Research on psychotherapy in India: A systematic review

Abstract

We systematically reviewed empirical studies of psychotherapy with Indian clients. We defined psychotherapy as an intervention aimed at treating mental disorders using “talk,” which, in a professional medical setting, along with the therapeutic relationship, acquires medicinal value. Besides manual searches in three leading Indian psychiatry journals, we conducted digital searches in PubMed, Google Scholar, and Scopus databases. We found that the commonly practiced evidence-based psychotherapy in India follows the cognitive-behavioral model. Our findings suggest several replication studies which claimed to have used the well-established western models of cognitive behavioural paradigm but have mostly focused on basic behavioural techniques in their protocol. A few innovations were observed, and several essential errors were noted. Innovations include contextual modifications to address the difficulties and challenges faced in service delivery, while errors include deviations from protocol without adequate rationale.

INTRODUCTION

The word psychotherapy generates definitions and descriptions from various international organizations, professional bodies, and other standard resources. For practical purposes, we define the significant determinants of psychotherapy based on essential overlaps. One such determinant is the medium used, and the other is the anchorage point. “Talk” is the medium used to transfer therapeutic techniques, and the anchorage point rests in the human-to-human therapeutic relationship. Hence, psychotherapy is an intervention to treat mental disorders using “talk,” which has medicinal value. The “talk” and the therapeutic relationship’s medicinal value are based on science and research evidence. Therefore, only psychotherapies with a solid evidence base can be recommended in a professional medical setting for treating mental disorders.

There is also a need to differentiate between psychological interventions and psychotherapy. All psychotherapies are psychological interventions, but not all psychological interventions are psychotherapies. So many psychological interventions use different modalities to approach the human psyche. Those methods that use talk as the modality to access the human mind and are intended to treat mental disorders are called psychotherapies. On this background, we shall review the topic “Research on Psychotherapy in India.”

Global stage

Numerous psychotherapies have been developed worldwide; some have endured, while others have failed. Those psychotherapies that survived have one thing in common, i.e., their evidence base. In the current scenario, several professional organizations mention cognitive behavior therapy (three generations) and psychoanalytic/psychodynamic therapies as the two major psychotherapies. The American Psychological Association’s Division 12 Task Force on Psychological Treatments mentions cognitive behavior therapy (CBT), a form of psychotherapy) as the only treatment with robust research evidence in more than 80% of disorders. It has been demonstrated that interpersonal psychotherapy (evidence-based psychotherapy) and several other cognition-oriented psychotherapies share a standard cognitive-behavioral prototype.[1] These psychotherapies focus their work on specific individual psychopathology and their relief. Although they generally fall under the banner of psychotherapy, family therapy and couple therapy are very broad-based and focus on entire family systems or the couple dynamics.

Indian scenario

Most evidence-based psychotherapies (EBP) practiced in India are based on Western models of psychotherapy. The momentum for empirical therapies in research settings has increased significantly since 2010 (from 2000 to 2010, n = 12 and from 2010 to 2023, n = 68). The most practiced EBP in India follows the cognitive-behavioral model. There have been attempts both to replicate the Western model in Indian settings and to innovate new techniques for global practice.

MATERIALS AND METHODS

We comprehensively explored databases that included psychotherapy research on the Indian population. We manually searched all the issues of the Indian Journal of Psychiatry, the Indian Journal of Psychological Medicine from 2000 to September 2023, and the Industrial Psychiatry Journal from 2008 to September 2023. We limit ourselves to these three journals published in India because they are the only Indian journals included in Pubmed. Pubmed inclusion and Scopus indexation are given special consideration because several universities across the globe approve their standards.[2] Two other Indian journals with Scopus indexation in Q4 (lower rating) were dropped from our search list because of lower credibility. Additionally, we conducted a digital search of all Indian studies with the keywords: psychotherapy, CBT, dialectical behavior therapy, mindfulness-based cognitive therapy, and psychoanalytic therapy in PubMed, Google Scholar, and Scopus databases.

Inclusion criteria

Research studies on psychotherapy published in PubMed- and Scopus-indexed journals that describe an evidence-based psychotherapy technique.

Exclusion criteria

Identification stage: We excluded studies on cognitive retraining/remediation/rehabilitation (behavioral training to improve attention, executive functions, and memory) in severe mental/neurological illnesses, Yogasanas used as treatments (yoga therapy), educational interventions, skills training related to rehabilitation, occupational therapy, Family therapy, Family intervention therapy, family education program. (Even though from a very broad perspective family, family-focused therapies, family therapies, and couple therapies are included under psychotherapies, they typically do not focus on one-to-one psychotherapeutic exchange, and their focus falls on the entire family system instead of the individual psychopathology. Hence, they are not included in the present review. This exclusion does not apply to group CBT wherein an individual’s psychological disorder is addressed through group format).

Screening stage: Opinion pieces on the Indian way of psychotherapy, editorials, commentaries, conference proceedings (a detailed report is unavailable), review articles on psychotherapies, psychoeducational interventions, personal reflections, psychotherapy programs that dealt with general well-being, interventions to improve mental health and mental health promotion.

Eligibility stage: Studies on cognitive self-regulation, studies with poor description of techniques viz., counseling, meditation, relaxation, general counseling sessions that do not follow a particular standardized protocol including tele counseling (n = 3), home-based interventions, mention of psychotherapy without any descriptions (n = 2), nurse led counselling, social skills training in rehabilitation, psychosocial interventions whose duration is less than 15 minutes, brief psychological interventions focusing only on psychoeducation, general relaxation, nutrition, exercise, protocol only research papers on psychosocial interventions (n = 5), brief self-management interventions, cognitive reading enhancement programs, group work intervention, Online methods of managing auditory hallucinations that do not follow a particular standardized protocol, solution focused therapy with poor description of steps, dream work/dream analysis, Indian journal reporting psychotherapy research study conducted outside India (Iran, n = 1; Pakistan, n = 1; Peru, n = 1; Germany, n = 1; USA, n = 1), unnamed therapy, brief social- and psychoeducation, brief intervention with only psychoeducational component, psychosocial model focused on basic needs, integrated intervention programs for alcohol dependence which includes cognitive remediation and mind body exercises (Qigong and Tai Chi Chuan), systematic enhancement of functioning, psychological intervention with parents (educational, supportive methods), modified brief interventions with session duration of 5 minutes, loosely described psychotherapies/psychological intervention that does not follow established psychotherapy models, psychological interventions on individuals without Axis 1 psychiatric disorders (n = 4), single session counseling, biofeedback therapy (not a formal psychotherapy procedure), study that evaluated the cognitive profile (angry cognitions predicting stress), study that worked on testing the resting state mindfulness, ASHA intervention on depressive symptoms in women living with AIDS, survey conducted to evaluate available psychological services.

Other therapies, like grief therapy, sex therapy, and motivational interviewing, are included because of the emerging evidence and their unique role in specific clinical conditions.

RESULTS

Of the 195 citations identified, 119 were assessed for eligibility, and 70 fulfilled the eligibility criteria [Figure 1]. We present the results of our systematic review of evidence from India derived from replication studies, the innovations that were tried, and essential mistakes committed. The various studies (other than case report/series) which satisfied our criteria for EBP and have an appropriate description of the therapy protocol/model are given in Table 1.

Figure 1.

PRISMA flow diagram of study selection process

Table 1.

Summary of studies of EBP (excluding case reports) for Indian clients

	Study	Design	Psychotherapy Used	Sample size	Clinical condition
	Therapist administered EBP
1	Srivastava et al.[3]	RCT	Computer-assisted CBT vs TAU	11+10	Adolescent depression
2	Manjula et al.[4]	RCT	CBT (Barlow and Craske model[5]) vs BT	15+15	Panic disorder
3	Samantaray et al.[35]	RCT	brief CBT (Heimberg & Becker’s group protocol) vs Psychoeducational-Supportive Therapy in groups	25+25	Social anxiety disorder
4	Pinjarkar et al.[7]	Case series	brief CBT (Clark and Wells model[8])	7	Social anxiety disorder
5	Pinjarkar et al.[9]	RCT	brief CBT (Clark and Wells model[8]) vs TAU	27+26	Social anxiety disorder
6	Samantaray et al.[37]	Case series	brief CBT (based on Clarke, Craske, and Barlow)	4	Panic disorder with agoraphobia
7	Behera et al.[10]	Non-randomized parallel group	CBT (Rapee and Heimberg’s model)[12]	20+20	Social anxiety disorder
8	Manjula et al.[13]	Non-randomized parallel group	CBT vs behavioral intervention	15+15	Panic disorder
9	Anand et al.[14]	Single-arm follow-up study	CBT (mostly exposure and response prevention)	31	Obsessive-compulsive disorders
10	Samantaray et al.[10]	Single-arm follow-up study	brief CBT (mostly exposure-based behavioral work)	115	Obsessive-compulsive disorders
11	Samantaray et al.[16]	Rater blinded random allocated parallel group	ERP (Craske et al.’s[17] model to optimize inhibitory learning) + SSRI vs SSRI only	14+14	Obsessive-compulsive disorders
12	Taksal et al.[42]	Single-arm follow-up study	Integrated Psychological Therapy (Brenner’s model[19]) with booster sessions at one month	29	Schizophrenia
13	Salam et al.[43]	Case series	CBT (mostly behavioral methods)	5	Dhat syndrome
14	Singh et al. [20]	Open label RCT	CBT vs TAU	45+39	Alcohol dependence
15	Raj et al.[21]	Non-randomized parallel group	CBT vs TAU	20+20	Deliberate self-harm (in anxiety/depressive/adjustment disorders)
16	Raj et al.[46]	Single-arm follow-up study	Mindfulness-based cognitive therapy (Segal’s model) in groups	30	Adolescent depressions and suicidal behavior
17	Lakshmi et al.[23]	Case –control design	Metacognitive therapy	2+2	Social anxiety disorder
18	Vijayakumar et al.[51]	RCT	Brief intervention & case finding (Babor and Higgins-Biddle’s model) vs TAU	320+360	Attempted suicide
	Lay providers administered EBP (community level)
19	Singla et al.[26]	Single-arm evaluation of therapy quality	CBT	11 clusters of primary health centers	Depression and alcohol use disorders
20	Singla et al.[27]	Single-arm evaluation of therapy quality	CBT	26 lay providers (67 individual sessions)	Perinatal depression
21	Chorpita et al.[28]	Single-arm follow-up study	CBT (with components of relaxation, behavioral activation, exposure, assertive communication, and problem-matched optional components of cognitive restructuring and problem-solving)	15	Adolescents scoring above the cut-off for the Strength and Difficulties Questionnaire
22	Michelson et al.[50]	Two-stage iterative pilot-cohort study	Contextually developed low-intensity transdiagnostic problem-solving therapy	45+39	Common mental health problems in school children
23	Patel et al., 2017[30]	RCT	Behavioral activation paradigm vs Enhanced usual care	24+31	Depressive disorder
24	Nadkarni et al., 2017[64]	RCT	Counseling for Alcohol Problems (cognitive- behavioral skill set) vs Enhanced usual care	10 primary health centers (378+189)	Harmful drinking
	Miscellaneous therapies
25	Sharma et al.[31]	Case series	Mindfulness-based stress reduction program	7	Dissociative disorder
26	Tikka et al.[32]	RCT	Motivational interviewing and the 3As model vs TAU	27+25	Nicotine cessation in head and neck cancer

EBP: Evidence-based psychotherapy; CBT: cognitive behavior therapy; TAU: Treatment as usual

Replication studies

Individual level

Cognitive behavior therapy

Depressive disorders

Srivastava et al.[3] conducted a randomized-controlled trial (RCT) using computer-assisted cognitive behavior therapy for adolescents suffering from depression. They showed that computer-assisted CBT performed better than treatment as usual in improving depressive symptoms. They also observed that treatment compliance was better with computer-assisted CBT, reducing the time therapists spent with their clients. We scrutinized the manual by Srivastava et al. (2015)[33] utilized in this research project. The researchers claimed to have adapted CBT for Indian adolescents, yet we could not find any identifiable modifications.

Sharma and Rao[34] have administered an eclectic psychological method in treating a Dysthymia patient who had comorbid Tuberous Sclerosis. In addition to cognitive retraining to improve cognitive deficits and family-focused interventions, the patient was offered CBT to manage her dysthymic states. Post-intervention, the patient has reported good treatment gains.

Anxiety disorders

Manjula et al. (2014)[4] applied the Barlow and Craske (1988)[5] CBT model to Indian patients who have panic disorder (n = 15) and compared it to behavior therapy (n = 15). They elucidated the pattern of change in recovery and discussed changes in the specific cognitive processes involved in the response, i.e., catastrophising, attentional bias, anxiety sensitivity, agoraphobic cognitions, and appraisal of social consequences.

A brief version of Heimberg and Becker’s[12] group protocol addressed social anxiety disorder (SAD) in 50 medical students.[6] The study reaffirmed that six 2-hour weekly group sessions of brief CBT are an efficacious treatment in a rater-blinded, placebo-controlled RCT with lasting improvement at two months follow-up. Samantaray et al.[35] followed up on these medical students with SAD during the COVID-19 lockdown (14 months after the initial intervention). They concluded that the effect of CBT was sustained throughout the lockdown period and that COVID-19 fear was lessened in those who underwent CBT. Pinjarkar et al.[7,9] have described using a brief CBT (seven sessions) program for SAD based on the Clark and Wells model.[8] They applied the model in an RCT on 53 Indian patients[9] and established its efficacy in treating SAD.

Behera et al.[10] have applied Rapee and Heimberg’s CBT model[12] in treating individuals with SAD. They compared in a nonrandomized fasion 20 patients receiving CBT and Paroxetine with 20 patients receiving Paraoxetine alone as treatment and reported that the CBT plus Paroxetine group responded well compared to the CBT alone group.

Samantaray et al.[36] have conducted a CBT program based on Clark and Well’s model[8] for SAD. They have reported that the combination of paroxetine and CBT does not provide any additional benefit over paroxetine-only treatment during the acute stages but instead provides significant benefit during the maintenance phase of treatment. Samantaray[37] has shown the therapeutic benefit of maximizing the non-specific therapeutic factors of credibility, expectancy, and therapeutic alliance in a brief CBT (five sessions) program for four individuals who have panic disorder and agoraphobia based on models by Clark et al.,[38] Barlow et al.,[11] and Craske et al.[39]

Manjula et al.[13] have reported the outcome of a trial that compared treatment responses in two groups of panic disorder patients. One group of 15 patients received CBT, and the other of 15 patients received a behavioral intervention involving psychoeducation and applied relaxation techniques.[40] They concluded that CBT has brought significant changes in panic symptoms, avoidance, safety behaviors, and cognitions compared to the behavior intervention.

Obsessive-compulsive disorders

Anand et al.[14] implemented CBT (20–25 sessions of CBT over three months) in 31 adults with obsessive-compulsive disorders (OCD) who were medication non-responders and followed them up for one year. They described a protocol that mainly consisted of exposure and response prevention strategies. They found that good homework adherence and a lower baseline Yale-Brown Obsessive-Compulsive Scale score predicted remission of OCD.

Selvapandiyan,[15] while trying to explain the negative side of culture-based CBTs, has demonstrated treatment response in a patient suffering from OCD by using the Western model of CBT for OCD, which was primarily developed by Paul Salkovskis, David Clark, Stanley Rachman, and Kieron o Connor.

Samantaray et al.[41] conducted therapy sessions with a brief CBT protocol for OCD (n = 115). The description of strategies indicates predominantly exposure-based behavioral work. They have found that anxiety sensitivity and non-specific therapeutic factors (credibility, expectancy, and therapeutic alliance) predicted significant CBT outcomes.

Samantaray et al.[16] have conducted an exposure and response prevention trial based on Craske et al.’s[17] model to optimize inhibitory learning in OCD patients. They compared the treatment response between a group who received medication and another group who received ERP based on inhibitory learning with medication. Even though immediate post-treatment differences were insignificant, they could identify that the ERP group had fared better than the medication-alone group during follow-ups.

Daniel and Bhat,[19] in their article on multicomponent behavior therapy in a child suffering from OCD, have primarily used the exposure and response prevention model to help the child manage her obsessive phenomena.

Schizophrenia

Brenner’s Integrated Psychological Therapy model,[18] a cognitive-behavioral program for schizophrenia, was implemented by Taksal et al.[42] on 29 Indian participants with clinically stable schizophrenia or schizoaffective disorder. They explained several steps to adapt the model to Indian patients, including photographs and social situation themes that are culturally relevant and contextualizing the social skills subprogram to the client’s current life circumstances. The improvement in social functioning and neurocognition lasted for three months of follow-up.

Alcohol dependence

Singh et al.[20] have applied CBT (protocol identified in the supplementary material) in individuals suffering from alcohol dependence syndrome. They have reported that the intervention group significantly improved the early maladaptive schemas, such as defectiveness, emotional deprivation, negativity, self-sacrifice, and unrelenting standards, compared to the control group. There was also a significant between-group difference in the area of perceived stress.

Dhat syndrome

Salam et al.[43] described a cognitive-behavioral therapy intervention for Dhat syndrome. In the five cases, the interventions described were mostly behavioral methods. Even though there were mentions of the plausible cognitive distortions that could be present in Dhat syndrome, this paper faces issues with a clear cognitive conceptualization of Dhat syndrome. The cognitive model is essential for expanding and adapting CBT to any new disorder, which then becomes a template to replicate the techniques in other patients.

Grover et al.[44] have reported follow-ups of patients with Dhat syndrome, focusing mainly on treatment response and resons for dropping out from the treatment. They used a therapy program mainly comprised of sex education and Jacobson’s Progressive Muscle Relaxation (JPMR). They have reported that patients with Dhat syndrome frequently drop out of treatment programs and have enumerated several reasons/themes for treatment dropout.

Tic disorder

Varadharajan et al.[45] used behavioral methods like Habit Reversal Training, comprehensive behavioral intervention for tics, and exposure with response prevention in seven individuals suffering from (adolescent-onset severe) Tourette’s disorder and found a good response.

Deliberate self-harm

Raj et al.[21] have implemented CBT in individuals who attempted deliberate self-harm with anxiety disorder, depressive disorder, or adjustment disorder as the primary diagnosis. They compared the efficacy of CBT by implementing the therapeutic program in the experimental group (20 participants) and treatment as usual in the control group (20 participants). They found that the experimental group did well on several variables like suicidal ideation, dysfunctional attitudes, hopelessness, problem-solving skills, and hostility. They did not find improvement in the impulsivity variable.

Mindfulness-based cognitive therapy

Segal’s model[22] of mindfulness-based cognitive therapy (MBCT) has been replicated in 30 adolescents suffering from depressive disorder and suicidal behavior.[46] They reported a significant improvement in depressive symptoms, life orientation, life satisfaction, and family functioning.

Acceptance and commitment therapy (ACT)

Singh et al.[47] replicated the ACT model of Hayes et al. in a case of OCD with substance use disorder as part of multimodal integrated interventions with improved outcomes.

Selvapandiyan[48] has given a pragmatic therapeutic approach and model for applying ACT to adolescents suffering from Asperger syndrome. This program is based on an eclectic model that addresses the core deficits of individuals suffering from Asperger syndrome, aiming for a holistic outcome.

Metacognitive therapy

Lakshmi et al.[23] have described the application of Wells model[49] of metacognitive therapy in individuals suffering from SAD. In a case-control design, they have used the applied relaxation technique given by Ost[40] in individuals allotted to the control group, and they used metacognitive therapy in the cases. They have reported that metacognitive therapy was marginally more effective than the applied relaxation technique, and metacognitive therapy has more specifically helped the patients in post-event processing, social avoidance, and self-consciousness.

Sudhir et al.[25] have applied metacognitive strategies along with traditional CBT in a patient suffering from generalized anxiety disorder and found that combining these strategies helped the patient better manage his anxiety and worry processes.

Community level

Singla et al.[26] used Rahman’s model of CBT-based intervention for severe depression and alcohol use disorders to implement their multi-site program across 11 purposefully chosen PHCs in Goa, India, involving lay providers. They found that peer supervision is as reliable as expert supervision in determining the quality of therapy sessions. In the same study setting, using the same model of CBT, Singla et al.[27] demonstrated that lay therapists can be adequately trained in evidence-based methods to deliver therapy for perinatal depression in low-resource settings.

Chorpita et al.[28] described the design process and protocol description of the PRIDE program[50] within a stepped-care approach for Indian school-going adolescents. Other than the initial steps of a universal informational component followed by low-intensity transdiagnostic problem-focused intervention, the additional steps were resource intensive that a lay therapist could deliver. The latter included contextually adapted universal components of relaxation, behavioral activation, exposure, assertive communication, and problem-matched optional cognitive restructuring and problem-solving components. The protocol was tried on 15 adolescents who scored above the cut-off of the Strength and Difficulties Questionnaire, showing 64% remission.

Babor and Higgins-Biddle’s model[24] of brief intervention for hazardous and harmful drinking was utilized in brief intervention for individuals who had attempted suicide as a part of the SUPRE-MISS trial launched by WHO. The center in Chennai[51] used this brief intervention in an RCT to show its effectiveness in the areas of risk management and case finding.

Miscellaneous therapies

Keith Hawton’s model of sex therapy[52] was utilized in treating an individual suffering from vaginismus.[53] They discussed an eclectic method consisting mainly of behavioral methods to reduce vaginismus. Manjula and Chandrashekar[54] describe the application of Grief Therapy to a survivor who engaged in filicide. The core aspects of the therapy involved concepts from existential therapy and other eclectic, pragmatic approaches.

Sharma et al.[31] have used a mindfulness-based stress reduction program developed by Jon Kabat-Zinn[55] to treat seven adolescents suffering from dissociative disorder. They reported a significant reduction in dissociative episodes and improved mindfulness skills.

Pattanaik et al.[56] have described a therapy protocol using motivational interviewing and other supportive techniques in an individual suffering from alcohol dependence syndrome. However, the title of their study is misleading, “Application of transtheoretical model in management of individual with alcohol dependence.” The transtheoretical model by Prochaska is the theoretical model that underlies several behavioral changes, and the actual techniques that they have utilized are motivational interviewing and other methods used in substance abuse treatment.

Tikka et al.[32] have implemented a brief intervention to aid smokeless tobacco cessation in patients diagnosed with head and neck cancer in a parallel arm RCT. Their intervention was based on motivational interviewing and the 3As model. They reported the effectiveness of their intervention in enhancing the discontinuation rates of the use of smokeless tobacco in head and neck cancer patients.

Tripathi and Mehrotra[57] have described using exposure and response prevention strategies in a patient with irritable bowel syndrome and improving symptoms.

Trivedi et al.[58] have tried graded exposure therapy with an individual suffering from alektorophobia and achieved good results.

Bharathi and Rao[59] have presented an insight facilitation intervention for a patient with an emotionally unstable personality disorder under the title “Trait changing therapy.” They have given a detailed description of the steps followed with that patient, which can be utilized for insight facilitation in individuals with personality disorders.

Research on other aspects psychotherpay

Malik et al.[60] explored the perceived barriers to homework adherence in CBT and found that task- and patient-related factors contributed much to homework adherence.

Jameel et al.[61] have conducted a qualitative study exploring the views of practitioners and patients to culturally adapt CBT in depressive disorders. They have reported that culturally sensitive assessment and cognitive conceptualization with minor adaptation in clinical practice is required. The practitioners participating in the study also recommended using proverbs, local stories, and simplified terminologies in therapy sessions.

Gupta et al.[62] have published their research on conducting CBT training programs in India. They have reported the naturalistic outcomes of increased patient attendance and symptom improvement.

Tharyan[63] has worked on an experiment in psychotherapy training. The psychotherapy content of the program involved various themes and streams. She reported that using groups as an addition to individual supervision has facilitated training, easy access to group support, and improved clinical audits.

Innovations

The criteria for innovation include an entity/technique that was previously unheard of and has been worked upon in Indian soil and is offered for the global community. The technique should also align with a parent model, a well-established evidence-based psychotherapy.

Individual level

Selvapandiyan et al.[48] have proposed a novel approach called imagery-based cognitive therapy” for children with PTSD. Since a child’s cognitive apparatus is immature, they have inherent difficulty understanding the cognitive-behavioral programs designed for adults. Hence, this imagery-based cognitive therapy helps them learn the techniques quickly and assimilate them into real-life practice.

Selvapandiyan[29] has proposed a new idea called psychotherapy titration, which can be applied in dialectical behavior therapy programs for borderline personality disorder to reduce the attrition of patients from therapy programs. As titration involves varying the dose of psychotropic drugs based on response and the side effects, psychotherapy titration involves a balanced titration of psychotherapy content/strata based on the difficulty experienced by the patient. It can be considered the first such application in the psychotherapy arena.

Community level

Michelson et al.[50] have developed a low-intensity, transdiagnostic psychological intervention for common adolescent mental health issues in schoolchildren. This intervention, known by the acronym PRIDE, is provided by lay therapists, is based heavily on problem-solving therapy, and has shown promising results and user satisfaction.

The first arm of the PREMIUM program, which is based on the behavioral activation paradigm, was successfully implemented in a cluster RCT using non-specialist health workers with patients suffering from depressive disorders. This community-based treatment method has achieved its intended purpose of reducing the treatment gap for depressive disorders.[30]

The second arm of the PREMIUM program was intended to help individuals with harmful drinking. It was based on a cognitive-behavioral skill set for managing alcohol use problems.[64]

Errors in therapeutic techniques

Particular research articles have lacunae in the techniques that were used or described. There was also no mention of the reason for the deviation from the standard therapeutic protocols.

For example, an exposure and habituation response was described as self-explored CBT.[65] Few mistakes were made in cognitive conceptualization, and the method used, i.e., a didactic method, was stated as a Socratic method.[66] In their paper, Behere et al.[67] tried to link the concepts of ayurvedic mental practices and psychotherapies. Many such attempts have been made in the past, and there are several byproducts of such attempts, i.e., the Guru Chela paradigm, the Bhagavad Gita in psychotherapy, or the ayurvedic concepts of mind. A stark revelation from these attempts is that they were not empirically tested.[15] The fundamental problem in comparing Indian philosophical, ayurvedic, and Vedic concepts with modern psychotherapies is that ancient Indian concepts deal with universal moral commandments and self-discipline to lead a balanced life, whereas modern psychotherapy is disorder-oriented and illness-focused.

An 8-week standard protocol is generally recommended based on empirical testing for achieving mindfulness in MBCT.[22] However, a research program by Kumar et al.[68] describes the direct leap to sitting mindfulness on day 1, and specific steps were not elaborated. Predominantly, a psychoeducational approach was described, and a few questions to check mindfulness practice were provided. Also, there is a report on using traditional CBT and mindfulness, but the specific strategies or intrusions were not mentioned (OCD is a heterogeneous disorder). Cognitive restructuring, a very broad term, is used to mention the treatment procedure, yet no elaborate descriptions were noted to understand what exactly was involved here.

Reddy et al.[69] have described CBT for stuttering in a case series that predominantly included techniques like JPMR, but cognitive conceptualization was not presented. Gupta[70] has described the application of CBT to an adult suffering from stuttering. The conceptualization presented in this paper does not follow the well-established taxonomy of cognitions.

Verma and Vijaykrishnan[71] have shared a case vignette titled “Psychoanalytic psychotherapy in addictive disorders.” A psychoanalytic description of the problem faced by the client was presented, but there needed to be a scientific way to apply and study its response.

The psychotherapy program Arora and Sharma[72] describe under the heading “Positive Affect, Psychotherapy, and Depression” is not based on any typical evidence-based psychotherapy program. If we must consider it a novel intervention, even the authors did not mention anything about its novelty. Also, the study needs to be adequately powered to test the hypothesis. The procedure described needs to be clarified further, and it is not easy to follow through the description.

Gupta et al.[73] attempted to describe the application of Dialectical Behavior Therapy (DBT) to two patients. The conceptualization was not presented in the first patient, and a superficial description of the techniques was noted. Mindfulness, the core strategy of DBT, has been given a corner space. There is also a description of mindfulness practice as altering thoughts and emotions that goes straight against the core principles of mindfulness. In the second patient, no DBT technique was used. Only cognitive restructuring was performed.

In the paper by Jha et al.,[74] under the title “CBT for psychosocial stress in Vitiligo,” the techniques described are not actual cognitive-behavioral techniques but general methods like breathing, relaxation, imagery, and self-statements.

Samantaray et al.[75] have described a four-session CBT program for obsessive-compulsive disorder. They have mentioned the use of metaphor for conceptualization in the title. However, in the manuscript, actual cognitive conceptualization needed to be included, and they gave a clinical analogy used to psychoeducate the patient. Also, the presented clinical analogy is not a metaphor.

Sondhi et al.[76] faced issues with correctly conceptualizing and applying therapeutic techniques.

Dua et al.[77] have described treatment methods which do not follow the recommended methods in exposure and response prevention, thereby indicating flawed application of techniques.

Halder and Mahato[78] have described several methods that are loosely connected under their therapeutic package, which poorly engages with cognitive-behavioral methods. (e.g. changing thoughts and beliefs, using hopeful statements, focusing on the positive).

In Madiha and Akhouri’s[79] research paper, although the title mentions mindfulness-based therapy for adolescents with suspected conduct disorder, there is no such therapy anywhere in the entire manuscript.

Priyamvada et al.,[80] in their research on the application of cognitive behavior therapy in SAD, have faced difficulties in conceptualization and use of outdated techniques.

Kumar and Jahan[81] have described a multimodal psychotherapy program for somatization disorder. The paper has been included in the present review since the described method had sections on psychodynamic psychotherapy and cognitive restructuring. However, the article has no clear description of the psychodynamic methods and an incomplete description of the steps in cognitive restructuring.

Sengupta and Singh[82] have published their research on functional analytic psychotherapy in schizophrenia patients. Their description of therapy techniques is fraught with several difficulties. First, it did not match the descriptions of techniques present in the referenced model by Dykstra et al.[83] Second, considerable confusion could be observed under the heading of the behavior rationale technique wherein cognitions and behaviors got mixed up, resulting in a confused passage.

Shukla et al.[84] have tried using cognitive behavior therapy for managing hallucinations in schizophrenia patients. The protocol they described as CBT deviates entirely from the core principles of CBT. Descriptions under the distraction technique, focusing, and exposure, behavioral control, and testing beliefs about control do not fall under any available EBP procedure. Other strategies, like reattribution of auditory hallucinations, do not conform with Schizophrenic psychopathology.

Srivastava et al.[85] have published their research titled “cognitive behavior therapy as an adjuvant in the management of alcohol dependence syndrome.” The description of techniques includes a single sentence mentioning functional analysis and skills training amounting to improperly performed CBT.

Bhardwaj and Sharma[86] have described managing a case of childhood OCD using CBT. However, the techniques utilized were psychoeducational methods and certain psychological exercises taught to the child to manage anxiety-provoking situations. These exercises/techniques do not match with a proper CBT protocol.

Hebbar[87] has published a case vignette of a patient suffering from OCD with chronic tic disorder. The case conceptualization was unclear. There were certain nontherapeutic lay suggestions mentioned in the paper. The examples given for the cognitive distortions elicited in the patient were not congruent.

Manjula and Prasadarao[88] have illustrated the use of CBT in a single male with sexual dysfunction. Most of the therapeutic work centered around psychoeducation, and the cognitive restructuring section was inadequately represented.

Mishra et al.,[89] when using MBCT in a patient suffering from depersonalization and derealization disorder, failed to use previously established protocols in MBCT.[22] Their discussion focused on using an array of techniques associated with mindfulness practice. We could not identify any sequential practice recommended in an evidence-based MBCT program.

Philip and Cherian[90] have described the application of ACT in a patient suffering from OCD. The flaw identified in this work is the absence of case conceptualization. In any EBP, the conceptualization of the patient’s disorder based on that specific psychotherapy forms the base over which the therapy is fashioned. Even though ACT conceptualization is less specific than other psychotherapies, it must be presented before describing the methods. A free-floating description of the methods/metaphors used in this case would not help the readers replicate it in their clinical practice. The authors have also described in a passage that the patient claimed that the metaphors offered were “childish,” indicating that the patient was not adequately socialized to the ACT model. One of the reasons for this could be the lack of proper conceptualization (roadmap for therapy sessions).

Raguraman and Priyadarshini[91] have described using CBT in a case of non-organic sexual aversion syndrome. The steps that they described include imaginal exposure and JPMR. The cognitive work section is incomplete. It does not contain clear and specific information regarding the patient’s cognitive profile.

Singh and Samantaray[92] have conducted a trial comparing brief cognitive-behavioral group therapy based on Heimberg and Becker’s[12] group protocol and a therapy called verbal exposure augmented CBT based on the protocol by Kumar.[93,94] Despite the latter protocol being published in non-PubMed and non-SCOPUS indexed journals, we evaluate the therapeutic content. The name of the protocol mentions it as verbal exposure augmented CBT, but we fail to notice any formal CBT paradigm in it. It is also noted that no cognitive restructuring activity is involved in it. Hence, the protocol by Kumar cannot be considered as a variant of CBT.

Vyjayanthi[95] has described the application of brief dynamic psychotherapy in a case of OCD. Most interpretations about the patient’s problems and the defense mechanisms elicited with the explanations surrounding them do not fit into the established psychodynamic definitions of the defense mechanisms. Moreover, the work is challenging to follow through and derive meaningful inferences from it.

Duggal et al.[96] and Shriharsh et al.[97] face problems implementing proper cognitive-behavioral techniques in schizophrenia patients. We could observe the use of non-specific terminologies, poor description of therapy programs and overinclusive descriptions.[98]

Sharma et al.[99] have described the use of MBCT for treating four individuals suffering from anxiety disorders and reported significant improvement in anxiety symptoms. They did not follow any previously tested MBCT protocol for their research work, but they described a mixture of steps, including self-monitoring of symptoms, education regarding anxiety, relaxation through mindfulness meditations, cognitive restructuring, sitting mindfulness meditation, and reattribution. The absence of a clear step-wise description of techniques would pose significant difficulty for a therapist who intends to replicate the therapeutic program.

Agrawal et al.[100] research publication has indicated the usage of non-specific techniques incompatible with schizophrenia psychopathology. The reference model by Morrison and Barrat[101] has nothing related to their article’s description of cognitive-behavioral methods.

DISCUSSION

The last two decades have seen modest interest among Indian researchers trying to implement EBP in the clinical population. Their attempt to introduce science-based psychotherapies is seeing the light of day, and a consensus has been achieved in formulating EBP in India. The clinical practice task force of the Indian Psychiatric Society published guidelines for running psychotherapy programs in India in a special supplement of the Indian Journal of Psychiatry (Volume 62, Supplement 2), which has strengthened this.

Our review was restricted to Indian studies (RCTs, studies with substantial samples with pre-post design, case series, and case studies) on psychotherapy for specific clinical conditions published in PubMed-indexed journals that describe an evidence-based technique and have adequate descriptions to scrutinize the therapy steps. Since psychotherapies are resource-, energy-, and time-intensive procedures, case reports are also given due importance during evaluation. A major problem that is inherent to psychotherapy programs is an extremely high level of heterogeneity. Finding an evidence-based practice in this heterogeneity, and evaluating them strategically is the prime focus of this paper. In research papers that provide a detailed description of case formulation, we carried out an in-depth analysis of therapy content’s congruence with standard protocols. However, research papers that simply state that a specific model has been followed, it is assumed that the exact model has been adhered to but could be less well scruitinized.

The most practiced EBP in India follows the cognitive-behavioral model. At the individual level, evidence of its use in depression, anxiety disorders (viz., SAD, panic disorder with agoraphobia, PTSD), OCD, schizophrenia, alcohol dependence, deliberate self-harm, tic disorders, and Asperger’s disorder exists. A common point that is observed in multiple trials is that the cognitive domain of CBT programs is given less space.[5,6,9,10,12,13,16,19,33,35,36,37,40,44,57] But it is the area where the therapeutic work will give rise to maximum and enduring response. Most space in those trials was given to behavioral activities/interventions, resulting in unbalanced behavioral weightage. Hence, the major thrust in any cognitive-behavioral training should lie on the cognitive domain with parallel behavioral works for optimal outcomes. Formats of CBT included the first wave (exposure and response prevention, habit reversal training), the second wave (Traditional CBT based on an information processing model), and the third wave (mindfulness-based therapy, ACT, DBT, Metacognitive therapy). At the community level, evidence suggests its use in severe depression, perinatal depression, adolescent depression, alcohol use disorder, and suicide.

Some researchers have also addressed the issue of contextual adaptations in psychotherapy for Indian clients. Prominent among them is the need for a briefer format of therapy.[6,7,29,37,41,42,64] Several researchers had errors in the techniques used or described. There were also no details about the reason for the deviation from the therapeutic protocols. Errors happened in the areas of the therapist’s understanding of the basic premise of therapy, theoretical underpinnings of the therapy, gross neglect of therapy structure, use of non-specific terminologies and poor descriptions, over-inclusiveness, use of outdated techniques like JPMR.[23,24,25,26,27,28,48,49,51,52,53,54,77,78,79,80,81,82,84,85,86,87,88,89,90,91,92,95,96,97,98,99,100]

Progressive muscle relaxation was first described in 1934 by Jacobson. Several adaptations of his model have emerged as a result of efforts from researchers like Wolpe, Bernstein, and Borkovec[102] and Lars Goran Ost.[40] These adaptations have modified the original protocol in several ways, and the major benefits of these adaptations include a reduction in time duration, simplification of steps, and ease of application by the client. An extensive search in the world’s reputed CBT journals like Cognitive Therapy and Research, Behavior Research and Therapy, and Behavior and Cognitive Psychotherapy reveals no to insignificant (sporadic) research publications on JPMR after the 1980s. However, in the Indian psychotherapy scenario, research on JPMR still finds space.[103]

Most studies followed up on efficacy and effectiveness until three months and one year after intervention, yet long-term follow-up evidence is missing. We recommend that researchers fill this critical gap.

With the addition of more EBP, we expect psychotherapy training among postgraduates and psychotherapy centers to improve in the coming decades. The need for psychotherapy case submissions and psychotherapy sessions under supervision is being employed in only a handful of training centers in India, which is a matter of concern for mental health professionals. Further innovations in cultural or contextual adaptations or modifications may also be expected. Policy planners, administrators, and combined government and non-government efforts are needed to rejuvenate this resurfacing area of psychotherapy, which is crucial for better patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.