Question 1

What cultural factors determine how teens cope with anxiety or depression?

Rajesh Sagar · Accepted Answer

Culture can affect both the way anxiety and depression are expressed and how the treatment is accessed. For example, in Asian culture, people more often experience bodily symptoms like disturbed sleep, headache, body pain, anhedonia, or crying spells as compared to western culture. These feelings are sometimes better explained by religious or spiritual beliefs, due to which they would take spiritual guidance or faith healer treatment first and may take a long time before visiting a mental health professional. Sometimes, higher belief in the medical model of illness (than the bio-psycho-social model) hinders the acceptability of non-pharmacological interventions. Those who prefer psychological interventions report larger benefits from culturally specified interventions such as yoga, meditation, and spirituality-based interventions. Further, culture also determines the meaning a person attaches to mental illness. Since expression of emotions and thoughts is not professed regularly and, in fact, at times interpreted and hence stigmatized as a sign of weakness, interventions focused on symptomatic relief, activity, and immediate benefit is preferred over discussion-based models. Suppression of affect or avoidance strategies will often be adopted more frequently than taking an active approach towards problem-solving. Lastly, in my opinion, family factors play a crucial role in protecting against or contributing to, the risk of developing a mental illness. For example, supportive families and positive sibling relationships can protect against the onset of mental illness or provide immense support during the implementation of interventions. On the other hand, a family environment marked by severe marital disharmony, and social disadvantage can contribute to the onset of mental illness. And since with each culture, many sub-cultures vary widely in their understating of mental health and the coping mechanism, interventions are tailored as per the needs of each person for its effective implementation.

Question 2

What mental health conditions do you see the most in adolescents?

Rajesh Sagar · Accepted Answer

Globally, one in seven children experiences mental disorders, contributing to 13% of the overall global burden of disease between the age group of 10-19 years. Most leading causes of illness in children and adolescents are depression, anxiety, and behavioral disorders. Suicide contributes to the fourth leading cause of death among 15-19-year-olds. According to the 2021 State of the World's Children Report, 1 in 7 youth aged 15 to 24 reported feeling depressed during the pandemic in India. As the protracted Covid-19 pandemic continues to pose issues for India, its huge impact on the mental health of young people, who account for roughly 27.5 percent of the population, must be addressed. Major mental health disorders manifest during the adolescent age with a higher risk for those with a genetic predisposition. Negligence in failing to address child and adolescent mental health in the early years of development may lead to limited opportunities for them to lead a fulfilling life as adults.
Depression is the most commonly reported diagnosis among the adolescent population. Mental Health Status of Adolescents in South-East Asia: Evidence for Action report released in 2012 by WHO reported that one in four teens in India were depressed. Depression in adolescents may be difficult to diagnose due to varied presentations making it all the more important to be diagnosed at an early stage. With the advent of technology and the ever-evolving school curriculum, children feel stressed, overwhelmed, and continuously under pressure. Anxiety is another major mental health concern among adolescents. Studies confirm the presence of anxiety not only among urban adolescents but a major percentage of adolescents in rural populations also reported anxiety.
There are various reasons which can contribute to adolescent mental morbidity. Family conflict, peer pressure, relocation, and performance pressure are some of the frequently reported reasons. With the technological advancements, other disorders also seem to be contributing to the deterioration of adolescent mental health like the internet, gaming and smartphone addictions. In current times, it is important to understand the needs and rights of the youth to receive mental health care. If left unaddressed, it can lead to dire consequences. Therefore it is the right time for all the stakeholders to take charge. Every initiative taking place immediately will add to the overall betterment of India's young population.
Some of the initiatives which can contribute to youth mental health care: are the promotion of psychological literacy among the youth in educational institutions. Providing adequate support and resources to children in distress. Capacity building for frontline community workers like ASHAs. Self-help resources to provide information on various mental health, tools to manage it, and knowledge on helplines. Telemedicine and digital technologies like WhatsApp and Facebook groups, and chatbots can be made accessible as an option for intervention. The development and expansion of youth-centric programs can help in reaching out to the youth population.

Question 3

What are some examples of non-western interventions for adolescent mental health? Is mental health pathologized like it is in the west?

Rajesh Sagar · Accepted Answer

Some of the popular non-western interventions include yoga, mindfulness, meditation-based practices, positive religious faith-based coping, and spiritual practices. The community and public health approaches are professed at quite a higher level. 
 
Regarding the second question, in my opinion, mental health pathologization in the non-western setting is comparatively less. One of the chief reasons is the lack of awareness and acceptance of mental health difficulties. Many times, we observe an opposite pattern where – due to the fear of diagnosis/labeling and hence the stigma, sometimes clinically significant symptoms are over-normalized or not acknowledged timely. Tremendous steps have been recently taken by national bodies towards the eradication of stigma and creating public awareness on mental health issues such that timely identification of mental health conditions and appropriate intervention can be initiated.

Question 4

What can be done to help destigmatize and spread awareness of mental health issues in non-Westernised communities?

Rajesh Sagar · Accepted Answer

* Stigma related to mental health is a global phenomenon and therefore must require a collaborative effort involving health workers, educational institutions, the judiciary, and media.

* Non-western countries currently emphasize a lot on the medical model of treatment, therefore more emphasis should be given on bio-psycho-social models of disorders.

* Public education and campaigns are also highly essential, that instead of using psychiatric terminology, employ symptomatic vignettes (using accessible language and pictures) to increase people's knowledge on the breadth of mental health conditions.

* Better awareness among the youth may be achieved by awareness campaigns including educational institutions and information related to culture and age-appropriate social roles.

* Education and awareness go hand in hand; therefore including mental health-related content in school and college curricula can have a great impact on how young people understand and deal with mental health.

* Specific stigma-related beliefs should be addressed for the patients to emphasize the importance. One way of reducing stigma in the patient is by informing that any psychiatric disorder is treatable therefore requires consistency and patience.

* Research should look at how to construct and test large-scale surveys that track people's beliefs with delivering appropriate communication programs targeting the same.

* Importance of mental health-friendly national and state policies, emphasizing the importance of mental health needs.

Stigma does require large scale initiatives. The National Alliance on Mental Illness (NAMI) suggests a few initiatives that can be taken on an individual level to reduce the stigma, which are :

* Use of social media and other mediums to talk openly about mental health 
* Acquiring and sharing knowledge related to various mental health conditions to clear the misconceptions and encourage only use of facts
* Conscious use of language to describe mental health conditions and restricting oneself from loosely using the terms
* Give equal emphasis to mental health just like physical health 
* Showing compassion and acceptance to people with mental illness 
* Normalizing different modalities of  mental health treatment
* Choose empowerment over shame when dealing with mental illnesses

Question 5

Is bullying among teens a universal problem?

Rajesh Sagar · Accepted Answer

Bullying is a social phenomenon that draws people into a social dynamic regardless of their location, financial status, or age. This dominance hierarchy is not limited to the human species but is also seen in animals in terms of the need to have a leader or create one's territory. Bullying may lack a universal definition, but it may, however, be defined as a type of aggression, a behavior intending to hurt someone, it may be by an individual or a group. One of the key features of bullying is its repetitive nature, intention for aggression, and inconsistency of power between the victim and the victimizer. With the advent of technology and connectivity, there are even newer versions of this act in the form of cyberbullying. 
Some of the basic features of bullying may include:
1) Bullying is not a random but an intentional act and therefore depends on a lot of individual characteristics 
2) It can happen across different age groups 
3) It can happen due to severe mental health conditions in the perpetrator. 
4) Effects of bullying can be long lasting and may lead to psychological problems in adulthood 
5) It can be one of the main precursors as a negative event to various mental health issues (Arsenault et al.,2009)
A study conducted across 15 locations across the country has found that 42% of early and middle stage and 36% of secondary and senior secondary stage experienced bullying by their peers. Some of the different ways opted by the perpetrators were teasing, insulting, ridiculing as forms of verbal abuse and physical fights. One important factor contributing to such action has been associated with the lack of social and emotional learning in the early years of schooling. Research on gender differences shows that bullying is present at similar levels in boys and girls however, differences have been seen in the type of bullying; boys are reported to be engaging in overt forms of bullying, whereas girls are engaged in more covert emotional bullying.
According to the psychoanalytical viewpoint, people go through a series of stages in which they meet conflicts between biological drives and social expectations, and how these conflicts are addressed relies on their ability to learn, live with others, and manage stress. According to Sigmund Freud, people use defense mechanisms when they feel overpowering anxiety to protect themselves against unwanted, scary feelings or weaknesses within their psyche or consciousness. The use of defense mechanisms may therefore emanate aggressive behavior such as bullying. According to Erickson, there is a fundamental conflict at every stage of an individual's life, when these conflicts are not resolved, it may lead to negative consequences such as bullying.
Various factors contribute to this activity, such as a bully's individual characteristics like; dominant personalities with high callous unemotionality and conduct issues, positive view of violence and prior experience of violence; common family characteristics, such as a lack of warmth and involvement from parents, inconsistent discipline, a lack of supervision, and exposure to violence at home. The prevalence of bullying and victimization is also influenced by the school's positive or negative climate. Negative school conditions like inappropriate teacher support, a strict school environment, and poor teacher-student relationships can contribute to higher levels of bullying within the campus. If students perceive their school atmosphere to be unpleasant, it may also affect the rate of reporting.
Bullying has the potential to harm children emotionally, physically, and academically. Fear, worry, and low self-esteem are all possible outcomes. Bullied children may be afraid to attend school and other places. They may isolate themselves from others and become unhappy. Some people experience bodily symptoms, including headaches and stomach aches. Bullying can also have long-term consequences like poor scholastic performance and troubled personal and social life. Bullied children and adolescents may develop depression and low self-esteem as adults.

Cyberbullying refers to any bullying that takes place in the digital world. It is the use of technology to harass or target another person. Types of cyberbullying involve offensive name-calling, spreading false rumors, embarrassing pictures, impersonations, and digital threats. India ranked third highest in the world in cyberbullying, around 53% of children reported facing one or different forms of cyberbullying. Therefore, a comprehensive research-based approach needs to be developed and incorporated within the school setup that can educate children regarding cyber ethics and cyber laws. Mental health professionals also play an important role in advocacy and developing school-based intervention programs dealing with children who face harassment in any form.

Question 6

What are the strengths of CBT to use in a non-Western setting? What are the barriers?

Rajesh Sagar · Accepted Answer

One of the key strengths of the CBT approach is its flexibility in accommodating culturally specific experiences. As it offers a very structured approach to treatment, it’s well applicable in most settings. Within the broad framework, changes in language, ways in which concepts are explained, metaphors used to explain the concepts, treatment focus, are the key areas that are adapted to culturally sensitize it. Further, the structured and solution-focused approach of CBT is very useful in offering a feasible intervention to people.

Regarding barriers, collaborative empiricism lies at the heart of CBT, and efforts are made in a similar direction with each client. However, the Guru-chela paradigm, which is very popular in eastern settings, inevitably creates a power hierarchy between therapist and client. This is not necessarily a barrier though, because often, it ensures very smooth rapport and high commitment to the treatment process, the point is that it’s different from what is suggested in the CBT model. Further, it has been observed that most clients prefer to not do therapy tasks or homework assignments outside the sessions. Having more frequent sessions is quite frequently preferred over completing homework assignments. Further, sometimes cultural differences also play a part. For example, in the Indian culture, it is not considered socially appropriate to talk too much about one’s thoughts or emotions, and also at times showing/expressing them can be interpreted as a sign of weakness, especially in males. This makes the task of therapy challenging. Similarly, the belief in the source of a problem outside self makes it difficult to work on internal processes in detail. Thus, a lot of work has been ongoing on the cultural adaptation of CBT for its effective implementation.

Question 7

Are there some general guidelines for making CBT culturally responsive for non-Western and ethnically diverse communities?

Rajesh Sagar · Accepted Answer

Some general guides for making CBT culturally responsive

Use of familiar idioms of distress to suit the cultural and religious needs
Development of culturally relevant material, e.g., Cognitive errors which are understandable in cultural context
Need to explore patient’s belief about healing which may directly reflect on the perception of symptoms, treatment outcome, and health-seeking behavior. For example: How does the patient perceive the symptoms, what could be some of the ways towards healing as understood by the patients 
Need to strike a balance between directive and collaborative delivery of therapy since Indian culture emphasizes the teacher-student model 
Importance of involvement of family taking into consideration the collectivistic cultural dynamics.
With the limited availability of psychotherapists, importance on capacity building to manage accessibility and improve therapist to patient ratio.
Translation of resources in all the possible languages without losing the conceptual meaning 
Religious beliefs can have an underpinning role for various distorted beliefs and misconceptions; therefore exploring the role of religion in a patient’s life becomes all the more important 
Culturally sensitive intervention modules for self-help as well as for the group to address problems with low severity in a larger group. 
Research and development of evidence-based approaches emphasizing the importance of the use of modified CBT techniques in different cultural contexts.

Hinton and Patel, 2017 suggested the following measures to make CBT culturally responsive 
1)     Positive expectancy of treatment can be greatly increased by addressing the symptoms that the patient comprehends instead of the diagnosis; this would also ensure treatment credibility. For example, if the patient believes that he is weak, lacks interest, and has sleep-related issues rather than a diagnosed problem of depression. Informing the patient that the therapy will target these concerns can lead to increased positive expectancy 
2)    Presenting CBT-related information in locally acknowledged spiritual, psychological, and physiological traditions; for example, many Islamic theological reflections curb the use of “should” as it may cause resentment and a sense of despair.
3)    Various culturally acknowledged techniques should be incorporated in the treatment, for example encouraging the practice of Yoga in the Indian population. 
4)    Use of culturally famous proverbs, folklores, and analogies to convey information related to cognitive behavioral therapy.

Question 8

What do you think has and will be the psychological impact of COVID-19 on adolescents and children?

Rajesh Sagar · Accepted Answer

The COVID-19 pandemic is the worst public health and humanitarian crisis faced by the children and adolescents alive today. The containment measures to control its spread included nationwide or regional lockdowns, which included shutting down of non-essential activities, travel restrictions, social distancing or isolation, banning places of social gathering or public recreation (e.g., amusement parks, gyms), and closure of schools and colleges. There has been a significant direct (fear of getting ill or spreading COVID-19) and indirect impact (disruption of daily routine due to containment measures) of the COVID-19 pandemic on the psychological well-being of children and adolescents. They suffer from a wide range of emotional and behavioral problems with varying severity and frequency. There has been an increase in the prevalence of symptoms of depression, anxiety, panic disorder, fear of getting or spreading COVID-19 infection, loneliness, boredom, increased irritability, sleep disturbances, and other sedentary behaviors among children. The risk of psychological distress is higher among children with pre-existing psychiatric disorders or problems, belonging to socio-economically disadvantaged families, and living with parents having high levels of psychological stress. Positive parenting practices and maintaining daily routines as much as possible during the COVID-19 pandemic could help to mitigate the negative effects of COVID-19 on mental health.

Question 9

Hi Rajesh, what is the best way to tackle depression and anxiety caused by migration amongst adolescents in marginal communities?

Rajesh Sagar · Accepted Answer

School-based mental health programs with a focus on teaching life skills to all students can play an important role in tackling the problem of depression, anxiety, and other associated mental health risk factors among adolescents irrespective of their community or socio-economic status. 
Special or extra classes/ sessions should be taken for adolescents from marginal communities to explore additional needs or problems experienced by them in integrating with other students or people in the school/ college or society. Attempts should be made to involve them in the co-development and implementation of proposed interventions aimed at meeting their perceived needs.

Question 10

How do we respond to students who say they feel completely alone at school despite being surrounded by others?

Rajesh Sagar · Accepted Answer

Everyone has different meanings in their mind when they say they are experiencing “loneliness”. Firstly, a genuine attempt to understand what the student wants to mean when he/she says that “they feel completely alone at school despite being surrounded by others” should be made by the school counsellor or mentor/ teacher. {It is not always the lack of people that makes a student feel lonely, but the lack of quality interactions.} Try and explore some of the associated details such as from how long is the student experiencing this, how did it start, is it getting worse or better with time, anything which he/she has observed to help or worsen this feeling….{This shall help to establish rapport and to communicate your interest in listening to their problems}
Second, after initial inquiry and getting to know some general background information about the student, one should explain that different people could experience loneliness due to different reasons. Also, share that this feeling which the student has shared is something not uncommon among people going through his/her life stage. For example, a study showed that about 40% of 16-24 years old said that they felt lonely (often or very often) in a large national survey in the UK. {This shall help them normalize their feelings and reduce the stigma experienced by them in freely sharing their feelings or thoughts}
Third, try and explore if this loneliness experienced by the student is a part of a mental health disorder such as depression, social anxiety disorder, etc., which also have their onset in adolescence and could present with such symptoms. If not sure, a formal screening or a formal consultation with a mental health professional should be arranged or encouraged to rule out any psychiatric disorder. 
Fourth, many times these students might be experiencing some mental health issues like bullying, sexual abuse, neglect by family members, academic difficulties (might be due to specific learning disorder), a recent change in school or class, etc. which might lead to decreased self-esteem and poor socializing skills with other students. A sincere attempt should be made to look out for these possible issues which could be a source of great distress to the child. Many times, children or adolescents would not directly make the link between these problems and their experienced loneliness or outrightly deny these problems due to feelings of shame, guilt, fear, or avoiding hurt to their pride. Thus, one should be careful and sensitive when enquiring about these issues and should not push the child to talk about them if he/she is not comfortable during the initial session(s).
Fifth, involving a friend or parent or another adult (e.g., teacher, relative) with which the student is close and comfortable in this process of exploring the underlying cause of the student’s loneliness and subsequent management is a welcome step and should be encouraged. But, if the child is not comfortable, then a counsellor or mental health professional should take regular sessions with the child (once every 1-2 weeks initially). This is important as having a stable positive relationship with an adult is good for the mental well-being and social and emotional development of children.
Finally, one should try and explore the good things or perceived strengths of the student and give them positive feedback about it. The students should be encouraged to pursue any of their hobbies or interests like playing a musical instrument (which might help them become part of a musical group where they could meet other people with similar interests as their own), dancing (might join a dancing group), any sports (might start playing as a part of a team), poetry or debate (might help them express their feelings and connect with a large number of people through their work), etc. This shall help in improving their self-esteem and also help in improving their feeling of loneliness. {CAUTION: Avoid offering too much advice if the student is not perceptive; But instead, try to position yourself as a secure or a safe place for them without being worried about getting judged or blamed by you}.

Adolescent Mental Health Concerns in Non-Western Contexts