Caregivers: Valuable Assets for Society

‘My mother-in-law is suffering from dementia. I have been taking care of her since a long time and I feel very good about it. But I admit that it is exhausting. It has been months since I have gone to meet my relatives or friends, or seen a movie. How can do that? What if something happens when I am away?’     

Imagine someone saying this. Imagine who that person could be. More often than not, you’ve thought of a caregiver.

In our society, each of us knows of at least one person in a similar situation. Caregivers turn into indispensable assets for society. Till a few years ago in India, families refused to send their relatives to geriatric centers, hospices, and centers for children with disabilities. Family members mainly fall under the category of ‘informal caregivers.’ With the development of institutions and long-term stay facilities, the staffs of such institutions are also included in this category, specifically as ‘formal caregivers.’ As health care professionals, it is not only important to deal with the stresses of individuals suffering from physical or psychiatric problems but also with the stresses of caregivers.

A caretaker’s daily life is filled with tension, conflicts, and anxiety, accompanied with a variety of emotions. Long-term impact includes caregiver’s burden, that is, sleep difficulty, depression, anxiety, and loneliness. The experience of caregiving tends to be a chronic stressor  (Bevans & Sternberg, 2012). Daily hassles in a caretaker’s life include providing assistance with transport and mobility, managing schedules for medication, and communicating with medical professionals. It also requires being vigilant about signs of any health scare, motivating the ones they take care of, and facing financial issues. The demands of caring can lead to restrictions on other areas of life including work, social functioning, thus reducing the quality of caregivers’ lives.

Caregivers are impacted psychologically, emotionally and behaviorally. Their thoughts are constantly focused on the health of the patient. This can lead to psychological morbidity which would further lead to poor bereavement outcome (Addignton-Hall & Ramirez, 2006). It is also likely for caregivers to develop depression and anxiety due to constant hypervigilance toward those under their care. Emotions of guilt, fear, and sadness are most common amongst caregivers. Lack of recreation further adds to the development of health complications. Other risk factors include hours spent in caregiving, social isolation, and psychological factors of the patient (Adelman, Tmanova, Delgado, Dion, & Lachs, 2014). When caregivers undergo so many problems, why are they a neglected sector in health care?    

First, it is assumed that caretaking is a responsibility or duty which has to be fulfilled whether the caregiver is a family member or a professional. If they complain, they are ridiculed and reminded about this ‘responsibility.’ Second, caregivers are susceptible to feel guilty when they prioritize their own problems over the patient’s problems. Third, their problems are always compared to what their patients are going through and are brushed off as minor stresses. Their thoughts and emotions are rarely taken into consideration unless they develop psychological symptoms which hamper their caretaking tasks.

Given the stressors outlined above, why do people choose to be caregivers for their relatives or volunteer for a career in caregiving? Caregiving is viewed as a noble deed in society. The motivation may not be monetary benefits, praise or recognition. It is the satisfaction and pleasure they experience that is often highlighted. Although it involves many stressors, the positive responses from the patients is the main reinforcement for caregiving behavior. They can be compared to backstage workers of a play, who silently strive to make the actors look good and the play to become a success. The play can collapse in their absence. In my experience as a Clinical Psychologist, I have often realized how the absence of a ‘caring’ caregiver can hinder the improvement of patients and how resolving caregivers’ stress can accelerate the patient’s progress.

Once in a lifetime, every individual faces the opportunity to be a caregiver – by choice or by design. It is important to make this opportunity less stressful by acknowledging that it is not an easy task, appreciating their effort and involvement in caregiving, and reminding them that their life and health are not to be neglected. It is important to assess them psychologically to prevent burnout  (Coping with Caregiver Stress and Burden, 2015). As professionals, providing them with the appropriate information about the diagnosis as well as a realistic prognosis would be beneficial. For formal caregivers, job satisfaction and job stress must be assessed at frequent intervals. Self help  (Caregiving Support and Help, 2015) and support groups have also been found to be helpful.       

Rupa Kalahasthi

Free Will: Is this the real life… Is this just fantasy?

“You say: I am not free. But I have raised and lowered my arm. Everyone understands that this illogical answer is an irrefutable proof of freedom.”
― Leo Tolstoy, War and Peace

When you were getting ready in the morning, did you choose the colour of the shirt you would wear today? Do you arbitrarily choose what dish you want to order at a restaurant? Did you voluntarily choose the subject of your undergraduate degree?

All these questions refer to the choice we have, while making decisions in life. The ability to make that choice is what we call free will. Free will is the ability of an agent to select an option (a behavior, an object, a course etc.) from a set of alternatives (Mick, 2008) .

Most people believe that they have free will, and they control their decisions. However, many psychologists and philosophers refute the idea of free will with the idea of determinism. Philosophy defines determinism as a notion that every event or state of affairs, including every human decision and action, is the inevitable and necessary consequence of the antecedent states of affairs. Putting it in simpler terms- all our actions are pre-determined, and we do not really have the freedom of ‘choosing what we want to do’. Daniel Wegner, in his book The Illusion of Conscious Will (2002), states that free will is just an illusion, and we attribute it to be the cause of events, whose actual causes we don’t really understand.

To test whether people really have free will, Benjamin Libet (1982) conducted an experiment, where he measured cerebral activity, and found out that freely, voluntary acts were preceded by a specific electrical change (readiness potential ‘RP’)  in the brain that began about 550 ms before the act. Human subjects became aware of the intention to act 350–400 ms after the RP began, but 200 ms before the motor act. He therefore concluded that the volitional process was initiated unconsciously (through a set of neurological functions), but the conscious function could still control the outcome. Hence, even though his experiments indicated that the choice made by people was not random, but predetermined, the existence of free will could not be completely eliminated.

Furthermore, even in the field of criminology, there is a long standing argument that we do not have free will; therefore, a person’s criminal behavior is determined by environmental, biological and social factors. Many have used this argument in the court of law to justify transgressions. But arguments of this nature haven’t found many takers in the legal system. For instance, American courts are not likely to warm up to the idea of genetic causes behind crime, and tend to stress on the fact the people have the free will to choose between right and wrong (Jones, 2003). Hence, even within the justice system, there is no clear acceptance or rejection of free will.

But what if we do indeed make choices consciously, and only come to know about them much later? Does that mean free will really exists, but we all have misinterpreted how it exactly  happens?  Holton (2004), in his review Wegner’s book The Illusion of Conscious Will (2002) stated that precursor events might be genuinely mental events of which the subject is not aware about until later. This leads to a whole different set of ideas about how free will operates.

People have argued strongly for and against free will, but none seem to have reached a consensus about it. One of the oldest questions to plague the field of psychology still remains unresolved. When I decided to write about this topic, was it my freedom of choice or was it some predetermined set of biological and neurological functions?

Sampada Karandikar

Mental(ity) Testing

Following the murder of a senior police officer at Mumbai’s Vakola Police Station by a colleague (who went on to commit suicide), Mumbai Police Commissioner Rakesh Maria set in motion mental health evaluations for the Mumbai Police force. This implied assembling trained mental health professionals to conduct comprehensive psychological tests on thousands of police personnel in Mumbai. Initial screening would determine which individuals would require further assistance, through awareness lectures and individual treatment. In fact, a senior psychiatrist also wrote an open letter suggesting several ways to curb suicides and promote mental health in the force.

However, how do you screen for mental illness? Typically through a questionnaire or a psychological test. The salient features of such tests are high reliability (consistency in measurement) and validity (they measure what they are supposed to measure). For instance, if you are asked a series of questions about your appetite, sleep patterns, changes in mood, or increasing disinterest in things you usually liked, you’re probably being screened for a mood disorder (depression). Such screening instruments have been developed keeping in mind the science of psychometrics (psycho meaning related to the mind, and metric meaning related to measurement). In essence, these are tools developed for psychological measurement, and have to be administered, scored, and interpreted by trained mental health professionals.

Returning to the mental health check-ups for the police, the tests included questions on physical and mental health, personal and emotional problems, and alcohol use. Tobacco use, which is on the rise among police personnel, was not mentioned as an area of assessment. Such test content is riddled with problems. For instance, it was unclear whether these tests had been translated into Marathi from standardized assessment tools, or were a set of compiled questions. The reason I raise such questions is because the psychometric sensitivity and specificity of such tools is paramount to the efficiency and success of any mental health screening. This basically means that the tests should be able to adequately discriminate between individuals who experience symptoms and those who do not. In the absence of standardized tools, we cannot claim with certainty which personnel require further assistance with mental health interventions; this is because we will not know above which cutoff score the individual’s score must lie, to require further assessment. Similarly, non-standardized psychometric tools runt the risk of being arbitrary when it comes to setting cutoff levels.

Let me explain this with an example. Imagine you’re playing a video game, where you have to collect a certain number of points to advance to the next level. This number is determined by averaging several other players’ scores on the same game. So if you’re above the average score, you’ll move to the next level. Now, unless you have data on other players’ scores (through research), you will not be able to determine the average, which is like the cutoff. If your score on a psychological test (the cumulative number of symptoms you experience) is above average (more than the cutoff), you need to go to the next level (individual treatment and therapy. This may be a crude analogy, but the necessity of having uniform tests for mental health screening, with cutoffs, had to be emphasized.

Using standardized psychometric tests is the first step. The second is to ensure that trained professionals interpret the test results; the dearth of such professionals can be addressed in another post. If the Local Arms Deputy Commissioner wants to allow only mentally fit personnel to be allocated firearms, then the criteria of mental fitness must be clearly defined, in a consistent and valid manner. A recent instance of a lack of face validity (the test does not “look” like it is measuring what it is supposed to measure) occurred with when Air India aspirants claimed that the 10-minute oral test with a psychologist asked irrelevant questions of them. Apparently, questions like “what does your father do?” were asked, which are regular fixtures in job interviews, but definitely not in psychometric assessments.

On the bright side, the DGCA is contemplating regular psychometric tests for pilots, in light of the Germanwings suicide-homicide. Although such evaluations are conducted upon induction into airlines (policy demands it), subsequent testing is absent. Physical health, on the other hand, is assessed every six months, which is characteristic of the lopsided emphasis on the body in lieu of the mind. However, as the DGCA is still designing the protocol for mental health screening and testing, it is important that they focus on the psychometric features of the tools. These include reliability, validity, test length, and areas (subscales) assessed by the test. For instance, whether the tool assesses anxiety and mood symptoms, which may be relevant areas for screening. Using available tools, like the General Health Questionnaire (GHQ) or the Self-Reporting Questionnaire found to have better discriminability, compared to other similar questionnaires (Patel et al., 2008) can be employed after appropriate translations are completed.

Similarly, private organizations may choose to provide support to their employees via Employee Assistance Programs (EAPs). Such initiatives include using psychometric assessments, such as the GHQ or resilience measures, to screen individuals and provide targeted help for dealing with personal and professional concerns. EAPs managed by external counseling agencies are being incorporated into corporate offices, and the initiative taken by Maria could be reframed as an EAP for government officials. However, for EAPs to be efficient, the psychometric tools used are, needless to say, standardized, reliable, and valid.

Addressing mental health in strictly hierarchical professions having long and erratic working hours is crucial. Another similarity between pilots and police personnel is that they’re meant to be responsible for the security and safety of others. Screening for mental illness is a significant step to combat myths and misconceptions associated with the same. However, such assessment needs to be conducted by psychologists and psychiatrists, using reliable and valid tools. Else, individuals with mental health concerns may go under the scanner, and screening may not be sufficient to prevent another fatal incident.

Hansika Kapoor