Subsequently, she became interested in Yoga, and to learn more about it, she returned to India in 1978. She completed her postgraduation in psychology from the University of Delhi. From 1980–1985, she worked in the Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh and did her doctoral research on ‘The application of Yoga Therapy techniques in the treatment of Psychoneuroses’. During this period, further work on Yoga was carried out in collaboration with other departments, 5evaluating the effectiveness of Yoga in stress related conditions such as psychogenic headache, burn-out syndrome, and essential hypertension.

She has taught undergraduate and postgraduate students in psychology at the University of Delhi. Currently, she is attached to a hospital in New Delhi as a Consultant Clinical Psychologist. She is additionally working with a public school of repute in the field of school mental health for primary prevention and conducting life-skill education workshops for the adolescents. In recognition of her work, the Royal College of Psychiatrists, United Kingdom awarded her a Conference Fellowship in 2006.

Psychotherapy in different cultures carries different meanings. In traditional or socio-centric cultures, the nature of the individual – be it egocentric or socio-centric – will determine what is acceptable in therapy. Furthermore, if the therapist and the patient come from different cultures and have different values, then the therapeutic interaction will become more complex. Issues of race and ethnicity further complicate this matter.

Professor Vijoy Varma is ideally placed to bring together different perspectives in psychotherapy across cultures. From the origins of Western psychotherapy to common ingredients of psychotherapy, worldview and emotional charge in these settings to the factors embedded in traditional therapies, Professor Varma highlights the therapy and its implications in economic and social costs and training issues. The role of society and social expectations linked with meditation and use of scriptures in therapy all indicate a broad overview in therapies which deals with all kinds of challenges a psychotherapist is likely to face. With case histories he illustrates components of psychotherapy. It is essential that therapists continue to question their own beliefs but also look at what beliefs and views the patient is holding. This is a remarkable book which will be of interest not only to psychotherapists but also to mental health professionals. This volume should be on the shelf of every therapist.

I went into medicine because it was socially valued and was considered to be financially rewarding and because I could compete to get into it. On completing the medical degree, came the issue of the choice of a specialty. This became a more complex exercise. My initial interest was probably for internal medicine, with specialization in cardiology or neurology. Following my role models, the obvious route was to go abroad. America was chosen largely as a route to England and to the coveted MRCP.

Perhaps what attracted me to psychiatry was that, within the confines of this discipline, I could develop and enjoy my interests in philosophy and social sciences. Or could do so without feeling guilty. Where your hobby and your vocation merge, you have real bliss. What is the nature of science? What is the place of an individual in the society? The development of the individual. The development of the society and nation and its problems. Social problems and issues. World peace. Poverty. You can pontificate on all of these. The nature of external reality and how to understand it. What motivates us in doing what we do? What makes us tick?

Apparently, I went into Residency training in psychiatry, because it was more readily available and was better paying. Or the real, “unconscious motivation” may have been my attraction for the functioning of the human mind. In psychiatry, you can move beyond the narrow biological, medical model.

To a large extent what attracted me to psychiatry was psychotherapy. I trained mostly at the University of Michigan graduate programme, which was acclaimed as a major center for Residency training and a proponent of a psychodynamic approach to psychiatry.

In those days, as a part of Residency training, each Resident had to ‘do’ quite a large amount of psychotherapy. We all had up to half a dozen patients, carrying out 2 to 4 sessions a week with each, 40–50-minute sessions. This was supplemented by weekly individual psychotherapy supervision and psychotherapy case conference.

On completion of training and certification, when I returned to India and was fortunate to get a faculty position at the Postgraduate Medical Institute in Chandigarh (PGI), I started what was actually the University of Michigan model. As at Michigan, the training programme at PGI included theoretical courses in psychodynamics and psychopathology. The practical 8training in psychotherapy had several components. It included actual conduct of psychotherapy, individual supervision by a faculty member, and psychotherapy case conferences.

For almost three decades, I taught psychodynamics and psychotherapy at the PGI. The theoretical courses included these and individual psychotherapy supervision. All along, I remained the faculty member conducting psychotherapy case conferences which are detailed more fully in this volume.

The place and practice of psychotherapy has undergone a sea change perhaps globally in the last four decades that I have been involved with it. There has been an explosion in psychopharmacology, starting with the invention of the first modern drugs, chlorpromazine and imipramine. Starting in 1970s, greater attention was paid to neurotransmitters, relating both symptoms and side-effects of medication to those, as also the mechanism of action of most of medicines. For example, the dopaminergic system was implicated in psychotic symptomatology. Antipsychotic medication intervened in it, but also produced extra-pyramidal side-effects mediated through it. The conventional antidepressants acted through both the serotonin and norepinephrine transmitters. Somewhat later, came the selective serotonin reuptake inhibiters (SSRIs), which worked exclusively on the serotonin system.

Fortuitously, chance brought me back full circle. On my retirement from the PGI, I relocated back to the United States; to my second stint here, “a Hindu re-incarnated in America.” On my return here, I found that the psychotherapy that I had been trained so assiduously and what I myself taught for decades had just disappeared. Or, it was no longer available to me as a psychiatrist. On account of the pecuniary considerations, psychiatrists can no longer afford to practice psychotherapy. Psychotherapy has been largely taken over by the non-medical mental health professionals like psychologists, social workers, educators, counselors, etc. I felt sort of cheated! I have no problem, let me clarify, with the non-medical professionals doing psychotherapy, but I thought that psychiatrists also should be able to do so.

In a popular article, A HINDU REINCARNATED IN AMERICA, I mentioned: “I started from my home country India for the US. Unfortunately, I ran short of money. I could not quite make it to the United States of America. Instead, I ended up in the (Fragmented) City of New York.” In a way, I ended up in the fragmented state of psychiatry!

In the last 30 years or so, psychotherapy globally has also undergone many changes. Psychodynamic models have been supplemented by approaches, notably such as cognitive-behavioral and interpersonal. More than anything else, medication has usurped the practice of psychotherapy. “A pill for every ill.”

However, the problems and limitations of drug therapy are becoming increasingly apparent. First is the issue of side-effects. Like I tell my patients, all drugs have side-effects. There is no drug known to man which does not. You take a drug for its effects on a particular system. But the drug does not know that; that it should work only on the brain and not on other systems. Side-effects are the logical effects of drugs on other systems.

The more important problem with drug therapy is the lack of full effectiveness. They work so far, but no further. In psychotic disorders, they have good effect on positive symptoms, 9but their effect on negative symptoms, disorganization and functional ability and in improving the quality of life remains quite short of optimal. “Hanging in there,” my patients often remark in response to my query, (after they have said “pretty good,” a very peculiarly meaningless American phrase, as I learnt over four decades ago, on my first contact with American patients). Very infrequently, you receive a fully satisfactory response from them. The experience is particularly frustrating in depressed and bipolar patients; from time to time, one wonders if medications are any good!

Of course, both medications and psychotherapy have their limitations. “An awareness of one's limitations and fallibility” is actually a hallmark of a psychiatrist.

In addition to being a treatment modality, psychotherapy is an excellent method of developing an ability to listen to the patient, to empathize with him, to develop sensitivity into the personality and its operations, which more than any other attribute distinguishes a psychiatrist.

For reasons not clear to myself, I have a rather obsessive fascination with differences across places, countries, societies, cultures. Whenever I go any place, I seem to be comparing it with my native place, as also other places, on both material culture and cultural and social variables. It is possible that this has led to my interest in transcultural psychiatry and psychotherapy. My travels and professional work in other countries may have indirectly further reinforced my transcultural perspective.

The other problem that I encountered on my return to India after psychiatric training was a cultural one. The patients you saw there did not fulfil the criteria as described in the Western books. It was like fitting a square peg in a round hole. You could not very well carry out psychotherapy by the Western rules. Of course, much has been written on these matters, and people have become increasingly aware of it.

Much of the present volume is addressed to these cultural differences. What are the social, psychological and cultural variables that may be relevant to psychotherapy? How to adapt psychotherapy across cultures? Transcultural issues are relevant not only for adapting the conventional Western-model psychotherapy to India. In America also, there are important issues: psychotherapy with minorities, African-Americans, Hispanics, immigrants, psychotherapy by immigrants. Cultural competency has emerged as a catch-phrase.

Overall, we live in an increasingly shrinking world, which is rapidly reducing the world virtually to a global village. The ease of travel, exploration and migration have resulted in increasing familiarity with and interest in other societies, other cultures, other religions and other philosophies. Differences across countries have been taken note of—from differences in personality to social organization, to mental illness and its treatment. This is the reality. As professionals, we must be aware of it, and adapt to it!

Coming back to the moot issue: I had seen a Bollywood movie ‘Fanaa’ in end-May 2006 in which a piece of dialogue from the movie had impressed me (Why- I do not know exactly?). In essence that particular dialogue, as per my understanding, meant—”To choose/decide between what is right and wrong is not difficult; most difficult is to choose which is better of the two available right ways, OR to choose which is more appropriate of the two available wrong ways as these decisions decide our lifepaths”. Maybe- it sounded too psychotherapeutic to me, and just helped in re-kindling the psychotherapy component of my mind. Within a fortnight of this experience Professor Varma came on a brief visit to UK, leading onto our discussions about psychotherapy in general and his rich experience and work in particular.

I just felt that although I had the fortune of having been taught by him (especially psychodynamics and psychotherapy) and my esteemed teachers, during my Junior Residency, there had always been something ‘missing’ for me during my professional career till date. Probably I have always felt that Indian Psychiatry, though so rich in knowledge, concepts and skills, suffered from the lacunae of not having a readily available resource related to the theory and practice of psychotherapy in India. Still, Indian psychiatrists have to rely on scholarly western treatises on psychotherapy during both training and practice, and addressing issues related to application of ‘western’ concepts in an ‘eastern’ setting (or with an ‘eastern’ mind) is done through supervision/discussion with peer(s) with/without personal experience/intuitiveness.

Personally, I have dreamt and envisaged that this compilation of Professor Varma's rich knowledge and experience of ‘context, concept and practice of psychotherapy’ (along with additional input from our invited contributors) serves as a useful resource for trainee and practicing colleagues in India in the years to come.

The idea of this book germinated during a lecture tour to England in June of 2006. Why not put together my many ideas about transcultural psychiatry and psychotherapy in a book form; ideas that I have talked and written about in my professional career, as a psychiatrist, over a span of over 30 years. Many of these have been published in some form or the other, but then, many have not, and exist only as my lecture notes, transparencies and power-point presentations. As I commented to one of my students, I wanted to put in black and white “before it is too late, before I am gone.”

My ex-student and co-author, Dr. Nitin Gupta, initiated the idea of the book and encouraged me in this endeavour. The first major input came when Nitin spent a week with me in the US in the autumn of 2006, having spared the time from his job in England. I would also like to acknowledge the help of his 9-year-old daughter, Aadrika, who accompanied Nitin during this trip, and was a great company and help to both of us. During this time period, the framework of the book was laid, and most importantly, the case vignettes of the psychotherapy cases were deciphered and written down.

The second major input came during my trip to India in February-March 2007, when I came in contact with a remarkable medical professional, Professor Harsh Mohan, of Chandigarh Medical College. He guided us in the nitty-gritty of compilation of the book and its publication. Professor Mohan has been involved with all aspects of the preparation of the book, and has been an invaluable guide.

Nitin took the advantage of his US trip of May 2007 to attend the annual meeting of the American Psychiatric Association and spent a long week with me. During this period we could complete a prodigious amount of work, about a chapter a day.

Another medical professional who has been very helpful was Dr. Niraj Ahuja. With a considerable amount of experience in publishing edited books, he was of immense help to both Nitin and me. We constantly used him as our “go to” resource. My younger brother, Air Marshal Lalji K Verma (Retired), who has recently published his own book on hospital waste management, gave a number of valuable tips about the process.

In order to make our work more comprehensive, we decided to add chapters on other psychotherapeutic approaches relevant to India. As such, we invited chapters on therapies such as yoga, vipassana, and transcendental meditation. Another chapter was invited to deal with eclectic approaches to psychotherapy. We are grateful to the authors who took up these challenges.

During the course of psychotherapy case conferences conducted by me at the Postgraduate Medical Institute in Chandigarh, India, a number of cases were discussed. I kept a record of the cases and the discussions. Looking at those, we could decipher almost 1250 cases. Ten have been selected for presentation in this volume. We are grateful to the respective Residents who carried out and presented the psychotherapy sessions. The cases presented in the vignettes in the book were presented by the following Residents (in alphabetical order): Dr. RK Agarwal, Dr. Rakesh Chadda, Dr. S. Chatterjee, Dr. RC Jiloha, Dr. Sameer Malhotra, Late Dr. KP Mangalwedhe, Dr. Balaji Motamarri, Dr. Rashmi Parhee, Dr. G Prasad Rao, and Dr. Gagandeep Singh. We are also grateful to the various consultants who referred the cases for the psychotherapy case conferences and to the Residents who made the presentations in the Psychotherapy Case Conferences. We are grateful to Professor Param Kulhara for the permission to present the cases.

Looking at my earlier relevant publications, my co-author, thought that we must reprint my published article, which was the subject of Dr DLN Murty Rao oration, earlier delivered by me. I sincerely appreciate the kind permission by the Editor of the Indian Journal of Psychiatry to reprint this article.

I am also grateful to the members of my family for supporting me during this endeavor. I am extremely grateful to Mr. Tarun Duneja and his colleagues at Jaypee Brothers Medical Publishers (P) Ltd., for their ever-helpful attitude, cooperation and professionalism

Finally and most importantly, we are thankful to the patients who were the ultimate source on which the whole exercise has been based.

My initial-most thoughts of gratitude are for my parent Institute, more importantly—my department (where I learnt my psychiatry), and most importantly—all my teachers (from whom I learnt the theory and practice of psychiatry, including the nuances of psychotherapy) and the patients (the pillars on whom this book, and my concepts, have been developed).

I have no words to express the depth of my feelings and gratitude for one individual; and that is my erudite teacher Professor Harsh Mohan. He has been a pillar of strength, support and sound advice throughout this venture. He kept a tight rein on things (including me) with his unflappable approach, and was par excellence regarding any aspect related to the publication process of this book. I personally have learned a lot from him in the last one year.

Certain colleagues (especially Dr. Pratap Sharan, Dr. Niraj Ahuja, Dr. Mrigendra Das) have been extremely helpful in providing a ‘listening ear’, ‘pieces of advice’, and ‘practical support’. My sincere thanks to them.

Thank you to all the authors and contributors whose thoughts are penned under different forms across the book.

I am extremely grateful to Mr. Tarun Duneja and his colleagues (especially Mrs. Y Kapoor, Senior Desktop Operator) at M/s Jaypee Brothers Medical Publishers (P) Ltd., for their professionalism, dedication, and speedy and skillful work.

At a personal level, my family has been a huge support and my source of ‘displacement’ and ‘sublimation’. Thanking them would probably be something that they may not appreciate (“family members aapke sukh-dukh mein saath rehti hain aur madad karte hain, unka shukriya in cheezon ke liye zaroori nahin hota”), but still….. Shukriya from the heart! Additionally, I retrieved my mentor's words of advice from my memory to provide me the much-needed ‘psychotherapy’ during difficult times in the whole process. Thank you ‘Guruji’ for being there despite the physical distance!

Last, but not the least, a BIG ‘Thank You’ to Professor Varma himself for his magnanimity at various times, and having confidence in me as a co-author for this venture. as, for me this book is his book—a compilation of four decades of his work in psychotherapy.

In the developing world, the biological model has sometimes been used as an argument for not being able to practice psychotherapy and to cover up for the ‘lack of available time’, which psychiatrists, as indeed most doctors, have often moaned about [see Nunley's (1996) article on “Why psychiatrists in India prescribe so many drugs”]. This is despite a rich history and tradition of psychotherapy in some of the developing countries, particularly India. In a sense, these psychiatrists might find comfort in Karen Horney's statement (Our Inner Conflicts, 1945) that psychotherapy “…is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist”. However, for many of our patients, life can be a very painful therapist, without the guidance and support of a trained psychotherapist.

It is therefore timely and apt that a textbook on Psychotherapy should emerge from the pen of Professor Vijoy Kumar Varma who is an authority and a ‘master’ in the art and science of psychotherapy. Whereas many of his contemporaries joined the popular bandwagon of biological psychiatry, Professor Varma had the vision and flair for popularising psychotherapy in almost a single-handed manner. After his initial medical training in India and residency training in the United States in the sixties, Professor Varma joined the faculty of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India in 1969. He was instrumental in introducing a mandatory supervised psychotherapy training course of 100 hours, for the postgraduate trainees at the prestigious Institute.

Apart from his experience in USA (where he is teaching as a Professor now) and India, Professor Varma has a rich experience of working in different cultures like London (UK), Vilnius (Lithuania) and Benghazi (Libya). Recently, he has served as the Secretary of the World Psychiatric Association's Transcultural Psychiatry Section. He has won virtually all the major national awards in Psychiatry, including Dr DLN Murti Rao Oration Award, Dr BC Roy National Award (as an eminent medical teacher), Dr Vidya Sagar Award (Indian Council of Medical Research's Award for Research in Mental Health), the Platinum Jubilee Lecture of the Indian Science Congress and Dr NN De Oration Award.17

“Psychotherapy in a Traditional Society: Context, Concept and Practice” has benefited hugely from his vast experience in the field of psychotherapy, transcultural psychiatry, and cultural and social dynamics of mental health, illness and psychotherapy. He is ably assisted by Dr Nitin Gupta, Consultant in Adult Psychiatry in England, who had previously trained under the supervision of Professor Varma in India and is therefore able to draw on his personal experiences of training in psychotherapy.

The book is intended for a student of psychotherapy, one who is just beginning to embark on training as well as the one who is a trained psychotherapist and is returning to update his/her skills. It is often the older and more mature clinician who is able to look at his/her own repertoire of skills and look at what he/she can do to make them better, as an integral component of continuing professional development. As Oscar Wilde said, “I am not young enough to know everything”.

Reading books, good supervision, discussion with peers, attending workshops and learning from the patient(s), are all excellent and non-mutually exclusive resources of learning. The introduction of illustrative case vignettes in the book has ensured that this book is not only an introductory resource but also a treasure trove that one can keep returning back to.

The book is divided into four sections: Theoretical basis of transcultural psychotherapy; Practice of individual psychotherapy in a traditional setting; Other non-dynamic psychotherapies; and an epilogue reflecting on thoughts and directions for an Indian model of psychotherapy for the future.

Drawing from his rich experience of practice in both cultures, Prof Varma offers comparisons between the Western and the more traditional cultures, after introducing the model of the Western psychotherapy first.

Some of the concepts well described in the book include: dependence vs. autonomy; guilt vs. shame; role of family in different cultures; traditional practices and techniques; prevalent religious and socio-cultural belief systems (including karma, sanskara and re-incarnation); and the role of mythology.

The invited chapters on Yoga, Transcendental meditation, Vipassana meditation and Eclectic psychotherapy in India have been written by very experienced practitioners and teachers in the field, many of whom had benefited from training with Professor Varma during the period of their own postgraduate education.

“Psychotherapy in a Traditional Society: Context, Concept and Practice” is directed at anyone who practices or intends to practice psychotherapy in a multi-cultural, multi-ethnic society where it would be helpful to suitably modify one's techniques to the transcultural issues relevant to the patient. Therefore, this book is equally relevant to a psychotherapist practising in the Indian subcontinent as it is for the one practising in UK or US where increasing cultural and ethnic diversity poses escalating challenges to the practice of psychiatry and psychotherapy.

Apart from his vast experience in teaching and training in Psychiatry and Psychotherapy, Professor Varma is well known for his versatile personality. His artist predisposition is quite evident by his deep love for poetry and Urdu shairi. This outstanding combination of scientific 18and artistic temperament suited him well to teach and practice the art and science of Medicine, Psychiatry and Psychotherapy. Each chapter in the book begins with a relevant couplet from his rich collections of poems, ghazals and shairi, to set the scene for the topic.

We have immensely enjoyed reading the book and hope that it will become an invaluable individual as well as library resource for anyone who desires to understand the transcultural issues to become an effective practitioner of psychotherapy anywhere in the World.