly population has been rising globally and India is no exception to it. Since independence, India’s population has more thandoubledandlifeexpectancyhas increasedfrom32during British rule to 65 in 2001.3

The economic revolution

The global economic changes had its reflections in India also. After independence, the changes in the age of retirement in various sections showed not only increasing life expectancy at birth but also gave reflections of rising economy. A soldier in the Indian army who used to retire at 35 years previously, since the late 90’s continues to serve till the age of 57 years. In other services and public sectors the superannuation age has gone up gradually to 62 years and in the Supreme Court, judges function up to 65 years. The economy improved, earning went up but also escalated the expenses and the cost of living. The serene feeling before retirement4 started getting replaced by anxiety of making both ends meet. The breaking up of joint family

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systems5, the migration for want of education and jobs and creation of nuclear families also made the elderly think seriously of their health and alternate jobs. This change occurred because the savings / pensions were not sufficient for a decent livelihood anymore. No speculation could come closer to the realities of a changing economy. The awareness of health and the requirement of health standards for alternate jobs made the elderly more demanding and dependent on the medical world, in which the cost of diagnostics as well as therapeutics continued to rise. The advancing age, decreasing physiological functioning of the organ systems, newer lifestyle afflictions, made the elderly a frequent visitor to the medical man. Multiple drugs for multiple ailments resulted into the practice of poly-pharmacy. Multiple adverse drug reactions6 and their management added further fuel to the fire. All this added to the cost of living. This was realized both by the Western world as well as in India. Thus came in the emergence of alternative systems of medicine which could be both safer as well as economical.

In recent years, meditation has been shown to reduce illness and reverse ageing process.7Although benefits of meditation is universal it is a must for the elderly, particularly for those who are alone, as meditation has been reported to convert loneliness into solitude.8 Meditation for the young, old and the sick has been

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reported earlier.9 At this juncture emerged spirituality.

Emergence of spirituality

Knowledge is nobody’s monopoly. The movement had been from East to West and vice versa also. The importance of high fiber content of Indian diet was picked up by the scientists in the West as an important tool in the management of diabetes10 and bowel motility disorders. In the 80’s the Western world made a big hype about this which was subsequently propagated by practitioners of modern medicine in India. In 90’s came the terms – ‘meaningful life’, ‘lifestyle changes’ and ‘quality of life11’ in the medical world of India via the West. The Westerners had adopted these terms by the positive results of innumerable studies on meditation and yoga which were a part of spirituality. These were tools of ancient India and its Vedic culture which were adopted by the Western world after scientific research. The religious color and connotations given by some critics and people with vested interests got eroded to everyone’s relief, from this scientific approach. The scientific validation and continued researches in the field of spirituality therefore made it acceptable as ‘non pharmacological measures’ 12. Truly, this was the need based acceptance in which economy played a major role as per the saying of Swami Chinmayananda who said “the basis of every thing is economy”.

The ethos of spirituality

Certain postures which helped in exercises, shaping of the body, helped in weight reduction, gave mental and physical relaxation, and helped in the management of certain medical disorders were termed as yoga. What an underestimation of a powerful scientific tool! There was a similar understanding about meditation. Gradually, there was an increased understanding of yoga and they were conceived as things much beyond physical measures. Yogic way of life and its wider perspectives along

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with meditation etc. were then correctly interpreted as spirituality by the Western world. Spirituality was then considered as a way of life in its total perspective.13 The unwanted color of religion got removed and the acceptance among all sections of society started improving. Caste and creed as well as geographical borders became unimportant and this scientific process made its footings firmer. All across the globe the understanding improved and its teaching became available in centers all over India also, with a larger participation from the intelligentsia. The scientists showed its beneficial effects on the human body and mind. The trials were on in many diseases which were of organic, psychological, lifestyle induced nature. The results were comparable as well as reproducible.14

Aging- elderly

“Aging is progressive, generalized impairment of function resulting in loss of adaptive response to stress and in increasing risk of age related diseases”. O.P. Sharma, Geriatric Care in India,1999.

Several theories have been forwarded to explain the biological basis of ageing.15 These include Immune Theory, Neuroendocrine theory , Free radical theory, Cell ageing theory, Somatic mutation theory, Error theory. Till date, there is no unanimity about the process of ageing though various postulations are there. Several biological changes have been observed with ageing. These are an increase in chromosome structural abnormalities, DNA cross-linking and frequency of single strand breaks; a decrease in DNA methylation and loss of DNA telomeric sequences. The primary structure of the protein is little affected while post-translational changes namely deamidation, oxidation, cross-linking and nonenzymatic glycation increase significantly. Alterations in mitochondrial structure have also been reported, though inconsistently.16 The biological changes are however much easier to understand than the

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mechanisms that mediate them. Whether senescence or ageing is a physiologic process like adolescence is not agreed upon by most biologists

The major characteristic of the ageing is the difference in physiologic processes when the elderly is compared to the young adult. There is a progressive constriction of the homeostatic reserve of the every organ system- a process termed ‘homeostenosis’, which starts in the 3rd decade of life. This process is gradual. The physiological slow down affects hearing, vision, cognition, locomotor activity; hormone support withdrawal results various functions and at the same time accentuation of clotting related problems increase heart attacks and strokes. In a nutshell one may say ageing is more of a natural phenomenon mediated by genes and physiological changes.

The ‘Vienna International Plan of Action on Ageing’ was adopted by the World Assembly on Ageing. In 1982, the World Health Organization (WHO) had implemented several worldwide programs for the elderly by adopting the theme “Add life to years” which was followed by Active Ageing and Healthy Ageing as concepts for living.

Elderly and Spirituality

The elderly have a dual burden, first of the same diseases as that of adults and secondly of diseases due to degeneration in body tissues and decline in the functioning of various organs. Forty five percent of the elderly have a chronic disease. Top ten common diseases are Hypertension, Cataract, Osteoarthritis, Chronic Obstructive Airway Disease, Ischaemic Heart Disease, Diabetes, Benign Prostatic Hypertophy, Dyspepsia, Constipation and Depression.17

This segment of society therefore becomes a more frequent visitor to the doctor, higher consumer of drugs with the highest

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vulnerability for adverse drug reactions (ADR)18 on account of polypharmacy which becomes inevitable in them. This coupled withretirement, lossofempowermentandeconomicconstraints make them ideal candidates for embracing ‘non pharmacological measures’ like spirituality. Here are some practical suggestions which could be incorporated in one’s life as a routine, not for not only disease prevention but also health promotion, anti ageing and rejuvenation.

The yogic lifestyle intervention program may consist of the following :

• Health rejuvenating exercises: A set of movements for improving general tone and flexibility of various parts of

the body
• Breathing exercises (Pranayama)
• Yogic postures for stretch relaxation (Asanas)
• Relaxation exercises (Kayotsarg): A method of complete

relaxation to prepare the body and mind for meditation
• Meditation (Preksha)
• Reflection and contemplation (Anuvrat and Anupreksha) • Stress management (by relaxation, breathing exercises

and Preksha meditation)
• Dietary control
• Moderate aerobic exercises.

The word meditation came from Greek word ‘medere’ (heal). It was practiced in ancient Greece since 3500 B.C., followed in India around 2700 B.C., and mentioned in the book of wisdom, the Vedas, 4000 years ago. In the West, meditation means a concentrated state of mind. In the East, meditation is fixing mind on a spiritual ideal. Zen meditation is feeling breath, an awareness of inner silence. Yoga meditation is absorption of the feeling of oneness with the ideal. For Hindus meditation is a repetition of mantra with feeling of spiritual oneness. For Muslims, meditation is repetition of selected names of God from the Koran. For

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Catholics, meditation is feeling of closeness with Jesus and for Buddhists to the Buddha.

Vipassana meditation, Suffism, Zen meditation, Rajyoga meditation, Om meditation, Tai Chi– a Chinese martial art used meditation in motion7, are the various suitable techniques that could be easily practiced in by the elderly. Transcendental Meditation (TM) is the most popular because of its proven benefits. Recently, a simple meditation called ‘Saral meditation’ without mantra has been in practice which is primarily based on TM but with a difference.

References :
1.
Ray, PC. History of Hindu Chemistry. 1994; Kashyap

Samhita Chowkhamba, Sanskrit Sansthan, Varanasi.

2. Dhar, HL. Clinical application of meditation. Medicine update 2008; 93: 712-716.

3. Dhar, HL. Drugs and elderly. Post graduate medicine 2008; 48: 452-458.

4. Bhatia, HS. 1983; Ageing and Society – A Sociological Study of Retired Public Servants. Udaipur: Arya’s Book Centre.

5. Sharma, OP. Geriatric Care, 2008; Viva Books India, pp. 1-6.

6. Sinha RSK, Drug Interactions , Geriatric Care, 2008; Viva Books India. Pp. 742-750

7. Dhar HL. Recent advances on anti-aging. J Gerontol, 2007; 21(1): 87-90.

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8. Dhar HL. Mechanism of Saral meditation without mantra that improves all round quality life. BHJ, 2004; 46(3): 291-94.

9. Dhar HL. Meditation for the young, old and the sick. Ind J Clin Pract, 2006; 16(10): 25-27 & 30.

10. Sharma OP, Handa V, Health Promotion and Preventive Strategies, 695-702, Geriatric Care, 2008; Viva Books India.

11. Ornish D, Brown SE, Scherwitz LW, Billings JR, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet, 1990; 336:129-133.

12. Manchanda SC, Narang R, Reddy KS , Sachdev U, Prabhakaran D, Dharmanand S Rajani M, Bijlani R. Coronary therosclerosis reversal potential of yoga lifestyle intervention. JAPI, 2000; 48:687-694.

13. Upoddhat P. Kashyap Samhita, Chaukhamba Sanskrit: Varanasi 1994. pp 3-6.

14. Manchanda SC, Aggarwal V. Preventive Cardiology and Non Pharmacological Measures, Geriatric Care, 2008; Viva Books India. Pp. 126-131

15. Sharma OP, Introduction, Geriatric Care, 2008; Viva Books India. Pp. 1-6,

16. Sengupta U, Sharma OP, Immunology of Ageing, Geriatric Care, 2008; Viva Books India. Pp. 15-23,

17. Sharma OP, Health Care Delivery in India, Practice of Geriatrics. 2004; John Wiley Publications : London.

18. Thate U, Clincal Pharmacology, Geriatric Care, 2008; Viva Books India pp. 718-726

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Dr Mahesh N. Hemadri

He has done his M.B.B.S. from AL-
AMEEN Medical College, Bijapur,
Karnataka and is now working in Global
hospital, Mount Abu. He has done a
Diploma in Hospital Management from Dept. of Health & Family Welfare, New Delhi, 2004 and a Post Graduate Diploma In Geriatric Medicine from Indira Gandhi National Open University, 2006

His future plans include: 1) Senior Citizen Township,2) Research Centre On Aging Process ,3) ‘Aging Gracefully’ senior citizen health education programmes in developing countries , 4) Senior citizen clinics all over India,5) To open several day care centers for senior citizens with the help of Ministry Of Social Justice & Empowerment,6) News letter to senior citizens in their regional languages.He has been practicing Rajyoga meditation for the last 25 years.

He has addressed more than 6000 senior citizens all over Karnataka, Gujarat, Rajasthan and Maharastra and distinguished gatherings in medical colleges and universities across the country.

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SPIRITUALITY FOR AGING GRACEFULLY

Mahesh N. Hemadri

Aging is a spiritual journey; because the mental, physical, and social, changes that are a part of aging process which prompt elders to ask spiritual questions: Was my time well spent? Did I love the right people, and the right things; did I help the next generation? If this is so there has to be an exploration of all that. Spirituality in the elderly is an evolution of their awareness for matured co-existence, and evolution of their conscience to accept and adopt to different adversities of their life. It is evolution of their own attitudes for developing conscientiousness, the blossoming spiritual awareness which makes their life more precious and more valuable like a shining diamond. Spirituality is gift of God; practicing self-awareness, reflections, deep meditation, spreading aura of peace, happiness, and serenity is itself a great gift to elderly people, but also a boon to their family and society. An aging individual has to pass through three different adversities – lifestyle, disease, and aging itself. To make his life’s journey simpler, non-dependent, inspiring, more economical, more creative, more balanced, more intuitive, more understandable, he needs to be spiritual. A spiritually aging person is like a growing banyan tree; his positive values, his spiritual practices, his vision, positive and powerful insights, his own sustainable pure awareness, positive life style, his/her, matured emotions, transcend all negative influences, and these become deep roots to support the banyan tree which symbolizes his perfect life.

An elderly person, who is spiritually aware, develops insightful living. He also develops the process of learning as a pre- requisite to lead an obstacle-free life. The essence of graceful aging is blessings, not only to the self but also to others who become a part of his life, as the power of blessings is the

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essence of spirituality. Spiritually enlightened person is bestowed with this value. The science of spirituality has shown the results which prove the power of the mind over matter, whether it is spontaneous regression of cancer, or healing certain illnesses, opening of coronaries in coronary artery disease, developing brain wellness, controlling the effects of stressors etc., or to transcend the negative effects of physical illness.

The algorithm which works is, pure intention to lead compassionate and spiritual lifestyle for graceful aging. Even scientific thought has now started recognizing experience rather than experiment, and persuades one to abandon all rationality and reason. Science is the process of evolution of thought, where as spiritualism is involution of thought. When people become more rational, atheistic and more scientific tempered, they deviate from the grace of metaphysical awareness, which is an essence of life, so as to say. The spectrum of spirituality for graceful aging is developing pure awareness at one end, and quantum realization of innate virtues at the other end. Spirituality is an inward journey, it is pure effort to stay in the realization of sentient energy which is in the form of sentient light which radiates, vibrates into spectrum of qualities, like purity, peace, serenity, bliss, love, harmony, detachment, creativity etc.

The ultimate objective of spirituality for graceful aging is for the consciousness to be able to perceive itself. The purpose of creation was for the source to experience itself, an awareness to experience itself as a state of pure harmony, stillness and introvert-ness. The ultimate purpose of going into pure awareness is to focus inside, because awareness when focused outside gets entangled in a web of duality, and then there is no limit for its indulgence. As you become aware of your own reality, you spread fragrance of pure being.

The psychological well-being index in a spiritually enlightened

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person is: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self acceptance. The more spiritually enlightened person shows more self determining state, is more independent, and regulates behavior from within, evaluates self by personal standards. The more the spiritually enlightened person, more the sense of mastery and competence in managing the environment, one who makes effective use of surrounding opportunities, and is able to choose or create contexts suitable to personal needs and values. The more the spiritually enlightened the person, the more the sense of continued development, sees the self growing and expanding; is open to new positive experiences, has sense of realizing his or her potential, sees improvement in self and behaviour over time. The more the spiritually enlightened the person, there will be more positive relations with others. The person will have warm, satisfying, trusting relationships with others, and concerned about welfare of others, and capable of strong empathy, affection and intimacy, and understands ‘give and take’ of human relationships.

The more spiritually enlightened the person, more the sense of directedness, one who feels there is meaning to present and past life, holds beliefs that give life purpose, has aims and objectives for living; acknowledges, accepts multiple aspects of life, including good and bad qualities of self and feels positive about past life.

Recognizing spiritual distress is always a challenge in the elderly person. What care providers must understand is that a person’s spirituality can be found at the root of every conversation, action and expressed emotion. Spiritual distress describes the reality of weakened human spirit. It is the state in which the individual or group experiences are at risk of disturbances in the belief or value system that provides strength, hope and meaning to life. There are other ways for care providers to become aware of spiritual needs of elderly, in spiritual care, the use of clinical

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tools is effective, but only if they are applied through the ‘heart’. Listening with the heart is an excellent way to really understand a person’s with spiritual needs. Spiritual care seeks discernment, not diagnosis, adopting beliefs and value systems that provide strength, hope and meaning. The insights of this explanation are helpful in evaluating spiritual care for elderly people; these are helpful for clinical work, no matter what our religious or spiritual belief might be.

The first stage is ‘struggle’. Struggle happens when old ways of thinking and believing and old foundations or values are challenged by new experiences in life. The second stage of spiritual journey is the ‘wounded feeling’, which happens when a person confronts internal conflicting ideas, but also comes to realize that life is not as simple and straight forward as once thought. Struggle is bad enough, but to be wounded, and become conscious of ones essential humanity and vulnerability is something else. In truth it is only by embracing the wounded ness that a person is able to move on to the next stage of ‘naming’ what is truly happening to them. ‘Naming’ can take many forms as wounded person comes to new understanding and perspectives that spread and enhance their lives. ‘Naming’ can mean change of the self, change in the expectation from others, and change in the individual’s perspective of the world.

Final stage is stage of ‘blessing’ where the fresh perspective, changed insight and altered understanding add to the view of one’s self, others and world around them. They are no longer seeing dimly in the mirror, but instead their perspective is enriched, expanded and grows. They are now a different person, having struggled with some thing new in their lives, have confronted their inner doubts and needs acknowledging their hurt, and embracing the new blessings that follow the person who has courage to complete this journey.

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Dr. Veena Kapoor

A graduate from the Maulana Azad Medical College, University of Delhi in 1965, she married a fellow physician and moved to London where she spent 7 years,

mothering 2 kids and attained Diploma in Clinical Pathology from the Univ. of London.

She further moved to USA and post-graduated in Psychiatry, completing Boards in Neurology and Psychiatry Univ. of Cincinnati, Ohio and then group practice in Birmingham, Alabama.

The training and further work in the field of Psychiatry led to a prolonged self-introspection when she took her final decisions of life and returned to Roots to her home town Delhi. She has been in charge of Psychiatry Department at Batra hospital in South Delhi and along with this she has been engaged in Private Practice.

Dr. Kapoor was active in formulating the Delhi Chapter of the Indian Association of Private Psychiatry from 2002-04. She has also been keenly involved in ‘The Art of Psychiatry’ section (Psychotherapy being her preferred mode of treatment).

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INTROSPECTION AND SPIRITUALITY: A TOOL FOR GROWTH OF THERAPISTS

Veena Kapoor

Indira said, “I have been watching the market and feeling really depressed.

I have lost so much. I don’t know how I am going to cope.

I think I am going to do Tara Puja. I don’t know how it is going to help but some how I get peace. Last time when I was feeling so bad, a solution came to my mind after 2 days and I was able to solve the problem. It sort of loosens the mind from the problem and you are able to think positive.”

Mental health professional in varied settings from all countries has to increasingly deal with clients who do not fall into watertight psychiatric syndromes. The needs of these large subgroups of patients are beyond what is taught as a part of psychiatric education. There is a growing sense of dissatisfaction from the mainstream medicine and the physical forms of therapy in psychiatry may not bring about holistic healing.

There is now increasing evidence of efficacy of many therapeutic techniques like Yoga, Meditation, Prayers and Spirituality based interventions. Peacefulness and blissfulness are no longer seen as signposts on the road to ‘Nirvana’ but also as attainable states of mind in stressed out individuals. Spirituality in individuals can lead to changes in society, family and the world.

All through history, all through cultures, man has felt a power, an inner presence and deep in the conscious a faith to which he resorts to, especially in distress and pain.

Often doctors are treated as God by patients, although, they

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may actually feel as total atheists within. Majority of our patients have spiritual concerns and we act like scientists not able to crack our own belief system. Often we have felt like saying “I am an atheist, plain and simple. I am a scientist. The only thing I believe is what I can see and touch. May be I will be better if I had some kind of proof of God or faith.” But frankly, I cannot stomach that kind of crap.

It is more the aptitude and personality of the therapist and less the designation whether psychologist, psychiatrist, counselor or a medical practitioner who treats the patient.

Dr. Ravi Kapur said, the idea of God is perhaps one of the oldest to have caught the imagination of humanity. When I say God, I refer also to spirituality in all its manifestations. So powerful has been the hold of this idea on the minds of people that in spite of millennia having passed, it has continued to occupy a permanent place in our lives. The idea has inspired the highest form of human endeavors – poetry, sculpture, philosophy as well as the lowest – wars, domination, slavery and all forms of aggression. As we know, it continues to do so to the present day.

Freud believed that God was an illusion created by the human mind to invoke a father figure who would hold our hands as we face nature’s capriciousness. He hoped that through education – he called it education to reality – man would become mature enough to forgo this idea (Freud, 1985).

Personally, we each need to revise our belief systems and examine how this very important aspect inter-twines in us personally and professionally.

I followed a long and tortuous path to be where I am today. My beginning takes me to age 4, Ludhiana in Punjab. My

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Nani wearing a white cotton sari, carries a Thali in her hand with a little Katori with some sweet milk in it. A few leaves of Tulsi from our Aangan, other little things, red powder, some sticks. I run after her, not afraid as I am with Nani. The road beneath my feet is rough, wet and dirty but I didn’t care, I am with Nani. We go up the steps of a big temple. There is a Peepal tree. Crowds of people are around it. Bells are ringing. In the small dark room Baba gives her something. She looks happy, I am happy too. At home she sits in the corner with a big long mala of beads, closes her eyes and mumbles, goes on and I leave her now.(It is a ritual with most Nanis and Dadis in most homes in North India, I was to realize later).

Age 10, Delhi Queen Mary’s School, we are marching to the music of piano to the assembly hall. We sing hymn No.1: “All things bright and beautiful, the Lord God made them all – All things wise and wonderful, the Lord God made them all” Sister Massey tells us the story of the creation of the universe. God wanted light and there was light. God wanted water and there was water. God made animals, plants, man etc. She told us the story of the Ten Commandants of Moses, the guiding principles of living a sin free life. It was all part of the school curriculum, as I saw then.

Age 30, I was now a psychiatrist at Baptist Methodist Hospital, Birmingham, Alabama in USA. John Sims, the chief pastoral counselor ran a group therapy programme with me. He started to refer cancer patients who were dying, the relatives of accidental death victims, terminally ill patients not referred by other physicians. He also started referring his own ‘pastoral colleagues’ who were having drinking problems, sexual problems, marriage problems, morality problems and I was shocked, not just surprised.

I was appointed as a Discussant in a 10-week seminar which

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was part of 2nd year Theology course affiliated with the University. I invited the students to present clinical cases followed by the spiritual meaning and relevance. This was a very personal experience. I did not feel a Hindu, Christian, Indian or American. The whole experience of a suffering human being who felt he was suffering because he had sinned beneath the cross was a recurring theme. As disciples of Theology and Psychology we tried to wade through the huge quagmire, where my job was to provide therapies for the man who felt he had sinned and for the counselor to redeem the man of the sin through spiritual means.

Academically, this experience increased my sensitivity for the first time to the existing gap in my own spiritual belief system.

Through the years of finishing school and Medical College in Delhi, I knew I was born of a Hindu Aryan family. Father was domineering, loving, and the strongest guiding force throughout. I didn’t think seriously if he believed in the existence of God.

A ritual he did every Diwali was ‘Hawan’. He would recite the Vedic mantras and translated them in English. It made no sense except a feeling of closeness, sacredness and some strange purposefulness. I could recite ‘Om Bhoor Bhuva’ and close my eyes when we all said Om. This would resound some where deep inside me then and later whenever I went to some sacred places up on the hills or on the side of the Ganga at Haridwar, the Ghats of Banaras, Badrinath at the foot of the Himalayas, Jaganath Temple at the lapping waves of Puri Beach or the sacred Rameshwaram temple. Father passed away. Death is strange. We all think we know it and yet none of us know it. It does always and invariably make us wonder. What is life, man, nature? Where and to what end?

In early life we build our egos and try to become capable of functioning in the world. In later life somewhere the task changes

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into spiritual awakening and there is initiation into the inner reality. This movement from one phase to another perhaps isn’t necessarily tied to a person’s age. For me the process occurred subtly in the last 20 years when I took part in some Buddhist teaching at Tushita, precious time at Mount Abu, retreat with Swami Sukhbodhnanda at Bangalore, and Vedanta classes at Delhi.

I met Judy who was a ‘Chemical dependency rehab counselor’ in Sydney, Australia. She was into Eastern spirituality. She visited Delhi and we did some workshops at my Psychiatry clinic and a seminar at India International Center where my colleague Dr .Avdesh Sharma was one of the invited speakers on “Alcoholism and Narcotics”.

Judy invited us to the week-long International Meditation Retreat at Mt. Abu at the Brahmakumari’s Spiritual University. This place was swarming with ‘double foreigners’ who were trying to find their ‘soul’. It is like a little university, teaching Raj Yoga, inspiration for purity, honesty and service. “Rajyoga simply means being the master of oneself. It preaches meditation as a tool to invoke positive vibrations,” says Sister Anita. “The aim is to equip the individual with innate strength to cope with chaos,” expounds Sister Babita.

Meditation is a method of disengaging from the mind and connecting with the deeper consciousness. It is silence. It is not silence of a still evening. It is the silence when all perception has entirely ceased. This meditative mind is the religious mind. Religion not touched by church, temple or any other organization. It is the expression of love, love that knows no separation. Love is not sharing but the will to expand oneself. Meditation involves being in close awareness of one’s body, its breathing patterns and the patterns of the mind to help achieve a state of complete relaxation.

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The “attitude” of the doctors towards patients forms the staple ingredient of spiritual healing. Interplay of spirituality and medicine at the Global Hospital at Mt. Abu has made considerable progress in providing holistic health care.

I was back after the Retreat. The Experience becomes a part of me and lingered on.

Spiritual growth is a journey out of microcosm into the macrocosm. In its earlier stages it is a journey of knowledge and not faith. We must continually expand our realm of knowledge and our field of vision. To develop a broader vision, we must be willing to kill the narrower vision. In the short run, it is more comfortable to stay where we are using the same road on the same map; the road of spiritual growth is an evolution of the individual, says Peter M Scott in ‘The Road Less Traveled’.

Another retreat. I ‘registered’ in the School of the BK’s, Prajapita Brahma Kumaris Ishwariya Vishwa Vidyalaya, at their new center at Manesar on the outskirts of Delhi. This time Dr.Avdesh had invited me. We hade been in this School of ‘Mind Body Spirituality ‘, he a more regular and committed student – participant, me an on and off ‘searcher’ and explorer. This seminar was like CME- continued education for us and 200 other doctors from all over India. He spoke on Mind-Body- Spirit connections and included me in the panel discussion on Ethics of Spirituality in Practice of Medicine. Leaders in their chosen specialties shared related research experiences and intimate inside feelings at professional and personal levels.

There were also concurrent ‘Meditation and Orientation’ sessions for us, the Scientists by Asha Behn in the mornings when the horizon, which was almost within reach, flushed with the rising sun and the evenings when the stars were beginning to twinkle in the galaxy above.

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I certainly felt ‘not just a body of Protoplasm’ which can be ‘Nuked’ by any earthly Super or Mini power but ‘beyond that— ‘ So Asha Behn re-instates the ‘Hope’, hope and the optimism of ‘living’, not just the body but mind, the spirit and the soul. The other ‘sisters and brothers’ with their simplicity and dedication for a certain ‘moral order’ set a role model. The periodic on and off devotional music resounding in the sprawling site, controls the ‘traffic of mind flow’ and instills devotion of a kind for all who choose to find it.

Again it had a deep introspective effect on me.

I always had a spiritual layer some where which remained mostly dormant but questioning in a subtle manner. From time to time when caught in a wave of turmoil, like most people, I have stopped, looked within, gathered some strength and some answers and gone on.

The shrink in me remains curious. Upon a chance discovery of a Vedanta center down the road, I had started attending the classes on and off.

Hinduism is a blend of Vedanta on the one hand and the worship of symbolic forms of Gods, Goddesses, rituals and ceremonies on the other.

Vedanta teaches about ‘Self’ the center of pure consciousness, which is the final deeper universal or collective consciousness beyond the waking, sleep and deep sleep state, or the 4th state of consciousness. ‘This is the depth of psyche or soul or Atma’.

Gita-chapter – 2 : When Arjun stands in the battle field, paralyzed at the sight of his kith and kin unable to pick up his bow to fight, he asks why he should battle with his brethren?

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And Krishna talks to him –

What was the battlefield? Who were the brethren? What was the battle? Why the battle?

The great mythological stories were transformed into the inner workings of life and mind itself.

The whole thing is on desire, control, discrimination, lessening of attachment, keeping energies directed to the goal, which ultimately is the ‘realization of the Self’.

In a talk, ‘Mental health and spiritual values- A view from the East’ Dr. N.N.Wig, our modern day Psychiatric Guru enumerates:

“Spirituality in India is a way of life. In the matters of health, Science alone can not provide all the answers. For the common man, the ideal state of mental health has always got a spiritual connotation”.

In the Jewish-Christian-Islamic tradition, God the creator of the universe is ‘outside’ this world and in Indian tradition, he is not out there some where but within you and within everything. Neither man nor universe is looked upon as physical in essence. Material welfare is never recognized as the only goal of human life. It is the concern with inner life and ‘Self’ rather than the external world of physical nature, which forms the true pursuit in Indian philosophy. Also it does not merely know it, but one has to realize and live it.

The four broad aims of Hindu view of life are;

Dharma righteousness or religious duty, which is the central axis around which life rotates

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Artha social and material needs
Moksha liberation or release from worldly bondage and

union with ultimate reality which is the spiritual dimension.

Karma is action. As in Newton’s 3rd law every action generates an equal and opposite reaction. Sanskar may be understood as repressed tendencies due to prior action. They are units of experience which can get active by an exogenous external situation or endogenous inner stimulus.

The central theme in spiritual approach to life is that there is an essential mystery at the heart of all things. This mystery can not be understood but has to be experienced. From the experience of this mystery we get this urge for ‘transcendence’. It is not something projected from the brain but something experienced from the heart”.

So today I believe, it is imperative that with our own evolution, we need to inculcate values in those around us that we touch.

In the framework for school education, growth and development of children must have several aspects including ‘spirituality’. Attempts should be made to link it to ‘value inculcation’.

Inter-religious conflicts have become the order of the day. It is from early childhood that children should be introduced to the discovery of ‘otherness’ and attitudes towards others.

A recent study, on Ethics in Medicine in the University Of Washington School Of Medicine also expresses that religious beliefs and practices are important in the lives of many patients seeking care, yet many physicians are uncertain about whether, or how, to address these.

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Often physicians are trained to diagnose and treat disease and have no training in how to relate to the spiritual side of the patient. Complicating it further, in our culture of religious pluralism, there is a wide range of belief systems ranging from atheism, agnosticism, to a myriad assortment of religions. At first glance, the simplest solution suggests that physicians avoid spiritual content at all. This however may not be the best. Within the boundaries of medical ethics and empowered with sensitive listening skills, the therapist may find ways to engage these beliefs in the healing process, and come to an understanding of ways how ‘his own’ can be included in transactions with patients. Humans grapple with common issues of infirmity, suffering, loneliness, despair, and death, while searching for hope and meaning in crisis expecting empathic understanding and acceptance.

Asked a student, how should I take a “spiritual history”? Often, it can be incorporated into what we may now want to call the “psycho-social-spiritual” history. By simply stating something like, “As physicians, we have discovered that many of our patients have strong spiritual or religious beliefs that have a bearing on their perceptions of illness and their treatment. If you are comfortable discussing this with me, I would like to hear from you about these.”

“Why did this happen to me? Was it God’s punishment for a previous sin”?

Care must be taken that the non-religious physicians not underestimate the importance of this oft repeated question, i.e. patient’s belief system. The respect for the patient should transcend the ideology of the physician. Physicians with spiritual beliefs that are important to them integrate their beliefs into their interactions with patients in a variety of ways. This also strengthens students in their commitment to relationship-centered

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therapy that emphasizes care of the suffering person rather than simply the disease, and recognizes the physician as a dynamic component of that relationship. Students also need to develop a program of ‘physical, emotional and spiritual self-care’, which includes attention to the purpose and meaning of their ‘own lives and work’.

All patients who come to therapy seek unconditional love under the guise of wanting to resolve conflicts, expecting it from the therapist (Who they trust as God). While we understand and initially provide this, correcting the transferred rejections by trying to balance the id, ego and the super-ego, later perhaps one can try to shift this to a transcending nurturing force outside of one i.e. ‘God’ if that is what the patient understands. As he progresses to this state of awareness he could be encouraged to realize that the source of love and acceptance is not external but internal at the center of his own being i.e. 4th state of consciousness. And finally move on to the merger with the universal or cosmic or the 5th state. I think it is here that the ‘responsibility ‘ shifts from parent, spouse, child, friend, therapist, me the person, to this ‘Force’ within and without.

Everything that happens in the patient originates somewhere from a common source, mine, yours and the cosmic Universal consciousness. There is a greater understanding of his suffering and acceptance of his spiritual concerns and pathological distortions if the therapist is clear about his own belief system. It doesn’t matter what name we give it. It is a question of semantics. But there is a feeling within that there is something beyond the body which is the mind, beyond the mind, the Spirit. I feel it in my horizons, other people have felt it and I hope you can too.

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Bibliography

Kapur, R.-Can Indian Spiritual practices be used for Psychotherapy?- A collection of papers- Nimhans publications: JRD Tata National Inst. of Advanced Studies, Bangalore. Wig N.N. (1995) -The Rees Memorial Lecture: Keynote address at World Congress of Mental Health in Dublin, Ireland August 1995.

Krishnamurti J. (1993) – The network of thought: Krishnamurthi foundation India

Krishnamurti, J. (1982) Krishnamurti’s Journal; Krishnamurthi foundation India

McCormick, T.R., (1998) Ethics in Medicine: University of Washington, School of Medicine.

Parthasarthy, A. (1989) Vedanta Treatise; Vedanta Life Institute, Vakil and sons Ltd.

Parthasarthy, A. (1992) Srimad Bhagvad Gita; Vedanta Life Institute, Vakil and sons Ltd.

Scott, P.M. (1978) The Road Less Traveled- A New Psychology of Love, Traditional Values and Spiritual Growth. New York: Simon & Schuster.

Swami Sukhabodhananda (1994) Meditation- the ultimate flowering : Sri Sudhindra Offset Press,Bangalore

Swamy Ajaya- (1984) Psychotherapy East & West; Himalayan Institute Press.

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Dr. Rajesh Nagpal

He has done his Post graduation in Psychiatry from PGIMER, Chandigarh & has almost two decades of clinical experience after that.

He is currently, in private practice at Delhi. His current positions include Secretary General, Indian Association of Private Psychiatry, Hony. Secretary, Indian Association Of Biological Psychiatry; Co-chairperson, Committee on Ethics, World Federation of Societies of Biological Psychiatry, Convenor of the IPS – IAPP Task Force on Mental Health Legislation; Honorary Secretary, Group For Research & Advancement in Clinical Ethics (Independent Ethics Committee in the private sector).

His current research projects include a Biotechnology project (Genetic susceptibility in schizophrenia), besides Phase III & IV drug trials.

He is involved in Continuing Medical Education & Professional Development. He has presented papers at several international & national conferences.

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Utilising Spiritual tools in Psychotherapy

Rajesh Nagpal

The Mullah, a preacher, entered a hall where he wanted to give a sermon. The hall was empty except for a young groom seated in the front row. The Mullah, pondering whether to speak or not, finally said to the groom, “You are the only one here. Do you think I should speak or not?” The groom said to him: “Master, I am but a simple man and do not understand these things. But, if I came into the stables and saw that all the horses had run off and only one remained, then I would feed it nevertheless”.

The Mullah took this to heart & began to preach. He spoke for over two hours. After that, he felt elated and wanted his audience to confirm how great his sermon had been. He asked, “How did you like my sermon?” The groom answered, “I told you already that I am a simple man & do not understand these things very well. However, if I came into the stables and found all the horses gone except one I would feed it, but I wouldn’t give it all the fodder I had.” (Oriental Fable)

Too much in too little time,
is to be avoided in psychotherapy.

For therapy to be comprehensible, the lexicon & content should be shorn of sophistication & elitism. Spiritual context of the discussion makes the listener connect. Since the spiritual context is free from the direct world of the patient’s experience, it circumvents resistance.

Confronted with child’s parents complaining of disinterest in study and mild conduct problems in an otherwise intellectually normal child, I ask the child of the five desirable qualities in students (from the Vedas) & proceed to expound on the patience of the bird catching fish by the riverside, sleep like a dog (sleep

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soundly but awakens instantly), eat minimally, alert like a crow & non interference in adult matters.

To explain the enduring & commonplace occurrence of panic attack, recounting the panic attack experienced by Arjun on the horns of a moral dilemma on the battlefield of Kurukshetra (Mahabharat), may prove to be therapeutic.

Wives faced with delusions of infidelity can sometimes be taken through the experience of Sita (from Ramayana) & draw solace from the stoic and dignified bearing of Sita.

Enunciating the usefulness of existential crisis to evolve into self actualization is the transformation of Arjun, after hearing Krishna, the charioteer.

The primacy of emotion over reason is best exemplified by Yudhistar’s loss in a game of dice.

Explaining the evolution of neurotic depression is a treatise by Bhagwan Rajneesh, combining insights from Zen Buddhism & Vedas.

The story of Nachiketa is held against the obsessive pseudo philosophy used by neurotics.

The concept of forgiveness (Judeo Christian concept) best exemplified by the parting words of Jesus Christ is often introduced to clients consumed by hatred.

Sometimes a spiritual story explains passive aggressive behavior in insight therapy.

In the garden of a wise man, there once lived a splendid peacock. The creature was a particular joy for the gardener, who

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took care of it devotedly. The creature was a particular joy for the gardener, who took care of it devotedly. Full of greed & envy, a neighbour kept looking over the fence and could not bear the fact that someone had a more beautiful peacock than he. In his envy, he threw rocks at the peacock. The gardener happened to see this and was enraged. But the peacock granted the neighbor no peace.

After a while, he began to flatter the gardener by asking if he couldn’t at least have a female baby peacock. Categorically, the gardener refused. Finally the neighbor turned reverently to the wise master of the house & asked if he couldn’t have atleast a peacock egg. He wanted to put it under a hen and let her hatch it.

The wise man requested that the gardener give the neighbor an egg from the peacock’s nest. The gardener did as he was told. After a while, the neighbor came & complained to the wise man, “Something is wrong with the egg. My chicken sat on it for weeks but no peacock wants to slip out of it”. Angrily, he went back home. The wise neighbor called to his gardener, “You gave our neighbor an egg. Why doesn’t a peacock hatch from it?” The gardener replied, “I cooked the egg first.” The wise man looked at him in astonishment. Then the gardener said in an apologetic tone, “You told me I should give him a peacock egg. But you did not say whether it should be cooked or not……..”

The Here & Now : A believer knelt in a mosque, deep in prayer. Someone near him was struck by his wonderful, artfully woven pointed shoes, called giwees. The man imagined how nice it would be to have shoes like these. The step from thought to deed is often smaller than one thinks. He approached the man from behind and whispered into his ear, “Don’t you know that prayers spoken with shoes on do not reach God’s ears?” The believer interrupted his prayer and whispered back just as softly, “Well, if my prayer is not heard, at least I will still have my shoes”.

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Spiritual tools are only tools designed for leverage, explain nuances, illustrate difficult concepts. They are not end in themselves. Further, the timing & relevance is of paramount importance. Spirituality is secular in nature & emphasis on any one religion may be counter productive in Psychotherapy.

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Section (III) : Projections for the Future

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PROF. DINESH BHUGRA

Professor Dinesh Bhugra is Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, King’s College London in the United Kingdom. He is also an Honorary Consultant at the Maudsley Hospital in London and runs the sexual and couple therapy clinic.

He has been awarded Honorary Fellowships of the Indian Psychiatric Society (2004) and of the International Medical Sciences Academy (2006).

He has authored/co-authored over 300 scientific papers, chapters and 19 books. His recent volumes are Culture and Self Harm,HandbookofPsychiatryforSouthAsia,TextbookofCultural Psychiatry and Management for Psychiatrists. He is the Editor of the International Journal of Social Psychiatry and the International Review of Psychiatry, and of International Journal of Culture and Mental Health, launched in July 2008.

Dinesh Bhugra was elected Dean of the Royal College of Psychiatrists in July 2003, and in July 2008 was elected President of the Royal College of Psychiatrists.

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Dr. Keir Jones

Dr. Keir Jones is an Academic Clinical Fellow and Specialist Trainee as part of the South London and Maudsley NHS Foundation Trust Training Scheme.

As well as completing the MBChB
medical degree in Bristol, he has an BSc (Hons.) in Bioethics and an MSc in Clinical and Public Health Aspects of Addiction from the Institute of Psychiatry. His research interests include pathways into addiction, ethics in psychiatry and spirituality and mental health.

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RELIGION, CULTURE AND MENTAL HEALTH: CHALLENGES NOW AND

INTO THE FUTURE.

Keir Jones Dinesh Bhugra

Introduction

Religion and spirituality form an integral part of every culture and in understanding our patients, it is crucial that we understand their religious and spiritual values. In any human’s functioning either at an individual basis or as part of a kinship society and collectivist or socio-centric society, it is significant that the clinicians are aware and explore individual spiritual values which must be separated from organized religion. Sometimes, however, the two sets of values merge into one other and individuals may carry out religious rituals and taboos to develop defence strategies whereas spirituality sometimes becomes an overarching strategy. Whereever migrants move to, they will carry their religious and spiritual values with them and these will definitely influence their thinking and coping.

In this chapter, we illustrate some of these issues using Britain as an exemplar. We provide a brief historical context of the interface between mental health care professionals and patients and their carers, some of the growing challenges facing modern professionals and provide some practical suggestions as to the ways in which to incorporate cultural and spiritual values into everyday practice.

Background

Britain’s history is based on immigration. From the arrival of the Celts to the Romans, to the Saxons, the settlement and integration of new communities has played a significant role in

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the growth and development of the country. The 2001 Census found that 13% of England’s population was of non White British origin (ONS, 2001). Although immigration has been mainly centered in the south of the country, every region of Britain has experienced migratory change, with the result that between 1991 and 2001, half of Britain’s population growth was due to immigration (IPPR, 2005). Indeed, figures from the Office of National Statistics show that in 2005, 35% of babies in the UK were born to non White British mothers, rising to 54% in London (ONS, 2008).

London is unarguably the most diverse region of the UK, with over 42% of the population belonging to a non White British minority, (ONS, 2006) over 300 languages spoken, (Baker & Eversley, 2000) and there are at least fifty non-indigenous communities of 10,000 people or more within the city (GoL 2008). The capital is also strikingly multi-faith with one in five adults (20%) belonging to a religion other than Christianity, half of adults being Christian (49%) and a quarter of Londoners (27%) having no religion (compared to the UK average of 39%) (Tearfund, 2007).

As a mental health worker in this increasingly diverse multi cultural and multi faith country, addressing the interface of psychiatric illness and spirituality has become progressively more important.

A Historical Context

The relationship between psychiatry and religion has varied over the centuries from being virtually synonymous with one another, to being in an open and impassioned conflict, and then a grudging acceptance of each other’s strengths. Before the establishment of secular medicine and the major scientific advances of the last two centuries, physical, mental and spiritual wellbeing were often viewed as one and the same thing.

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Therefore, the practice of healing ills and the maintenance of health were seen as the domain of spiritual leaders. Nowhere was this juxtaposition quite as obvious as in mental health. In the Middle Ages, ideas of possession and witchcraft and the experience of religious visions which by modern psychiatric formulation would be identified as symptoms of a psychotic illness (for an historical account see Porter, 2002) were commonly construed as spiritual experiences. Positive visions or events that would appear to a modern psychiatrist to be clear evidence of hallucinations were seen to be messages from God or thought to be suggestive of enlightenment. Disorganised, irrational or disturbed behaviours were seen to indicate a need for religious forgiveness, salvation or even exorcism (Lipsedge, 1996).

Perhaps as a counter-reaction to this and also in trying to establish practice of psychiatry as a science, modern psychiatric thinking developed in such a way to become quite suspicious of religion and uncomfortable with more spiritual constructions of mental health. Arguably, the most well-known and direct criticism in the early days of the specialty came from Freud, who expressed a sometimes quite aggressively anti-religious sentiment:

“The whole thing [religion] is so patently infantile, so foreign to reality, that to anyone with a friendly attitude to humanity, it is painful to think that the majority of mortals will never be able to rise above this view of life” Freud, 1930.

To this day, (often unjustified) criticism continue to be levelled at organised religion by psychiatrists, fuelled by an increasingly scientific construction of religious experiences, an increasingly secular health workforce and media coverage of growing fundamentalist or minority religious groups that hold more controversial views and practices. Suggestions have included that religions attracts or recruits the mentally unwell,

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that religion has the potential to cause harm by inducing feelings of guilt or by repression, that religion compromises autonomy, and that symptoms of mental illness are sometimes ignored due to their supposed association with religious beliefs.

Equally, some religious leaders have found psychiatry objectionable. Perhaps the most fundamental criticism that is levelled is that by ignoring an individual’s spiritual development, psychiatry fails at a fundamental level to understand the human psyche and therefore, is left severely limited in its ability to support a lasting recovery. Added to this are more general anti-psychiatry arguments that include the difficulty in justifying seemingly arbitrary, culturally constructed and culturally defined especially in relation to what is deviant. Perceived fluid diagnostic categories, a sometimes weak evidence base for treatment options, and that the specialty may fundamentally be a function of social control repackaged for convenience, all contribute further to a sense of bewilderment which is often reflected in a rigid response to criticism.

There is good evidence that both groups present valid arguments, but also less founded concerns. Research into both genetic and neurobiological factors in psychiatric illness is gathering pace, with the results perhaps supporting the argument for objective and secular practice. However, equally good evidence is building of the protective role of religion in mental health both in term of Christianity in the West and other cultures and religions worldwide (e.g. Vasegh et al., 2007).

In recognition of this, over the past two decades there has been an increasingly open dialogue between both psychiatric and religious scholars and a growing acknowledgement of a benefit of a coordinated and mutually respectful approach in maximising the health and welfare of service users. Some of these modern imperatives and the effect they may have on this

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fragile and complex dynamic are worth exploring in some more detail below.

Challenges for Now and in the Future

(i) Multicultural societies and migration : It has been argued that with increased modernity as a result of industrialisation and urbanisation influenced by globalisation and other econimc factors, the explanatory models of mental illness start to change from supranatural towards more psychological and social explanations (see Tseng, 2001). As already discussed, traditional social and spiritual boundaries have long been shattered, particularly in the large urban metropolises. This applies to both service users and doctors – indeed the most recent figures complied by the Royal College of Psychiatrists here in the UK, suggested that only 6% of doctors taking the first membership exam were UK graduates (Royal College of Psychiatrists, 2008). So with truly international and multi-faith doctors practicing in truly international and multi-faith societies, clearly there are some extremely pertinent challenges, and opportunities, facing modern psychiatry.

Migrants are at higher risk of suffering from a range of mental health problems, particularly schizophrenia (Cantor-Graae & Selton, 2005) and to a lesser degree mood disorders (Swinnen & Selton, 2007). With ever growing migrant communities in most parts of the world, it is becoming imperative for psychiatrists to have a basic understanding and respect for wide cultural and religious differences. Added to the increased risk of suffering from mental illness, migrants may also experience a range of other social difficulties including: deprivation, persecution or victimisation due to migrant or minority status, a lack of understanding or even lack of tolerance of their faith, cultural beliefs or practices, language barriers, loss of religious support or networks, differing constructs of mental illness from their indigenous culture, or isolation.

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Equally, psychiatrists who migrate may face a range of added challenges on arrival in their adopted country including; differences in psychiatric teaching and formulation in different countries, reduced access to training/opportunities/jobs, language difficulties and differences in cultural norms, expectations and standards. The perspectives and construction of mental (or indeed spiritual) ill health can vary greatly depending on the religious and cultural viewpoint of both the professional and the service user.

On a more positive note, multi-faith and multicultural practicioners have a great opportunity to learn new skills and different approaches from each other. The challenges presented by modern practice can create an exciting and varied caseload and collaborations with religious leaders present a new and potentially very beneficial approach to easing the distress of the unwell patient.

(ii) Divergence of Spirituality in Modern Society: The growth of atheism and fundamentalism : Here in the UK, as in much of the Western world, there appears to be a divergence in the spirituality of the modern society. That is, while a growing proportion of the population report being ‘atheist’, ‘agnostic’ or non- practising believers (see table below – NCSR, 2007), more fundamentalist groups of the major faiths are also experiencing a marked growth in membership.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

The percent who : 1964 1970 1983 1992 2005

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= Belong to a religion/ 74 71 55 37 31 attend services

Does not belong 3 5 26 31 38

Source : British Social Attitudes (2006/7)

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In a modern society that is grounded on scientific principles, it could be argued that the growth of atheism (the belief that God does not exist) and agnosticism (the belief that it is not possible to know whether God exists or not) (Oxford English Dictionary, 2008) is an understandable and natural process. All religions require the follower to have a degree of faith, that is, they are obliged to believe in some aspects that lack unequivocal scientific proof. It seems possible, therefore, that the more a society becomes more scientifically advanced and able to explain the world through observation, experimentation and evidence, the more its members may feel the inclination to look to science to explain natural, physiological and psycholgical experiences rather than looking to religious explanations.

However, paradoxically, as Western cultures become ever more reliant on science to explain the world around them, fundamentalist factions of the major religions and new religious movements have increased quite dramatically in popularity( Barker 1996). Suggestions as to why this might be include, that it is a counter-reaction to the growing scientific movement, that these groups provide community and acceptance in increasingly disparate societies or that the more mainstream branches of the major religions have lost their unifying voice and strength of conviction (Barker, 1996). There is, however, great fear and deep suspicion amongst the general public of such groups, and members can be met with great hostility, dismissed as being ‘brainwashed’ by a ‘cult’. There is arguably a possibility that people change religions for all kinds of different reasons some of which may be personal whereas others may be related to peer pressure.

The effect of this growth of new religious movements or more radical or fundamentalist branches of older religions on the mental health of those involved is largely unknown. The general consensus seems to be that while membership may prove beneficial, damaging or unimportant on an individual level with

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regards to the risk or course of mental illness, consistent difficulties arise if the individual encounters hostile, prejudiced or ignorant reactions from non-members. Like the role of culture, religion may contribute to pathology or may be a protective factor or may perpetuate idioms of distress. Therefore, each case needs to be judged individually, and professionals should always resist making uninformed decisions about the effects of less- common religious beliefs.

Should we be concerned at this seemingly increasingly divided society as mental health professionals? Clearly, there is great potential for conflict between the more extreme and/or aggressive religious and non-religious groups who find their viewpoints increasingly opposed. Adding to this, modern rhetoric such as ‘War on Terror’ and ‘Weapons of Mass Destruction’ carries significant religious and cultural undertones and tensions to many and can be perceived as further alienating and dividing factions of our multicultural society.

But perhaps from a more ‘everyday’ perspective, the risk seems to be a lack of mutual understanding and tolerance on an individual level and lack of community cohesion and national identity on a greater scale. The effects of this from a mental health perspective are potentially far-reaching and complex, but evidence exists of an increased risk of psychiatric morbidity (e.g. Brown & Harris, 1978).

(iii) Spirituality in Modern Mental Health Services : So how do we address these growing challenges? Firstly, at a level of service delivery, it is clearly important that we provide care that is inclusive, that is, equal in access, free from prejudice and that takes a global view of mental health and can meet the needs of an individual irrespective of religious and cultural background. This is a big task and while some of it lies at a organisational level, it could be argued that a significant proportion is at the individual level.

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It is very easy to remain passive with regards to this issue. It is possible to fulfil one’s contractual obligations without ever mentioning religion or considering the effect of cultural values in day to day practice. Faced with increasing case loads and time pressures, and an increasingly diverse and non-religious workforce, it is easy to see why asking staff to consider spirituality may be met with some resistance. However, it must not be forgotten that there is significant evidence that considering the spiritual needs of service users can confer significant benefit (e.g. Cantor-Graae et al. 2005; Huguelet et al. 2006) both as a protective factor and a function of illness management.

Presented below are four practical ways in which a mental health professional may aim to incorporate cultural and religious considerations into their practice:

Key Points for Mental Health Professionals

1. Consider spirituality as integral part of the individual psyche. Questions regarding spiritual beliefs and practices should be considered a routine part of a psychiatric formulation. Consider religious hallucinations or delusions in the social, religious and cultural context of the individual concerned. It is far easier to ignore such questions as they can further complicate an already difficult construction, but to do so is doing your patient a disservice.

2. Do your research. Practitioners should aim to have a basic understanding of the cultural and religious ideas, practices and values of the major groups represented in their practice area. They should also ideally have access to resources or sources that can provide a basic understanding of cultural or religious groups less commonly encountered. Embrace the opportunity to practice from a global perspective – enjoy the challenge!

3. Avoid prejudice and fear. Remember that each case is 419

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unique. Construct each person’s illness and beliefs in context and try to avoid making judgments or assumptions. Also be aware of your own cultural norms and religious beliefs and do not let them affect case formulation or alter management plans. This includes dismissing or ignoring spiritual context.

4. Work with religious and cultural leaders. Open channels of communication, to promote mutual education, understanding and development and also to allow coordinated patient management if appropriate.

Conclusions

Modern societies are becoming increasingly cultural and spiritually diverse and this brings many new pressures and challenges for mental health services and their professionals, including increased migrant populations, communities with diverging spiritual beliefs, and the risk of increasing alienation of minority groups.

There is good evidence to suggest that incorporating spiritual and cultural needs into the management of a patient can confer significant benefit. Therefore, as mental health professionals, it is imperative that we are mindful of these factors while formulating a patient’s illness and constructing management plans.

References :

Baker, P. & Eversley, J. (2000) Multilingual Capital- The Languages of London’s Schoolchildren and Their Relevance to Economic, Social, and Educational Policies. Battlebridge, UK.

Barker, E. (1996) New Religions and Mental Health. (ch.9) In: Bhugra (ed.) (1996) Psychiatry and Religion: Context, Consensus and Controversies. Routledge, London.

Bhugra, D. (1997) Religion and Mental Health. (ch.1) In:

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Bhugra (ed.) (1996) Psychiatry and Religion: Context, Consensus and Controversies. Routledge, London.

Bhugra, D. & Bhui, K. (2007) Culture and Mental Health. Hodder Arnold, London.

Brown, G.W., & Harris, T. (1978) Social Origins of Depression. Tavistock Publications, London.

Cantor-Graae, E. & Selten, J. P. (2005) Schizophrenia and Migration: A Meta-Analysis and Review. American Journal of Psychiatry, 162, 12-24.

Freud, S. Civilization and its Discontents; 1930; http://www.freud.org.uk/religion.html

Government Office for London (GoS) (2008) http://www.gos.gov.uk.

Huguelet, P., Mohr, S., Borras, L., Gillieron, C., Brandt, P.Y. (2006) Spirituality and religious practices among outpatients with schizophrenia and their clinicians. Psychiatric Services. 57(3):366-72

Institute for Public Policy Research (IPPR) (2005) Beyond Black and White – Mapping new immigrant communities. http://www.ippr.org.

Lipsedge, M. (1996) Religion and Madness in History (ch.2). In: Bhugra (ed.) Psychiatry and Religion: Context, Consensus and Controversies. Routledge, London.

The National Centre for Social Research (NCSR) “British Social Attitudes 2006/2007” (2007). Edited by Alison Park, John Curtice, Katarina Thomson, Miranda Phillips and Mark Johnson.

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Published by SAGE Publications, London, UK.

Office of National Statistics (ONS) (2001) Census Data. http://www.statistics.gov.uk.

Office of National Statistics (2006) Resident Population Estimates by Ethnic Group (Percentages)- England 2006. http://www.statistics.gov.uk.

Office of National Statistics (2008) Birthweight and gestational age by ethnic group, England and Wales 2005: introducing new data on births. http://www.statistics.gov.uk.

Porter R (2002): Madness: a brief history. Oxford: OUP

Royal College of Psychiatrists (2008) November 2008 Newsletter: http://www.rcpsych.ac.uk/member/rcpsychnews/ november2008.aspx

Swinnen, S.G.H.A & Selten, J.P. (2007) Mood Disorders and Migration: A Meta-Analysis. British Journal of Psychiatry. 190, 6-10.

Tearfund (2007) Churchgoing in the UK. http://www.tearfund.org.

Tseng W-S (2001): Handbook of Cultural Psychiatry. San Diego ,CA: Academic Press

Vasegh, S. & Mohammadi, M-R. (2007) Religiosity, anxiety and depression among a sample of Iranian medical students. International Journal of Psychiatry in Medicine. 37 (2): 213-27.

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Dr Ajit Kumar Avasthi

Professor of Psychiatry at
Postgraduate Institute of Medical Education
and Research (PGIMER), Chandigarh,
India, Dr. Avasthi is the joint winner of
prestigious Marfatia Award (1989) and PPA-I Award (1990, 1999, 2005, 2008) of the Indian Psychiatric Society. He has won Dr. G.C. Boral Award (1997), Dr. A.K. Kala Award (1997) and Dr. Buckshey Award (1998 and 2002) of the same Society.

Dr Avasthi has served as the Associate Editor of Indian Journal of Social Psychiatry (1988-94) and on the Editorial Boards of Indian Journal of Psychiatry, Archives of Indian Psychiatry, Journal of Mental Health and Human Behavior, Practitioner Update, Current Medical Journal, JK Science, IJM Today, Health and Disease. He has held the office of President of Indian Psychiatric Society – North Zone (1998-99) and is the President Elect of IPS.

He has delivered more than 120 Guest/Invited Lectures in meetings of the professional bodies and has read more than 110 papers in national and international conferences and has published over 120 research papers in reputed journals. He has edited 8 books in the filed of Psychiatry and has contributed a score of book chapters.

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Dr. Suresh Kumar

He has done his MBBS, MD, DNB, MSc [Science of Living, Preksha Meditation & Yoga] and is the Associate Professor [Psychiatry], PGIMER, Chandigarh.

He is a Life Member of World Association for Psychosocial Rehabilitation – Indian Chapter; Indian Medical Association; Indian Psychiatric Society- North zone; Life Member of Punjab & Chandigarh Chapter of Indian Psychiatry Society; Global Meditating Doctors Association; Sri Aurobindo Society, Pondicherry.

He has over 50 Publications and over 60 presentations.

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SPIRITUAL ASPECTS IN PSYCHIATRY- THE WAY FORWARD FOR THE FUTURE

ABSTRACT

Spiritual dimension has received widespread acceptance throughout the world as an important aspect of health. Need of the hour is to define the construct of spirituality, devise an instrument for its assessment, use such an instrument in researching the impact of this dimension on the different levels of prevention [primary, secondary and tertiary as per World Health Organization] in healthcare in general and mental healthcare in particular. Some preliminary efforts in the developed countries show that majority of the mental health patients want the spiritual dimension to be addressed in their assessment as well as management. India, being a nation with enormously rich heritage with respect to spirituality, warrants, all the more enthusiastically, addressing this issue. Before that, a stock taking exercise would be worthwhile to estimate where we are currently and then formulate the way forward from there.

Introduction

In 1978, a new dimension was added to the understanding of health when, India’s representative to World Health Organization [WHO], inspired by the vision of Sri Aurobindo, proposed that the definition of health be enlarged to cover spiritual well-being in addition to its physical, mental and social counterparts [Bisht, 1985]. This proposal was considered during the 36th World Health Assembly in 1983, and in 1984, the 37th World Health Assembly adopted the historic resolution that the spiritual dimension should be added to the scope of health. Though the spiritual dimension was accepted by WHO as an

Ajit Avasthi Suresh Kumar

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important dimension of health, it was left to the individual countries and regional offices to consider including in their strategies for health for all, a spiritual dimension in accordance with their social and cultural patterns. This paved the way at a global level to broaden the focus of measurement of health beyond the traditional healthcare indicators such as morbidity and mortality [Basu, 1995].

Studies and surveys undertaken in the USA and UK supported the notion that patients welcome the spiritual dimension of health being addressed as part of their healthcare delivery system. The USA has by and large pioneered the introduction of the teaching of spirituality in the curriculum of many medical schools [Puchaski et. al, 2001]. In the United Kingdom, the major impetus towards teaching of spirituality in the curriculum should be attributed the work of Special Interest Group [SIG] at the Royal College of Psychiatrists [Sims, 1994].

It is surprising that the developed countries have started incorporating spiritual dimension in their healthcare that is based on modern system of Medicine but India, that has always had spirituality in its local folklore as well as in the local health system [Ayurveda], has not made any headway in this direction despite repeated calls for action suggested by a number of stalwarts in Indian Psychiatry [Venkoba Rao, 2002; Varma, 1982; Wig, 1999; Kuruvilla, 2000; Neki, 1975].

With this background, let us examine what potential future applications the spiritual and religious aspects have for the psychiatry practice in India. To make it simple, these potential applications are being discussed under the following categories based on the levels of prevention given by WHO:

1. Promotion of mental health in general population as well as ill population

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It has been established by several studies world wide that people who follow the spiritual and religious practices enjoy better mental health, fall ill less frequently, cope with their illness better and recover quickly [Kendler et al, 2003; Braam et al, 1997; Koenig et al, 1998]. Majority of people in India do believe in and also practice such techniques. However, no systematic enquiry has been made into this field.

2. Prevention of psychiatric disorders in the high risk individuals & prevention of relapses and suicide in episodic/ chronic psychiatric disorders

Stress diathesis model is often invoked to explain the genesis of illness as well as occurrences of relapses or recurrences in a given individual. Going by that model, practices that have a potential to reduce stress level and improve resilience and adjustment levels would reduce the emergence of such illnesses in the general population in general and in the population at high risk in particular. Same mechanism should be operating to reduce the likelihood of relapses or recurrences of psychiatric illnesses. In a population where spiritual and religious aspects and practices are ingrained in the culture, it should not be difficult to operationalize and exploit them therapeutically. Though, this argument seems appealing, no studies are available to endorse it. It may be worthwhile trying out this approach as add on intervention to the routine care.

A study by Gupta et al [2006] examined the relationship between religiosity and psychopathology in patients with depression. It found that presence of high religiosity predicted lower hopelessness and lower suicidal ideation.

3. Treatment of acute disturbances in psychiatric disorders Indigenous therapy using the principles of Patanjali’s

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Ashtanga Yoga has been examined in randomized placebo controlled trials in neurotic and psychosomatic disorders and found to useful [Vahia et al, 1966; Sethi et al, 1982, Grover et al, 1994].

Antidepressant effect of an indigenous method of breathing control [Sudarshan Kriya Yoga] has been studied in a Randomized Controlled Trial [RCT] and found to be as efficacious as Antidepressant Medications though less efficacious than ECT in patients with Melancholic Depression [Janakiramaiah, 2000].

Impact of add on yoga on persons with schizophrenia was studied at National Institute of Mental Health and Neurosciences [Ganesan, 2005] using a randomized control design. The patients in the yoga group showed significantly more improvement than in the physical exercise group on several measures viz. CGI severity of illness score, Negative Symptom Score, General Psychopathology Score, Anergia and Depression subscores and Quality of Life.

4. Facilitate rehabilitation and adjustment in chronically disabled or partially recovered individuals

There is a large minority of persons with psychiatric disorders that do not respond at all or respond only partially to the medication. Resultantly, part of the psychosocial management in these cases involves educating them to accept and get adjusted to the persistent or residual symptomatology or disability. The spiritual and religious traditions have rich elements in them that help the person with disability as well as his or her caregivers and community at large to give a positive meaning and interpretation to the disability and carry on. This approach to rehabilitation has intuitive appeal and perhaps is being used in many parts of India for the benefit of several patients. However, no systematic studies are available to substantiate it.

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5. Improve quality of life by encouraging a spiritual perspective during all phases of health and illness

It is often said that spiritual perspective affects the outlook as well as the behavior and that it affects the overall life in general. Some studies have suggested that persons as well as patients with spiritual inclinations enjoy a better quality of life than their “non-spiritual” counterparts [Fehring et al, 1987]. Further, it has been proposed that wellness and illness are separate dimensions and that a person may be ill but still be high on wellness dimension. On the other hand, a person may not have any illness but still be low on wellness and well-being. So, inculcation of practices that improve wellness, quality of life etc. would be beneficial, irrespective of the presence or absence of illness and further, irrespective of the stage of illness. This is another area that requires future research in healthcare.

Conclusions

World Health Organization defines health as a state of well- being in the physical, mental, social and spiritual domains. The spiritual domain of health has started receiving attention and recognition in the scientific and academic circles. The spiritual domain is an overarching dimension that cuts across all the other three domains viz. physical, mental and social. The greatest interaction and impact appears to be on the psychological/ mental domain. That spiritual dimension can have positive impact on mental health has never been disputed; what was disputed was whether spiritual aspects can be helpful in treatment of diseases/ illnesses.

The recent scientific and research endeavors and their outcomes worldover endorse the notion that inclusion of spiritual domain in the modern psychiatry training, practice and research is in fact warranted. Spiritual aspects have potential applications in the following aspects of psychiatry in the future- promotion of

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mental health in general population, prevention of psychiatric disorders in the high risk individuals, treatment of acute disturbances in psychiatric disorders, facilitate rehabilitation and adjustment in patients with chronically disabled or partially recovered individuals, improve quality of life by encouraging a spiritual perspective during all phases of health and illness. There is a need for the interdisciplinary collaboration, such that the rigorous scientific methodology of the modern science and the spiritual traditions of the ancient wisdom are judiciously mixed to give better health and quality of life to the persons with mental illness.

References :

Basu S. (1995) How the Spiritual Dmension of Health was acknowledged by the World Health Assembly- a Report. New Approaches to Medicine and Health, 3: 47-51.

Bisht DB. (1985) Spiritual Dimension of Health. New Delhi: Directorate General of Health Services.

Braam AW, Beckman AT, Deeg DJ, Smit JH, Van Tilberg W. (1997) Religiosity as Protective or Prognostic Factor of Depression in Later Life: Results from a Community Survey in Netherlands. Acta Psychiatrica Scandinavica, 96 [3]: 199-205.

Fehring RJ, Brennan PF, Keller ML. (1987) Psychological and Spiritual Well-being in College Students. Research in Nursing and Health, 10: 391-398.

Ganesan D. (2005) Yoga as an Add On Treatment in the Management of Patients with Schizophrenia- Randomized Controlled Trial. MD Thesis submitted to Institute of Mental Health and Neurosciences, Bangalore [Unpublished].

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Grover P, Varma VK, Pershad D, Verma SK. (1994) Role of Yoga in the treatment of Neurotic Disorders: Current Status and Future Directions. Indian Journal of Psychiatry, 36 [4]: 153-162.

Gupta S, Avasthi A, Kumar S. (2006) Relationship between Religiosity and Psychopathology in patients with Depression. MD Thesis submitted to Post Graduate Institute of Medical Education and Research, Chandigarh [Unpublished].

Janakiramaiah N, Gangadhar BN, Nagavenkateshmurthy PJ, Harish MG, Subbakrishna DK, Vedamurthachar A. (2000) Antidepressant Efficacy of Sudarshan Kriya Yoga [SKY] in Melancholia: a Randomized Comparison with electroconvulsive Therapy [ECT] and Imipramine. Journal of Affective Disorders, 57: 2555-259.

Kendler KS, Liu XQ, Gardner CO, McCullough ME, Larson D.(2003) Dimensions of Religiosity and their relationship to Lifetime Psychiatric and Substance Use Disorders. American Journal of Psychiatry; 160 [3]: 496-503.

Koenig HG, George LK, Peterson BL. (1998) Religiosity and remission of Depression in Medically Ill Older patients. American Journal of Psychiatry, 155 [4]: 536-542.

Kuruvilla K. (2000) Cognitive Behavior Therapy- Yesterday, Today and Tomorrow. Indian Journal of Psychiatry, 42 [2]: 114- 124.

Neki JS. (1975) Psychotherapy in India-Past, Present and Future. American Journal of Psychotherapy 29 : 92.

Puchaski C & Larson D, Lu F. (2001) Spirituality in Psychiatry Residency Training Programs. International Review of Psychiatry, 13 [2]: 131-138.

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Sethi BB, Trivedi JK, Srivastava A, Yadav S. (1982) Indigenous Therapy in Practice of Psychiatry in India. Indian Journal of Psychiatry, 24 [3]: 230-236.

Sims A. (1994) Psyche- Spirit as well as Mind? British Journal of Psychiatry, 165: 441-446.

Vahia NS, Vinekar SL, Doongaji DR. (1966) Some Ancient Indian Concepts in the Treatment of Psychiatric Disorders. British Journal of Psychiatry, 113: 1089.

Varma VK. (1982) Present State of Psychotherapy in India. Indian Journal of Psychiatry 24 [3]: 209-226.

Venkoba Rao. A. (2002) Mind in Ayurveda. Indian Journal of Psychiatry, 44 [3]: 201-211.

Wig NN. (1999) Mental Health and Spiritual Values-a View from East. International Review of Psychiatry, 11: 92-96.

World Health Assembly [WHA] 37.13, EB 73.R3, 1984.

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Dr Rajesh Sagar

He obtained his MBBS from
Maulana Azad Medical College, New
Delhi and MD from NIMHANS,
Bangalore. He is a Member of National
Academy of Medical Sciences (MNAMS), Fellow of International Medical Science Academy (FIMSA).

He is presently as Associate Professor in Deptt. of Psychiatry at AIIMS, New Delhi. He is also a Secretary of Central Mental Health Authority, Govt. of India and expert/advisor for WHO & Ministry of Health & Family Welfare.

He has published numerous articles and acted as Investigators for many funded research projects (incl. WHO projects & also a coordinator of India for World Mental Health Survey).

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INTEGRATING SPIRITUALITY AND INDIGENOUS METHODS IN MENTAL

HEALTH DELIVERY

Rajesh Sagar Rohit Garg

Introduction

Humans try to understand the world around and spirituality helps as a way in understanding this meaning. Spirituality can vary according to age, gender, culture, political ideology, physical or mental health and other various factors. Spirituality is shaped and directed by the experiences of individuals and of the communities in which they live and is an outward expression of the inner workings of the human spirit (Swinton, 2001). Spirituality gives meaning and direction to a person’s life and answers important dimensions of life such as the quest for meaning, purpose, self-transcending knowledge, meaningful relationships, love and commitment (Swinton and Pattison, 2001). Connection between spirituality and mental health has been recognized (e.g. Buddhism) for many centuries (King, 1998). Holistic approach to treat individuals has explored spirituality as one of the dimension among cognitive, emotional, interpersonal and psychological facets that make up a human being. Interaction between the spirituality and mental health is likely to be complex, interactive and dynamic due to internal and external factors influencing it.

Indigenous knowledge has multiple sources, including traditional, spiritual, and empirical. This plurality of indigenous knowledge engages a holistic paradigm that acknowledges the emotional, spiritual, physical, and mental well-being of people. Traditional healing includes wide range of activities, from physical cures using herbal medicines and to the promotion of psychological and spiritual well-being using ceremony, counseling

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and the accumulated wisdom of elders (Royal Commission on Aboriginal Peoples, 1996). Today, the revitalization of traditional medicinal healing practices is going public or mainstream therefore in this chapter we will be discussing about the ways of integrating spirituality and indigenous healing methods with the mental health delivery.

Defining spirituality and indigenous medicine

Spirituality means different things for different people at different times in different cultures. Earlier it was mainly expressed through religions, art, nature but its meaning has now become varied and diffuse as defined in following ways at various places:

· a sense of purpose

· a sense of ‘connectedness’ – to self, others, nature, ‘God’ or Other

· a quest for wholeness

· a search for hope or harmony

· a belief in a higher being or beings

· some level of transcendence, or the sense that there is more to life than the material or practical

· activities giving meaning and value to people’s lives.

There is lack of consistency and clarity in the terms used to describe tradition medical practices. It is at times loosely applied to a variety of diverse activities that are not always uniformly acknowledged among Indigenous practitioners and their clients. The Report of the Royal Commission on Aboriginal Peoples (1996) defines traditional healing as “practices designed to

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promote mental, physical and spiritual well-being that is based on beliefs which go back to the time before the spread of Western ‘scientific’ bio-medicine.

Impact of spirituality and indigenous healing on mental health

Benefits of spiritual activity have been well recognized for physical disorders like cardiovascular disorders (Matthews et. al, 1998), AIDS (Evans et, al. 1997) and cancer (Fehring et. al, 1997) and living longer (McCullough et. al, 2000). Depending on how spirituality is expressed or which aspects of it are measured, positive associations have been found between some styles of religion/spirituality and general wellbeing, marital satisfaction and general psychological functioning (Gartner, 1996).

Recently, professionals in psychology, psychiatry, nursing and gerontology feel that mental health and spirituality are intrinsically linked and thus individuals from all these sectors should communicate with and learn from one another (Faulkner, 1997; Gartner, 1996). The attitude of mental health caregivers differs towards spirituality, as in a recent survey, 45% of mental health professionals felt that religion could lead to mental ill health and 39% thought that religion could protect people from mental ill health (Foskett et. al, 2004). Freud called religion “the universal obsessional neurosis of humanity (Freud, 1959) and others argue lack of attention to spirituality in both psychiatric textbooks and mental health services (Swinton, 2001).

Evidence now exists and various mechanisms have been proposed to support the role of spirituality in various mental disorders. Feelings of hopelessness, lack of meaning or purpose in life and low self-esteem, are closely linked with what many people understand as spirituality (Swinton, 2001). Hodges describes four dimensions of spirituality – meaning of life, intrinsic values, belief in transcendence and spiritual community – and

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argues that each of these dimensions has an inverse linear relationship with depression (Hodges, 2002). Depressive cognition makes the individual question self existence again, e.g. “Why am I here? What’s the point of living?” Spirituality is helpful in reducing depressive symptoms and/or increasing general wellbeing (Koenig,1998). Spirituality offers the meaning of self existence and restores the meaning, purpose and hope, amidst an otherwise confusing or depressing existence.

Swinton (2001), proposed that stress and anxiety have spiritual symptoms too like loss of meaning in life, obsessional religious thoughts and actions, loss of previous spiritual belief, no sense of the future, fear of death, fear of the consequences of sin. In a study it was found that spiritual involvement, beliefs and spiritual coping mechanisms lead to decreased anxiety symptoms among women with diagnosis of cervical cancer (Boscaglia et. al, 2005). Various activities like yoga and meditation have been associated with improved mental health and reductions in anxiety. A recent systematic review found eight studies that found positive impact of yoga on anxiety but stated that due to methodological inadequacies further research was necessary (Kirkwood et. al, 2005).

Religion and spirituality are highly valuable to people in times of crisis, trauma and grief (Weaver et. al, 2003). Review of the literature (Shaw et. al, 2005) found that religion and spirituality is beneficial to people in dealing with the aftermath of trauma, they show that traumatic experiences can lead to a deepening of religion or spirituality, that positive religious coping, religious openness, readiness to face existential questions, religious participation, and intrinsic religiousness are typically associated with improved post-traumatic recovery and reducing post traumatic stress disorders.

Religion and spirituality are relevant in the lives of many

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people with schizophrenia and in many cases seem to offer valuable benefits to living with and recovering from the illness. One review of the literature looking at religious and spiritual coping amongst individuals with chronic schizophrenia concluded that “religion plays a central role in the processes of reconstructing a sense of self and recovery” (Mohr et. al, 2004). It has also been seen that religiosity of a family of a schizophrenia patient helps in holding the family together and supporting the family (Margetic, 2005). It has been seen that people with schizophrenia find hope, meaning and comfort in spiritual beliefs and practices (Mohr et. al, 2004; Kirkpatrick et. al, 2001; Weisman 2000).

Need for integration of spirituality and indigenous healing in mental health delivery

Currently available literature and research evidence supports the positive role of spirituality in mental illnesses. Though spirituality has been largely considered a different field but in reality it is not separated and is in close and complex relation with mental health. There is however a growing recognition of the importance of spirituality in health care in the dominant society (Stoter, 1995). Researchers in Canada and the United States have shown the importance of spirituality in the rehabilitation of Indigenous prison inmates (Waldram, 1994; Atlee, 1997). It is also important to realize that a healthy spirit is essential to live a healthy mental life and the current scenarios demands the integration of these services for holistic care of the mentally ill people.

Factors mediating the relationship between spirituality and mental health

There are various mechanisms through which potential benefits may occur and which explore the association between spirituality and mental health. Mechanisms most often discussed are :

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1) Coping styles
2) Locus of control
3) Social support and social networks 4) Physiological mechanisms

1) Coping styles : Religious coping acts can act as a mediator between spirituality and mental health, particularly during stress. Religious beliefs about ‘divine’ can have a major impact on coping abilities (Pollner 1989) and based on this theory following ways of religious coping are suggested (Pargament et. al, 2000, 2001, 2004).

a) Collaborative approach : Individual enters into collaboration with God and the problem solving process and the responsibility for a solution is considered as a shared process.

b) Deferring approach : Individual acts passive in problem solving and trusts God to fully resolve the problem without their own intervention.

c) Self-directing approach : Person feels full responsibility for problem solving and believes that God has provided the strength required for successful coping (Fabricatore et. al, 2004).

d) Plead approach : Individual refuses to accept the current problem and wants God to intervene in a miraculous way for desirable outcomes.

It was found in a study that collaborative approach is helpful and beneficial for mental health, whereas deferring and self- directing styles have yielded mixed results and pleading approach or bargaining for a miracle leads to more distress and is considered a maladaptive style of coping (Fabricatore et. al, 2004, Yangarber-Hicks 2004).

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2) Locus of attribution/control : The way an individual attributes, interprets and gives meaning to various events and experiences in life, associate spirituality and mental health (Seligman et. al 2005, Abela et. al, 2004; Seligman et. al, 1984, Miller et. al, 1975; Raps 1987). Locus of attribution helps in developing insight about the illness, which is often lost in psychotic states and some control over the situation may help in developing confidence and bringing down hopelessness of an individual. Mechanisms proposed to be associated with better mental health are:

a) Optimisticattributionstyle:Perceivingnegativeevents as externally caused and positive events as internally caused and is associated with better mental health (Seybold et. al, 2001).

b) Internal locus-of-control : Individual’s belief that they have some control over the outcome is associated with better mental health than an external locus of control (Peterson et. al, 1981).

Religious beliefs may generate internal locus of control, lessen the stress and allow a person to reinterpret events earlier presumed as uncontrollable (Margetic 2005). Optimistic attribution style, help individuals to make sense of the suffering associated with a mental health problem e.g. negative events are God’s will, rather than anyone’s fault and positive events are a consequence of good behavior (Sethi and Seligman, 1993).

3) Socialsupport:Social,spiritualorreligioussupportis considered as key mediator between spirituality and mental health as it increases self-esteem, companionship and help people to cope with stress and negative life events. Spiritual support may provide more beneficial support than other social or cultural networks (Cohen et. al, 1985; Hill et. al, 2003). Some of the specific ways in which the spiritual community provides support are (Loewenthal et. al, 1995):

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• Preventing social isolation
• Strengthening family and social networks
• Increasing sense of belonging and self-esteem • Offering spiritual support in times of adversity.

Various studies have reported leaders of religious com munities as “front-line mental health workers” (Weaver et. al, 2003; Foskett et. al, 2004).

4) Physiological impact : Anger or fear during an illness triggers the release of norepinephrine and cortisol which may hinder the recovery from illness. Emotions generated in spirituality like hope, contentment, love and forgiveness, affect endocrine and immune systems and promote recovery from illness (Larson et. al, 1998; Seybold et. al, 2001). Meditation and yogic activity reduce the levels of norepinephrine, cortisol thus and thus reduce stress, anxiety, post-traumatic stress disorder, depression and stress-related mental illness (Brown et. al, 2005). It is suggested that 30 minutes of daily yoga practice enhances well-being, mood, attention, mental focus and stress tolerance for these individuals (Brown et. al, 2005). Specific breathing techniques improve heart rate variability, which in turn has been linked with improvements in mental health outcomes (Servan-Schreiber, 2005).

Barriers in the integration of spirituality and indigenous medicine with mental health delivery

1) Culture and regional sensitivity : Indigenous healing practices are restricted to locality and culture. It is therefore difficult to deliver common, successful methods of traditional medicine to culturally diverse people. It is strongly tied to land, language and the natural environment shapes the medical expertise and practices employed by each indigenous group.

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2) Attitude of the mental health professionals : Benefits of spiritual and religious expression and activity have often been ignored or dismissed by those working in mental health services (Nicholls, 2002). Spirituality is also assumed to be an area not deemed credible in terms of research in psychiatry (Swinton, 2001). A study reported that 44% of spiritual and religious leaders thought that mental ill health might lead to greater religious belief; 52% believed that religion may lead to mental ill health; 45% thought that mental ill health could reduce religious belief; 22% thought that religion might protect people from mental ill health; 39% thought that religion might be a way to sublimate psychological problems and just 1% thought that there was no link between mental health and religion or spirituality (Foskett, 2004 b).

It is difficult to discuss spirituality among psychiatrists because of the model of the mind and the biological basis of psychiatry on which so much of psychiatry is founded. The psychiatrists do not explore or look into the spiritual beliefs of the patients due to lack of time and training, concern about stepping outside one’s area of expertise, discomfort with the subject, different self beliefs and lack of interest or awareness.

3) Exploitation and Authenticity : Many people present themselves as healers or spiritual leaders who exploit their own communities and the users of those services. This brings in a bad name for these practices among mental health professionals and policy makers, thereby putting the integration of spirituality and indigenous healing on the back bench

Ways to integrate spirituality and indegenous methods with mental health delivery

1) Decolonization and de-stigmatization : Since ages indigenous knowledge and spirituality has been regarded as

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unscientific and superstitious by the education curriculums and residential schools. These practices have also been stigmatized by various organizations who even jailed many political and spiritual leaders until the mid-1900s. The ‘de-stigmatization’ of traditional medicine is critical, since its essential philosophy is the belief system of the individual, and the individual’s subsequent willingness to take responsibility for his or her own well-being. There is need to educate people and mental health professionals to work towards restoring the respect and honor of indigenous knowledge and spirituality and challenge stigma and discrimination. This can be achieved by involving spiritual communities in helping mentally ill patients as well as recognizing and promoting the value of spiritual places and buildings (Dawn Martin Hill National Aboriginal Health Organization March 19, 2003).

2) Reaching the Children in Schools : Due to the industrialization and growth in the concept of nuclear family the schools are the primary place for children to learn. They no longer interact and are not taught by the grandparents resulting in no knowledge and respect for spirituality and indigenous medicines. It has been seen that at times school environment even results in unhealthy lifestyle and eating habits like junk and fast food leading to various illnesses. Due to lack of love and encouragement in some school settings children may suffer from low self-esteem, suicide and self-destructive behavior. It has been suggested that elders or traditional healers can be appointed in the schools who would teach children about the spirituality and traditional methods of medicine along with the emotional and psychological support. Appointing them in schools would also restore elders role as mentors, offer them something positive to do for society.

3) Enhancing the skills and knowledge of spiritualist/ healers/mental health professional together : Most of the

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health care providers do not learn about other ways of treating or providing better health. There is need to learn each other’s ways (biomedicine, spirituality, naturopathic and traditional medicine) for understanding the way they could all contribute to the current practices and knowledge and work towards networking, conferencing and ongoing dialogue with one another for providing better mental health services. Due to difference in opinion about the importance of spirituality and indigenous healing in mental health there is need to educate spiritual leaders, indigenous healers and mental health professional at the same place, so as to learn how to really work together.

Workshops and interactive group sessions can be taken up for professional and intellectual development. While emotional, psychological and physical trauma may lead to various mental illnesses, biomedicine normally does not incorporate traumatic experience in treatment. Therefore, there is a need to work in collaboration with spiritual leaders and indigenous healers which can deal with aftermath of trauma in various ways. The special interest group (SIG) in Spirituality and Psychiatry at the Royal College of Psychiatrists (RCPsych) suggests that psychiatrists should show genuine interest and respect for spiritual and religious beliefs of the patient. One way of doing this is by considering a person’s religious or spiritual beliefs during assessment. Assessment of spirituality needs sensitivity, creativity, unbiased approach, knowledge about own spiritual beliefs and how they differ culturally from others in order to remain non-judgmental.

4) Mentorship between Youth and Elders : Elders/healers felt that they were losing valuable knowledge because there was no interest from youth in learning indigenous knowledge or spirituality practices. The data about people interested in indigenous medicine, spirituality and mental health can be collected and common teaching platform can be created. It has

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also been suggested that schools could credit young people for apprenticing with elders and learning spirituality practices and knowing about indigenous healing methods.

5) Developing appropriate policies and protection for Indigenous knowledge : The native healers and spiritualists may be scared over the chances of exploitation of their practices and knowledge. The information generated out of research or collective approaches by various health providers would belong to the specific communities. This is critical in developing strong relationships or “rebuilding trust” between various health agencies, researchers, spiritualists, indigenous healers and mental health professional.

6) Maintaining autonomy of indigenous medicine and spirituality : The government is finding ways to control and regulate spiritual practices, healing, and ceremonies as these at times have harmed the mentally ill people. In Western countries issues of insurance arise when there is damage due to traditional healing methods. Working in collaboration with mental health professionals also might generate the fear among healers and spiritualists for being regulated by the same rules applicable to mental health services. The government can formulate policies and regulations which can make healers and spiritualists more confident for working in collaboration with mental health providers and the patients. The development of codes of ethical conduct can protect people from being abused or exploited.

7) Research in the field of spirituality and mental illnesses : Spirituality is a multidimensional concept which acknowledges socio-demographic, social and health factors therefore, researchers need to investigate complex and interactive nature of spirituality and mental health rather than simple linear relationships. Researchers should ensure that the methodologies they employ are those most appropriate to answer

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the questions being addressed. Research should be able to differentiate clearly between the benefits of spirituality and indigenous medicine in mental health and benefits of other social activities which are part of human behavior. The service users can be involved in the design, conduct and analysis of research projects.

Studies need to explore how ethnicity, culture, socio- economic status and religious preference affect the association between spirituality and mental health. There is a need to develop a measure of religion and spirituality that is above all these factors and traditions. Research should explore the impact and effectiveness of the ‘healing’ dimensions of different spiritual activities.

Suggested recommendations

1) A national conference on indigenous medicine, spiritual leaders and mental health providers may raise awareness, enhance their skills and facilitate understanding and learning from one another and develop networks to work together.

2) Facilitate local public awareness campaigns about traditional medicine, spirituality and mental health that would reduce stigma.

3) Development of a national database of healers and spiritual leaders and integrate it with the locally available mental health providers to prevent exploitation of service users.

4) Building strong and effective links with spiritual groups and indigenous healers in the local community.

5) Support the development of ethical guidelines, research codes of conduct, the protection of indigenous knowledge and ways to preserve authentic spiritual practices.

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6) Development of incentive policies for medical universities that would expose students to diverse approaches to medicine.

7) Development of curriculum that could be used by elementary and post-secondary schools on the topic of Indigenous knowledge and medicine.

8) Askingmentallyillpeopleabouttheirspiritualandreligious needs upon entry to the service and throughout their care and treatment

9) Ensuring that all mentally ill people are offered the opportunity to speak with a spiritual leader if desired.

10) Providing good access to relevant and appropriate religious and spiritual resources.

11) Offering or making available safe spaces along with mental health services where users can pray, meditate, worship or practice their faith.

12) Providing opportunities for service users to discuss their spirituality or religion with mental health professionals.

13) Avoid dismissing or ignoring the religious or spiritual experiences of service users.

References :

Abela, J. R., K. Brozina, and M. E. Seligman, (2004); A test of integration of the activation hypothesis and the diathesis-stress component of the hopelessness theory of depression: British Journal Clinical Psychology, 43, 111-128.

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Atlee, T. (1997) Bringing down walls: A Native Elder’s Earth & Spirit-Based Prison Program. EarthLight. #28, Winter 1997-8, 8-9 & 22-23.

Boscaglia, N., D. M. Clarke, T. W. Jobling, and M. A. Quinn, (2005); The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer: International Journal Gynecology Cancer, 15: 5, 755-761.

Brown, R. P., and P. L. Gerbarg, (2005a); Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: Part I-neurophysiologic model: Journal Alternative Complement Medicine, 11: 1, 189-201.

Brown, R. P., and P. L. Gerbarg, (2005b): Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression. Part II—clinical applications and guidelines: Journal Alternative Complement Medicine, 11: 4, 711-717.

Cohen, S., and T. A. Wills, (1985); Stress, social support, and the buffering hypothesis: Psychology Bulletin, 98: 2, 310-357.

Evans, D. L. et al., (1997); Severe life stress as a predictor of early disease progression in HIV infection: American. Journal Psychiatry, 154:5, 630-634.

Fabricatore, A. N., P. J. Handal, D. M. Rubio, and F. H. Gilner, (2004); Stress, Religion, and Mental Health: Religious Coping in Mediating and Moderating Roles: International Journal for the Psychology of Religion, 14: 2, 91-108.

Faulkner, A., (1997); Knowing Our Own Minds: London, Mental Health Foundation

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Fehring, R. J., Miller J. F, & Shaw C. (1997); Spiritual well- being, religiosity, hope, depression, and other mood states in elderly people coping with cancer: Oncology Nursing Forum, 24: 4, 663-671.

Foskett, J., A. Roberts, R. Mathews, L. Macmin, P. Cracknell, and V. Nicholls, (2004); From research to practice: The first tentative steps: Mental Health, Religion & Culture, 7:1, 41-58.

Foskett, J., J. Marriott, and F. Wilson-Rudd, (2004); Mental health, religion and spirituality: Attitudes, experience and expertise among mental health professionals and religious leaders in Somerset: Mental Health, Religion & Culture, 7:1, 5-22.

Freud, S., (1959); Civilisation and its discontents: London, Hogarth.

Gartner, J., (1996); Religious commitment, mental health and prosocial behaviour: a review of the empirical literature. In EP Shafranske (ed.) Religion and the clinical practice of psychology: Washington DC, American Psychiatry Association, p. 187-214.

Hill, P. C., and K. I. Pargament, (2003); Advances in the conceptualization and measurement of religion and spirituality. Implications for physical and mental health research: American Psychology, 58:1, 64-74.

Hodges, S. D., S. C. Humphreys, and J. C. Eck, (2002); Effect of spirituality on successful recovery from spinal surgery: South Medical Journal, 95:12, 1381-1384.

King, U., 1998, Spirituality. In J.R. Hinnels (ed.) The New Penguin Handbook of Living Religions: London, Penguin Books, p. 667-681.

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Kirkpatrick, H., J. Landeen, H. Woodside, and C. Byrne, (2001); How people with schizophrenia build their hope: Journal Psychosocial Nursing Mental Health Services, 39:1, 46-53.

Koenig, H. G., L. K. George, and B. L. Peterson, (1998); Religiosity and remission of depression in medically ill older patients: American Journal of Psychiatry, 155:4, 536-542.

Larson D. B., and S. S. Larson, (1998); Spirituality’s potential relevance to physical and emotional health: a brief review of quantitative research: Journal of Psychology & Theology, 31: 1, 37.

Loewenthal, K. M., (1995); Mental Health and Religion: London: Chapman & Hall.

Margetic, B., and B. Margetic, (2005); Religiosity and health outcomes: review of literature: Coll.Antropol., 29:1, 365-371.

Matthews, D. A., M. E. McCullough, D. B. Larson, H. G. Koenig, J. P. Swyers, and M. G. Milano, (1998); Religious commitment and health status: a review of the research and implications for family medicine: Archives Family Medicine, 7: 2, 118-124.

Miller, W. R., M. E. Seligman, and H. M. Kurlander, (1975); Learned helplessness, depression, and anxiety: Journal Nerv Mental Disorders, 161: 5, 347-357.

Mohr, S., and P. Huguelet, (2004); The relationship between schizophrenia and religion and its implications for care: Swiss Medicine Weekly, 134: 25-26, 369-376.

Nicholls V. (2002); Taken Seriously: The Somerset Spirituality Project: London: Mental Health Foundation.

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Pargament, K. I., H. G. Koenig, and L. M. Perez, (2000); The many methods of religious coping: development and initial validation of the RCOPE: Journal Clinical Psychology, 56:4, 519-543.

Pargament, K. I., H. G. Koenig, N. Tarakeshwar, and J. Hahn, (2001); Religious struggle as a predictor of mortality among medically ill elderly patients: A 2-year longitudinal study: Archives Internal Medicine, 161:15, 1881-1885.

Pargament, K. I., H. G. Koenig, N. Tarakeshwar, and J. Hahn, (2004); Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: A two-year longitudinal study: Journal Health Psychology, 9: 6, 713-730.

Peterson, C., S. M. Schwartz, and M. E. Seligman, (1981); Self-blame and depressive symptoms: Journal of Personality and Social Psychology, 41:2, 253-259.

Pollner, M., (1989); Divine relations, social relations, and well- being: Journal of Health and Social Behaviour, 30, 92-104.

Raps, C. S., K. E. Reinhard, and M. E. Seligman, (1980); Reversal of cognitive and affective deficits associated with depression and learned helplessness by mood elevation in patients: Journal Abnormal Psychology, 89:3, 342-349.

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Seligman, M. E., C. Peterson, N. J. Kaslow, R. L. Tanenbaum, L. B. Alloy, and L. Y. Abramson, (1984); Attributional style and depressive symptoms among children: Journal of Abnormal Psychology, 93:2, 235-238.

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Seligman, M. E., T. A. Steen, N. Park, and C. Peterson, (2005); Positive psychology progress: empirical validation of interventions: American Psychology, 60:5, 410-421.

Servan-Schreiber, D., (2005); Healing without Freud or Prozac: Natural Approaches to Curing Stress, Anxiety and Depression: London: Rodale International Ltd.

Sethi, S., and M. E. P. Seligman, (1993); Optimism and fundamentalism: Psychological Science, 4, 256-300.

Seybold, K. S., and P. C. Hill, (2001); The Role of Religion and Spirituality in Mental and Physical Health: Current Directions in Psychological Science, 10:1, 21-24.

Shaw, A., S. Joseph, and P. A. Linley, (2005); Religion, spirituality, and post traumatic growth: A systematic review: Mental Health, Religion & Culture, 8:1, 1-11.

Stoter, D. (1995) Spiritual Aspects of Health Care. Mosby: London, UK.

Swinton, J., (2001); Spirituality and Mental Health Care: Rediscovering a forgotten dimension: London: Jessica Kinglsey Publishers.

Swinton, J., and S. Pattison, (2001); Spirituality. Come all you faithful: Health Services Journal, 111: 5786, 24-25.

Waldram, J. (1994) Aboriginal spirituality in corrections: A Canadian case study in religion and therapy. The American Indian Quarterly. 18: 2, 197-215.

Weaver, A. J., L. T. Flannelly, J. Garbarino, C. R. Figley, and K. J. Flannelly, (2003); A systematic review of research on religion

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and spirituality in the Journal of Traumatic Stress : 1990-1999. Mental Health, Religion & Culture, 6:3, 215-228.

Weisman, A. G., (2000); Religion: a mediator of Anglo- American and Mexican attributional differences toward symptoms of schizophrenia?. Journal Nerv Mental Disorders, 188:9, 616-621.

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Uday Chaudhuri

MBBS, DPM, MD, DNB (Psych), Associate Prof. of Psychiatry, Vivekananda Institute of Medical Sciences, (since 1995), Kolkata, India.

For the past few years, Dr. Chaudhuri has also been a member of the National Task Force, IPS Guidelines for Depression & Substance Abuse Disorder. He is also a member of the Lundbeck Institute, Denmark, the American Psychiatric Society & the World Federation of Biological Psychiatry. He is one of the founder members of the Indian Association of Biological Psychiatry. He works extensively on combining Spirituality in Mental Health and Vivekananda Institute of Medical Sciences.

These programs have given Dr. Chaudhuri the opportunity to work with a large number of internationally acclaimed psychiatrists & other mental health workers. The chapter on anxiety disorders in the API Textbook of Medicine, 2006, was published by him.

Dr. Chaudhuri has also published numerous articles & review papers in peer reviewed journals.

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COMBINING SPIRITUAL PRINCIPLES IN MENTAL HEALTH CARE

Uday Chaudhuri

Introduction

Spirituality involves a dimension of human experience that psychiatrists are increasingly interested in, because of its potential benefits to mental health care. Mental health is much more than the absence of mental illness. The word ‘spirituality’ flows from the Latin term ‘ spiritus’, which means ‘breath’- referring to the breath(essence) of life. Spirituality consists of two dimensions, one transcendent of the physical world and the other consisting of connectedness to the physical world. Spirituality, described as linking the deeply personal with the universal, is inclusive and unifying. Spiritual dimension is not an intellectual attainment; but lies in the essence of what it means to be human. It leads to recognition that to harm another is to harm oneself and equally that helping others is to help oneself. Spirituality applies to everyone, including those who do not believe in God or a ‘higher being’ and those who do. The universality of spirituality extends across creed and culture; but at the same time spirituality is felt as unique to each and every person.

In intellectual development we can get much help from books, but in spiritual development almost nothing. In studying books, sometimes we are deluded into thinking that we are being spiritually helped; but if we analyse ourselves we shall find that only our intellect has been helped, and not the spirit. That is the reason why almost every one of us can speak most wonderfully on spiritual subjects, but when the time of action comes, we find ourselves so woefully deficient. It is because books cannot give us that impulse from outside – it is all about ‘being and becoming’.

Life of Sister Alphonsa is manifest spirituality. “I want to be

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careful never to reject anyone. I will only speak sweet words to others. No matter what my sufferings may be, I will never complain”- Sister Alphonsa. These beautiful sentiments are ideal for a harmonious life and human excellence.

Spirituality in Health Care

Illness is generally associated with grief, pain, morbidity and suffering. Dealing with such state often demands tremendous energy and strength which is beyond what one is normally equipped with. Spirituality has been known to be a source of comfort, hope and faith in crises (Jackson, 2004). Health care organizations have additional responsibilities of catering to the spiritual needs of patients and family members. Health care providers can offer spiritual therapies to patients who can actually help them to cope and recover from their illness, and manifest their divinity within.

History of Health Care

The roots of the health care movement can be found in spirituality (Goddard, 2000). Ayurveda, the science of life and longevity is the longest unbroken medical tradition in the world today. Having originated in the ancient Vedic traditions of India, it prescribes comprehensive, holistic health care for the ultimate self-realization (Chopra, 1997). Its major premise of wellness involves equilibrium of body, mind and spirit. Prophets like Jesus, Buddha and others were actively involved in healing the sick. They encouraged their followers also to serve and show compassion to the sick (Graber and Johnson, 2001).

Changes in Health Care scenario

Gradually there was a separation of secular medicine from theological domination. The relationship between spirituality and science changed significantly as a result of the scientific revolution and emergence of the scientific method in the late

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1500’s (Kliewer, 2004). Empiricism gained support as the basis for medical science and thus spiritual issues were discarded to the field of metaphysics or rejected completely. The medical education of clinicians was distinctly located in the Cartesian model, based on a strict mind-body dichotomy (Maughans, 1996). Health profession education was based on reductionist explanation of illness. This was not helpful when dealing with the patient who considers himself as something more than a collection of atoms, molecules and microorganisms (Graber & Johnson, 2001). Medical practices become focused on the task of selecting treatments proven effective only through meticulous research methods (Evidence Based Medicine, EBM).

Resurgence of spirituality in Health Care

Currently we are witnessing a resurgence of spirituality in health care (Kliewer, 2004). Despite several significant developments in medical technology and equipment, illness and health problems persist. Even as some are eradicated, others appear. This requires constant humility and surrender and leads to acknowledgement that we are not all powerful and need some Divine assistance. Modern developments and inventions cannot be a substitute for compassionate and holistic care (Graber & Mitcam, 2004). The World Health Organization’s (WHO’s) definition of health includes four domains of wellbeing: physical, mental, social and spiritual (WHO, 1998). The WHO reported that… “until recently the health professions have largely followed a medical model, which seeks to treat patients focusing on medicines and surgery and gives less importance to beliefs and to faith in healing in the physician and in the doctor-patient relationship. This mechanistic view of patients is no longer satisfactory. Patients and physicians have begun to realize the value of elements such as faith, hope and compassion in healing process…”(WHO, 1998). Today health is no longer considered a passive state of being, but a dynamic process of attaining higher levels of wellness with each of the four dimensions.

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Currently, holistic care (Bio-psycho-social-spiritual) includes the dimension of spirituality and is being extensively discussed and practiced (Strang, Tornestedt, 2002). Another factor influencing the revival of spirituality is research evidence demonstrating the link between spirituality and health outcomes at both the physical and mental levels. Spirituality improves immune function (Woods, Antoni, Ironson & Kling, 1999).Religious practice/spirituality decreases the incidence of depression (Kennedy, Kelman, Thomas & Chen 1996), lowers suicide rates (Neeleman, Haipern & Leon, 1997) and prevents substance abuse (Bell, Wechsler & Johnson, 1997). Studies in this field have been criticized for using various definitions and conceptualizations of religion and spirituality without sound methodology (Sloan, Bagiella & Powel, 1999). Despite this, it is now widely recognized and accepted that there can be some positive outcomes of spirituality on physical and mental health (Kliewer, 2004).

Mental Health Care paradigm in the 21st century – From Patienthood to Personhood to Human Excellence

In the initial stages, psychiatric care meant safe guarding the society from the so called mentally ill-persons (insane) by banishing them away from the locality to the asylums. In the eighteen century humanitarian care started; pioneered by Philip Pineal in Paris (France), it then spread across the globe. Entire mental health care revolved round segregating mentally ill from the population, based on the ‘patienthood’. In the 21st century mental health is much more than the absence of mental illness. More and more people are attending mental health care systems for improvement, betterment and expression of talents in the area of education, sports, vocational choice and to manifest ‘personhood’. But only improving and enhancing performance can no doubt give rise to productive men and women, but the need of the hour is human qualities so that the world becomes a better place for living. The mental health care paradigm for the

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21st century should be ‘from patienthood to personhood towards human excellence’. Here, there is an immense role of the concept of spirit (soul) beyond body mind complex – as inner essence.

Swami Vivekananda was the embodiment of spirituality/ divinity within. In his powerful words-“Teach yourselves, teach everyone his real nature, call upon the sleeping soul (spirit) and see how it awakes. Power will come, glory will come, goodness will come, purity will come, and everything that is excellent will come, when the sleeping soul is roused to self-conscious activity”. The goal/mission of mental health care should be towards human excellence.

In Swamiji’s words “ye are the children of God, the shares of immortal bliss, holy and perfect beings. You are souls immortal, spirits free, blessed and eternal; ye are not matter, ye are not bodies; matter is your servant, not you the servant of matter. If the fisherman thinks that he is the spirit, he will be a better fisherman; if the student thinks he is the spirit, he will be a better student”. In mental health care, if the carer thinks he is the spirit (eternal soul), he will be a better mental health professional.

Each soul is potentially divine. The goal is to manifest this ‘divinity’ within by controlling nature, external and internal. This can be achieved either by work, or worship, or psychic control or philosophy all together or individually to free oneself. The more blissful we are within, the more spiritual we are. That is the essence of ‘mental health’ both for caregiver and care recipient.

Should Psychiatrists in the East Reinvent the Wheel?

India and China has a rich past waiting for rediscovery. Psychiatry can have a better wheel from this knowledge of spirituality. Yoga and meditation can be incorporated for physical, mental, social and spiritual wellbeing. The concept of supra- conscious state – beyond body-mind complex by manifestation

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of divinity within – can go a long way towards human excellence.

Spiritual principles – not only improve the quality of one’s psyche but also inspire one to strive for higher values of life. These principles have universal acceptance throughout mankind. A life, that to many of us today have lost its true relevance, can once be rejuvenated by the practice of spiritual principles. This practice provides one with a pleasurable and fruitful existence that allows one the freedom to exercise one’s thoughts and actions for the betterment of patient care. Simplicity in both life and thought is sufficient to give us purpose in our venture. Love, compassion, contentment, goodness, sacrifice and forgiveness are such values which are the essence of spirituality. Spiritual principles are a way of life, an attitude towards life which teaches us a way to rise above troubles of life. It is finally a way to achieve the ultimate happiness, blissful untroubled peace along with the complete opening up and understanding.

Gautam Buddha lived a life of spirituality. According to him “ it is the noble eightfold path ; Right views, Right aspirations, Right speech, Right behavior, Right livelihood, Right effort, Right thoughts, Right contemplation – which is essential for spiritual life”. Spirituality gives birth to ‘loving kindness’.

I fervently hope that harmonization of psychiatric knowledge of the West and the East and combining spiritual principles in mental health care – will take psychiatry beyond ‘Patienthood to Personhood towards Human Excellence’.

References :
1.
Culliford,L. (2002): Spirituality and clinical care. British

Medical Journal, 325, 1434-1435.
2. Hermann Hesse (2004): Siddhartha.

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3. Kliewer,S. (2004): Allowing spirituality into the healing process. The Journal of Family Practice, 53, 616-624.

4. Maughans,T. (1996): The spiritual history. Archives of Family Medicine, 5,11-16.

5. Neeleman,J, Haipern,D. (1997): Tolerance of suicide, religion and suicide rates: An ecological and individual study in 19 western countries. Psychological Medicine, 27, 1165-1171.

6. Post,S.Puchalski,C.&Larson,D.(2000):Physicians’and patients’ spirituality.

7. Powel,A.(2002):Mentalhealthandspirituality.
8. Selections from the complete works of Swami

Vivekananda,24th impression, March 2007.

9. Sloan,R.P., Bagiella,E. (1999): Religion, spirituality and medicine. Lancet, 343, 664-667.

10. Swami Tathagatananda (2005): Light from the Orient, October.

11. Swinton,J.(2001): Spirituality and mental health care. Rediscovering a forgotten dimension. London: Jessica Kingsley.

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DR. S K KHANDELWAL

Sudhir K Khandelwal, MD, MAMS,
MRCPsych is Professor of Psychiatry at
the All India Institute of Medical Sciences,
New Delhi. He received his training in psychiatry at the Postgraduate Institute of Medical education and research, Chandigarh. Besides working in India, he has wide experience of teaching and practicing psychiatry in different cultural settings in countries like Ethiopia, Nepal and England.

He has regularly contributed scientific papers in national and international journals and books. His research interests over the years have included general adult and old-age psychiatry, neuro- psychiatry, and mental health services and policy.

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SPIRITUALITY AND MENTAL HEALTH

Sudhir Khandelwal

The mental health care has made rapid strides in developed as well as developing countries in last few decades. Neurosciences have discovered and invented new tools to study the complex working of brain and new understanding has emerged on its normal functioning and malfunctioning. Disciplines like neurophysiology, neurochemistry, neuroendocrinology are adding our knowledge of cause and effect relationship of mental health and illnesses. Psychopharmacology has progressed rapidly to become a multi-billion industry now. New drugs are being added everyday, with each drug offering rapid, safer and better outcome. There are now drugs for each illness described in the classificatory systems. Things seem to be going of hand as drugs are prescribed even for life style and social problems.

Many long-term studies on psychotropic drugs are now available which have shown that the drugs, which were previously marketed as safe drugs are producing disabling side effects. Even in illnesses where drug therapy has been essential and drug treatment has progressed in complete rational and ethical manner, a large number of areas of person’s functioning have remained unsatisfactory. Mental illnesses cause considerable burden to the family members and other caregivers too, and their concerns have largely remained unmet.

Lately, mental health professionals have been exploring innovative strategies to promote better mental health care, and finding ways to address all the unmet needs of mentally ill individuals and their family members and caregivers. Alternative systems of medicine are fast creating a niche for itself in the modern health care system. Role of spirituality in promotion of health and mental health, as well as, in complementing the

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existing form of care is widely attracting attention.

Though the word ‘spirituality’ is used very frequently in literature as well as in scientific studies now, yet its meaning differs very widely in writings as well as across cultures. The concept of spirituality is inclusive and affects everybody. It overlaps with that of religion, but unlike spirituality, religion is potentially divisive and adopted only by some. By permitting consideration of ‘secular’ spiritual activities and short-circuiting destructive arguments about beliefs, a valuable perspective can be applied to the whole field of mental health care.

Spirituality involves a dimension of human experience that psychiatrists are increasingly interested in because of its potential benefits to mental health. It is not necessary to hold formal religious beliefs, or engage in religious practices, or belong to an established faith tradition, to experience the spiritual dimension. However, for many people or groups, religion is the vehicle for a journey to spirituality.

How do we define spirituality? According to one definition, “The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes especially into focus in times of emotional stress, physical and mental illness, loss, bereavement and death.” This desire for wholeness of being is not an intellectual attainment, for it is no less present in people with learning disability, but lies in the essence of what it means to be human. It naturally leads to the recognition that to harm another is to harm oneself, and equally that helping others is to help oneself. It applies to everyone, including those who do not believe in God or a ‘higher being’. The universality of spirituality extends across creed and culture; at the same time spirituality is felt as unique to each and every person. One or more common themes of spirituality include: purpose in life, sense of connectedness (to nature, God, a power), a quest for wholeness,

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harmony with self and environment, and a feeling of transcendence. There is recognition that there are differences between religion and spirituality and that either can be practiced without the necessary involvement of the other. However, the distinction between religious and spiritual practices is often blurred.

In healthcare, spirituality is identified with experiencing a deep-seated sense of meaning and purpose in life, together with a sense of belonging. It is about acceptance, integration and wholeness. From the spiritual perspective, a distinction must be made between cure, or relief of symptoms, and healing of the whole person. The relief of suffering remains a primary aim of health care, but it is by no means the whole story.

A recent meta-analysis has demonstrated that people with a high religious involvement were likely to die older than their non-religious counterparts (Barker et al, 2005). Beneficial effects of spirituality have also been reported in cardiovascular disorders (Matthews et al, 1998), AIDS (Evans et al, 1997) and cancers (Fehring et al, 1997; Musick et al, 1998).

People suffering from mental illnesses have diverse needs for their proper rehabilitation back into the society; they also need support for fighting stigma and for their rights and rightful place in the society. Some of the needs identified for comprehensive mental health care are: an environment for purposeful and creative activity and work; feeling safe and secure; being treated with respect and dignity; being valued and trusted; opportunity to develop meaningful and professional relationship with the treating team so as to understand illness and various experiences; freedom and encouragement to follow and practice one’s own belief systems.

The relationship between spirituality and mental health is

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being explored in a number of ways. Experts from various groups like psychology, psychiatry, theology and nursing are examining this relationship. There are many elements common to both, personality (and mental health) and spirituality. Both are shaped and influenced by personal experiences, internal dynamics, group and community living, and ability to transcend (Swinton, 2001; Baetz et al, 2004; Foskett et al, 2004).

Studies on burden of diseases and coping styles in various mental illnesses have documented patients and their caregivers using spiritual beliefs in their day to day coping behaviour. Many studies have pointed towards a protective or beneficial effect of religious or spiritual activity for mental health (Seybold et al, 2001; Weaver et al, 2003). Besides a positive association between spiritual and religious beliefs and general psychological wellbeing, such beliefs have been found to have beneficial effects on many mental health problems like depression, anxiety disorders, PTSD, and even severe mental illnesses.

Depression is one of the leading causes of burden of diseases all over the world. During depression, person develops ideas of hopelessness, worthlessness and death wishes. He/ she questions and doubts everything, his own existence as well as his relationship and usefulness to the world. The spirituality attempts him/her to get reconnected with inner self as well as with the world (Hassed, 2000; Koening, 1999). Researchers have also examined the relationship between spirituality and anxiety, stress and PTSD. One of the important features of such states is fear of unknown or fear of sudden impending death.

Yoga and meditation have shown beneficial effects of such interventions in qualitative research. Role of spirituality or turning to religion has been documented in a number of studies studying the burden and coping style of patients and caregivers in severe mental disorders like schizophrenia and bipolar disorders.

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However, much of the research done on the effects of spirituality on mental disorders is qualitative and has not yet established one to one relationship. Not all research done in this area has shown beneficial results. We are still far from conducting well designed, long-term and controlled trials to firmly establish the link between spiritual interventions and outcome.

Some of the research has attempted to explore the mechanism mediating potential benefits of spiritual practices in mental health. Undeniably, much of the explanation remains hypothetical and at a discussion level only. Improvement in coping behaviour has been conceptualized during periods of stress with religion and spirituality. Indian texts and practices recommend again and again people to turn to God or the ‘all powerful one’ or indulge in meditation during the period of stress and difficulties.

Locus of control is another mechanism offered to understand this relationship. Locus of control has been widely used to determine the motivation for treatment in alcohol and substances use disorders. An internal locus of control whereby an individual believes that they have some power over given outcome is usually associated with better mental health than an external locus of control. Beliefs may allow a person to reframe and interpret events that are seen as uncontrollable. The support individuals derive from fellow members and leaders of religious or spiritual groups is widely considered one of the key mediators between spirituality and mental health. Membership with such groups can be an important source of self-esteem and support enabling members to cope with stress and negative life events. It protects people from social isolation and strengthens family and social network.

It appears from the review of literature that the doubts and skepticism associated with role of spirituality and religion in modern medicine is slowly reducing. Many working in mental

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health services are aware of the links between mental health, spirituality and religion. However, the nature of those links is less precisely understood. Number of prestigious scientific journals related to systemic medicine and mental health are now carrying articles on these subjects. The concept of holistic medicine is also gaining ground. Prestigious professional societies like World Health Organization and Royal College of Psychiatrists have established ‘special interest group’ to study and practice role of spirituality in modern medicine. However, there are a number of barriers which are to be surmounted which include lack of time and training of practitioners, skepticism and discomfort with subject, lack of interest and awareness etc.

What is required is that the mental health practitioners need to be open minded to explore all avenues to bring about relief to their chronically suffering patients. Holistic medicine has to be practiced and made relevant. Mental health practitioners should attempt to assess a person’s religious and spiritual beliefs during assessment and advise appropriately.

India has been a land of most ancient traditions in the field of religion in man’s daily life. It is a land which has seen birth of four major religions of the world: Hinduism, Jainism, Buddhism, and Sikhism. It has a rich heritage in our ancient texts which have dwelt in length on mind body relationship. Right from the concept of mind in Vedas (circa 10,000 – 5,000 B.C.) to Upanishads and Gita (circa 5,000 – 2.500 B.C.), a lot has been written on how mind can influence the maladies of body and also aid in its recovery.

Ancient Indian medical text, Ayurveda, has described various kinds of personality and insanity and their treatment. Besides physical form of treatment (herbs etc), a lot has been mentioned on spiritual aspects of treatment. Yoga and meditation have always played an important part in Indian culture in total evolution

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of mind and in promotion of total health of a man. Lately, a lot has been written on the therapeutic aspects of such techniques in a number of psychological and physical disorders. Though many studies have appeared in national and international journals on the benefits of yoga, meditation, transcendental meditation (Khandelwal, 2006) in a number of psychological and physical disorders, long-term and controlled studies are still needed to firmly establish their place in the modern medicine.

References :

Baetz, M., R. Griffin, R. Bowen, H. G. Koenig, and E. Marcoux, (2004), The association between spiritual and religious involvement and depressive symptoms in a Canadian population: J.Nerv.Ment.Dis., 192:12, 818-822.

Barker, P. & Buchanan-Barker, P. (2005) Breakthrough: Spirituality and Mental Health. London: Whurr Books

Evans, D. L. et al., (1997) Severe life stress as a predictor of early disease progression in HIV infection: Am.J.Psychiatry, 154:5, 630-634.

Fehring, R. J., J. F. Miller, and C. Shaw, (1997) Spiritual well- being, religiosity, hope, depression, and other mood states in elderly people coping with cancer: Oncol.Nurs.Forum, 24: 4, 663-671.

Foskett, J., A. Roberts, R. Mathews, L. Macmin, P. Cracknell, and V. Nicholls, (2004) From research to practice: The first tentative steps: Mental Health, Religion & Culture, 7: 1, 41-58.

Khandelwal, S.K. (2006) Transcendental Meditation. In Psychotherapy in a Traditional Society: Context, Concept and Practice; Ed: V.K.Varma and N.Gupta;New Delhi, Jaypee

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Publishers.

Koenig, H. G., (1999) How does religious faith contribute to recovery from depression?: Harv.Ment.Health Lett., 15:8, 8.

Matthews, D. A., M. E. McCullough, D. B. Larson, H. G. Koenig, J. P. Swyers, and M. G. Milano, (1998) Religious commitment and health status: a review of the research and implications for family medicine: Arch.Fam.Med., 7:2, 118-124.

Musick, M. A., H. G. Koenig, J. C. Hays, and H. J. Cohen, (1998) Religious activity and depression among community- dwelling elderly persons with cancer: the moderating effect of race: J.Gerontol.B Psychol.Sci.Soc.Sci., 53:4, S218-S227.

Seybold, K. S., and P. C. Hill, (2001) The Role of Religion and Spirituality in Mental and Physical Health: Current Directions in Psychological Science, 10:1, 21-24.

Swinton, J., (2001) Spirituality and Mental Health Care: Rediscovering a forgotten dimension: London, Jessica Kinglsey Publishers.

Weaver, A. J., L. T. Flannelly, J. Garbarino, C. R. Figley, and K. J. Flannelly, (2003) A systematic review of research on religion and spirituality in the Journal of Traumatic Stress : 1990-1999: Mental Health, Religion & Culture, 6:3, 215-228.

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DR. A.K. AGARWAL

Prof. Anil Kumar Agarwal did his DPM (NIMHANS), 1965 and MD (AIIMS), 1968
and worked as faculty in AIIMS and then
mostly at KGMC, Lucknow from being a
reader to Prof. of Psychiatry and Head of Department.

He was theEditor, Chair – Awards and Ethics committee of Indian Psychiatric Society (IPS) and also President of IPS in 1994. He received Sandoz award in 1972 and DNL Murthy Rao Oration in 1998. He is currently in practice and the President, Richmond Fellowship, Lucknow branch.

He has been actively involved with public awareness campaigns and the lay press on issues of mental health. He has more than 100 scientific publications to his credit. He has written four books and edited two.

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UTILIZING TOOLS OF SPIRITUALITY IN DAY TO DAY CLINICAL PRACTICE

A.K.Agarwal

Spirituality in clinical practice has been utilized by some practitioners from time to time but there had not been any systematic and large size study on this aspect. Recent developments have brought Spirituality into the focus of psychiatry but till date, hard data is difficult to come by. This presentation will focus on what is spirituality and how it has been utilized in clinical practice, what are its limitations and what are the future hopes.

What is spirituality?

There is no single definition of spirituality. Following are some of the concepts which different definitions usually encompass.

“In every human being there seems to be a spiritual dimension, a quality that goes beyond religious affiliation that strives for inspiration, reverence, awe, meaning and purpose even in those who do not believe in God. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite and comes essentially in focus in times of emotional stress, physical(and mental) illness,, loss, bereavement and death.”

– Murray and Zentner (1989)

Ellison(1983) suggests that spirituality “enables and motivates us to search for meaning and purpose in life. It is the spirit which synthesizes the total personality and provides some sense of energizing direction and order. The spiritual dimension does not exist in isolation from the psyche and the soma, but provides integrative force. It affects and is affected by our physical state, feelings, thoughts and relationships”

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Others feel that spirituality brings meaning to experiences. Many other feel that like love, joy, faith etc., spirituality can not be put into words. This is an experience which has a very personal meaning for the individual and often can not be described in words. Few others protest that any attempts at definition of spirituality may destroy its very essence. Concluding, one can say that spirituality is an important dimension of each individual, it is difficult to define, but is generally accepted as a dimension which may provide meaning to ones behavior and experiences, may often be related to and accessed through religion but religion is not a necessary condition for experiencing spirituality.

It also needs to be emphasized that spirituality may never find overt expression in large number of people. Spirituality is often experienced at times of adversity. Most of us experience a feeling of nothingness or detachment when we accompany a dead relative to cremation ground. Many of us think about the futility of running after worldly pleasures at such times. This is called ‘shamshan gyan’. These thoughts and feelings of detachment disappear as soon as we leave the cremation ground. This appears to be a spiritual experience.

Spirituality is often equated with religion. Both can coexist but one is not essential for the other. One can be religious without being spiritual and vice versa. Religion is often preoccupied with overt rituals and may take political hue and may loose the spiritual dimension. The basic religion which is involved with exploration of meaning of different experiences is nearer to spirituality. Spiritual experiences may need the structure of religion to become comprehendible. But what is more important to note is that the spiritual dimension appears to be an essential part of human psyche. It may remain dormant in large population as the psychosocial factors may inhibit its expression. It can also be comprehended as a power beyond self or as the true inner self and does not require the vehicle of religion for its expression.

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How does spirituality relate to mental illness and its treatment?

Many people like to equate an episode of mental illness as a spiritual experience and coming out of it as the integrative effect of such experience. Many of us might have seen such patients who became stronger after an episode of the illness where the illness might be called spiritual experiences but almost all of us would agree that not all mental illnesses have such a quality. Some people have described their integrative experiences.

Sally Clay shuttled in and out of mental hospitals for thirty years. Although she was a Buddhist, she set down her spiritual change in a Biblical context. Jacob named the place of his struggle ‘Peniel’, which means “face of God”. “I too have seen God face to face and I want to remember my Peniel”. “I really do not want to be recovered. From the experience of madness, I received a wound that changed my life; it enabled me to help others and to know myself. I am proud that I have struggled with god and with mental health system. I have not recovered, I have overcome” (Phil Parker and Pappy Buchanan-Barker 2004) .This description may indicate that the illness of Sally clay provided her an integrative experience. We are not certain of the quality of her illness or the diagnosis but it has to be accepted that such experiences have been described.

This author has experienced an amazing cure of a physical illness. A friend in mid fifties was diagnosed as total renal failure in one of the most premier medical institution of the country. He was advised renal transplantation. He took a conscious decision that he would not have a renal transplant but would let the nature take its course. He told his family that he will shift to Rishikesh (Hindu religious place, where many shift to pass their last days) and await death. He went to Rishikesh and joined an ashram. As he was very weak, he had no appetite; he would keep lying near the Ganges and would drink the river water, whenever he felt

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thirsty. After a week he started feeling that his strength is returning, his appetite has improved and within a month he felt better. The in-charge of the ashram asked him to go back to the same institute for check up. Repeat investigation revealed that both his kidneys had become functional. He decided to continue his life as a sadhu as he had already given up the worldly ties. Was this recovery because of wrong diagnosis, appears very unlikely because no responsible institution would advice renal transplantation without a very thorough investigation. Was the recovery due to starvation or due to the medical properties of Ganges water or was it a real spiritual transformation that cured the renal failure? Impossible to say.

During my psychiatric career which spans over forty five years, I have come across only one case of Obsessive Compulsive Disorder who seemed to be helped by staying in an ashram. This patient was being treated by me in mid seventies and he did not show any improvement. He returned to me in mid nineties with a relapse of the same illness. He reported that during the last episode, as he was not getting better, he joined a sadhu and lived according to the rules of the ashram and all his obsessions disappeared in two months. Was it a spontaneous recovery or the routine of the ashram protected him of the anxiety of not performing the rituals or it improved because of a spiritual experience. The last option does not appear to be true as he again went into the same ashram during this relapse without any benefit.

All of us must have seen large number of patients where religious beliefs or spiritual experiences helped them to keep there anxieties, depressions and even psychotic experiences in control. Though most patients could do so only either in the initial part of the illness or at a time when the illness has started improving either with drugs or without drugs. The role of faith or spirituality seems restricted to the control of symptoms but not in there integration and improvement in their personality.

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Many Indian workers have tried to utilize religious teachings in psychiatric treatment.

Vahia (1972; 1973) published a number of papers on the use of Yoga therapy in some of the neurotic disorders and reported benefit. The Yoga treatment utilized by him was mainly based on Yogic exercises and the religious or spiritual dimension was conspicuous by its absence. There had been large number of articles on spirituality in the treatment of psychiatric disorders but mostly speculative and thought provoking but hardly any evidence of clinical efficacy (Neki 1977,Venkoba Rao 1978). Some Western authors have studied the role of religion /spirituality in schizophrenia, others in addictions and in other neurotic disorder. Religious symbolism in symptoms of mental patients is well documented. We have also observed symptoms of religiosity and spirit possession. Many such patients do not agree to be treated by a psychiatrist as they feel that there problem is primarily related to ‘tantra’ and spirit possession. They seek different kind of religious healers. Some get better and others return to the mental health system. Most of these cases suffer from schizophrenia, obsessive disorders and dissociative disorders. While patients suffering from dissociative disorders sometime do improve in such settings, others usually revert back to psychiatric treatment. Even the cases of dissociative disorders that improved were largely due to suggestion and not due to any spiritual experience.

What I am trying to emphasize is that in my long clinical career, I do not remember seeing patients where spiritual issues could be of importance. This distorted observation could be due to sampling bias where all those who had spiritual problems might have been treated by others and did not reach me or could be a part of my blindness as it is very well known that the mind does not know what the eyes can not see.

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I had opportunities to treat some religious leaders whose main function was to preach. They were considered enlightened by their disciples. These religious leaders included Hindu saints, few ladies who headed big religious congregations and few Muslim religious leaders. All of them were held in high esteem by their disciples and their words provided solace and relief to the troubled souls. The diagnostic categories of these patients were: depression, panic disorder, anxiety and one had a schizophrenic illness. In spite of their deep faith in the religion and having achieved reasonable success in spiritual achievement, they were not able to handle the symptoms of panic, depression and severe anxiety. One that had schizophrenia was totally perplexed. But all of them responded well to drug treatment and returned back to their former vocation except the one who had schizophrenia. What can we infer from this observation? Persons who have achieved peak of spirituality find it difficult to handle symptoms of illnesses like depression, panic, severe anxiety or schizophrenia. But short term treatment with appropriate drugs and psychological help made a very fast recovery. One may conclude that people with spiritual awakening may be able to integrate illness more quickly than others.

From the day I was asked to write this article, I consciously started asking all my patients regarding there belief system and how it appears to be related to their illness. The questions I asked were:

Do you think this problem has some relation to your religious/ spiritual activity?

What seems to sustain you during adversity or illness?

Do you think prayers or some other religious activity could help you overcome this illness?

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The answers I received were perplexing. Most patients were very forthright in emphasizing that they were deeply religious. They generally did not find any association between religiosity and the illness except few obsessive or depressive disorder patients where religious doubt was part of there symptoms. They felt that they have already tried religious control before consultation. They did not see a link between illness and religion or spirituality. Religiosity was easily comprehended by most patients while spirituality was not. One patient with schizophrenia did say that his illness is religious in nature and the psychiatrist can not understand him. He had multiple religious delusions. What I am trying to infer is that average patient makes a clear distinction between illness experience and religion. Most patients could not clearly define spirituality same way as many of us. Most patients repeated Gita’s concept of surrendering self to God as highest level of spirituality but found it difficult to practice. I have put this question only to Hindu patients because of my poor familiarity with other religions. On the contrary, two of my patients who went to a psychiatrist who uses spiritual methods in treatment felt distinctly uncomfortable and requested me that they will discontinue treatment with that psychiatrist. This is worth emphasizing that the psychiatrist should not force his personal belief system on the patient.

Place of spirituality in day to day psychiatric practice

What are the indications of using spiritual methods in day to day clinical work? There could be two extreme responses: Spiritual methods should be part of all clinical work or spiritual methods have no place in evidence based psychiatry. I would like to use moderation and would like to define indications where one could use spiritual methods.

The therapist himself should have certain basic qualities without which he can not use spiritual methods in treatment. The therapist should have some of the following qualities.

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· Being self reflective and honest

· Being able to remain focused on present, remain alert, unhurried and attentive

· Being able to rest, relax and create a stable peace of mind

· Develop greater empathy for others

· Finding courage to endure distress while sustaining an attitude of hope

· Developing improved discernment for example about when to speak or when to remain silent

· Learning to give without feeling drained
· Being able to grieve and let go.
(Adapted from a leaflet of Royal College of psychiatrists)

These are the qualities which will make the patient respond to the therapist positively and will awaken similar responses in them. What I am trying to emphasize is that the concept of wearing a therapist persona as taught in some of the psychotherapies, cannot work in spiritual work. Unless the therapist is basically spiritual, he can not induce spirituality in the patients. This is a major restriction in practicing these methods. The principle of reciprocity is important, the patient as well as the therapist both should experience the change.

Which patients appear suitable?

· The patient should be inclined to use spiritual/religious

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percepts in treatment.

· The therapist should not push his belief system on the patient.

· The patients who are severely depressed or are suffering from schizophrenia, acute anxiety may not be suitable.

· This kind of treatment is practicable when acute symptoms have subsided. The patients should be able to handle the emotions and thoughts reasonably.

· All patients who have interest in religion and or spirituality and are able to attempt various practices as enumerated below could be encouraged to spiritual methods.

· The patients with ‘existential’ anxieties without psychotic process are suitable.

· Elderly who are suffering from loneliness when deeds of the past haunt them and physical ailments make them weak and frail, spirituality may help them lead a better life. They should not have loss of cognitive function to an extent where they are not able to retain the proceedings of the sessions.

· Patients who come with adjustment problems, with stable personalities and intolerable life circumstances are most suitable for it.

Case illustration – 1

A forty-eight year old woman reported to me with symptoms of ‘gas’, anxiety and sadness. She had been thoroughly investigated for gastric problems and was treated for the same for nearly past two years. The history revealed that she was married to a very domineering husband. He cared for her but on

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his own terms. She had always feared him and could not communicate with him. She had two children who were well educated but had picked up the behavior pattern of their father. She felt alienated from them. She was unhappy but not depressed. She was a religious person and used to pray daily. She felt nice and relaxed during prayers. She was encouraged to take up social work (teaching children).She enjoyed this activity and felt that was best part of her day. She was encouraged to talk over her distress with god. She improved over a period of time.

Case illustration – 2

Another female patient was under my treatment for depression and she was taking antidepressants and felt slightly better. She asked me whether she could go to her religious congregation in Haridwar. I said that she should go if she feels like going but she should continue taking drugs. She returned after a month and reported that she is feeling very much better. She said that “when I took part in the congregation, I felt that if I trust god, then why I should be bothered by these negative thoughts. He will take care of me”. She had lost negative thinking and was feeling quite happy. Is it the effect of drugs or spiritual experience or both?

What are the methods of spiritual treatment?

There is no standard method of treatment but there are different steps which could be attempted depending on the patient’s preference. Following are some of the options –

· Person should belong to a faith or tradition.

· Rituals and symbolic practices including other types of worship could be attempted

· Pilgrimage and retreat

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· Meditation and prayer

· Reading scriptures

· Listening to sacred music and singing devotional songs and prayers

· Acts of compassion · Deep reflection

·  Yoga and other kinds of meditation

·  Energizing with and enjoying nature

·  Contemplative reading
· Appreciation of art and creative activities · Maintaining stable family relationships
· Participate in team sports and recreation
The list above has been taken from a leaflet of the Royal College of Psychiatrists, entitled Spirituality and Mental Health. This list is neither complete nor comprehensive, but it does provide some options. There could be many other ways which could be effective.
The same leaflet also describes favorable conditions for spiritual treatment:
· An environment for purposeful activity such as creative art, structured work and enjoying nature
· Feeling safe and secure
· Being treated with respect and dignity allows you to develop

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a feeling of belonging, of being valued and trusted
· Having time to express feelings to sympathetic and

concerned member of the staff
· Opportunities and encouragement to make sense of, and

derive meaning from experiences including illness
· Permission and encouragement to redevelop relationship with God or the Absolute (however the person conceives whoever is sacred)

Rehabilitative services in India come closest to the above mentioned condition in most of the well run centers. The patients are usually treated in groups and they have a structured program. They usually have a time for prayer and they involve in group activities, both creative and routine. The staff is generally motivated and responds well to the queries of the patient. A large number of patients do improve to a level where they can have reasonable adjustment in society. I do not remember an instance where a patient would have been transformed in any rehabilitative service.

Neki (1977) while describing ‘guru chela’ relationship as a paradigm of psychotherapy describes the guru as “He is in this world, yet not of this world. He has emancipated himself from the bondage of social conditioning, yet he does not discard it”. A psychotherapist who has attained such a state could be effective in awakening spiritual longings of his client. How ever, most of us would not be able to attain that level of spiritual maturity. What an average psychiatrist can attempt is the following:-

Suitable patients who have some spiritual inclination and are willing to make an effort to practice some of the methods which have been recommended above could be selected. Prayers, chanting of mantras and reading religious scriptures are well tried methods to sooth the mind and to discover holy bliss. Each individual should select methods suitable to him.

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Spiritual methods should not be used exclusively but should form a part of the package which should include other methods of treatment including biological therapies.

Contraindications to spiritual methods

· Do not force spiritual methods on people who do not want it.

· Never impose one’s understanding of spirituality on others · Patients who have active psychotic symptoms and who

are not able to properly conceptualize should not be encouraged for such treatment

· When there is a possibility that such treatment would induce more ritualistic behavior

· When a patient is misusing religious percepts for his psychopathological needs

· This should not become the dumping ground of patients who are not recovering

Conclusions

Spirituality is an essential dimension of human psyche. This often remains dormant but becomes operative in periods of adversity. It refers to a dimension which helps a person to understand meaning of life and his relationship with the world. Scientific psychiatry has so far tried to maintain distance from this aspect. There is reasonable evidence that spirituality could be a useful tool in establishing peace and tranquility in the patients. How to do it, and who can do it, are the questions which have not been answered. We acknowledge the existence of spiritual dimension and its role in mental health. This presentation conceptualizes certain indications and methods but all of them are still in the realm of possibility and will require vary careful documentation before they could be used in day to day clinical work.

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References :

Barker, P. & Buchanan-Barker, P (2004) Spirituality and Mental Health from the Net

Ellison, C.W, (1983) Spiritual well being conceptualization and measurement. J. of Psychology and Theology.11, 4

Murray, R.B. & Zentner, J.P. (1989) Measuring concepts for Health Promotion, London. Prentice Hall

Neki, J.S.(1977) Psychotherapy in India. Indian J.Psychiatry. 19, 2

Royal College of Psychiatrists- Spirituality and Mental Health

Vahia, N.S., Doongaji, D.R. & Deshmukh, D.K. (1972) A deconditioning therapy based upon the concepts of Patanjali. Int.J.Soc.Psychiat. 18: 6166-72

Vahia,N.S., Doongaji,D.R., Kapoor,D.V., Ardhapurkar,S.N. & Ravindranath (1973) Further experiences with therapy based on concepts of Patanjali in the treatment of psychiatric disorders. Indian J.Psychiatry,13, 32

Venkoba Rao,A,(1978) Psychiatric thoughts in ancient India. Indian J.Psychiatry.20.1

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PROF. HAROON RASHID CHAUDHRY

Prof. Chaudhry is currently working
as Head Department of Psychiatry, Fatima Jinnah Medical College; running the Fountain House, an NGO, in an honorary capacity and Convener of three other mental health NGOs i.e. ‘PEACE’ ‘FLAME’ and ‘FIND’ working for public mental health education, also rendering free consultation services at community psychiatric unit, Ahbab Hospital, Qila lashman Singh, Lahore for last 23 years.

Over 120 research publications to his credit, covering the entire breadth of psychiatry ranging from biological psychiatry, psychopharmacology, transcultural psychiatry, neuropsychiatry, community psychiatry, history of psychiatry and phenomenology

He currently is holding posts for: Vice President, World Federation for Mental Health, Eastern Mediterranean Region; Secretary, WPA section on Rural Mental Health; General secretary, IPPPS ; President Elect, Pakistan Psychiatric Society

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SPIRITUAL AND RELIGIOUS BELIEFS IN HEALTH CARE DELIVERY

IN A DEVELOPING COUNTRY

Haroon Rashid Chaudhry Raumish Masood Khan 1 Ismeet Leghari 2

Throughout the history of humanity it has been said that the individual ego, is a very limited form of identity. Spirituality is shaped by larger social circumstances and by the beliefs and values present in the wider culture. In Asia, as compared to other regions, people fall back on spiritualism. Mental health professionals, laymen and patients have great interest in spirituality and religious activities but still it is one of the most neglected fields of life. Spirituality and religion often are used interchangeably and it has also been described as an individual search for meaning. In psychiatry, religion and spirituality play a vital role in an individual’s personal and social life. They are part of a very powerful medium to help in the healing process. Spiritual people know the meaning and goal of their life, have strong belief and firm faith in God or themselves, they can easily cope with stress and have the ability to adjust in every situation.

They have satisfaction and contentment. They are less anxious and depressed and if they feel so, they try to overcome it through religious activities or rituals. Patients who depend heavily on their religious faith are significantly less depressed than those who don’t. Spiritual practices foster an awareness

1. Clinical Psychologist, Fountain House Lahore 2. Research Associate, Fountain House Lahore

 

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that serves to identify and promote values such as creativity, patience, perseverance, honesty, kindness, compassion, wisdom, equanimity, hope and joy, all of which support good healthcare practice. Spirituality and religion form a bridge of contact between human, a composite of body and soul, and the Creator. Realizing this need, mental health professionals working in this field need to understand the spiritual values of patients and incorporate them in assessment and treatment. (Chaudhry, 2008 ).

Every culture must deal with mental illness to guarantee its stability. However, it is important to recognize that standards of mental illnesses are relative because the social context in which a particular behaviour occurs affects whether it is adjudged normal or abnormal. Depending upon the situation, the same behaviour may be considered as mental disorder, declared criminal, or even socially acceptable. In recent decades concern has developed about inequalities in mental health and health care delivery.

The Republic of Pakistan is a South East Asian country with a population of over 160 million. Its population is fast-growing and the majority (70%) live in rural areas with a feudal or tribal value system. Pakistan has come a long way since it gained its independence in 1947, when there were only three psychiatric hospitals in the country. Today, over 20 medical colleges support psychiatric wards. At the moment, there are some 4,100 beds in the public and private sector and about 342 practicing psychiatrists, mostly located in major cities. Behavioural sciences and psychiatric training form an essential part of undergraduate medical teaching. Islam is the main religion and ‘mental illnesses’ are stigmatized and widely perceived to have supernatural causes. The traditional healers along with limited psychiatric services are the main mental health service providers and people prefer to consult them due to easy availability, proximity,

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affordability, family pressure, strong opinion of community, poverty, illiteracy and limited knowledge of mental health and disease (Kareem et al, 2004).

There are many players and factors involved in the access, provision, delivery, functioning, and uptake of mental health services in Pakistan Awareness about mental illness is still poor in Pakistan. Such illness is generally attributed to supernatural causes – it is considered to be a curse, a spell, or a test from God. Those who experience mental illness often turn first to religious healers and General practitioners (GP’s), rather than mental health professionals, since patients and their families tend to have great faith for both. Religious healers use verses from the Quran to treat patients. Results of a recently published study showed that 95 out of 107, that is, 89% people visited General practitioners (GP’s) for the treatment of psychiatric illness as shown in the following table but since GP’s had inadequate knowledge of psychiatric disorders, they failed to diagnose them and hence and gave them symptomatic treatment (Mirza et al., 2006).

Five types of health care providers (in rural Punjab)

 

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Next, patients turn to traditional and alternative healers, who are also popular in Pakistani society (as physical handicap and mental illness are stigmatized and discriminated), possibly due to fewer stigmas, easy access and more acceptances in the society (Gilani et al., 2005). In developing countries, as compared to men more women are taken to the traditional healers.

In developing countries the numbers of trained mental health professionals are less in number as compared to the population demands and the mental health services are virtually non-existent in the rural settings. For extension of mental health services in the periphery, in collaboration with WPA section on education, we are running a one year certificate course on psychiatry for GP’s since 2005. GP’s from remote areas participate in this course. They are trained to recognize and treat major psychiatric illness and in case of complexity they refer them to the tertiary care facilities. In addition, for over 15 years in a programmed titled “Reaching the Unreached” we have been organizing regular free psychiatric camps in remote areas with the help of local GP’s in providing treatment to psychiatric patients.

Lack of data on prevalence of various mental illnesses and monetary constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the ‘Community Mental Health Programme’ and ‘Schools Mental Health Programme’ have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a ‘National Mental Health Policy’ and ‘Mental Health Act’ in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery (Kareem et al., 2004).

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Community awareness programs addressing psychiatric illness and epilepsy are also being organized and the target population is teachers, housewives, students, clergymen and philanthropists etc. It has been observed that most of them have very limited knowledge of mental health and often share the rural community’s views about spiritual causation. Recovered patients and their family members also address the audience which certainly provide more motivation and reduce the stigma towards psychiatric illnesses and more acceptances towards modern psychiatric treatments (Chaudhry, et al., 1997; 2001).

Similar programs addressing hazards of drug addiction are arranged by Anti Narcotics Force (ANF) in rural and urban areas addressing working women, clergymen, teachers, housewives, and medical persons.

The main objectives of good mental health care are scientific and humanistic (least restrictive) giving no harm (no side effect) to the users, affordable for every one and deal with the sufferer according to the Biopsychosocial Spiritual Model (Chaudhry, 2008). Spirituality and religion are the bridges of contact between man, who is a composite of body and soul, and the Creator. Realizing this need, the mental health professional working in this field need to understand the spiritual values of the patients and incorporate them in assessment and treatment.

References :

Chaudhry, H. R. (2008). Psychiatric Care in Asia: Spirituality and Religious Connotations. Unpublished manuscript.

Chaudhry, H. R. (2006). Tradition of religious healings in Punjab. In proceedings of the Annual Conference of Indo Pak Punjab Psychiatric Society, September, 15-17, 2006.

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Chaudhry H.R., Ali. A, Cheema E. A. (1997), Family and Community Education Programme regarding Epilepsy in Pakistan: Epicadec News. 10, 17-18.

Chaudhry H.R., Syed, S. & Ahmad, I. (2001) Community Education Programme On Epilepsy in Pakistan,. Proceedings in First International Symposium on Psychiatry, 13-14.

Gilani A.I, Gilani U.I, Kasi P.M., and Khan M.M. (2005). Psychiatric Health Laws in Pakistan: From Lunacy to Mental Health, PLoS Medical. 2 (11): e317.

Kareem. S , Saeed. K, Rana. M. H, Mubbashar. M. H & Jenkins. (2004) Pakistan mental health country profile, International Review of Psychiatry, 16 (1–2), 83–92

Mirza, I., Mujtaba, M., Chaudhry, H. R. & Jenkins, R. (2006). Primary mental health care in rural Punjab, Pakistan: providers and users perspectives of the effectiveness of treatments. Science & Medicine. 63. 593-597.

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Dr. E. Mohandas

He is a postgraduate( M.D.
Psych.)from the All India Institute of Medical
Sciences(AIIMS), New Delhi, India.He has
served as consultant in Zambia for 3 years.
For the last 24 years, working as senior consultant at Elite Mission Hospital, Trichur, Kerala.

He has chaired the awards and C.M.E. committees of Indian Psychiatric Society .He has been an international resource person on various aspects of mental health and has innumerable publications in international and national publications. He is the recipient of several professional and public awards

His current Positions include: WPA Zonal Representative- Zone 16; President Elect, Indian Psychiatric Society; President, SAF International ; Chairman, Indian Association of Biological Psychiatry; Director, Skill & Training, WPA Section on Developing Countries

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Dr. Rajmohan. V

A graduate of Calicut Medical College, he completed his MD in Psychiatry from the same institution. For the last two years, he has been working as consultant psychiatrist at Elite Mission Hospital, Thrissur.

He is a CME speaker at zonal and national level and is a regular contributor to state, zonal and national journals in psychiatry. His areas of interest include functional neurology and psychopharmacology. He is also an executive council member of Thrissur Psychiatry Guild.

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NEURAL CORRELATES OF SPIRITUALITY

E. Mohandas Rajmohan.V

Spirituality refers to individual’s personal experience of attaining positive emotions- love, hope, joy, forgiveness, compassion, trust, gratitude and awe- which provide a great sense of inner peace and harmony.1 Spiritual practices ( activities associated with cultivating spirituality) include prayers, meditation, yoga, chanting, religious worship and rituals. Spiritual experiences described are feeling of transcendence, tranquility or quietitude, sense of joy and pleasure, feeling of detachment, feeling of union with God, visual experiences, analgesia, mystical and trance states. In extreme stages of spiritual practices psychotic states may surface. Spiritual practices have been reported to enhance physical functioning, self esteem, drug compliance, and longevity. Beneficial effects of spirituo-religious practices have been cited in mental health arena. Spiritual practices may have anxiolytic, antidepressant, antisuicidal and anticraving effects. Increased self esteem and hope generated by spiritual exercises promote better functional ability and perceived health.2

The spiritual practices and experiences may reflect specific cognitive mechanisms. Recent neuroimaging techniques have partly delineated changes in diverse brain areas during meditation, yoga and spiritual chants. There is a paucity of evidence regarding the neural correlates of spiritual practices and most studies that have explored spirituality have concentrated on meditative practices. Most studies use functional imaging as the investigation tool, to delineate the neural mechanisms involved in these practices. The studies include the Positron Emission Tomography (PET) studies on Yoga, Tantric Yoga, Yoga Nidra and chanting; the Magnetic Resonance Imaging (MRI) study on

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Kundalini Yoga; and the Single Photon Emission Computerized Tomography (SPECT) study on Tibetan meditation and verbal meditation. These studies have demonstrated changes primarily in prefrontal cortex, parietal cortex, hippocampal-amygdalar complex, temporal lobe, and thalamus. Hypothalamus is involved reflecting various neurophysiological changes.3-9

Neural correlates of positive emotions

Love : Neurobiological pathways of love involve reward and motivation circuitries. Ventral tegmental area (VTA), nucleus accumbens, amygdala, hippocampus and the orbitofrontal cortex (OFC) are involved in motivational and reward aspects of love. VTA or mesolimbic dopamine is integrated with several other brain regions to enrich an experience with emotion. The amygdala assesses the pleasurable or aversive nature of experience. The hippocampus records memories of an experience, including where, when, and with whom it occurred. The frontal cortex especially OFC and cingulate, coordinates and processes all information and consequently determines the ultimate behavior. The striatum (caudate nucleus, putamen, globus pallidus) responds to sexual arousal. Hypothalamic activation specific to romantic love could reflect the component of erotic arousal inherent to this sentiment. The inhibition of sympathoadrenal and stress response activity (HPA axis activity) mainly via oxytocin is involved in the formation of social attachment. Social interactions and attachments then activate endocrine or autoregulatory signaling systems that are able to further reduce stress and the related autonomic nervous system’s involvement, thereby, perhaps, accounting for health benefits that are attributed to loving relationships.10

Forgiveness: Empathy and forgiveness involve the activation of left precuneus, the left superior frontal gyrus, right orbitofrontal gyrus and posterior cingulate. Spirituality may enhance empathetic and forgivability judgments which might be helpful

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for evaluation of the self and others.11,12

Compassion : Compassion is the ability to suffer with another; sympathize for the suffering of others, and often the desire to help. Compassion is based on empathy which is the ability to identify with and understand another person’s feelings or difficulties. Empathy and compassion involves the interaction of the core mirror neuron system (MNS) and its limbic extension. (Figure 1)13,14

Morality and Trust : Both cortical and subcortical are involved in moral cognition. Diverse cortical regions are involved: PFC [anterior prefrontal cortex (aPFC), the medial and lateral OFC (mOFC and lOFC), and DLPFC (mostly the right hemisphere)], the anterior temporal lobes (aTL) and the superior temporal sulcus (STS). Subcortical structures involved include the amygdala, ventromedial hypothalamus, septal area and nuclei, basal forebrain (especially the ventral striatum/ pallidum and extended amygdala) and brainstem tegmentum.
(Figure 2)15,16

 

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Functional Neuroanatomy of Spiritual/ Religious Activities

Frontal Lobes : The frontal lobe especially the prefrontal cortex (PFC) mediates both the preparedness of religious experience and conscious cognitive process involved in the appreciation of religious experience. 17 PFC is primarily concerned with executive functions. (Figure 3)Certain prosocial behaviours such as empathy, perspective taking, forgiveness, and theory of mind (ToM) are accounted by PFC. 4, 9 Decision making and impulse control is also under the control of PFC. Afferent connections of dorsolateral prefrontal cortex (DLPFC) are from dorsofrontal and parietal area. Dorsal parafascicular thalamus, medial pars compacta of substantia nigra, raphae nucleus, and central midbrain tegmentum send afferent projections to DLPFC. Orbitofrontal cortex (OFC) receives afferent inputs from superior temporal area, entorhinal cortex, amygdala, rostromedial parafascicular thalamus, medial pars compacta of substantia nigra, raphae nucleus, and central midbrain tegmentum. The medial PFC (mPFC) along with the posterior cingulate is involved in self-reflective thought and this helps the person to have an insight into his own experience and the perception of self in relation to the divine being. Anterior cingulate cortex (ACC) is reciprocally connected with the prefrontal, premotor, motor cortical regions, and medial temporal cortical regions. In the medial temporal cortex, ACC is strongly connected with the prosubiculum, entorhinal cortex, and perirhinal cortex. In addition, it projects to the molecular layer of the CAI subfield of Ammon’s horn. ACC has four components with specific roles- anterior (involved in executive functions) posterior (evaluative functions), dorsal (cognitive function), and ventral (emotional functions). ACC is involved in regulating autonomic functions and rational cognitive functions (reward anticipation, decision-making, empathy, error detection, anticipation of tasks, motivation, conflict monitoring, and reward-based learning).4,18,19

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Neuroimaging studies have demonstrated activation of PFC during meditative/ spiritual practices. PFC provides cautious rationality to the emotional experiences surfacing from limbic system mastery. 3 Religious experiences is a cognitive process, mediated by a pre-established neural circuit, involving DLPFC, dorsomedial frontal and medial parietal cortex. The preparedness for religious experiences is probably mediated by the dorsomedial frontal cortex. The experience becomes religious by conscious identification of the experience. This cognitive process most probably involves the DLPFC and medial parietal cortex. The mPFC is needed to maintain balanced religious activities. 20, 21

Temporal Lobes : Temporal lobe is integral to auditory perception, receptive components of language, visual memory, declarative (factual) memory, and emotion. The role of temporal lobe is inferred from the observation that temporal lobe epilepsy is characterized by religious experiences as part of the ictus and the inter-ictal behaviour. Activation of temporal cortical areas (mainly left) is associated with hyperreligiosity in TLE. Reported literature suggests that greater number of temporal-lobe ‘‘signs,’’ similar to those associated with TLE (temporal lobe epilepsy), occur in normal individuals who hold above-average beliefs in

 

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spiritual and paranormal phenomena and/or are more prone to paranormal or transcendental experiences.22 Psychophy- siological ictal phenomena, like hallucinations, dejà vu, depersonalization etc are tagged to limbic system activation. The limbic marker hypothesis states that limbic system tags ordinary experiences as profoundly important, as detached, as united into a whole and as joyous experiences. These form the basis of religious experience.23 In spite of the evidence pointing to a temporal lobe involvement, there is no literature, which shows that lesions or removal of temporal lobe resulted in a change in religious activity.24

Amygdala-Hippocampus Complex: Amygdala is involved in emotional processing, fear conditioning, emotional memory, implicit processing and unconscious memory, and modulation of cognitive functions, such as attention, perception, and explicit memory.25 The central nucleus of amygdala (CeA) controls the behavioral (freezing), autonomic and endocrine responses through its influence on hypothalamus. Hippocampus is involved in the formation of declarative memories. Physiological arousal, a component of emotion, affects hippocampal processing of memory.26 Moderate arousal can improve memory, but extreme arousal will impair memory. The hippocampal stimulation decreases cortical arousal and responsiveness. The partial deafferentation of the right PSPL during meditation results in the stimulation of the right hippocampus which in turn influences the right lateral amygdala. Over stimulated amygdala becomes hyperactive leading to emotional intensity. This influences hypothalamic activity reflected by changes in autonomic nervous system (ANS). Sympathetic activation prepares the body for action. The meditative/ spiritual activity results in parasympathetic overdrive leading to relaxation and tranquility (right lateral amygdala stimulating ventromedial hypothalamus).3 The sympathetic system is also activated but to a lesser degree than parasympathetic, leading to raised perceptual sensitivity.

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However, in certain frenzied mystical states and possession states there may be a sympathetic overdrive (via lateral hypothalamus). When sympathetic and parasympathetic system fire simultaneously at maximum levels, a state of cosmic or ‘God’ consciousness or probably ‘nirvana’, or ‘anandamaya’ may be attained.27

Parietal Cortex : Parietal cortex represent somatosensory cortex (Primary and Secondary), precuneus , parietal operculum, parietal lobules (Superior and Inferior), and angular gyrus. The posterior superior parietal lobule (PSPL), a part of complex attentional network including PFC and thalamus is implicated in the analysis and integration of higher order visual, auditory and somaesthetic information.28,29 The PSPL helps construct a complex three-dimensional image of the body in space. These functions help distinguish self and the external world and a deafferentation of PSPL may result in an altered perception of self-experience during spiritual practices.30 Precuneus may be a part of the neural network sub serving self-awareness and conscious experience. Precuneus together with the posterior cingulate cortex is specifically involved in processing intentions related to perspective-taking thereby playing a role in empathic judgment and theory of mind.11

Thalamus : The PFC activates the thalamus, especially the reticular nucleus of the thalamus during spiritual experiences. Thalamic reticular nucleus, a thin lamina of neurons located between thalamus and cortex functions as an “attentional gate,” which regulates the flow of information between the thalamus and cortex. Reticular nucleus regulates thalamocortical transmission and the contents of consciousness. The thalamus mediates the flow to the cortex of visuo-spatial information. When excited, the reticular nucleus via inhibitory GABAergic (gamma amino butyric acid) projections cuts the input via the lateral geniculate body (LGB) and the lateral posterior nucleus (LPN) to

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the striate cortex and the PSPL (especially right). This functional deafferentation enhances the sense of focus during meditation.31

Neurochemistry of Spirituality

Dopamine is associated with the gating of cortical- subcortical interactions, leading to an overall decrease in readiness for action that is associated with spiritual practices. Dopamine is integral to the reward pathway and plays a role in the positive emotional states associated with religio-spiritual practices. Changes in DA (dopamine) levels are positively correlated with variations in religiosity. Hypodopaminergic state in parkinsonism is associated with significant loss of religiosity. The mesoaccumbens DA system involved in reward circuits may influence the positive effects of spiritual practice. Kjaer et al. (2002) reported activation of DA receptors in the striatum during meditation using [11C] raclomide. Decrease in binding of injected [11C]raclomide during meditation reflected the greater occupancy of DA receptors. Repeat alleles of the dopamine D4 receptor gene (DRD4) were also correlated with ‘‘spiritual acceptance’’. The valine allele of COMT (catechol O-methyl transferase), which confers relatively higher levels of enzyme activity with the resultant decrease in extra synaptic DA is correlated with lower activity of DLPFC. Valine/ Methionine (Val/Met) COMT polymorphism has been correlated positively with suggestibility. However, a recent study of paranormal experience and COMT DA gene could not find any correlation with different COMT genotypes.4,7,30,32

During meditation, lateral hypothalamic activation will release serotonin through raphae nucleus. 5HT 2A receptors are abundant in cortex, claustrum and basal ganglia whereas 5HT 1A receptors are rich in the hippocampus, septum, and amygdala. Reduced 5-HT receptor density has been correlated inversely with ‘‘self- transcendance,’’ a personality trait associated with spirituality. Serotonergic deficiencies appear to be associated with extreme

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religious beliefs and practices that resemble OCD symptoms and anti-serotonergic drugs create mystical states and religious experiences. Extreme stages of spiritual practices may activate cortical 5HT 2A receptors. This activation along with its interplay on thalamocortical circuits leads to sensory flooding, cognitive fragmentation and ego dissolution (psychotic phenomena). 5HT 1A activation may also contribute to the hallucinogenic effect.30,33

Melatonin surge during meditation is the result of lateral hypothalamic activation on pineal gland. Melatonin may partly account for the calmness and decreased pain observed during meditation.3

Acetylcholine may enhance attentional processing and spatial orientation during progressive deafferentation of input to PSPL. However, the exact variation in acetylcholine during spiritual practices is not clear. Parasympathetic overdrive dampens PGN (paragigantocellular nucleus) and thereby reduced firing of LC. This results in reduced noradrenaline.30

Alteration of amino acid neurotransmitter levels may occur during meditation. The increased PFC activity produces an increase in the level of free synaptic glutamate in the brain. NAA (N-acetylaspartate) is a direct precursor for the enzymatic synthesis of the neuron specific dipeptide N- acetylaspartylglutamate (NAAG), the most concentrated neuropeptide in the human brain. NAA in neuronal tissue can serve as a large reservoir for replenishing glutamate in times of rapid or dynamic signaling demands and stress. Glutamate activates the N-methyl-D-aspartate receptors (NMDAr). When NMDAr activation reaches a threshold, the brain might limit the production of N-acetylated-Ü-linked-acidic dipeptidase, the enzyme that converts NAAG to glutamate. This prevents excitotoxicity. However NAAG accumulation may contribute to dissociative, mystical or psychotic states. Reticular nucleus

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activation may increase GABA.3,34

Parasympathetic activation, dampening PGN, leads to reduced LC (locus coeruleus) firing of the paraventricular nucleus (PVN) of the hypothalamus. This results in a decrease of CRH (corticotrophin releasing hormone) and cortisol. The decreased baroreceptor stimulation during parasympathetic overdrive may disinhibit the supraoptic nucleus, leading to the release of arginine vasopressin (AVP). AVP may have some role in arousal and learning mechanisms. Release of â-endorphin (BE) secondary to increased glutamate levels may contribute to the euphoria and analgesia.3,30

Do spiritual practices exert antidepressant effect?

Spiritual practices may contribute to antidepressant effect possibly through elevated dopamine, serotonin, melatonin, AVP, and a – endorphin. NMDAr antagonism and decreased level of

 

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CRH and cortisol may reflect probable antidepressant mechanisms. (Table 1)3,30

Do spiritual practices have anxiolytic effect?

Spiritual practices result in increased parasympathetic activity, decreased LC (locus coeruleus) firing with decreased noradrenaline, increased GABAergic drive, and decreased levels of the stress hormone cortisol. This may explain Anxiolytic mechanism of spiritual exercise. (Table 2) 3, 30
Table 2: Anxiolytic Effect

Do spiritual practices produce Analgesia?

Cognitive modulation of pain is related to activation of prefrontal brain areas: DLPFC, VLPFC (ventrolateral prefrontal cortex) and ACC, which modulate activation in pain-associated regions in the cortex [ACC, SI (sensory area), SII/insula and thalamus], brainstem and dorsal horn. Attention engages the DLPFC and ACC, whereas reappraisal relates particularly to the VLPFC. Expectation has been associated with both densely interconnected prefrontal areas. The DLPFC is connected to the ACC, which, in turn, projects to thalamus and the PAG, a core component of the descending pain modulatory system. This system eventually facilitates and/or inhibits pain processing at the level of the spinal cord dorsal horn. Spiritual practices lead to the modulation of ACC, OFC, PAG and modify the cognitive

 

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control of pain. Release of â –endorphin and AVP may reduce pain sensitivity.3,35

Spirituality and Mystical and Dissociative States

Spirituality leads to dissociation via increase in melatonin and serotonergic transmission. Heightened activation increases 5-methoxy-dimethyltryptamine (DMT), a powerful hallucinogen leading to dissociative and mystical states. NAAG accumulation can contribute to mystical and out of body experiences. Hyperdopaminergic state in extreme peaks of spiritual experience may also have a role.3,4,30

Do spiritual practices produce Psychosis?

In extreme stages of spiritual practices psychotic like states may occur. Previous history of psychiatric disorders, substance use, sleep deprivation, and fasting may facilitate the onset of psychotic like states. Hypoxia is known to release dopamine. The probable Neurochemical factors involved are hyperdopaminergic state, cortical 5HT 2A receptor activation, increased DMT, and increased NAAG.3,4,30

Conclusion

Spiritual/ religious practices involve complex cognitive processes. Desirable and positive results in health parameters have been widely suggested. The quest to understand the brain mechanisms attributable to the positive impact of spiritual exercise has helped researchers to identify activation patterns in certain brain areas with deactivation in other areas. The studies have included different religious/ spiritual practices and different neuroimaging techniques. Future research may provide a better understanding of the neurobiological underpinnings of religious practice and spiritual experiences.

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References :
1.
Vaillant G. (2008) Positive Emotions, Spirituality and the

Practice of Psychiatry. Mens Sana Monographs 6 (1): 48-62.

2. Thoresen CE and Harris AHS (2002) Spirituality and health: What’s the evidence and what’s needed? Ann. Behav Med. 24 (1): 3-13.

3. Mohandas E. (2008) Neurobiology of Spirituality. Mens Sana Monographs 6 (1): 63-80.

4. PrevicFH.(2006)Theroleofextrapersonalbrainsystems in religious activity. Consciousness and Cognition, 15: 500-539.

5. Lazar SW, Kerr CE, Wasserman RH, et al (2005), Meditation experience is associated with increased cortical thickness, Neuroreport , 16(17): 1893-1897.

6. Lou HC, Nowak M, Kjaer TW. (2005) The mental self, Prog Brain Res, 150: 197-204.

7. Kjaer TW, Bertelsen C, Piccini P, et al (2002) Increased dopamine tone during meditation-induced change of consciousness, Brain Res Cogn Brain , 13 (2): 255-259.

8. CahnBRandPolichJ.(2006)Meditationstatesandtraits: EEG, ERP and neuroimaging studies, Psychol Bull , 132 (2): 180-211.

9. Seybold KS. (2007) Physiological Mechanisms Involved in Religiosity/Spirituality and Health. J Behav Med. 30 (4): 303-309.

10. Esch T and Stefano GB. (2005) The neurobiology of love. Neuroendocrine Letters. 3 (26): 175-192.

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11. Cavanna AE and Trimble MR. (2006) The precuneus: a review of its functional anatomy and behavioural correlates. Brain, 129 (3):1-20

12. Stein DJ and Kaminer D. (2006) Forgiveness and Psychopathology: Psychobiological and Evolutionary Underpinnings. CNS Spectrums, 11 (2): 87-89.

13. Dossey L. (2007). Compassion. Explore, 3 (1): 1-5. 14. Rajmohan V and Mohandas E. (2007) Mirror neuron

system. Indian J Psychiatry; 49: 66-69.

15. Moll J, Zahn R, de Oliviera- Souza R, et al. (2005) The neural basis of human moral cognition. Nat Rev. Neuroscience, 6: 799-809.

16. Casebeer WD. (2003) Moral cognition and its neural constituents. Nat Rev. Neuroscience, 4: 841- 846.

17. Azari NP, Nickel J, Wunderlich G, et al (2001). Neural correlates of religious experience, Eur J Neurosci, 13: 8, p1649-1652.

18. Tekin S, Cummings JL. (2002)Frontal-subcortical neuronal circuits and clinical neuropsychiatry: an update. J Psychosom Res.;53(2):647-54.

19. Mega MS, Cummings JL.(1994) Frontal-subcortical circuits and neuropsychiatric disordersJ Neuropsychiatry Clin Neurosci.;6(4):358-70.

20. Giordano J and Engebretson J. (2006) Neural and cognitive basis of spiritual experience: Biopsychosocial and ethical implications for clinical practice. Explore, 2: 216- 225.

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21. Muramoto O. (2004) The role of the medial prefrontal cortex in human religious activity, Med Hypotheses, 62 (4): 479-485.

22. Hollingsworth A. (2008) Neuroscience and spirituality: Implications of interpersonal neurobiology for a spirituality of compassion. Zygon, 43 (4): 837-860.

23.NewbergABandLeeBY.(2005)Theneuroscientificstudy of religious and spiritual phenomena: Or why God doesn’t use biostatistics. Zygon. 40 (2): 469-489.

24. Saver JL, Rabin J, (1997), The neural substrates of religious experience, J Neuropsychiatry Clin Neurosci, 9 (3): 498-510.

25. LaBar KS and Cabeza R. (2006) Cognitive neuroscience of emotional memory. Nat Rev Neuroscience; 7:54-64.

26. Rajmohan V and Mohandas E. (2007) The limbic system. Indian J Psychiatry; 49:132-139.

27. Lee BY and Newberg AB. (2005) Religion and health: Review and critical analysis. Zygon. 40 (2): 443-468.

28. Fernandez-Duque D and Posner MI. (2001) Brain imaging of attentional networks in normal and pathological states. J Clin Exp Neuropsychology; 23: 74–93.

29. Lynch J. C. (1980) The functional organization of posterior parietal association cortex. Behav Brain Science; 3: 485–499.

30. Newberg AB, Iversen J. (2003). The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations, Med Hypotheses, 61(2): 282-291.

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31. McAlonan K and Brown VJ. (2002) The thalamic reticular nucleus: More than a sensory nucleus? Neuroscientist, 8(4): 302–305.

32. Raz A, Hines T, Fossella J, et al. (2008) Paranormal experience and the COMT dopaminergic gene: A preliminary attempt to associate phenotype with genotype using an underlying brain theory. Cortex 44:1336- 1341.

33. Geyer MA and Vollenweider FX. Serotonin research: contributions to understanding psychoses. Trends in Pharmacological Science, .29: 445-453.

34. Moffet JR, Ross B, Arun P, et al. (2007) N-Acetylaspartate in the CNS: From neurodiagnostics to neurobiology. Progress in Neurobiology 81: 89–131.

35. Wiech K, Ploner M, Tracey I. (2008) Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8): 306-313.

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Dr. Chittaranjan Andrade, MD

Dr. Chittaranjan Andrade, MD
(Psychological Medicine), is a psychiatrist
with 25 years of experience in his field. He is the Professor and Head of the Department of Psychopharmacology at the National Institute of Mental Health and Neurosciences, Bangalore.

His academic record comprises 25 prizes in pre-collegiate education, 4 prizes in pre-professional collegiate education. He has received 3 international awards, 10 national awards (including all the major awards of the Indian Psychiatric Society and the Indian Association of Private Psychiatry) and 4 state and other awards in recognition of his research. He has published 11 books, approximately 30 chapters in various texts, and approximately 400 scientific papers in peer-reviewed journals.

He has published various print newsletters down the year, including Psychiatry Update, Psychiatry Review, Risperidone Update, News from the World of Medicine, and the Avanza Times. He is a referee/reviewer for 24 international journals, 5 national journals, and 2 international scientific publishing houses. He is an active freelance journalist with a regular crossword column, and over 500 articles in various newspapers and magazines. He has played 4 musical instruments for several orchestras and musical groups in Bangalore. He has been a mountaineer, having scaled 6 peaks in the Himalayas.

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Dr. Rajiv. Radhakrishnan

M.D. Psychiatry from Rajiv Gandhi
University of Health sciences, St. Johns
Medical College, Bangalore, did his MD
Thesis on “Psychiatric morbidity among patients with Systemic Lupus Erythematosus- A hospital-based prevalence study of 100 patients.”

Presently working as Research Officer in the NIMH sponsored international project “D-Serine Facilitation of Cognitive Retraining in Schizophrenia” in collaboration with Yale university.

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THE BIOLOGY OF SPIRITUALITY: RELIGION FROM A PILL

Chittranjan Andarade

Rajeev Radhakrishnan Introduction

“Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the masses”

– Karl Marx

“Science without religion is lame. Religion without science is blind.”

– Albert Einstein

Religion is an important determinant of social behavior. Religion has influenced policies, politics, crime, wars, genocide, geographical delimitations, and diverse other issues. Religion has dominated society and world history for millennia. Whereas much good is effected in the name of religion, for the most part, mankind continues to suffer from religion even in the present century. Religion, by itself, is not the disease; rather, religion as a rallying point or as a militant ideology, used by political or otherwise amoral forces, is the destructive influence.

This short article seeks to demonstrate that religiosity is not merely a sociopolitical construct describing indoctrination or philosophical derivations. Rather, religiosity, at least in part, is a construct to which man suffers biological vulnerability; and a construct that is capable of being chemically modulated. In our article, we provide a brief introduction to the neurobiology of religiosity and spirituality, and then turn to a study of the pharmacological manipulation of religious experience, conviction, and behavior.

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Religion, science, and medicine: a background

Religion provides explanations for natural phenomena that influence life: the sun, seasons, disasters, disease, and death. In these contexts, religion fosters superstitious behaviors as a means of gaining control over life events; at least some of these behaviors, at times, may have had survival value. Religion also encourages the practice of morality within a group and, through a sense of collective identity, the struggle for dominance against other groups. In these contexts, religion promotes group solidarity and cohesion, and improves the chances of survival in the face of competition. Finally, religion suggests practices such as prayer and sacrifices to appease the Gods and Goddesses of health and disease; in these contexts, religion may recruit the powerful placebo effect which largely dominated the history of medicine until the 19th century, and which is still important today. Thus, religious beliefs and behaviors are likely to have conferred an evolutionary advantage to the species. Under these circumstances, it is very likely that natural selection has favoured persons who are predisposed to religious beliefs and behaviors.

The need for cognitive control over life events has been a subject of systematic study since the 1960s1. Health-related control beliefs are important for both physical and psychological adjustment; persons who believe that they can exercise control over their illness have more positive adaptation1,2. With this background, religious beliefs have been found to have a beneficial effect on hypertension3, stroke4 heart disease5, cancer6, depression7 and other conditions; however, negative studies have also been reported8. Certain religious attitudes, reflecting a religious struggle, may be associated with a small but significant increase in the risk of death in elderly patients with medical illness9. The God Locus of Health Control Scale was designed to assess an individual’s cognitions regarding the extent to which belief in God influenced coping with physical illness10.

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Does religion have a neurobiological basis?

Although this is not the primary focus of our article, we wish to illustrate that there are many strands of evidence which suggest that neurobiological factors play a role in spirituality and religiosity. We provide a small overview of literature, and cite the results of a few studies by way of example.

Hyperreligiosity has, for long, been recognized as a part of personality change in patients with temporal lobe epilepsy and psychotic disorders11,12. Hyperactivity of the medial prefrontal cortex has been hypothesized to mediate attributes such as excessive concern about one’s existence (excessive self- reflection) and delusional interpretation of God’s mind (excess of theory of mind)13.

Based on his work using the self-transcendence scale, in his controversial book The God Gene, Dean Hamer proposed the vesicular monoamine transporter 2 gene (VMAT2) as a putative “God gene”14. However, this gene explains less than 1% of the variance of spirituality and by no means conclusively fosters spirituality.15

Mystical experiences have been shown to arise from the use of psychedelic drugs such as D-lysergic acid diethylamide (LSD) and psilocybin16,17,18. As both of these drugs have serotonergic effects, it was hypothesized that serotonin may mediate nondrug-induced mystical experiences as well19. In a study which examined 5-HT1a receptor density and personality traits in healthy men, 5-HT1A receptor binding was found to correlate inversely with spiritual acceptance (as opposed to material rationalism) scores of the self-transcendence dimension of the Temperament and Character Inventory.20

Apart from the serotoninergic system, other neurotransmitter systems may also contribute to various aspects of religiosity. In

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an fMRI study of the neural mechanisms underlying charitable donations, the fronto-mesolimbic network was found to reinforce charitable behaviour21. Polymorphism of the dopamine D4 receptor was found to be associated with self-reported measures of altruism22. Vasopression influences moral-social behaviors ranging from altruism to sexual fidelity23,24.

Religion from a pill

Psilocybin, found in certain mushrooms, is a tryptamine alkaloid. It acts primarily at serotonin 5-HT2A and 5-HT2C receptor sites. It has hallucinogenic effects that are similar to those elicited by LSD, mescaline and related drugs. In certain cultures, it has been used for centuries to induce mystical experiences. Griffiths et al17 examined mystical experiences with psilocybin in a double-blind, controlled study.

The sample comprised36 healthy volunteers with no previous hallucinogen exposure. The mean age of sample was about 46 years (range, 24-64). All subjects were well-educated. No subject had a current, past or family history of major psychiatric illness. All subjects reported regular participation in religious or spiritual activities. Although most subjects led very busy lives, they were interested in the study and participated because they were curious about the effects of psilocybin.

Subjects (n=36) were randomized to a 2-session or a 3-session study. In the 2-session study,30 subjects were randomized to receive either oral psilocybin (30 mg/70 kg) or oral methylphenidate (40 mg/70 kg); 2 months later, each of these subjects received the other drug. In the 3-session study, 6 subjects received methylphenidate in the first two sessions and unblinded psilocybin in a third session; these sessions were also 2 months apart. The purpose of this extra group of 6 subjects was to obscure the study design to the main group and hence reduce the expectancy effect.

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To further reduce the expectancy effect, subjects were told that they might receive a low, moderate, or high dose of psilocybin, or various doses of 11 other drugs (dextromethorphan, nicotine, diphenhydramine, caffeine, methylphenidate, amphetamine, codeine, alprazolam, diazepam, triazolam, or secobarbital), or placebo.

The sessions lasted 8 hour each and were conducted individually. During the sessions, the subjects were encouraged to wear eye masks, listen to classical music, and direct their attention inward. An experienced monitor sat through the entire session to provide guidance and reassurance.

Subjects were assessed using an extensive battery of questionnaires. Assessments were conducted 7 hour after each session as well as 2 months later. Subjects were also rated by monitors who were present during the sessions. Finally, each subject was also rated by 3 adults in his/her family or social circle. The acute effects of psilocybin included a wide range of perceptual changes, subjective experiences, and lability of mood, including anxiety. Psilocybin was more likely to elicit visual pseudohallucinations, illusions, synesthesia, feelings of transcendence, grief, joy, and/or anxiety; and a sense of meaning and/or ideas of reference.

Based on a priori criteria, 61% of the psilocybin sessions resulted in a complete mystical experience in contrast with only 11% of the methylphenidate sessions. Strong or extreme fear was experienced during 31% of psilocybin sessions but in none of the methylphenidate sessions. Many of the subjects so affected also experienced mild, transient ideas of reference or paranoia. Two subjects compared the experience to being in a war, and 3 indicated that they would never wish to repeat the experience. Nonetheless, no subject rated the experience as resulting in a decreased sense of well-being or life satisfaction.

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At 2 months, a third of the subjects rated the experience with psilocybin as being the single most meaningful experience in their lives, and two-thirds rated the experience as being among the top five most meaningful experiences. Many descriptions of the experience related to a sense of unity without content (pure consciousness) and/or unity of all things. In contrast, only 8% of methylphenidate experiences were rated to be among the top five spiritually significant experiences, and none as the most important experience.

Subjects attributed to psilocybin sustained positive changes in their sense of well-being, mood, attitudes, satisfaction with life, social relationships, and behavior; these changes were consistent with objective reports of changes in the behavior of the subjects, obtained from community observers. Psilocybin increased the current sense of personal well-being or life satisfaction moderately (50%) or very much (29%); in contrast, these figures were 17% and 4%, respectively, after methylphenidate. Measures of personality and general positive and negative affect were unaffected by psilocybin.

In a 14-month follow-up study of the original group 18, 58% of subjects rated the psilocybin experience as being among the 5 most personally meaningful experiences, and 67% rated it as being among the 5 most spiritually significant experiences in their lives. Furthemore, 64% indicated that the experience increased their well-being or life satisfaction, and 58% met criteria for having had a ‘complete’ mystical experience

Critical comments

In a previous study, 20 theological students received either psilocybin (30 mg) or nicotinic acid (200 mg) in a group setting during a religious service; this became known as the Good Friday Experiment. Subjects who received psilocybin experienced a heightened sense of mystical experience and reported positive

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changes in attitudes and behavior at a 6-month and 25-year follow up 25,26 Blinding in this study, however, was poor.

On the surface, the psilocybin reports appear to suggest that a life-changing spiritual experience can be artificially induced by the drug. This, however, is not the case because the studies were conducted on persons who were already religiously inclined, and who entered the study with the expectation that they might have a mystical experience with a study drug. So, what the study actually found was that in such predisposed and primed individuals, psilocybin was more likely to inducess a mood state during which a spiritual experience emerged. Perhaps the mood state induced by psilocybin was special; or, it might merely have been sufficiently hallucinogenic for the expectations of the subjects to create the spirituality of the experience. What is now required is a study of whether psilocybin is capable of eliciting spiritual experiences in persons with no religious convictions, and who have no preconceptions about what to expect. Such a study may not be easy to conduct because naive subjects require to be guided through an exposure to hallucinogens in order that the trip be pleasant; this guidance could be the source of bias. Furthermore, considering the role that religion plays in everyday life, it would be impossible to find subjects with no previously held knowledge or beliefs about religion; accordingly, it is perhaps inevitable that the melting pot of emotions and perceptions induced by psilocybin will elicit cognitive interpretations that are based on religion.

In other words, psilocybin may merely induce the brain to experience a bizarre Rorschach ink blot of emotions and perceptions; as humans strive to attribute meanings to experiences, it is likely that preconceived ideas about religion will bias the interpretation of this metaphorical ink blot. This means that religiosity may not be a specific cognitive effect of psilocybin; however, it does mean that religiosity can be pharmacologically

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manipulated. Also important here is that transcripts of descriptions of the experiences of the subjects18 emphasize that the experience of mysticality and transcendence is a brain- based phenomenon that is capable of pharmacological modulation; thus, it is not necessarily an extracorporeal experience as popular views on religion may suggest. In this context, hypoxia has also been suggested to mediate mystical and religious experiences27.

Returning to religion from a pill, it is likely that the effect of pharmacological manipulation will be one-way because it is hard to create an experience which would simulate the absence of mysticality, and which would consequently be interpreted as the lack of divinity in life. In other words, pharmacological manipulation may make religious persons more religious, or may stimulate religiosity in persons with low spiritual inclinations; however, it is unlikely that pharmacological manipulations will make religious persons atheists!

Curious readers may wish to note that psilocybin and other hallucinogens can be associated with bad trips, and can lead to dangerous behavior in naive persons who use the drug without guidance.

Parting observations

Religion and science are not mutually exclusive. Scientific theories about the origins of the universe in many ways enlarge the idea of God rather than contradict it. Although there are notable exceptions, most books by renowned physicists and cosmologists seriously discuss the nature of God because no amount of science can explain away the origin of the universe and, more importantly, the origin of the rules that govern it. As authors of this article, we offer the view that the very narrow concept of religion that has preoccupied humanity down the ages is a sociopolitical construct with biological underpinnings; a

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construct that has been responsible for more harm than good. We suggest that the ability to artificially induce mystical experiences could facilitate scientific investigation into their causes and consequences, and hence a better understanding of the phenomenon.

References :

1. ShapiroDHJr,SchwartzCE,AstinJA.(1996)Controlling ourselves, controlling our world. Psychology’s role in understanding positive and negative consequences of seeking and gaining control. Am Psychol. 51(12): 1213-30.

2. AffleckG,TennenH,PfeifferC,FifieldJ. (1987)Appraisals of control and predictability in adapting to a chronic disease. J Pers Soc Psychol. 53(2): 273-9.

3. LevinJS,VanderpoolHY.(1989)Isreligiontherapeutically significant for hypertension? Soc Sci Med ; 29: 69-78.

4. Colantonio A, Kasl S, Kasl V, Ostfeld AM. (1992) Depressive symptoms and other psychosocial factors as predictors of stroke in the elderly. Am J Epidemiol; 136: 884-894.

5. Watson JS. (1991) Religion as a cultural phenomenon, and national mortality rates from heart disease. Psychol Rep; 69: 439-442.

6. Dwyer JW, Clarke LL, Miller MK. (1990) The effect of religious concentration and affiliation on county cancer mortality rates. J Health Soc Behav ; 31: 185-202.

7. KoenigHG.(2007)Religionandremissionofdepression in medical inpatients with heart failure/pulmonary disease. J Nerv

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Ment Dis. 195(5): 389-95.

8. BlumenthalJA,BabyakMA,IronsonG,ThoresenC,Powell L, Czajkowski S, Burg M, Keefe FJ, Steffen P, Catellier D; for the ENRICHD Investigators. (2007) Spirituality, religion, and clinical outcomes in patients recovering from an acute myocardial infarction. Psychosom Med. 69(6): 501-8.

9. PargamentKI,KoenigHG,TarakeshwarN,HahnJ.(2001) Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. Arch Intern Med ; 13: 161, 1881-1885.

10. Wallston KA, Malcarn VL, Flores L, Hansdottir I, Smith CA, Stein MJ, Weisman MH, Clements PJ. (1999) Does God Determine Your Health? The God Locus of Health Control Scale Cogn Ther Research, 23 (2):131-142.

11. Tucker DM, Novelly RA, Walker PJ. (1987) Hyperreligiosity in temporal lobe epilepsy: redefining the relationship. J Nerv Ment Dis. 175(3): 181-4.

12. Brewerton TD.(1994) Hyperreligiosity in psychotic disorders. J Nerv Ment Dis. 182(5): 302-304.

13. Muramoto O. (2004) The role of the medial prefrontal cortex in human religious activity. Med Hypotheses. 62(4): 479-85.

14. Hamer D. (2004) The God Gene: How Faith is Hardwired into Our Genes, New York: Doubleday.

15. Zimmer C. (2004) Faith-boosting genes: a search for the genetic basis of spirituality. Sci Am. 291:110–111.

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16. Lerner M, Lyvers M. (2006) Values and beliefs of psychedelic drug users: a cross-cultural study. J Psychoactive Drugs. 38(2): 143-7.

17. Griffiths RR, Richards WA, McCann U, Jesse R. (2006) Psilocybin can occasion mystical-type experiences having substantial and sustained personal meaning and spiritual significance. Psychopharmacology (Berl) 187: 268-283.

18. Griffiths R, Richards W, Johnson M, McCann U, Jesse R. (2008) Mystical-type experiences occasioned by psilocybin mediate the attribution of personal meaning and spiritual significance 14 months later. J Psychopharmacol. 22(6): 621-32.

19. Goodman N. (2002) The serotonergic system and mysticism: could LSD and the nondrug-induced mystical experience share common neural mechanisms? J. Psychoactive Drugs. 34(3): 263-72.

20. Borg J, Andrie B, Soderstrom H, Farde L. (2003) The serotonin system and spiritual experiences. Am J Psychiatry; 160: 1965-1969.

21. Moll J, Krueger F, Zahn R, Pardini M, de Oliveira-Souza R, Grafman. (2006) Human fronto-mesolimbic networks guide decisions about charitable donation. J.Proc Natl Acad Sci U S A. 103(42):15623-8.

22. Bachner-Melman R, Gritsenko I, Nemanov L, Zohar AH, Dina C, Ebstein RP. (2005) Dopaminergic polymorphisms associated with self-report measures of human altruism: a fresh phenotype for the dopamine D4 receptor. Mol Psychiatry. 10(4): 333-5.

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23. Ophir AG, Wolff JO, Phelps SM. (2008) Variation in neural V1aR predicts sexual fidelity and space use among male prairie voles in semi-natural settings. Proc Natl Acad Sci U S A. 105(4):1249-54.

24. Israel S, Lerer E, Shalev I, Uzefovsky F, Reibold M, Bachner-Melman R, Granot R, Bornstein G, Knafo A, Yirmiya N, Ebstein RP. (2008) Molecular genetic studies of the arginine vasopressin 1a receptor (AVPR1a) and the oxytocin receptor (OXTR) in human behaviour: from autism to altruism with some notes in between. Prog Brain Res. 170: 435-49.

25. Pahnke WN. (1967) LSD and religious experience. In: DeBold RC, Leaf RC (eds). LSD man & society. Middletown, CT: Wesleyan University Press, 60-85.

26. Doblin R. Pahnke’s (1991) Good Friday experiment: a long-term followup and methodological critique. J Transpers Psychol ; 23: 1-28.

27.ArzyS,IdelM,LandisT,BlankeO. (2005)Whyrevelations have occurred on mountains? Linking mystical experiences and cognitive neuroscience. Med Hypotheses. 65(5): 841-5.

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Dr. Arun V. Ravindran

He holds degrees of MSc., PhD,
FRCP(C), FRCPsych. Dr. Ravindran is
currently Full Professor in the Departments
of Psychiatry and Psychology at the
University of Toronto and the Clinical
Director of the Mood and Anxiety Disorders Program at the Centre for Addiction and Mental Health.

He is also a Full Member of Graduate Faculty of the Institute of Medical Sciences of the University of Toronto. His clinical and research interest are in the area of mood, anxiety and related spectrum disorders, particularly in relation to the behavioural pharmacology of psychotropic agents, their synergy with psychological therapies and the use of neurobiological approaches to examine the aetiological and treatment correlates of these illnesses.

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Lakshmi N. Ravindran

She has done her MD, FRCP(C). Dr. Ravindran completed her residency training in psychiatry and then a research fellowship in mood disorders at the University of Toronto.

She currently holds an advanced research fellowship in psychiatry and psychology with Veterans Affairs at the University ofCalifornia,SanDiego. Herclinicalandresearchinterestsare in the behavioural pharmacology and neurobiology of mood and anxiety disorders, with a focus on social anxiety disorder and post-traumatic stress disorder.

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NEUROBIOLOGY OF SPIRITUAL PRACTICES: A BRIEF REVIEW

Lakshmi N. Ravindran Arun V. Ravindran

Spirituality is one of the characteristics that distinguish humans from other species on the planet. Though defining spirituality is a complex challenge, broadly it may be understood to be the human need to seek understanding and meaning in one’s existence, which often includes the need to feel a metaphysical connection to something greater than oneself. Although ‘religion’ and ‘spirituality’ are often used as interchangeable terms, organized religion is only one way in which spirituality may be manifested. There are a number of other practices that may be equally valuable in enhancing one’s spirituality, such as yoga, meditation and self-reflection.

Understanding how spirituality may influence both physical and mental health and the physiological dimensions that mediate such benefit has been of increasing research interest. To that end, a number of studies have been able to demonstrate that spiritual beliefs and practices have been associated with normalization of hypothalamic pituitary adrenal (HPA) axis and improved immune function, leading to lower incidence of heart disease and hypertension, as well as more adaptive health behaviours [1]. While demonstrating the positive impact of spirituality and spiritual practices on health is useful, eliciting the causal neurobiological mechanisms that may be involved in achieving these effects is the next logical step.

There is a wide range of spiritual practices but most reported neurobiological investigations have focused on meditation practices, yoga and their variants and combinations. Populations studied have ranged from healthy subjects to those with

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significant physical and mental illnesses. With no randomized controlled investigations currently available, this review is based on open trials and case series. Among the research strategies used, electrophysiology, neuroendocrine and immune measures and, more recently, neuroimaging stand out.

Electrophysiological Studies

Electroencephalogram (EEG) studies of meditative practices have elicited certain robust findings. One oft-reported phenomenon is an increase in alpha power, particularly in the frontal regions of the brain, observed during meditation tasks [2- 5]. While alpha waves have been associated with states of relaxation and calmness, changes in its power are said to relate to cognitive and memory performance, as well as attentional processes. Thus, it has been proposed that alpha power changes may be the adaptive mechanism by which one inhibits conflicting processes while attending to the most relevant attentional task [6]. Along these lines, Cooper et al. [7] noted that increases in alpha amplitude, which have also been observed during the meditative state [8-10], were greater not only during periods of internally directed attention (as compared to externally directed attention), but also as task demands increased. These areas of increased alpha power were subsequently found to correlate with decreased functional magnetic resonance (fMRI) signal in some regions (occipital, superior temporal, inferior frontal, and cingulate cortex), but with increased signal in thalamus and insula [11].

In addition to variations in alpha power, increases in theta band power have also been observed during the meditative state, most notably in frontal regions with increased frontal midline (FM) theta power [12-15]. This EEG rhythm has been previously linked to processing of memory and emotion, but is also induced during tasks of mental activity, particularly sustained attention [16,17]. Moreover, EEG studies of anxiolytic agents have demonstrated that relief from anxiety is reflected in the appearance of FM theta rhythms, suggesting it as an objective indicator of improvement [18,19] and lending credence to the suggested relaxation effects

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of meditation. Using magnetic encephalogram, Asada et al. [20] demonstrated that FM theta activity during cognitive tasks appears to be linked to activity in the medial prefrontal cortex (MPFC) and anterior cingulate cortex (ACC; a proposed site of action of antidepressants). Subsequent functional neuroimaging studies have suggested that MPFC activity, particularly in the dorsal area, is increased when attention is directed specifically toward self-referential or introspectively oriented mental activity [21]. Further, the ACC has been found in subsequent neuroimaging studies to show increased activity during attention- requiring tasks [22,23]. Building on the above findings, Aftanas and Golocheikine [15] demonstrated that meditative states of more experienced practitioners were characterized by increased theta activity, in the anterior frontal and frontal midline areas, which in turn correlated to the intensity of the reported blissful experience.

In yoga, electrophysiological studies are few with variable findings, but they generally indicate that yoga affects brainwave activity. One study reported a significant increase in beta activity (a marker of cortical activation during attention) in experienced yoga practitioners compared to controls, suggesting a propensity to mental alertness without need for external stimuli, similar to results with meditation and alpha power [24]. In another study of note, Kimura et al [25] found an increase in alpha waves and a decrease in plasma cortisol in yoga instructors during yoga compared to during a rest period, indicating a decrease in stress reactivity. Yoga also shows electrophysiological benefits in clinical populations. A particular brainwave measured by P300 amplitude, seen to be abnormal in depressed individuals compared to controls [26,27], has been found to return to normal status after 3 months of yoga [27].

Functional Neuroimaging Studies :

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Positron emission tomography (PET)

Lou et al. [28] compared PET scans during guided meditation induction and normal resting consciousness (control) in experienced yoga teachers. Though topics of reflection varied, certain common neural substrates were noted which included altered activation of anterior parietal, occipital sensory and association regions, and bilateral hippocampi. In contrast, normal consciousness produced increased activation in the orbital and dorslolateral prefrontal, ACC, temporal, inferior parietal lobule, caudate nucleus, thalamus, pons and cerebellar regions, all regions implicated in executive function.

Subsequently, Azari et al. [29] used PET technology to examine the neural correlates of the religious experience in self- identified religious subjects. Although not strictly a study on meditation, the religious state was induced through recitation and focus on the text of a Biblical psalm, a process akin to focusing on a mantra during certain meditation practices. Compared to controls, PET images of the religious subjects noted activation of the right dorsolateral prefrontal cortex (DLPFC) with activation in the dorsomedial frontal cortex and right precuneus although no regional cerebral blood flow (rCBF) changes were seen in the limbic areas. These results contradict the earlier findings of Lou et al. [28] who found greater activation of DLPFC during normal consciousness than during meditation. A possible explanation is that passive guided meditation requires less engagement of executive attention capacity than inducing the meditative state on one’s own [30,31]. The activation of this fronto-parietal circuit seen by Azari et al. has since been replicated in subsequent neuroimaging studies of meditative experiences, as we will discuss.

Single Photon Emission Computed Tomography (SPECT)

SPECT was used to elucidate rCBF changes in Tibetan

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Buddhist meditation practitioners [32]. As hypothesized, activations in the DLPFC, inferior and orbital frontal cortices were seen, as were rCBF increases in the sensorimotor cortices, dorsomedial cortices, midbrain, cingulate gyri and thalami. The increased activation of the frontal areas (consistent with previous studies [31,33]), was attributed to the increased attention/focus of meditation. An inverse relationship of rCBF between the PFC and the posterior superior parietal lobes (SPLs) was also observed. Subsequently, the same authors conducted a SPECT study of meditative prayer in Franciscan nuns [34]. As before rCBF was increased in the PFC, inferior parietal and inferior frontal lobes, with strong inverse correlations once again being seen between metabolism in the PFC and the ipsilateral SPLs.

Thus, published PET and SPECT studies on meditation provide evidence for a fronto-parietal circuitry mediating the relaxation and focused attention responses seen in different kinds of meditative practices. It would also appear that the regions to initially engage in the process of focusing and sustaining attention during meditation are likely to be the PFC and the cingulate gyrus [35].

Magnetic Resonance Imaging (MRI) and Functional Magnetic Resonance Imaging (fMRI) Studies

In an early report, Lazar et al. [31] used fMRI to compare the neural circuitry of the induction and relaxation phases of meditation versus a control task, in practitioners of Kundalini yoga (which involves attention to breathing along with silent repetition of a mantra). The induction phase was associated with activation in the putamen, midbrain, ACC and hippocampal/parahippocampal formation, while the relaxation phase was associated with activation of the prefrontal, parietal and temporal cortices, the pre-central and post-central gyri and hippocampal/ parahippocampal formation. In a similar fMRI study, Baerentsen et al. [36] reported activations of the left frontal, inferior parietal

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and lateral temporal cortex, as well as in the ACC, hippocampus and PFC during the switch from normal consciousness to the onset of meditation.

Holzel and colleagues [37] investigated effects of meditation on cognitive functions in practitioners of Vipassana, a Buddhist mindfulness meditation technique focused on breathing, versus controls. Meditators had greater activation in both the dorsal MPFC (implicated in emotional processing) and bilateral ACC, particularly in the rostral sites (which are associated with happy emotions; [38]). This suggests that, compared to controls, meditators might experience greater well being and contentment during meditation, and may also be more practiced at emotional self-regulation.

Several investigators have reported differences in both structural and functional imaging between habitual meditation practitioners and novices. These investigations have implications for long-term structural changes, neuroplasticity and cognitive well being. In one such study [39], cortical thickness was assessed in subjects experienced in Insight meditation versus controls using MRI. Although overall thickness was comparable, regional differences were noted. The meditation group had greater relative thickness in a large region of the right anterior insula, as well as right middle and superior frontal sulci. Further, decreased cortical thickness, which is known to occur with age particularly in the frontal regions [40], was found in the control group but not in the meditator group. The authors theorized that long-term meditation may promote increased cortical thickness in areas related to the tasks of meditation (e.g., the insula which is related to interoceptive function) as well as possibly slow frontal age-related cortical thinning. Furthermore, the observed differences were more prominent in the right hemisphere, with its greater role in sustaining attention. Although the results are based on cross-sectional data, the possibility that meditation may

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positively impact neural plasticity is intriguing, with implications for long-term cognitive health. Elaborating on these findings, Pagnoni et al. [41] investigated possible age-related grey matter volume changes in Zen meditation practitioners and controls. An inverse correlation (with a trend for significance) between age and total grey matter volume was found in the control group, but not in the meditators. Furthermore, in the meditation group, the age-related decline in grey matter volume was significantly less in the left putamen, which is thought to play a role in cognitive processes involving executive function, such as selective attention, a function critical to the practice of meditation.

Using fMRI to explore possible long-term cerebral effects, Baron et al. [42] found differential patterns of activation between lessandmore-experiencedmeditators. Experiencedparticipants had greater DLPFC activity but less ACC activation over time during meditation, with the reverse noted for novices. The proposed roles for the DLPFC in sustaining attention, and the ACC in error monitoring, such as for correction of wandering attention [43], may explain these results. In a similar study, Brefczynski-Lewis et al. [44] found an inverted U-shaped function for activation of the attention-related networks (which included fronto-parietal, cerebellar, and temporal regions) and visual cortex during meditation. As expected, novices had less activation than the moderately experienced meditators, but the most experienced meditators also had less activation in the regions examined, conceivably because of less effort required to sustain attention. As with the findings of Baron et al. [42], ACC, as well as right middle insula, activation was greatest in novice meditators. This adds credence to the theory that ACC activation may be greater in novices due to increased need for error monitoring during meditation, while insula activation in novices may be linked to greater effort to monitor one’s internal state during the tasks.

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Neuroendocrine and neuroimmune studies

The proposed benefits of meditation, yoga and related practices in stabilizing physiological systems is said to be mediated by decreasing allostatic load and improving adaptation [45,46]. Allostasis – the ability to achieve stability through change [47] – is considered critical for survival. Through allostasis, the autonomic nervous system, the HPA axis, cardiovascular, metabolic and immune systems protect the body by responding to internal and external stressors [48]. Excessive prolonged allostatic load is said to lead to chronically stressful states accompanied by high levels of cortisol [48]. Sustained high cortisol in turn leads to diminished neurotropic support, impaired neuroplasticity and neurogenesis and decreased cellular resilience [49].

Significant decrease in salivary cortisol (a marker of altered HPA axis activity) after yoga has been reported in healthy volunteers [50,51], yoga practitioners [25], and distressed women after intensive yoga treatment [52]. Similar changes were also noted in a population of depressed and anxious patients in whom the reduction was much more robust and significant, as hypercorticoselemia is a frequent accompaniment of these disorders [45,46,53,54]. The findings of Gangadhar et al. [46] are of particular note, as a significant decrease in plasma cortisol levels was found after only brief yoga treatment. Elevation of plasma prolactin, which tends to be reduced in depressives, has also been found with yoga [55], and while studies of prolactin in anxious human populations are lacking, animal models suggest that prolactin increase may alleviate anxiety [56]. Altered activity of the ã-aminobutyric acid (GABA) neurotransmitter system, involved in the pathophysiology of anxiety and depression, and specifically thought to have a role in neuroplasticity, has been investigated in yoga practitioners. Magnetic resonance spectroscopic (MRS) imaging has noted an increase in brain GABA levels in regular yoga practitioners compared to non-

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practitioners even after a single yoga session [57].

The modulation of immune responses by yoga, meditation and related practices has been well reviewed by Arora and Bhattacharjee [58]. As they note, reduction in stress and parallel improvement of immune function has been described in normal populations as well as in disorders such as cancer. Immune alterations reported included increase in natural killer cells (NK), increased response to NK cells and recombinant IFN gamma, and decreased proliferative response to peripheral blood lymphocytes to T cell receptor antibodies. Qi gong training, a Chinese meditative practice, has been reported to be associated with an elevation in CD4 T cells and higher CD4/CD8 ratio, and this is stronger in the practitioners compared to controls [59]. Although there are few comparative studies, the impression is that several forms of stress reduction therapies, including yoga, meditation, cognitive behavioural stress management (CBSM), may mediate their immune system changes and the benefits through similar mechanisms [46].

Methodological Limitations of Current Research

While the findings from the above studies are helpful in providing an initial framework, several shortcomings prevent more robust generalizability of conclusions. These include the cross-sectional design of the studies, small samples sizes, and heterogeneous study populations used (e.g. experience of meditators, type of practice, demographic characteristics, etc.).

Specific to electrophysiological studies, increased alpha and theta power were found in some but not all studies. Whether these EEG patterns are characteristic of the state of meditation, itself, or merely an enduring change resulting from long-term practice remains unclear. These issues are well reviewed by Cahn and Polich [30].

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With neuroimaging studies, measurements were often performed at a single time point, predetermined as the presumed start or peak of meditative experience and ignoring individual variations. Confirmation of a satisfactory meditative experience is drawn from subjective questionnaires completed by the participants. Further, while fMRI provides certain advantages over other neuroimaging techniques, it has its own limitations including the need to meditate in an awkward posture and environment with distracting auditory stimuli. As with the other imaging studies, finding sufficient numbers of appropriate subjects is difficult, thus introducing a selection bias and a lack of power. Variation in quality and uniformity of meditation practices further add to the limitations.

Furthermore, neurohormonal and endocrine levels are very sensitive to multiple factors, e.g nutrition, non-specific stressors, etc., that are difficult to control for.

Conclusions

Spiritual practices, such as meditation, have existed for many years but underlying mechanisms have been investigated only recently. Nevertheless, neurobiological studies provide a preliminary framework to understand them. The findings of increased frontal alpha and theta power from EEG during meditation confirm processes of sustained internally directed attention that are greater in more experienced meditators. Results from PET, SPECT and fMRI add to these findings, supporting the involvement of the fronto-parietal circuit, with a particular role for the PFC and ACC. Across various meditations techniques, these structures appear to play a critical role in the engagement and maintenance of attention and regulation of the internal state even in the presence of potentially distracting events, with different neural structures being active at different phases of the practice. There is evidence to suggest that spiritual practices positively influence adaptive stress response contributing to decreased

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neurotoxicity, and improved neuroplasticity and resilience by reducing hypercortisolemia with positive implication for long-term well being. There is early evidence to suggest that meditation may impact neural plasticity leading to long-term structural and functional changes in the brain, with implications for long-term well being.

It is expected that future studies will continue to elucidate these mechanisms and address current limitations, the crux of which lie in issues of statistical power and the heterogeneity of techniques, populations and practices. Further elucidation of underlying neurobiology of various spiritual practices would likely contribute not only to the understanding of brain function but also serve to enhance these practices, contributing to better physical and mental health outcomes.

Acknowledgements

The authors would like to thank Tricia da Silva, MA, for her assistance in the preparation of this paper.

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Dr P. K. Singh

Dr. P. K. Singh: born 1954; did MBBS
from All India Institute of Medical Sciences
in 1976; MD in Psychiatry from Post-
Graduate Institute for Medical Education &
Research, Chandigarh in 1980; currently working as Professor and Head of the Department of Psychiatry at Patna Medical College, Patna, Bihar; has presented several talks and papers at zonal, national and international levels.

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Dr. Vinay kumar

Dr.Vinaykumar: born1961;didMBBS
and MD from Patna Medical College, Patna
in 1991; currently working as Consultant
Psychiatrist, Manoveda Mind Hospital &
Research Centre Pvt. Ltd. Patna; has
presented talks and papers at zonal, national and international levels; has received ‘Ramchandra N Moorthy Award-2007’ of

IndianMedicalAssociation;editsManovedaDigest,1st mental health magazine in Hindi.

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SPIRITUALISM AS A PREVENTIVE STRATEGY

Introduction

Spiritualism is esoteric and prevention is pragmatic. The whole process of spiritualism is an exercise in attempting to unite the ethereal with the material. From this perspective, it is quite contemporary to explore the preventive potential of spiritualism. In fact, like the eternal soul, preventive spiritualism is already there in force. In fact, we only have to discover and define it. Individually, we all dwell within our minds even though we do not know what mind is. It is only through the medium of mind that we become aware of certain other dimensions of man, other than the mental or the psychic. They are the somatic, the social and the spiritual dimensions. The social is similar in substance to the psychic except for the numbers. The somatic and the spiritual seem to differ qualitatively from each other. In fact, for a common man, they seem to belong completely to two different worlds. The former is available to scrutiny by the senses, the exteroceptive ones, while the latter can be explored only through introspective means.

Modern science has excelled in discovering complexities no less than a universe within the somatic dimension of each individual but it has completely turned a blind eye towards his spiritual dimension. On the other hand sages from the ancient times have explored the spiritual world of man’s existence in great and lucid details. Their formulated insights can hardly be ignored by any sentient mind.

The Twin Traditions

We, in the twenty first century, are proud inheritors of both

P. K. Singh Vinay Kumar

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these traditions. Scientists and sages, both are our venerable ancestors. Objectivity demands that we impartially evaluate the respective place of both these lines of pursuits. Ideally, they should converge as they actually do in the existence of man. Emergence of mind is a great phenomenological leap for mankind. It suddenly and tremendously enlarges his existential horizons and reach. It also grants him limited freedom from the blind dictates of causal chain. Simultaneously, it also betrays a deep yearning for going beyond the limits of senses and psyche; to find a place and meaning on the canvas of eternal universe. Science says the only truth is ‘here and now’; spiritualism says ‘here and now’ is a falsehood; the eternal truth is ‘there and forever’. However, we are now witnessing a gradual convergence between the two. It was in 1999 that World Health Assembly added ‘spiritual well being’ to the WHO definition of Health.

Sources of Spiritualism

All religions have talked about a spiritual world even though they differ in details. It is surprising how different religions, having originated at different time and place in history, seem to be talking in almost similar language when it come to matters relating to spirit and soul. This seeming similarity is indicative of there being some fundamental truth about it. Swami Vivekananda (1, 2) has said that all religions are a product of “supersensuous’ state of mind, wherein it crosses the limits of body and senses. It is not necessary to subscribe to any religion to be spiritual. Secular spiritualism is a valid concept (3). Even an atheist can be a spiritual person. Swami Vivekananda (1) goes one step further. He says, ‘He who does not believe in himself is an atheist.’ In fact, religion is a subsequent ‘expression of spiritual belief through a framework of rituals, codes and practices’ (4). Spiritual experience and spiritual faith is primary. It essentially means having firm conviction about there being existences which are beyond human and yet which is in constant communion with the human beings. Such a conviction completely transforms the

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attitude of any individual and thereby his mental state and behaviour.

There is ‘monism vs. dualism’ debate about the substance of such existences but those are issues of philosophical value and not of immediate concern to practicing psychiatrists. Even if we take the extreme position of completely disregarding the existence of soul or spirit, the fact remains that spiritualism as a belief system does and will continue to exist. Further, it will continue to affect the mental health of individuals. Most people have generally ill-defined spiritual aspirations, a deep desire to transcend the limits of his body and mind and establish some kind of communion with that which is eternal and universal and not accessible to his sentient apparatus. Non-fulfillment of this aspiration will have a telling effect on the mental health of individuals. This will make him more vulnerable to decompensation and resistant to therapeutic interventions.

Essence of Spiritualism

Who is a spiritual person? A spiritual person is he who practices moral purity and an attitude of inwardness rather than being preoccupied with rituals or outward appearances. “Spiritualism is believing, thinking, acting and living like an immortal spirit”(5). The decisions and actions of such individuals will be guided and determined not by ego considerations but by spiritual considerations. The deepest parts of his being shall constantly endeavour to establish a contact with all that is universal and eternal. He will display following characteristics :

· Believes in the existence of Soul or innermost self · Accepts it as his true self
· Identifies himself with it all the time

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· Lives and acts as if he is the Self, not his mind and body

· Dwells deep within himself to understand the true nature of his existence.

· Does not see any difference between himself and the rest of creation

· Is morally pure.

· Disinterested in showing off his spiritual power for personal popularity

However, when people are asked to describe what spirituality exactly means to them, they have different things to say, which does not fully correspond to the abovementioned description of a spiritual man. Research by Martsolf and Mickley (6) has highlighted the following areas as worthy of consideration, which have emerged as consensual key concepts.

· Meaning – significance of life; making sense of situations; deriving purpose.

· Values – beliefs, standards and ethics that are cherished.

· Transcendence – experience, awareness, and appreciation of a ‘transcendent dimension’ to life beyond self.

· Connecting – increased awareness of a connection with self, others, God/Spirit/Divine, and nature.

· Becoming – an unfolding of life that demands reflection and experience; includes a sense of who one is and how

one knows.

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In fact societies may also differ on spiritual indices. Variable degree of spirituality may be integrated into the value systems of all cultures. Societies which place high premium on individualism are least likely to be high on spiritualism, because spiritualism involves shifting of locus of control predominantly to the spiritual forces. On the other hand, there are cultures which have spiritual explanations and spiritual paradigms readily available for almost all situations of life, be it birth or death, victory or defeat, loss or gain, failure or successes. These paradigms function as spiritual defenses at cultural level to regulate individual emotions and actions and thereby the mental health of the masses. It would be interesting to compare these two types of societies on indices of mental health and quality of life parameters. Common sense suggests that spiritual beliefs and practices may serve as protective factors against mental sufferings and decompensation. They may serve as spiritual defenses. Its contribution to positive mental health can hardly be doubted.

Place of Preventive Spiritualism

‘Prevention is better than cure’ is an old adage. We are familiar with talks about nutrition, exercise, hygiene and vaccines. They are all for the body; after all sound mind resides in a sound body. We have also heard talks about self-discipline, detachment, equanimity, sharing, affiliating and networking as preventive strategies for mental health. In fact, anything and everything that is done in society has a bearing on the mental health of its members. However, hardly have people been talking about the preventive value of spiritual engagement and practices for mental health. Intuitive and also some documentary evidences suggest that this may actually be true.

The appeal for preventive spiritualism becomes even more attractive when we realize that this may be the most cost-effective strategy or input for maintaining the mental health of any society and its members. It is operative at individual level, requiring only

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a small bit of his private time and space. It does not require any large infrastructure or large funding or any large body of people to be made operational. Prevention must necessarily be cheaper and simpler than the cure or else it becomes meaningless to focus on it.

Based on several studies, Andrew Sims has listed following outcome gains from religious involvement which essentially means spiritual engagement. (7)

· Well being, happiness and life satisfaction · Hope and optimism
· Purpose and meaning in life
· Higher self esteem

· Adaptation to bereavement

· Greater social support and less loneliness

· Lower rates of depression and faster recovery from depression

·  Lower rates of suicide and fewer positive attitude towards suicide

·  Less anxiety
· Less psychosis and fewer psychotic tendencies

·  Lower rates of alcohol and drug use and abuse

·  Less delinquency and criminal activity

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· Greater marital stability and satisfaction

Presumptive Principles

A perusal of the above observations, which essentially is an incomplete list, suggests that spiritual practices do have a protective role in many situations. It seems to act as an effective antidote to many psychological stressors which torment an average human mind like cyclones and volcanoes. Lack of spiritual practice has been proposed as an important risk factor for psychological distress by Dr. Niko Kohls and Professor Harald Walach (8). They have concluded that “Regular spiritual practice seems to be able to endow an individual with an important resource for resilience against destabilizing experiences.” The trauma of loss, separation, deprivation, surplus, isolation, closeness, failures, frustrations, constraints, restrictions, unwanted changes, unpleasant changes, sudden changes, changelessness, defeat, insult, victory, frictions, discord, competition etc. etc. create turbulence within human mind of variable proportions which eventually lead either only to distress or further to dysfunction or decompensation. The impact of these stressors gets automatically dampened when they are viewed through spiritually charged glasses, because spirituality changes the perspective and all proportions of life. Bhagwad Gita is an epic illustration of how spiritual initiation can prevent an imminent acute decompensation even in the battlefield.

The various ways in which spiritualism can lead to realignment of psychological forces are being formulated below:

1. Unity and universality are the key qualities of spiritual experience. Feeling one with the Almighty gives one a feeling of power and immense growth. This feeling of strength protects against many maladies.

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2. The same experience also protects against any feeling of being deprived, dispossessed or disadvantaged because of feelings of identity with the supreme. This also protects against the feelings of incompetence and inadequacy. All this have a supportive effect on the mental health of individuals.

3. Since spirituality leads to experience of actorship, getting outsourced to the spiritual domain, the individual no longer feels the same degree of responsibility or accountability for his acts of omissions and commissions. He is freed of the burden of guilt and shame to a very large degree and thereby feels protected from the emotional turmoil.

4. Similarly, experiences of victory and defeat, joy and sorrow also get outsourced to the spiritual powers, thereby protecting the individual from the turbulence of ups and downs of life. As a consequence the individual is blessed with experience of peace and equanimity.

5. Spiritual convictions protect one from feelings of isolation and loneliness. He always has a ‘companion’ even in times of his worst crisis and solitude. That becomes a perennial source of hope and strength and thereby a protective influence. Having ‘God’ on one’s side is a great morale booster.

6. Individual superego also derives strength from spiritualism. Since his personal rules no longer remain his rules alone, he feels constrained and proscribed from violating it. This helps him in leading a disciplined and virtuous life and thus keeps him protected from many vices and their consequences in terms of emotional disturbance. Declining spiritualism has led to weakening of superego, which manifests itself in lawlessness and chaos in society.

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of the Spiritual one, a more egalitarian and non-exploitative interaction among individuals in society is facilitated. It also protects against arrogance, overconfidence and egotism. This has a de-stressing effect for the majority.

8. By identifying oneself with the spiritual dimension, the canvas of existence is enlarged to such an extent that everyday quivers of emotion and passion get miniaturized to the point of getting obliterated. The same also applies to the seemingly irresolvable problems of life. Human beings then experience the bliss of eternal peace and all suffering is alleviated.

9. By identifying with something that is eternal and universal one is freed of the fear of disappearing into nothingness after physical death and thereby experiences immortality which becomes a source of hope and strength specially in times of crisis.

10. The attitude of oneness with the only existence that is there in the universe gives one a feeling of transcendence and enlightenment and thereby all activities in the world feel like a blissful role-playing and not a condemned or purposeless rambling.

Preventive Strategies

There would be many more ways in which spiritualism can contribute to positive mental health and also as a protective and preventive influence at multiple levels of mental decompensation. It can act at the level of primary prevention as it probably does by culturally integrated spiritual defense mechanisms. It can also act at the level of secondary and tertiary prevention by its inherent property of being universal de-stressor and a nonspecific buffer for extraneous influences. Early intervention and disability limitation has a lot to imbibe from spiritual principles.

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Since spiritual dimension is integral to human nature, all comprehensive and eclectic therapies must include spiritual therapy in addition to the usual pharmacotherapy and psychotherapy. Spiritual therapy would focus on fulfilling the spiritual aspirations of individual, on enhancing his spiritual quotient by optimizing and streamlining his spiritual convictions and practices. This would lead to a deep sense of satisfaction and internal peace which would in turn have a positive preventive and therapeutic effect on the individual concerned. There is a beautiful and revealing report by Raguram (9) regarding improvement in the psychopathology of patients simply after short full time stay at temples in south India without any specific intervention. There are many other spiritual practices and activities prevalent in different parts of the world. A list is given below.

Spiritual practices given below span a wide range, from the religious to secular (10) :

· belonging to a faith tradition, participating in associated community-based activities;

· ritual and symbolic practices and other forms of worship; · pilgrimage and retreats;
· meditation and prayer;
· reading scriptures;

· sacred music (listening to, singing and playing) including songs, hymns, psalms and devotional chants;

· acts of compassion (including work, especially teamwork);

· deep reflection (contemplation);
· yoga, Tai Chi and similar disciplined practices;

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· engaging with and enjoying nature;

· contemplative reading (of literature, poetry, philosophy etc.);

· appreciation of the arts and engaging in creative activities, including artistic pursuits, cookery, gardening etc.;

· maintaining stable family relationships and friendships (especially those involving high levels of trust and intimacy);

· group or team sports, recreational or other activity involving a special quality of fellowship.

According to Royal College Of Psychiatry’s leaflets on Spirituality and Mental Health, Spiritual skills include

· ·

·

· ·

·

· ·

being self-reflective and honest;

being able to remain focused in the present, remaining alert, unhurried and attentive;

being able to rest, relax and create a still, peaceful state of mind;

developing greater empathy for others;

finding courage to witness and endure distress while sustaining an attitude of hope;

developing improved discernment, for example about when to speak or act and when to remain silent;

learning how to give without feeling drained; being able to grieve and let go.

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Scientific Spiritualism is the Future

Spiritual skills and practices have been there from time immemorial. They have ranged from being purely meditative to exclusively ritualistic. They have always served as a defense against the unknown dangers and fears. Man’s capacity to know has also made him acutely aware of what he does not know. Gradually he realized that the size of what he knows is much much smaller than the size of what he does not know or possibly can never know. His continued quest to transcend his own limits to identify with the unknown superstratum of existence has given birth to many of the profoundest insights and have remained one of the deepest yearnings of mankind. Those insights form the main body of spiritualism and cannot be separated from its existence. For long in the recent past, they have been relegated to relative insignificance by the onslaught of nascent science. The maturing science now has realized its limits and has extended a friendly hand to its most eligible ally i.e. the spiritualism. It is high time that spiritualism is applied in a scientific way to maximally optimize the mental health of one and all.

References :
1.
SwamiVivekananda;PracticalVedanta,AdwaitaAshram

Publication Department,Calcutta,2004

2. SwamiVivekananda;Chapter-TheNecessityofReligion, Jnana Yoga, Adwaita Ashram Publication Department, Calcutta,1989

3. Culliford Larry; Love, Healing and Happiness: Spiritual wisdom for secular times http://www.larryculliford.co.uk/ ?page_id=54

4. Editorial,Spiritualneedinhealthcare;BMJ2004;329:123- 124 (17 July), doi:10.1136/bmj.329.7458.123

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5. Jayram V., The true meaning of spiritualism; http:// http://www.hinduwebsite.com/divinelife/spirit.asp

6. Martsolf D.S. & Mickley J.R. (1998) The concept of spirituality in nursing theories: differing world-views and extent of focus Journal of Advanced Nursing 27, 294-303.

7. Sims, A. Spirituality in Psychiatry http://www.cmf.org.uk/ literature/content.asp?context=article&id=1921

8. Kohls Niko, Walach Harald: ‘Lack of Spiritual Practice – an important risk factor for suffering from distress’ Newsletter No. 25, July 2008, Spirituality and Psychiatry Special Interest Group, Royal College of Psychiatry; http://www.rcpsych.ac.uk/ college/specialinterestgroups/spirituality/publications/ newsletter25.aspx

9. RaguramR,VenkateswaranA,RamakrishnaJayashree, Weiss Mitchell G; (2002) Traditional community resources for mental health: a report of temple healing from India; BMJ, 325:

38-40

10. Leaflet on Spirituality and Mental Health – November 2005 http://www.rcpsych.ac.uk/mentalhealthinfo/treatments/ spiritualityandmentalhealth.aspx

11. Koenig H, McCullough M, & Larson D. (2001) Handbook of Religion and Health. Oxford: Oxford University Press.

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Dr. Avdesh Sharma

Avdesh Sharma, D.P.M., M.D.
(NIMHANS, Bangalore) Gold Medalist,
practicing psychiatrist for twenty five years,
President Elect of Indian Association of
Private Psychiatry, Chair of task force on
Spirituality of I.P.S., and Chair – Media & Public Education Committee of Indian Association of Private Psychiatry; past president of Indian Psychiatric Society (North Zone) and Delhi Psychiatric Society; scientific presentations in more than 50 international and 100 national forums; involved in electronic and print media for more than 25 years; three published books and chapters in books including for WHO and UNDP.

Dr. Avdesh Sharma is Master Teacher Healer of ‘Reiki’. He has been trained in ‘Reyukai’ (Japanese Meditation), Transcendental Meditation, Sukhbodanada’s Meditational techniques, Deepak Chopra’s Beej Mantra Meditation and Brahma Kumari’s Raj Yoga Meditations.

He is recipient of ‘Community Awareness Award’ and ‘Dr. Ramachandra Murthy Award’ as Psychiatrist of the Year (1998) from Indian Medical Association& Gem of India Award’, listed in ‘Indo-American Who’s Who’ and ‘Reference Asia’s Men and Women of Achievement’.

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Dr. Sujatha D. Sharma

M.Phil., Ph.D. (Clinical Psychology),
Consultant Clinical Psychologist is a
practicing clinical psychologist for more
than twenty five years. She had been the
Consultant Neuropsychologist to Indo-U.S. Cross-National Study on Dementia Epidemiology under the aegis of National Institute of Aging, U.S.A., and Consultant to UNICEF and NIPCCD working on Training Module on ‘Counseling Services for Child Survivors of Trafficking’.

She has been weekly guest columnist of a national newspaper Hindustan Times (H.T. City) for about three years in the columns ‘Behavior’ (Mental Health) and ‘Relationships’. She has co-authored two books on Stress. She has conducted Stress Management Programs and Workshops on Substance Abuse and Positive Parenting for many organizations and schools. She also conducts workshops on Counselling skills and techniques for trainees at NIPCCD, NCERT and NISD.

Dr. Sujatha D. Sharma is a Certified Clinical Hypnotherapist and uses hypnotherapy in regular clinical practice. She is a Master of Reiki Healing.

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MEDITATION: THE FUTURE OF MEDICATION?

Avdesh Sharma Sujatha D. Sharma

Introduction

Complementary medicine is a seven billion dollar business in the U.S. and meditation is one of the top 10 alternative therapies used by its population. The National Center for Complementary and Alternate Medicine reports that 8% of Americans use meditation as a health tool.

Meditation can be used as a technique or it can be a meditative life style. Medicine and meditation come from same root word ‘medere’ – making whole. Even Healing and Holy have the same origin.

Meditation is practiced in all cultures, religions and regions, both West and East. The standard dictionary definition is “thinking deeply or spiritually about a subject.” Yet it is different from ordinary cognitive processes – being more than relaxation, concentration, contemplation or posturing. It is a technique or method of freeing one’s mind from emotions and other distractions to allow deeper insights into ourselves and the world around us. The ultimate goal is illumination, and while this may not be fully achieved, along the way, peace and relaxation, quietening of emotions, insights and perspectives may be accomplished.

The mind during meditation connects us with our inner selves, the ‘Master Within’. Meditation has taken on a very esoteric meaning but is just a disciplined way of reflecting on the self, one’s relationship with the world and God, the present and future path of life and the meaning and higher purpose in life. The techniques and range differs from practices of concentration,

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awareness or altered states of consciousness. It may be focused (using a mantra) or non-directional. Meditation may be practiced for a short period or as a way of Being (with a particular life style). It is most effective when practiced with a sense of gratitude while letting go of thoughts, emotions and judgements. It may be practiced alone or in a group and may be accompanied by incense, music, special colours or light.

Many practices of meditation may not change, or even address, the belief system of the participant although for some, holding a belief system may be required for the practice of meditation. Similarly, spirituality may be a component of some meditational practices, although certain meditation techniques may be practiced without any underlying spiritual belief system.

Well-known meditations include Raj Yoga, Mantra, Mindfulness, Vipassana, Transcendental Meditation, Kundalini, Sudershan Kriya, Kirtan Kriya, Sahaj Samadhi, Osho’s Meditations, Silence, and Pranayama.

How does meditation work?

The basic principles of meditation involve relaxation, oxygenation, imagery, visualization, concentration, self-hypnosis, cognitive restructuring, peak experiences and secretion of endorphins.

More specifically, the process of meditation raises energy levels and strengthens the immune system to fight or ward off illnesses. It induces the relaxation response and associated psychophysiological processes. It acts on the Karmic/ Sanskar levels to neutralize the causes and effects of illness. It enhances the positivity of the person about self and healing, thus setting off chain reactions of healing. It induces a connection to the source (God) to draw the power to heal. It stimulates life style changes, which are useful for self-healing and allows external healing forces

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to act better. If practiced regularly for 20-45 minutes once or twice daily, all meditations, to various degrees, produce :

· Decreased heart rate and blood pressure.

· Increased blood flow to brain and heart.

· Positive changes in EEG, EMG and skin resistance.

· Improved sleep and digestion.

· Less irritability, anxiety and depression on rating scales.

· Less frequency and duration of illnesses.

· Decreased accidents and days lost at work.

· Improved interpersonal relationships.

· Improved scores on self-actualization inventories, and emotional and spiritual quotients.

The beneficial effects of meditation : These are found in allergies, asthma, anxiety, acid-peptic disease, cancer, coronary disease, depression (neurotic), diabetes, hypertension, irritable bowel syndrome, migraine, substance abuse (tobacco & alcohol also), tension headache, healing and enhanced recovery from all diseases. However, the relative contra- indications of mediatation include psychosis, severe depression, confusional states, extreme anxiety and the dementias.

Evidence of Efficacy

There is now increasing evidence of benefit from many therapeutic techniques like Yoga, Meditation, Prayers and

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Spirituality-based interventions which are well-documented in ‘Meditation Practices for Health: State of the Research’ (2007), prepared for the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

The above document is a review of 813 studies (547 intervention studies and 266 observational/analytical studies) out of 11200 references which were searched and those meeting rigorous criteria selected. The highest number of studies has been in healthy populations (553 comprising 196 intervention and 257 observational, analytical studies). The second highest is for individuals with mental health disorders (66 studies, 65 interventional and 1 observational).

The populations studied include those with physiological illnesses like hypertension, cardiovascular accidents, coronory artery disease, HIV, infections, dental problems, psoriasis, obesity, diabetes, irritable bowel syndrome, infertility, menopause, pre-menstrual syndrome (PMS), epilepsy, chronic fatigue, multiple sclerosis, muscular dystrophy, pain syndromes, osteoporosis, developmental disabilities, migraine and tension headache, asthma, chronic bronchitis and tinnitus. Healthy populations included college and school students, the elderly, healthy volunteers, army, industrial workers, athletes, prison inmates etc.

The mental health disorders studied include: insomnia, anxiety, binge eating, burnout, anger, depression, mood disorders, ‘neurosis’, obsessive compulsive disorders, personality disorders, post traumatic stress disorder, psychosis, substance abuse, early cognitive deficits and parents of children with behaviour problems.

Similarly, Aries et al. (2006) carried out a pooled search of 82 studies, of which 20 were RCTs (958 subjects; 397 clients,

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561 controls) and reported no serious adverse effects of meditation. On the contrary, meditation demonstrated strong efficacy for epilepsy, PMS, and menopause, and was found to be beneficial for mood and anxiety disorders, auto immune illnesses and emotional disturbance in neoplastic disease.

Outcome measures of efficacy studies in meditation have included psychosocial, clinical, neuropsychological, neurophysiologic, neurochemical, neurobiological and health care utilization outcomes.

Neurobiological explorations into Spirituality and Meditation

Different meditative techniques may produce different and differential neurobiological effects, with corresponding subjective feelings and clinical changes. However, there is a paucity of evidence regarding the neural correlates of spiritual practices and most studies that have explored spirituality have concentrated on meditative practices. They include Positron Emission Tomography (PET) studies on Yoga, Tantric Yoga and Yoga Nidra; Magnetic Resonance Imaging (MRI) on Kundalini Yoga and Single Photon Emission Computerized Tomography (SPECT) on Tibetan meditation (E. Mohandas, 2008).

Neurobiology

The regional maps of brain blood flow/perfusion differ between meditation, slow-wave sleep and wakefulness. PET, SPECT and fMRI allow examination of changes in regional blood flow, metabolism or receptor (sites of neurochemical and drug actions) activation in the brain in response to various tasks.Some studies have compared meditation tasks with restful wakefulness. Test results at baseline are mathematically subtracted from the meditative state. Such studies thus show changes in blood flow or metabolism that are related to the task.

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Most types of meditation, which involve an initial focusing of attention, are associated with increased regional blood flow or glucose metabolism in the prefrontal and cingulate cortex, areas that are important in selection of a mental task. During visualization, regional blood flow increases in the visual cortex and visual association areas in the occipital lobes. In contemplation of ‘self’, the parietal lobes on both sides are activated.

Thus, meditation appears to begin by activating the prefrontal and cingulate cortex, associated with the will or intent to clear one’s mind of thoughts or to focus on an object. However, studies on the guided type of meditation (externally guided word generation ) show a decrease in frontal activity when compared to volitional (internal) word generation. Thus, prefrontal and cingulate activation may be associated with the volitional aspects of meditation.

The studies point to prefrontal activation, transient hypofrontality, increased frontal lobe and decreased parietal lobe activity and also to a deafferentation of the posterior superior parietal lobule (PSPL). The functional deafferentation means a decrease in the arrival of distracting stimuli to the striate cortex and PSPL, enhancing the sense of focus during meditation. This deafferentation results in an altered perception of self-experience during spiritual or meditative practices. The PSPL deafferentation is supported by three neuroimaging studies, all of which showed decreased activity in the region during intense meditation (Newberg and Iversen, 2003).

Some studies during meditation show increased activity in the hippocampus or inner aspect of the temporal lobe. The hippocampus is part of the limbic system and has close functional connections with the hypothalamus and autonomic nervous system. Thus, during meditative practice, there is enhanced

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opportunity for the autonomic nervous system to integrate with those aforementioned parts of the brain that show increased activation without the constraints imposed by ego-directed activity.

There is activation and increased activity of the hippocampus and amygdala as well as limbic stimulation in experiences similar to meditation. FMRI studies of Kundalini Yoga support this notion of increased activity of the hippocampus and amygdala in meditation (Newberg and Iversen, 2003). Stimulation of the right lateral amygdala results in stimulation of the ventromedial hypothalamus with stimulation of the peripheral parasympathetic system. The increased parasympathetic activity is associated with a subjective sensation, first of relaxation and later, a more profound sense of quiescence. Activation of parasympathetic system results in decreased heart and respiratory rate. All these physiological responses are observed during meditation.

Neurochemical changes

When the breathing and heart rates slow down, as they do in meditation, there is decreased activity of a centre in the brainstem known as the locus ceruleus. Relatively greater activity of the parasympathetic than sympathetic nervous system in meditation leads to decreased production by the adrenal medulla of the catecholamines, epinephrine and norepinephrine.

There is evidence for increased brain serotonin during meditation. Serotonin is important in regulating mood, as shown by the antidepressant effect of the antidepressants known as specific serotonin re-uptake inhibitors or SSRIs, resulting in increased serotonin activity in the brain. In addition to elevating mood, serotonin can stimulate increased production of acetylcholine, involved in memory mechanisms and attention.

There is decreased noradrenaline, a finding seen in urine and plasma studies of subjects practicing meditation. The urine

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and plasma studies show decreased cortisol level during meditation.

EEG and Meditation

Meditation has been reported to be ‘the fourth state’ (apart from dreaming, sleep and wakefulness) with mainly increased alpha and then theta rhythms, and increased alpha coherence (with increased blood flow and melatonin being observed in mediation, unlike sleep) ( Cohn & Polick, 2006).

There is also reporting of increased cortical coherence and left right brain interaction. Additionally, there is increased gamma wave activity during the practice of ‘compassion’ technique in meditation.

EEG studies during meditation have revealed continued, awake-and-aware type activity in the mid and posterior part of the brain, while the frontal lobes show greatly modified, simplified activity.

Evoked Potentials and Meditation

Meditation sometimes produces altered amplitudes, with practitioners seeming to demonstrate decreased amplitude and latency for sensory EPs and with mindfulness inducing a decrease in habituation.

Meditation and Neuroplasticity

A recent MRI study was conducted to assess the cortical thickness in 20 participants with extensive ‘insight meditation’ experience, involving focused attention to internal experiences. The participants were typical Western meditation practitioners who incorporated their meditation practices into their careers and family life. The study showed that brain regions associated with attention, interoception and sensory processing like the PFC

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and right anterior insula were thicker in meditation practitioners in comparison with matched controls. The prefrontal cortical thickness was most pronounced in older participants, suggesting that meditation probably offsets age-related cortical thinning.The data provides structural evidence for experience-dependent cortical plasticity associated with meditation practice, suggesting that meditation practices promote neuroplasticity (Lazar et al. 2005).

Meditation and Psychiatric Disorders

Neural Correlates of Anxiety : Meditation due to the neurochemical changes can produce an anxiolytic effect. The factors decreasing anxiety during meditation are an increased parasympathetic activity, decreased LC firing with decreased noradrenaline, increased GABAergic drive, increased serotonin and decreased levels of the stress hormone cortisol. The increased levels of endorphins and AVP also contribute to the anxiolytic effects of meditation (Newberg and Iversen, 2003).

Neural Correlates of Depression : Spiritual practices can have considerable antidepressant effects due to the associated increase in serotonin and dopamine. Additional factors like increased levels of melatonin and AVP contribute to the antidepressant effects. There is an observed increase of â- endorphin, as also NMDAr antagonism during meditation, both of which have antidepressant effects. The decreased level of CRH and cortisol also play an important role in alleviating depression. Thus, via multiple neurochemical changes, spiritual practices can counteract depression (E. Mohandas, 2008)

Neural Correlates of Psychosis : Meditation can induce psychotic states via mechanisms such as increased 5HT 2 receptor activation, increased DMT, increased NAAG and increased dopamine. The mechanisms include the 5HT inhibition of LGB, the hallucinogenic effects of DMT, the dissociative

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hallucinogenic effects of NAAG and the action of increased dopamine in the temporal lobe. A variety of schizophrenomimetic effects can be seen as a result of these complex neurochemical changes.

Psychological benefits that can help us in our day-to- day lives include : Improved concentration and attention, allowing for greater productivity, problem-solving, creativity, learning ability and organization of memory, enhanced self-image, less ‘catastrophic reaction’ to stressful situations, e.g., in survivors of attempted suicide, better sociability and tolerance, improved mood, improved sleep and improved scores on self-actualization.

Areas of concern

· Adverse events during Meditation and Yoga with certain types of personality and psychosocial experiences (specially handling silence). These need to be kept in mind while initiating a practice and preferably should be guided by a practitioner who is aware of these aspects.

· Forced implementation of certain ways of living/philosophy on an unsuspecting individual, sometimes leading to emotional abuse/guilt.

· Psychotic reactions (mostly uncovering in susceptible individuals) with certain types of meditative practice.

· Religious conversions/religious philosophy being perpetrated in subtle/gross manner by a leader/group.

· Stoppage of required/appropriate mainstream treatment as experimentation/ due to lack of knowledge.

· Conflicting ideas about causation and possible management of distress/disease leading to worsening of

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symptoms or lack of proper, holistic treatment.

· Outright exploitation of various types in the name of religion/ spirituality during meditative practices.

Implications for Psychiatry

· Constraints experienced by mental health professionals and resources could be lessened by ‘meaningful, appro-

priate integration’ of CAM – based treatments (complementary and alternative medicine).

· Low cost treatment, with continuation for life (if possible/ desired) with little or no updating.

· Group dynamics and group practice may economise on resource requirements.

· Combination with therapy as in Mindfulness-Based Cognitive Behaviour Therapy or Spiritually Augmented CBT.

· More research may provide insight into matching of techniques/life styles for different symptoms/ syndromes.

· The techniques/life style could be incorporated into models of preventive psychiatry.

· Meditation used as enhancing one’s psychological resources/holistic living/self actualization.

· Meditative state changes may develop into traits, leading to long-term consolidation and prevention of future episodes

of anxiety/depression/psychosomatic/stress-mediated and other illnesses.

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Implications for The Therapists

· These techniques may be used to improve the mental health of the therapist, especially to prevent burnout.

· Therapists should have experience of the technique, if possible, to be able to best guide the integration.

· Meditation to be used as one of the many ways of ‘cleansing the toxic reactions’ in the therapeutic processes.

· Need to be in touch with one’s own mental health issues and to prevent them from spilling into therapy.

· There need to be studies on the neurobiological correlates of the effects of therapy on therapists, with possible ways

of reversing them if maladaptive.

Implications for The Clients

· Meditation techniques are already being used by clients for anxiety, depression, OCD, panic attacks, PTSD, PMS, menopause, substance abuse, tobacco/alcohol abuse,

psychosomatic illnesses, insomnia, early cognitive deficits etc.

· A planned, strategic, appropriate combination would reduce costs to the client and service providers and minimize

investigations and waiting time, promote ‘holistic health’ and provide what many clients may want as component

of therapy.

· Care givers may need support for their burnout, guilt and failure to understand the meaning of disease, and may also additionally benefit from such techniques/life style.

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Future needs

· Strategies to enhance wellness and well-being in healthy population.

· Standardization of therapeutic meditation.

· Dose response of meditation practices to determine effective duration of intervention.

· Development of varieties of meditation to suit different sets of distress and dis-ease.

· Development of specific target organs with subsets of meditative/spiritual practices.

· Seeking co-relations between neurobiological changes in specific illnesses and the meditative practices for reversal

of those changes.

·  Aiming for person-centred, rather than disease-specific health care.

·  Becoming aware of the existing and potential techniques of complementary medicine for liaising with practitioners
of ‘other systems’.
· Being knowledgeable about the ‘spiritual practices and techniques’ which could be/are utilized by the clients.
· Learning about (if possible through practice of) the techniques first hand, to see how best a network for
delivery could be established.
Thus, Meditation which has been with humanity for thousands of years and has stood the test of time is still relevant

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and useful for myriad illnesses as well as states of consciousness. The challenge in future would be to see how it could be used instead of, with, before or after medication (assuming that medications are chemicals). It is quite apparent that in future it may not be an alternative or complimentary but a mainstream form of treatment.

References :

Aries et al; 2006, Systematic review of efficacy of meditation techniques, Journal of Alternative and Complementary Medicine 2006.

Cahn B.R., Polich J., (2006), Meditation states and traits: EEG, ERP and neuroimaging studies, Psychol Bull , 132 :2, p 180-211.

Lazar S.W., Kerr C.E., Wasserman R.H., Gray J.R., Greve D.N., Treadway M.T., McGarvey M., Quinn B.T., Dusek J.A., Benson H., Rauch S.L., Moore C.I., Fischl B., (2005), Meditation experience is associated with increased cortical thickness, Neuroreport , 16 : 17, p 1893-1897.

Meditation Practices for Health: State of the Research (2007), prepared for: Agency for Healthcare Research and Quality,U.S. Department of Health and Human Services. http://www.ahrq.gov

Mohandas E., (2008), Neurobiology of Spirituality, 6:1, p 63- 80, Mens Sena Monograph.

Newberg A.B., Iversen J., (2003), The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations, Med Hypotheses , 61 : 2, p 282-291.

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Afterword

We hope you have enjoyed reading,
imbibing and applying the wisdom of the ages through SPRITUALITY & MENTAL HEALTH, Reflections of the Past, Applications in the Present and Projections for the Future.

The spiritual journey for all of us is a path which we travel on and then guide others. We hope this process would be an ongoing one so that we can transform the world through transforming ourselves.

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Indian Psychiatric Society ‘Spirituality and Mental Health’ Task Force (2008-2009)

In association with

Medical Wing,
Rajyoga Education and Research Foundation, Mount Abu

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