Social Work Students of Sweden in India

Who are we:
Sofia Idström, 26 years, comes from Gothenburg in Sweden. I have one bigger brother, Alex who does his PhD in chemistry, Father J.P, doctor in Chemistry, mother Ulla, social worker. I finished 12 standard in 2003 and after that I travelled India, south America, Oceania and Europe and I been working. I started my social work studies in 2008 at MidSweden University, Östersund. I love travelling, playing and listening to music, create, and photography.

Sara Handzic, 24 years, comes from Värmland in Sweden. My family are: my boyfriend Rickard, my mother Silvia and my father Dirk, my sister Katja, her finance Joakim and their son Alfons, my brother Kaj and his girlfriend Lisa and there is two dogs and one rabbit. I like spending my free time outdoors in the nature, photography is another interest of mine. I also like to travel, experience new cultures and get to know new people. I started my social work studies in 2008 at MidSweden University, Östersund.

1. Few words about your internship programme in India
We are staying in Bangalore for 20 weeks for a block placement as a part of our BSW, we study the sixth semester out of seven. The first two weeks we had orientation visits to different NGOs and after that we chose to have our placement at an NGO called Child Rights Trust (CRT) which is working with creating awareness about child rights in the society. We have joined their programmes but also continued visiting more NGOs to get a wider view oft eh social work in Bangalore.

2. How is your experience?
In the beginning it was a big culture chock to come here. The difference between India and Sweden is big, we had to adjust to the climate, the food, the traffic and the large amount of inhabitants in Bangalore. We have enjoyed the time here in India and we have learnt a lot about India as well as about ourselves. Being in a new country and being put in new situations is very developing for the own person, and you get to know things about yourselves you never would have if you stay inside your own comfort zone.

3. Objective of your training programme
We study a intercultural and international programme, so for our second block placement we have to go abroad to get exposure to other countries social work, but there is also a great learning process to be in a new country and get to know that experience. The most important thing is that there isn't one answer how to solve a social problem.

4. Can you compare social work education of Sweden and India? What are you observations?
In Sweden, a larger number of the social work students are female, here we have noticed it is a male dominated field, so there is a gender difference between who is choosing social worker as a profession. In Sweden, we also have a larger age range among the students, there can be 19 year old as well as 50 years old who study to become a social worker. The biggest difference is that in India, most of the students only study a MSW of two years. In Sweden, you have to have a bachelor degree in social work to be able to work in the field, most of the degrees are 3,5 years. When it comes to study a master in social work, it is not sufficient as it is in India.
In Sweden you also have to have a degree in social work to be able to continue to higher studies, but for work it is only required that you have a BSW.

5. Can you describe sw education in Sweden
We have 16 universities where it is able to study social work. Until now, they could have a specialisation, like our university has International and Intercultural specialisation, but now the Institute for Higher Studies have decided that all of the social work programmes should be generalised. So today, still there is differences between the universities. For example, the practice placement can be 15 weeks + 20 weeks, 2 weeks + 15 weeks, or as you have in India, two days every week.

6. What do you like about sw education in India
It seems very good to have the field practice a side of the theoretical studies, that the students every week get the opportunity to see the real social work and find out their field of interest. As well to learn how to apply the theories from the books on the real practical work.

7. What do you don't like about sw education in India
We feel that our 3,5 years of social work studies will not be enough for us to go into the field in Sweden, so the only thing that might be lacking in the education in India is that it is mainly on Master level, and that it is only for two years. But of course, if the students find it sufficient with two years, than there is no problem.

8. What's your future plans?
Sara: I would like to work with children and youth or within the field where nature is being used for its healing part to rehabilitate people. I have not decided yet if I will continue my studies for a master or if I will start to work when I graduate.
Sofia: Since we study an international aim, I would like to work a couple of years abroad. If I would work in Sweden I would like to work with the prevention of crime and abuse, then mainly with youths in high school.

9. Describe social workers role in Sweden
The goal is that there should be no need for social workers in the country, the work is being done in fields were a social worker already is required, but there is also focus on the prevention, for example having councillors in schools is a way to discover a child at risk in a early stage so future problems can be erased.

10. Tell us something about our magazines
We think you are doing a very important work with your magazine. Starting the first social work magazine in Karnataka is a great achievement and we really hope it will get great success and that people in the field realize how important it is to keep yourselves update even after the studies. As well for the social work students, since the text books often a printed some years back.

11. Tell us something about swedish sw magazines
The biggest social work magazine in Sweden is called Socinomen (the Social Worker) which publish reports from different fields, new research, new information and literature. The magazine reaches to all interested in the social work, the magazine is published by the biggest social work union in Sweden. This union is also working to support all social workers that's in the union, for example at their workplace for getting the right salary, or if they lose their job support will also be given by the union.

12. Why you chose India for your internship
Sara: I always wanted to go to India, because it seemed like a very interesting and fascinating country, so it felt like the right time for me to come here and experience it for real. It is a good opportunity to see more of the real India, then when you are only coming as a tourist.
Sofia: This is my second visit to India, the first one was in 2007. It was on that trip that I decided that I wanted to study social work and that I would like to come back here some day as a professional, so I decided this would be a good place for my internship.

13. suggestions for the social work students in India
Speak up for the people that no one listens to, and work with your heart. Never forget your role as a social worker, to be there for the ones in need.

14. What is the fields work pattern in Sweden
In Sweden there is a large public sector for the social welfare which is working for individuals as well as families, both children and adults. There a various other fields where social worker are required in Sweden, in the schools there has to be a councillor for the children and in the hospitals the patients need to have the possibility to meet councillor. There is also a large amount of rehabilitation homes for example people with drug and alcohol addiction, children and youth in risk zone and refugee children coming without there parents.

15. Tell us something about India and Karnataka people, culture, tradition in social work perspective
We have meet a lot of inspiring people doing a great work with a lot of passion for people in more vulnerable position in the society. We have also experienced that people here are very helpful, for example in the beginning when we were taking the bus to different places. There is also a great hospitality here, we went to a Hirakumbalagunte, a village in Bellary district and there we could really experience the great hospitality, in every house we were offered food or tea. Such a nice experience!

16. why you chose social work as your career
Sara: I felt that I wanted to work with people and in the world today there are a lot of people suffering, I felt that if I can contribute with something I wanted to do that.
Sofia: I have always known that I want to work with the inequality in the world. The poverty in the world as well as poverty within a county is because of greed and selfishness, and I believe that it is possible to eradicate, I want to be a part of that. I do not want to stand on the side watching other people suffer.

17. What are the fields of social work in Sweden
The biggest social problems in Sweden are mental illness, narcotics, organized crime. There is a large amount of people suffering from mental illness due to stress, pressure, family situations and many other things, we have to put a lot of effort in this field, since a larger amount of young people suffer from depression. The attitude against substance abuse is quiet liberal, which mainly effects the more poor people, who might end up with an addiction they can't afford, this is also connected to the mental illness. The organized crime in Sweden is growing, there is a market for traffic goods and people, which makes it possible for them to continue their work.

18. What are the specializations in Sweden social work?
In Sweden the aim is that all universities should have the same programme for the students, so mainly the social work students study the classic programme which covers all the fields of social work, if you continue your studies for a master you can chose if you want to specialise or continue in the field of ”social work”.

19. What are the employment opportunities?
There are a lot of social workers going to retire the coming years, so this is the right moment to get this education. As we mention earlier there are 16 universities educating social worker, so every year a large amount of social workers will be graduating, which makes the concurrence bigger in a small country like Sweden with only 9,5 million inhabitants.

PROBLEM OF ELDERLY DISABLED

PROBLEM OF ELDERLY DISABLED

Introduction:-

Old Age and disabilities of old people has never been a problem for India where a value based Joint Family system is still prevailing in many parts. The Indian culture is respectfully supportive to the elders. In the background the abuse of elders has never been considered as a problem in India. It has always been thought as a western problem. However, the coping capacities of the younger and older family members are now being challenged.

Censes:-

Rapid advancement in the field of medicine has increased the life expectancy of people all around the globe, India being no exception. The reality of the ageing scenario in India is that there are 77 million older people in India and their number is growing to grow to 177 million in another 25 yrs.( As per Help Age India news letter).as per our knowledge, 2001 census, That there are 21.9 million disabled in the country, according to Census data released by the Registrar-General of India. This is about 2.13 per cent of the total population.

Of this 1.03 per cent is visually impaired, 0.16 per cent speech impaired, 0.12 per cent `hearing' impaired, 0.59 per cent `movement' impaired and 0.22 per cent `mentally' disabled.

The 2001 Census figures show that the highest percentage (48.5) of disabled is in the visual impairment category followed by the disability in `movement' (27.9 percent). The lowest percentage (5.8) has been reported for hearing disability.

A higher percentage of disabled women are in the visually impaired and hearing impaired categories. In the case of males a higher percentage has been reported in the `movement' and `mental' categories.

The number of disabled is increasing across all age groups. Disability has afflicted a higher percentage of males than females.

Three out of five children in the age group of 0-9 years have been reported to be visually impaired. This declines initially and increases with age to reach a high of 51.9 per cent among those aged 60 years and above. Speech disability afflicts the younger population more whereas hearing disability is more of an `old age' phenomenon. However this is not without problems with this kind of a ageing scenario there is pressure on all aspects of care for the older persons-be it financial health or shelter with more older people living longer the households are getting smaller and congested, causing stress in joint and extended families even where they are co residing isolations, insecurity, is felt among the older persons due to generation gap and change in life styles.

Generally increase in life span resulted in chronic functional disabilities creating a need for assistance required by the older person to manage simple activities of daily living.

With the tradition of India makes the lady of the household to look after the older members of the family. This is slowly changing. The women of the house hold are also participating in activities out side home and have their own career ambitions. Hence, the old people are being treated as a burden by their children.

Now we can understand that if this is what seniors undergo at home then what about their disabilities in old age? The thought it self is painful.

In our (All India Institute of Physical Medicine and Rehabilitation) Institute when we interview 10 old people above 50-70 both male and female we found many problems---Mainly in the areas of Health, finance, family, acceptance in society/community, along with architecture barriers. By and large they tend to be neglected because of socio-economic conditions or loss of spouse or mainly disabilities. etc.

Majority of the elderly disabled are economically non-productive and many of them will be socially isolated.

Main problems as faced by elderly males and female are,

Male:- Discussion with male group indicated that the middle income group listed economic problems on priority. The second group form the upper middle class prioritized mental health problems focusing more on non acceptance by there kith and kins. Difficulties in performing daily living activities, lack of facilities for utilization of leisure time and general feelings of loneliness and “taking to walls”.

The problem here did not seem to be lack of money and disability but lack of love and affection by members of there family. Both the groups felt that they felt a need to talk to their family who did not seem to have time for them. The words were many-ranging form “neglect” because of disability with old age from family.

“ Experience of loneliness in everything” ,

“ a sense of insecurity and feeling” or “burden”

and “old age itself was a disability.” Lack of accommodation was also a problem identified by the older persons.

Females:- Economic hardships along with disability became very prominent in the women of the lower socioeconomic group while the higher socio-economic category put loneliness as the primary problem. The lower economic group felt that if the women has money she had power or else she had to be dependent on children for financial support, health, taking care of her disability and also ill treatment and complete neglect form family problems This situation leads lot of mental health problems lot of mental health problems some of which could not even be described.

Case – 1 :- Ambubai a 70 yrs. Old lady diagnosis as Rt Amuptation. Staying at Govandi a slum area in Mumbai. Since last 40yrs.

Ambubai when she was in her 40 s she met with an road accident were she lost her right leg and come to Institute for fitting of artificial limbs. After some time she lost her husband. Then alone with disability she taken care of her 2 children one 10yrs boy and 13 yrs girl. She worked very hard as casual worker. And she some how manage with his bread and butter with her children responsibility. During the year passes and the completed her duty to upbringing her children. Her daughter married with a nice man and she settled with her husband. Then Her son Married and he is working as Driver after the Marriage of his new bride come to home and the happiness and her desire and hope of betterment of her life goes down. Family problems starts with son and daughter in laws Even she help to her daughter in laws in her day to day work still she can’t mange with her livings with them. Often times when he takes alcohol and Drugs he ill treats her; many times she can’t get the food.

Case-2:- Mr.Kelkar 75 yrs old man and he has been advised by the doctor to replace both the Knees. Staying at Mumbai. A financially well of. Mr. Kelkar is staying with his wife in big apartment of 1500 sq ft in the heart of the mumbai is having two sons, both are well educated settled in life. Now Mr. Kelkar is having disability, can’t walk both the knees has to be replaced he also can’t hear and vision effected money is not issue at once . But today he is full dependent on his wife who is also 70+ for his physical mobility. He and his wife is fully neglected by his children. Both the son and daughter in laws fights with old disabled coupes for property handover, they don’t give them meals, no other households facilities are not permitted the old couple to use like phone/ A/c, fans etc. In one small room they both cook for themselves. Emotional disturbances in adding there problems.

Health problems surfaced as being the most common problem faced by the older persons in the mixed group both in the lower and upper middle class strata of society followed by financial problems. The views were similar in both the focus groups. They stressed on the physical disabilities and problems of mobility, as well as problems of living alone with disabilities.

Conclusion:-

We can safely conclude that those who are all working for elderly (ie GO’s and NGO’s) have to co-ordinate among themselves and implements plan’s in to actions. Making Policies, Rules, Old Age Homes are not only answer for all these problem. Awareness among children, youth and family members and the society’s equally important. Creating elderly disabled friendly Community is the need of the time:

- intervention aimed at promoting health and disability should be better late then never.

- Negative life style in younger people be avoided and this is ever more desirable in older disabled.

- Careful planning of health promoting and disability prevention is essential for older disabled people.

Mrs. Anjana Neglur ( MSW)

Mr. Kailas Goswami ( Lect. MSW)

(All India Institute of Physical Medicine and Rehabilitation. K. Khadye Marg, Haji Ali Park, Mahalexmi Mumbai – 34.)

Overview of Labour Law Compliance

Overview of Labour Law Compliance

Ram K Navaratna

Chief Executive

HR Resonance

Bangalore

An Introduction: Globalisation in new economy has paved way for open business and everything is measured and looked from the angle of global standard and best of best in the form of world class. This has led to lot of quality systems in technology, supply chain, banking, and finance and also in Human resource management. Talent can move anywhere and people are also mobile. To have continuous flow of business in smooth way many approvals, certifications and compliance have become need of the hour and these are subject to various and continuous audits by internal and external agencies.

In few cases customer’s requirements have to be fulfilled in legal aspects particularly in connection with employee related matters which are governed by various laws comprising both central and state legislations. Keeping this in view management of labour law plays a very important role.

2. What is compliance? When business is governed by certain regulations that too when it is global in nature, ILO conventions are followed. With the conventions, various laws like factories act, Minimum wage etc have to be followed in toto in addition to all the applicable laws depending on the nature of industry. Adherence to these laws and implementation is becoming need of the business without which further progress will be blocked. Hence such kind of law has to made known to all concerned and have to be followed. These are under scrutiny. As such compliance (adhering and following) is gaining vast importance.

3. Why compliance: It has to be understood in multiple ways. First being compliant with the laws of the land, regulatory affairs for approvals, social security and fair work, fair treatment and right of association and expression. Further there should not be any discrimination based on caste, creed, ethnic and sex. For everything parameters will be the applicable laws. Without this business is not recognized nor accepted. In the absence of compliance, there are chances of losing the business and in some case black listing the non compliant establishments. Therefore compliance is becoming a priority.

4. Coverage: For compliance wider coverage like regulatory laws, payment laws, social security laws, employment laws, Industrial relations laws, welfare laws, law of association - matters. Depending on the nature of the industries all these have to be followed in action and spirit.

5. Applicability: Every employer or an occupier has to be aware of the applicability of various laws for every establishment. Whether certain laws are applicable or not? If applicable the minimum requirement of workers and to what extent. Under the applicability what are to be followed and maintained to be known. In India most labour laws are based on the number of employees in the establishment. Hence the applicability is important.

6. Implementation: Once the coverage and applicability is known implementation becomes very easy and mandatory. When the number reaches to certain levels, it will go without saying. On an average in India normally for any establishment there are about 14 to 16 labour laws are applicable. They are;

Factories Act, Shops and Commercial establishment Act, Contract labour, Building and construction workers act, plantation labour act, Interstate migrant workmen act, Mines act etc.

Payment of wages, Minimum wages, Payment of Bonus, Payment of Gratuity, Provident Fund, ESI, Maternity Benefit act, Employees Compensation Act, Labour welfare Fund act, Industrial Employment Standing orders Act, Industrial Disputes Act, Trade Union Act, Equal Remuneration Act, Apprentice Act, National and Festival Holidays Act, Sexual harassment prevention committee provisions etc.

Above list is not exhaustive. Employer has to look into many of these acts depending on the nature and implement which is his prime responsibility.

7. Audit and Check: Once these are covered and applied and having implemented, sustenance of these compliances is to be monitored. There are no holidays for these laws. HR being a dynamic function in nature number and nature of compliance fluctuates. Depending on these factors, implementation also matters. Hence it is the onus of the employer to ensure that the implementation of law is in place as per the framework of laws throughout the year. They are subject to inspections and scrutiny. Some authorities inspect critically and some superficially. But it is the responsibility of the employer to be compliant. Hence audit and checking play an important role from compliance point of view.

Few governments have allowed for self certification by the employer. OHS, SHE audits are inbuilt in complying laws like working hours, safety, health, welfare, social security etc. Regular self audit, internal audit should help the employer to upgrade the compliance level from time to time thereby reaching to the competitive edge. For hazardous industries audit by External agencies are mandatory to make it more objective and effective.

8. Know the subject: From this perspective knowledge and awareness about the subject, provisions of various applicable laws are important. Further superficial knowledge will not be adequate. What we call substantial law is the need of the hour. It is like human body where outside view will not determine the good health but internal system should be in order to stay healthy. In the same manner labour laws also have to be understood. Bare knowledge is not sufficient. All provisions and methods are to be adhered.

9. Reports: Based on this an employer has to generate various reports by way of MIS, compliance reports etc to know the status and also understand the gaps and lapse if any. Looking at reports he will understand the status for further needful. Some times reports by experts in the field, regulatory authorities are important and help for improvements.

10. Inspections: Under all laws and particularly labour laws, we see chapters/sections on Inspectors where their powers and duties are prescribed. Under the statutes they are empowered to exercise certain powers and also by duties. It is the duty of the employer to co operate and support the inspector while inspecting. Employer has to provide all necessary documents, information, particulars, records, registers etc to the authorities. ILO convention also prescribes this.

Inspection to be taken seriously and many a time they are eye openers. These will put a break for establishments also from bad/unfair practices. Hence inspections have to be taken seriously and complied religiously and meticulously. It is always advisable to attend correct and comply at the initial stages of the inspections to prevent any further damage and serious observations. Inspecting authorities to be seen as well wishers rather than as pain and nuisance. If they are convinced they extend their helping hands for employer. However for them advise and inspection cannot go together.

11. Consequence: Non compliance may end up in legal actions like penalty, suspension of licence, imprisonment etc and other by way of bad corporate governance. Corporate to be on the line, good governance to be ensured. Negative side may affect the reputation of the company thereby it may not attract the required talent and human resource and subject to question by many others concerned. Non compliance may lead to series of problems like prosecutions, unionism, suspicions, etc. In the long run business may get affected. Establishment has to spend their time and energy in litigations and wasting their valuable productive time.

12. Benefits: Timely compliance ensures an employer to be upright, conscious, law abiding, compliant and to carry on his business without any fear or favour and all the time he will be on right track and achieve success and industrial peace. Timely compliance ensures that employees do not have any reason to crib on non compliance issues and may help to nurture good relations leading to good production and productivity.

For government and statutory authorities it becomes easy it will nurture peace contentment and prosperity everywhere.

13. Competitive advantage: Thus by following applicable laws an establishment can run business without much hurdles and stand up all the time. By this it will have a competitive edge in future to gain good reputation and revenue by the certified authorities. By being compliant an employer can gain benefits when it comes without wasting time as fire fighting. Without proper governance and compliance at each and every level establishment has to face problems and obstacles. Thus one can see more advantage in compliance since they are integrated with all the stake holders of the industry.

14. Conclusion: To conclude non compliance will only put positions like occupier, director into problems and they have to face the music of judiciary, cases, prosecutions, imprisonment, fine, personal accountability etc and have to waste time and energy in facing these issues. In the process relationship may also get affected with the authorities and may be with employees and union.

Thus every prudent employer should always look at the positive side of compliance thereby making all the stake holders happy and achieve the goals of the organization and can concentrate on strategic issues as priority.

Establishment should also ensure the respective dues to the employees are paid on time and the welfare is taken care of in reasonable good manner. Added to this what an amount of mental peace and respect from all the concerned! Country needs such situations. Survey Janahaa Sukheeno Bhavantu (Let all people be happy- Upanishad) Such legislations ultimately ensure right way of happiness to stakeholders. Finally, one must keep in mind and know that Compliance cost is cheaper than Litigation cost. It is better to manage the law before it manages you. Comply and be Safe. Good luck.

NB: This article published in 1. ARBITER-Journal of the Industrial Relations Institute of India-Mumbai in Vol.28 No11, June 2011

2. The Human Resource Journal of National Institute of Personnel Management (NIPM) Karnataka Chapter Journal Vol. 18 (1) Annual Issue-July 2011.

For HR and Labour Law compliance audit, service, training, assistance contact: HR Resonance. Email: hrresonance@gmail.com. Visit: hrresonance.googlepages.com

Psychosocial Interventions for Elderly Patients

Psychosocial Interventions for Elderly Patients

Dr. A. Thirumoorthy *, Dr. R. Dhanashekarapandian *

Introduction

Geriatric psychiatric disorders usually occur in the context of medical illness, disability, and psychosocial impoverishment. Preliminary evidence suggests that psychotherapy can reduce not only psychopathology but also physical complaints, pain, and disability and that it can improve compliance with medical regimens. Psychotherapy has been found effective in treatment of depression related to bereavement and caregiver burden.

Psychosocial intervention models need to be developed and tested to integrate psychotherapy and other mental health services in primary care settings so that timely and appropriately targeted interventions can be provided.

Psychotherapy and other psychosocial interventions may help elderly patients cope with late-life stressors, such as loss of loved ones and increases in functional disability, which contribute to the development of psychopathology and influence its course.

Most elderly patients with psychiatric symptoms or disorders are treated by primary care physicians (1,2). Recognition of psychiatric symptoms and syndromes may be complicated by comorbid medical disorders, the attitudes of patients and physicians, and other factors (3,4,5). Therefore, studies that examine the delivery of psychotherapy in the primary care setting may offer information important for designing a sound health care system for elderly persons.

Research on psychotherapy with elderly patients is limited, although most findings suggest that psychotherapy is effective for this group of patients. This paper highlights the existing knowledge about the use of psychosocial interventions with elderly patients and discusses directions for future practice and research that may improve the care of the elderly population.

Short term psychotherapeutic approaches

Short term psychotherapies, typically based on treatment manuals, target the stressors and losses common in late life with an aim of reducing psychopathology and enhancing the quality of life. In a meta-analysis of 17 studies of cognitive, behavioral, supportive, interpersonal, reminiscence, and eclectic psychosocial interventions for late-life depression, treatment was found to be more effective than no treatment or placebo. The efficacy of diverse psychotherapeutic approaches may in part be explained by the presence of common elements among the various treatments (8).

Cognitive-behavioral therapy

The goals of cognitive-behavioral therapy are to change thoughts, improve skills, and modify emotional states that contribute to psychopathology. Cognitive, behavioral, and brief psychodynamic therapies were shown to reduce depressive symptoms among 70 percent of elderly patients (9). In a two-year follow-up study, 70 percent of these patients maintained treatment gains and no longer met criteria for major depression (10).

In a trial with depressed older adults were randomly assigned to receive cognitive group therapy and alprazolam, cognitive group therapy and placebo, placebo alone, or alprazolam alone. The groups who received cognitive therapy had greater improvement in depressed mood and sleep efficiency than the groups who received alprazolam alone or placebo. The gains from treatment were evident three months later. The efficacy of cognitive-behavioral therapy has also been demonstrated in the treatment of other geriatric disorders, including anxiety disorders, insomnia, and the behavioral and mood symptoms of demented patients (11, 12).

Problem-solving therapy

Problem-solving therapy posits that deficiencies in social problem-solving skills increase vulnerability to depression and other psychiatric symptoms. Improvement in problem-solving skills is assumed to make elderly patients better able to cope with current and future difficulties and less likely to develop psychopathology (13).

Problem-solving therapy has been found to be effective in the treatment of depression of geriatric patients and other medical patients. Elderly patients who participated in problem-solving therapy and reminiscence therapy had reduced depressive symptoms and signs, compared with those who were placed on a waiting list. However, problem-solving therapy led to greater improvement than reminiscence therapy.

In a study of depressed younger primary care patients, six sessions of problem-solving therapy were found to be as effective as compared to anti depressants and were associated with greater compliance with treatment (15). Finally, a randomized clinical trial involving terminally ill patients demonstrated that problem-solving therapy is both feasible and acceptable despite some practical difficulties with its implementation (16).

Interpersonal psychotherapy

Interpersonal psychotherapy, developed as a time-limited treatment for mid-life depression, focuses on grief, role disputes, role transitions, and interpersonal deficits (17). Interpersonal psychotherapy is likely to be a meaningful treatment for patients with late-life depression, which is associated with multiple losses, role changes, social isolation, and helplessness.

Interpersonal psychotherapy combined with nortriptyline and psychoeducational support groups reduced attrition and led to remission of major depression among 79 percent of the elderly patients who completed 16 weeks of treatment. Similarly, interpersonal psychotherapy was found to be effective in the treatment of depression following bereavement.

Psychodynamic psychotherapy

The goals of psychodynamic psychotherapy vary depending on patients' medical health and functioning. For elderly patients who are not disabled, psychodynamic psychotherapy focuses on resolution of interpersonal conflicts, reconciliation of personal accomplishments and disappointments, and adaptation to current losses and stressors. The aim of psychodynamic psychotherapy is to facilitate mourning of lost capacities, promote acceptance of physical limitations, address fears of dependency, and promote resolution of interpersonal difficulties (18).

The effectiveness of various forms of psychodynamic psychotherapy has been compared with that of cognitive-behavioral therapy in reducing symptoms of geriatric depression. An earlier study noted that psychodynamic psychotherapy was associated with a higher relapse and recurrence rate within one year compared with cognitive and behavioral therapy. However, in a larger sample, psychodynamic psychotherapy was equally as effective as cognitive and behavioral therapies and superior to placement on a waiting list in preventing depressive recurrences over periods of one and two years (19).

Reminiscence therapy

Reminiscence therapy was developed as a treatment for elderly persons. Its basic assumption is that reflection on positive and negative past life experiences enables individuals to overcome feelings of depression and despair (19, 20).

Reminiscence therapy has been found to reduce depressive symptoms in nonclinical samples and among cognitively impaired nursing home residents. Reminiscence therapy was shown to be more effective than no treatment among elderly community volunteers. Similarly, reminiscence therapy produced a short-lived amelioration of depression among cognitively impaired nursing home residents (21). Among homebound elderly patients, the effect of reminiscence therapy on depression was comparable to friendly visits. Reminiscence therapy was found to be less effective than problem-solving therapy among depressed elderly outpatients (14).

Interventions for particular patient groups

Elderly patients with disabilities often develop psychopathology that influences their rehabilitation (6,7). Among nursing home residents with major or minor depression, psychosocial interventions that increased patients' control over recreational and other activities were found to enhance problem-solving skills and socialization. Weekly cognitive-behavioral therapy group sessions appear to reduce pain and pain-related disability among patients in nursing homes (22).

Family members and caregivers

Elderly patients with dementing or other psychiatric disorders are cared for principally by their families. Caregivers of elderly patients are at risk for depression, anxiety, and medical problems (23). A meta-analysis of 18 studies examined the efficacy of psychosocial interventions in alleviating caregiver and family distress (24). Interventions included psychoeducation, support, cognitive-behavioral techniques, self-help, and respite care. Both individual and respite programs reduced caregiver burden and dysphoria, but group interventions were only weakly effective.

The increasing diversity of the elderly population suggests that new interventions should take into consideration cultural attitudes toward care giving. Other factors that are expected to influence the nature of new interventions include whether the patient has a cognitive or functional disability, the duration of the patient's disability, whether the caregiver is a member of the patient's family, whether the caregiver is a child or spouse of the patient, and type of distress experienced by the caregiver, including dysphoria, anxiety, somatization, and disability.

Bereaved patients

Most studies of bereavement have focused on the death of a spouse and its effect on the surviving elder. Spousal bereavement appears to be associated with declining physical and mental health (25) and increased mortality (26). Self-help groups appear to ameliorate depression, improve social adjustment, and reduce the use of psychotropic drugs among widows (27,28). The efficacy of self-help groups approximates that of brief psychodynamic psychotherapy among elderly bereaved individuals without significant prior psychopathology (29). Group psychotherapy, however, has been found to be only slightly more effective than no treatment (30).

Cognitively impaired patients

As the number of patients with dementing disorders rises, so will the relevance of psychosocial interventions for behavioral disturbances resulting from these conditions. Depression and anxiety occur most frequently during the early stages of dementing disorders. Research findings suggest that cognitive-behavioral therapy is beneficial in the treatment of depressed demented elderly patients.

Psychosocial interventions targeting the caregivers of cognitively impaired elderly patients with dementia not only reduce caregiver burden but also influence many patient- or caregiver-related outcomes. A psychosocial intervention for spouses who were caregivers was shown to delay institutionalization of demented patients. Focused behavioral techniques have been found to improve the quality of caregivers' sleep, and psychoeducation and family support appeared to facilitate patient management. These observations suggest that development and study of psychosocial interventions appropriately targeted to problems related to caregiving can improve the care of demented patients as well as the quality of life of both patients and caregivers.

Primary care patients

Most of elderly patients with psychiatric problems are treated by primary care physicians (1, 2). Approximately 6 to 9 percent of primary care patients meet criteria for major depression (31,32), and 17 to 37 percent have minor depression syndromes.

More than 80 percent of primary care patients prefer to receive help for emotional distress from their primary care physician, while only 5 percent wish to be referred to a mental health specialist (33).

These findings suggest that mental health care for elderly patients should best be provided at the primary care site.

A direct benefit of psychosocial treatments is that they have the potential to increase compliance with medical and psychiatric regimens. Developing rapport, providing psychoeducation, and addressing the patient's concerns and misconceptions are part of psychosocial treatment regardless of orientation. Frequent follow-up offers an opportunity to monitor compliance and intervene if the patient becomes negligent or resistant to treatment.

Psychosocial interventions that are modified to target not only psychiatric symptoms but also disability may have a significant impact on the adjustment of elderly patients. A study of depressed elderly patients has shown that impairment of instrumental activities of daily living was associated with anxiety and depressive ideation (34).

Suicidal patients

The rate of suicide almost doubles in late life and reaches a rate of 22.8 per 100,000 in the population age 75 to 84 (34,35). Among adults who attempt suicide, elderly persons are most likely to die as a result of their attempt; the ratio of completed to attempted suicides increases from 1 to 200 among young women to 1 to 4 among elderly persons (35). These observations suggest that aging reduces the rate of suicide attempts but increases their lethality.

Depression is the most common psychiatric diagnosis among elderly suicide victims (34,35,36). Approximately 76 percent of elderly suicide victims have psychopathology; 54 percent meet criteria for major depression, and 11 percent meet criteria for minor depression (38).

Hopelessness is strongly associated with suicidal ideation. Elderly patients with severe depression are more likely to have suicidal ideation with increasing hopelessness. More than 70 percent of suicide victims see their physicians within the month before their death (39).

These observations suggest that interventions delivered at the primary care site may reduce the rate of suicide. Mental health professionals integrated in primary care practices may provide effective screening, as well as timely and appropriately targeted interventions and follow-up. The presence of mental health workers in the primary care office is crucial because educational methods aimed at primary care physicians have been found to have little sustained impact on either physician behavior or patient outcomes (40,41).

Conclusions

Psychosocial interventions will play an increasingly important role in the treatment of psychiatric syndromes and symptoms of older adults. Increased life expectancy and the resultant medical comorbidity may complicate the use of pharmacotherapy among a large percentage of elderly patients. The goal of psychotherapies will be expanded to include reduction of disability, pain management, and adherence to medical and rehabilitation regimens. Because much of the stress experienced by elderly persons results from medical disorders and disabilities, psychotherapeutic interventions that strengthen coping mechanisms and reinforce health-promoting behaviors are expected to be a crucial part of health care. Self-help groups and counseling will play an increasing role in the care of bereaved elderly persons and in the care of caregivers of elderly patients. Brief, focused psychotherapeutic interventions may be particularly useful for individuals who develop significant psychopathology or find psychotherapy to be meaningful in enhancing adaptation. Integration of mental health professionals in primary care practices will allow the timely and appropriately targeted interventions and follow-up necessary for the treatment of psychiatric disorders, most of which are chronic. Further research on brief standardized psychotherapies is expected to provide effective and well-accepted treatments for elderly persons. This view is based on the fact that existing therapies, including interpersonal psychotherapy, problem-solving therapy, and cognitive-behavioral therapy, have been found to be beneficial in the acute treatment of geriatric depressive and anxiety disorders

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* Associate Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore - 560029