PSYCHOSOCIAL ISSUES
An issue which can be the focus of attention of the therapist or the affected person for healing is classified under psychosocial issues. Most of us have issues in various domains of life that need sorting. In the course of case history taking and assessment these issues become apparent. Some of the issues become explicit during the course of treatment. It may happen that the affected person presented with problem ‘A’ but in fact he has problem ‘B’ which need be corrected. The study of psychosocial issues in the life of the affected person would clarify such a situation and also would provide a comprehensive list of the issues faced by an affected person in his life. First a comprehensive random list of the problems is prepared and then it is classified into domains. For example, an affected person came with following issues in his life:
1. Phobia of darkness
2. Difficulties in running business
3. Phobia of height
4. Persistent sadness after demise of a family member
5. Marital discord
6. Problems in intimacy with spouse
7. Feelings of inadequacy
8. Insecurity for spouse and his son
9. Lack of meaningful engagement in life
10. Financial difficulties
11. Hopelessness
12. Worries over academic performance of his son.
All of these problems do not fall in the category of phobia and OCD. Instead these problems spread over multiple domains of life. The problems can be classified in following domains. Other domain may be added as and when required.
1. Emotional Issues: All kinds of personal emotional problems of the affected person would be listed here. It would include the problems of phobia, OCD, jealousy, depression, and the like.
2. Interpersonal Issues: All relationship problems related with other persons in the life including parents, children, spouse, friends, fellow workers would be listed here.
3. Occupational Issues: Non-interpersonal problems in occupational functioning and related matters will be listed here.
4. Other Issues: Any other problems in life will be listed here.
The problems enumerated in above examples can be classified into domains of psychosocial issues as under:
(i) Phobia of darkness
(ii) Phobia of height
(iii) Persistent sadness after demise of a family member
(iv) Feelings of inadequacy
(v) Insecurity for spouse and his son
(vi) Hopelessness
(vii) Worries over academic performance of his son
(i) Marital discord
(ii) Problems in intimacy with spouse
(i) Difficulties in running business
(ii) Financial difficulties
(i) Lack of meaningful engagement in life
A comprehensive listing of the psychosocial issues and their classification provides a holistic view of the problems faced by an affected person in his/her life. This enables a therapist to keep a watch on what is happening in the life and how the affected person is progressing. When specific problem of any domain is taken up for treatment, problems of other domains may show changes. Most of the time it is not that only the specific problems need be handled; instead attempts shall have to be made to make the life of the affected person adjusted and harmonious. During the course of treatment issues of multiple domains may have to be targeted through appropriate psychotherapies.
In above case following problems of emotional domain may be targeted through Cognitive Drill Therapy:
(i) Phobia of darkness
(ii) Phobia of height
(iii) Insecurity for spouse and son
(iv) Worries over academic performance of son
Any emotional problem may contribute its portion in the severity of other problems. When specific problem is resolved, it results in deduction of the severity level from other problems too. We need to be alert and open to examine to what extent a given problem is addition to other problems and when specific problem is resolved, to what extent other problems improves. The resolution of the problems of phobia and insecurity in above example might results in partial or total improvement in following problems too:
(i) Feelings of inadequacy
(ii) Insecurity for spouse and his son
(iii) Hopelessness
(iv) Marital discord
Domains of psychosocial issues create a global picture in the therapist’s mind for the range of problems being faced by the affected person and his/her family. It may be possible that the assessment of psychosocial issues may point out to the need for handling a problem other than phobia on priority. Other problem may be more problematic and pressing than the phobia/OCD. In that case, CDT may be postponed until resolution of the pressing problem. That problem may call for a treatment other than drill therapy.
OCD is a chronic and debilitating condition in some affected persons. Despite best applications of drill therapy or even any other forms of psychotherapies are unlikely to produce significant gains in the condition of the affected person. Since, there are less chances of substantial improvement in the condition of the affected persons, there may be a temptation to give up the case totally. In such circumstances, the affected person may seek the help of other therapist or simply cease to seek further help.
I am proposing a tested idea that in the cases when the problem of OCD/phobia cannot be healed significantly and directly; in that case, a therapist should look into the other domains and problems which are likely to respond to psychological input. For example, along with the problem of OCD, a person has serious marital discord at the verge of divorce, in that case, instead of OCD; the marital discord can be prioritized for psychological treatment. Remember, resolution of any problematic psychosocial issue unburden the affected person to some quantity. An affected person carries the mental load of multiple psychosocial issues. The unloading of even a single issue will result in reduction in the mental load caused by so many issues. Each issue has its own mental load; which can be additive or multiplicative with other issues. I have seen changing the lives with extraction of associated psychosocial issue where the primary issue was unresponsive to the psychological input.
For clarification of identification and classification of the problems into various domains, I am citing more examples from real case studies. A person presented with following picture:
An adult person presented with the problems that he is not able to take up lifts as he feels that he may get suffocated inside the lifts. He avoids visiting his family members who stays in multistory apartment. He can’t bear to full close the door glasses in the car because of the fear that he may get suffocated. For the same reasons, he would avoid caves, sitting on the back seat of the car and other closed places. He also becomes irritable if somehow he is caught in a closed place. Also he cannot stand on high rise building and look downward. He feels dizziness when looking down from the rooftop of high rise building. He feels shy when he is required to give any presentation related to his business. He also becomes self-conscious when he speaks with persons in authority. He is having problems with his wife who does not take proper care of his old parents.
The psychosocial issues depicted in above case study may be classified as under:
1. Claustrophobia
2. Acrophobia
3. Social Anxiety
1. Problems with wife
Occupational Issues: None reflected in the case study
Other Issues: None reflected in the case study
While classifying psychosocial issues in various domains, it should be remembered that as far as possible the issues are identified at the syndromal level. Each phobia/OCD has its own symptoms like dizziness, sweating, breathing difficulties, danger perception and so on. In classification, each of these symptoms are not listed instead the issue represented by these symptoms is listed. This is done, because Two layer partition will include all these symptoms of the issue. Also, we are not supposed to treat the individual symptoms of the issue involved. For example, in a case of phobia, we are not going to treat directly any of the following symptoms individually: breathing difficulty, dizziness sweating etc. These symptoms will automatically go away because of the corrections in bottom layer.
The exercise in classification of psychosocial issues, is extremely useful in dealing with the problems of the affected person holistically and heal him/her to the maximum extent possible. Also, it can point out to the need for combining multiple psychological treatment approaches other than Cognitive Drill Therapy in the effective management of the affected person and resolution of his problems.
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