Push and Pull: Role of Therapist Mentalizing in Navigating Therapeutic Distance

In the relational playground of psychotherapy, negotiating therapeutic distance is crucial for the process as well as the outcome of treatment. The challenge of navigating this closeness and distance may be accentuated during emotionally charged interactions in therapy. Therapist and client may get locked in complementary, rigid positions, leading to either submission or resistance to the others' demands. The therapist's ability to respond appropriately to these pushes and pulls is supported by their ability to mentalize, which is their ability to attend to and understand their own states of mind while being aware of others' states of mind. Therapists are expected to maintain a mentalizing stance throughout and despite the relevance and impact of therapist mentalization, there is relatively less research, training, or practice-related guidance on how to maintain this balance. We use case illustrations to demonstrate therapeutic interactions that can trigger non-mentalizing for the therapist and reflect on ways of recognizing and addressing these patterns related to closeness and distance. We also share recommendations for reflective practice and supervision, training as well as research on therapist mentalization.

Development of an IEC resource (brochure) on suicide prevention for college students: A qualitative study in the Indian context

BACKGROUND

Information Education Communication (IEC) materials play a vital role in behavior change by raising awareness about health issues. In India, suicide is the leading cause of death in the age group of 15-39 years, exemplifying the pressing need for raising awareness about suicide prevention. This study aimed to develop a brochure on suicide prevention for young adults with the help of scientific methodology.

MATERIALS AND METHODS

A cross-sectional qualitative research design was used in the study, and purposive sampling was used to collect the data. The study analyzed the awareness level and existing knowledge gap about suicide prevention among college students with the help of focus group discussions (FGDs) conducted independently among mental health experts, college teachers, and college students. Based on the findings from the FGDs, a comprehensive brochure was developed. The qualitative data collected by FGDs were analyzed using direct content analysis.

RESULTS

The findings of the FGDs helped identify the knowledge gaps with regard to young adult suicide prevention, and a brochure was prepared to address the same.

CONCLUSION

The development of young adult suicide prevention IEC resources pertinent to Indian settings is crucial. To bridge the knowledge gap on suicide prevention among college students and raise awareness, a brochure was developed based on scientific findings of the FGDs.

Effectiveness of multi-disciplinary structured training program on mentoring and mental well-being for officers and instructors in the Indian Air Force

Background

The military environment is characterized by unpredictable situations, intensive training, demanding workload, and job-associated stressors, which make it highly stressful. Mentorship and mental well-being training could be beneficial to both officers and the new adolescent recruits of the Indian Air Force (IAF).

Aim

This study aimed at evaluating the effect of a multi-disciplinary structured training on mentoring and mental well-being among officers and instructors in the IAF.

Methods

Seventy IAF officers/instructors underwent a week-long multi-disciplinary structured training program, which was conducted at a tertiary care neuro-psychiatric hospital in South India. A quasi-experimental design with a single-group pre- and post-test was adopted. Outcome measures included a) knowledge on mentorship and mental health and b) self-perceived competence in addressing mental health distress.

Results

Post training, there was a statistically significant improvement in scores on mentorship/mental health knowledge and a significant increase in self-perceived competence in addressing mental distress.

Conclusion

Mentorship and mental well-being training for officers and instructors in the IAF improved mental health knowledge and self-perceived competence. Therefore, administration of regular and in-depth structured mental health-related training interventions could be beneficial not only to the officers but also to the new recruits/mentees in the IAF.

Reasons for recovery and readiness to change among adolescents and young adults engaging in self-injury

Background

Non-suicidal self-injury (NSSI) typically begins during adolescence and the process of treatment and recovery can be challenging. We examine NSSI through the lens of the Transtheoretical Model of Change, a framework that views the process of change as five stages, with differing degrees of readiness to change.

Methods

Thirty participants, both adolescents and young adults (14 to 35 years), were recruited from a tertiary care neuropsychiatric hospital. The participants were predominantly female and had self-injured at least once in the last year. They completed the Inventory of Statements about Self Injury, the University of Rhode Island Change Assessment and the Reasons to Stop Self-Injury Questionnaire.

Results

Seventy-three percent were in the contemplation stage with respect to their readiness to change, while the rest were in the pre-contemplation stage. Participants endorsed a range of vulnerability and resilience related reasons to stop injuring; reasons related to self-efficacy, the addictive nature of NSSI, self-efficacy and impact on interpersonal relationships were prominent levers for the recovery process. Preliminary trends indicated that participants in the contemplation stage endorsed reasons to stop self-injuring more strongly than those in pre-contemplation.

Conclusion

The findings carry implications for assessment, the amplification of reasons for recovery and individualized interventions to support the recovery process with individuals who engage in NSSI.

Contextualizing motherhood in persons with borderline personality vulnerabilities: cultural adaptation of the parent development interview-revised in an Indian context

An understanding of the complex intersection of borderline personality vulnerabilities and motherhood calls for an integrative and culture-sensitive lens in assessment and therapeutic interventions. The aim of the study was to explore constructions of motherhood in an Indian context to inform the adaptation of the Parent Development Interview-Revised (PDI-R) for use with mothers with borderline personality vulnerabilities. A stepwise framework was followed to obtain conceptual, semantic, and operational equivalences for the PDI-R adaptation. Interviews on contextualised aspects of motherhood were conducted with a sample of eight mental health practitioners specializing in borderline personality disorders, women's mental health or child psychology, two cultural psychologists, one gynaecologist and one paediatrician. Six emergent themes were identified through thematic analysis, 'The ideal mother and her search for identity,' 'Mothering the mother and the vicissitudes of care,' 'Not just mine - negotiating boundaries,' 'Mother knows best,' 'Food, feeding and embodied nurturing,' and 'Approaching motherhood in the clinic.' The proposed adaptations to the PDI-R were further reviewed by two experts, a clinical psychologist and a psychiatrist specialised in perinatal services. This was followed by the process of operational equivalence through administration of PDI-R with two mothers with borderline personality vulnerabilities and two mothers from the community. The expert review and the administration informed the final adaptation of the PDI-R. A systematic process of adaptation can support the use of measures like the PDI-R in different cultures. A contextual understanding of constructions of motherhood and borderline personality has potential to support meaningful assessment and targeted parenting interventions.

Safeguarding adolescent mental health in India (SAMA): study protocol for codesign and feasibility study of a school systems intervention targeting adolescent anxiety and depression in India

INTRODUCTION

Symptoms of anxiety and depression in Indian adolescents are common. Schools can be opportune sites for delivery of mental health interventions. India, however, is without a evidence-based and integrated whole-school mental health approach. This article describes the study design for the safeguarding adolescent mental health in India (SAMA) project. The aim of SAMA is to codesign and feasibility test a suite of multicomponent interventions for mental health across the intersecting systems of adolescents, schools, families and their local communities in India.

METHODS AND ANALYSIS

Our project will codesign and feasibility test four interventions to run in parallel in eight schools (three assigned to waitlist) in Bengaluru and Kolar in Karnataka, India. The primary aim is to reduce the prevalence of adolescent anxiety and depression. Codesign of interventions will build on existing evidence and resources. Interventions for adolescents at school will be universal, incorporating curriculum and social components. Interventions for parents and teachers will target mental health literacy, and also for teachers, training in positive behaviour practices. Intervention in the school community will target school climate to improve student mental health literacy and care. Intervention for the wider community will be via adolescent-led films and social media. We will generate intervention cost estimates, test outcome measures and identify pathways to increase policy action on the evidence.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the National Institute of Mental Health Neurosciences Research Ethics Committee (NIMHANS/26th IEC (Behv Sc Div/2020/2021)) and the University of Leeds School of Psychology Research Ethics Committee (PSYC-221). Certain data will be available on a data sharing site. Findings will be disseminated via peer-reviewed journals and conferences.

How can we mainstream mental health in research engaging the range of Sustainable Development Goals? A theory of change

Mental health is a leading cause of ill-health worldwide, disproportionately affects low-and-middle-income countries and, increasingly, is considered relevant across the Sustainable Development Goals (SDGs). Hence, we ask: How can we mainstream mental health in research engaging the range of SDGs? We use the UK Research and Innovation Global Challenges Research Fund (GCRF) as a case study. In a previous scoping review, we purposefully sampled non-mental health focused GCRF grants for diversity from 2015 until May-end 2020 (N = 36). In the present study, the principal investigator of each grant in this sample was invited to interview (11 accepting). Snowballing, our networks, and returning to the funding archive secured a further 15 interviews sampled for diversity (Final sample: 13 UK researchers and 13 of their overseas collaborators). A thematic analysis of this data organised key information into a trajectory from the challenges of incorporating mental health impact, to how these challenges might be overcome and, finally, to support needs. This analysis was then organised into a Theory of Change designed to promote the mainstreaming of mental health in global challenges research. We outline the implications for global challenges researchers, mental health practitioners, and global challenge research funders. One important implication is that we provide evidence to encourage funders to engage with the desire of researchers to contribute more broadly to the wellbeing of the communities with whom they work.

The conceptualization and assessment of social cognition in personality and common mental disorders

Social Cognition is a crucial transdiagnostic construct with clinical and functional relevance across a range of neuropsychiatric disorders. Most research has focused on schizophrenia and autism spectrum disorders and has informed frameworks for assessing social cognition in schizophrenia. The current review focuses on the more recent developments pertaining to personality and common mental disorders (PCMDs). Two main questions are addressed: 1. What are the important domains and patterns of social cognition impairments among the personality and common mental disorders? 2. What are the trends in the assessment of social cognition among personality and common mental disorders? We synthesize research findings on the conceptualization of SC and the application of these frameworks for assessment with PCMDs. We have outlined a typology of criteria and guidelines for selecting and developing measures of SC in the PCMDs. We conclude that there is a need for a reconceptualization of social cognition or PCMDs with a focus on higher-order processes and suggest that mentalization could be a suitable framework to understand and examine social cognition in the PCMDs. Future efforts to develop, adapt and use more complex, nuanced, sensitive, and culturally valid measures of social cognition in interpersonal contexts can aid the detection of subtle, context-dependent, and dynamic impairments across these disorders. Social cognition is a promising transdiagnostic construct and warrants more conceptual clarity and research on the varied patterns of impairments across disorders.

Associations between countertransference reactions towards patients with borderline personality disorder and therapist experience levels and mentalization ability

OBJECTIVE

This exploratory study locates countertransference as a pan-theoretical concept, comprising of thoughts, feelings, and behaviors expressed or experienced by therapists toward their patients. It aims to understand the patterns of countertransference experienced in working with borderline personality disorder. Associations between countertransference reactions and therapist-related variables of experience and mentalization ability are also examined.

METHOD

Psychotherapists (n = 117) completed the Therapist Response Questionnaire to assess patterns of countertransference experienced with a representative patient diagnosed with borderline personality disorder. They also completed a measure of mentalization ability that examined self-related mentalization, other-related mentalization, and motivation to mentalize.

RESULTS

The profile of responses across eight countertransference dimensions is discussed, with the most strongly endorsed reactions being positive/satisfying, parental/protective, and helpless/inadequate. More experienced therapists reported less negative countertransference reactions in select dimensions. Therapists' self-reported ability to reflect on and understand their own mental states was negatively correlated with a range of difficult countertransference experiences. There were few associations between their ability to make sense of others' mental states, the motivation to mentalize, and the strength of their countertransference reactions.

CONCLUSION

The implications for countertransference management as well as therapist training and development are highlighted.

Supported employment programme for persons with severe mental disorders in India: A feasibility study

BACKGROUND

A number of persons with severe mental illnesses are unable to prepare for, find or keep a job due to factors linked to their illness as well as psychosocial issues.

AIM

To test the feasibility of a supported employment programme to help persons with severe mental disorders obtain and sustain employment.

METHODS

A supported employment programme was developed for persons with severe mental disorders with components of (a) assessment of vocational potential, (b) vocational counselling, (c) networking and liaison with prospective employers, (d) job-related training and placement and (e) continued support for 6 months. Job placement status, social occupational functioning and disability (quantitative data) and benefits of enrolling in the employment programme (qualitative data) were assessed.

RESULTS

A total of 40 employers were liaised with for providing job placement and reasonable accommodation. Out of 63 participants recruited into the study, 32 (50.8%) participants were placed in competitive jobs, placement was actively attempted for 17 (27.0%) participants, 7 (11.1%) were referred for skill training and 7 (11.1%) dropped out from the study. The disability score significantly reduced and socio-occupational functioning significantly improved in those who were placed over a period of 6 months.

CONCLUSION

The supported employment programme was found to be feasible as it showed good placement rates and improvement in socio-occupational functioning and disability scores.

Neurasthenia: tracing the journey of a protean malady

Neuresthenia has had its popularity waxing and waning over the years. This review article traces the path and trajectory of the concept of this disorder, how it changed and varied over time, to the current times, when it has been almost forgotten and the concept is heading towards oblivion. Although its place in the diagnostic systems is currently in question, neurasthenia is still part of professional conversations and practice. The concept of neurasthenia emerged at the intersections of clinical, cultural and sociological dimensions of society. A deeper examination of how neurasthenia was situated at the intersections of race, class and gender exemplifies how psychiatric diagnoses may reflect and shape societal biases. The neurasthenia label has all but disappeared from contemporary nosological frameworks, however, there is a proliferation of other disorders, e.g. chronic fatigue syndrome, fibromyalgia, that try to capture the experience of fatigue, pain, weakness, and distress even in the absence of clear-cut medical aetiologies. Only time will tell, if this concept has indeed been buried, or will rise as a phoenix in the years to come. Newer nervous fatigue syndromes are expected to emerge from the use of technology, screen time and the virtual world.

The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity

BACKGROUND

Recognizing the need for good quality, scientific and reliable information for strengthening mental health policies and programmes, the National Mental Health Survey (NMHS) of India was implemented by National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, in the year 2015-2016.

AIM

To estimate the prevalence, socio-demographic correlates and treatment gap of mental morbidity in a representative population of India.

METHODS

NMHS was conducted across 12 Indian states where trained field investigators completed 34,802 interviews using tablet-assisted personal interviews. Eligible study subjects (18+ years) in households were selected by a multi-stage, stratified, random cluster sampling technique. Mental morbidity was assessed using MINI 6. Three-tier data monitoring system was adopted for quality assurance. Weighted and specific prevalence estimates were derived (current and lifetime) for different mental disorders. Mental morbidity was defined as those disorders as per the International Statistical Classification of Diseases, Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR). Multivariate logistic regression was conducted to examine risk for mental morbidity by different socio-demographic factors. Survey was approved by central and state-level institutional ethical committees.

RESULTS

The weighted lifetime prevalence of 'any mental morbidity' was estimated at 13.67% (95% confidence interval (CI) = 13.61, 13.73) and current prevalence was 10.56% (95% CI = 10.51, 10.61). Mental and behavioural problems due to psychoactive substance use (F10-F19; 22.44%), mood disorders (F30-F39; 5.61%) and neurotic and stress-related disorders (F40-F48; 3.70%) were the most commonly prevalent mental morbidity in India. The overall prevalence was estimated to be higher among males, middle-aged individuals, in urban-metros, among less educated and in households with lower income. Treatment gap for overall mental morbidity was 84.5%.

CONCLUSION

NMHS is the largest reported survey of mental morbidity in India. Survey estimated that nearly 150 million individuals suffer from one or the other mental morbidity in India. This information is to be used for planning, delivery and evaluating mental health programming in the country.

Carbapenem-resistant Enterobacteriaceae in patients with bacteraemia at tertiary hospitals in South Africa, 2015 to 2018

Enhanced surveillance for CREs was established at national sentinel sites in South Africa. We aimed to apply an epidemiological and microbiological approach to characterise CREs and to assess trends in antimicrobial resistance from patients admitted to tertiary academic hospitals. A retrospective analysis was conducted on patients of all ages with CRE bacteraemia admitted at any one of 12 tertiary academic hospitals in four provinces (Gauteng, KwaZulu-Natal, Western Cape and Free State) in South Africa. The study period was from July 2015 to December 2018. A case of CRE bacteraemia was defined as a patient admitted to one of the selected tertiary hospitals where any of the Enterobacteriaceae was isolated from a blood culture, and was resistant to the carbapenems (ertapenem, meropenem, imipenem and/or doripenem) or had a positive result for the Modified Hodge Test (MHT) according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. A positive blood culture result obtained after 21 days of the last blood culture result was regarded as a new case. To distinguish hospital-acquired (HA) from the community-acquired (CA) bacteraemia, the following definitions were applied: the HA CRE bacteraemia was defined as a patient with CRE isolated from blood culture ≥ 72 h of hospital admission or with any prior healthcare contact, within 1 year prior to the current episode or referral from a healthcare facility where the patient was admitted before the current hospital. A case of the CA CRE bacteraemia was defined as a patient with CRE isolated from blood culture < 72 h of hospital admission and with no prior healthcare contact. The majority of carbapenem-resistant Enterobacteriaceae (CRE) (70%) were hospital-acquired (HA) with Klebsiella pneumoniae being the predominant species (78%). In-hospital mortality rate was 38%. The commonest carbapenemase genes were bla-_OXA-48 (52%) and bla-_NDM (34%). The high mortality rate related to bacteraemia with CRE and the fact that most were hospital-acquired infections highlights the need to control the spread of these drug-resistant bacteria. Replacement with OXA-48 is the striking finding from this surveillance analysis. Infection control and antibiotic stewardship play important roles in decreasing the spread of resistance.

Barriers to Professional Help-seeking for Distress and Potential Utility of a Mental Health App Components: Stakeholder Perspectives

Introduction

A high prevalence of common mental disorders and the associated treatment gap, particularly in low and middle-income countries such as India, calls for novel mental health approaches with widespread reach. There is a need to enhance our understanding of the barriers experienced by distressed persons as well as to utilize these insights for breaking such barriers. Despite the rise in the use of technology-based solutions in the field of mental health, there is a dearth of app-based interventions that help in breaking barriers to seeking professional help for mental health concerns in distressed persons. The present study aimed at exploring the perspectives of distressed persons concerning barriers to seeking professional help for mental health concerns. It also sought to understand their perspectives on the perceived utility of proposed app components for breaking these barriers.

Methods

The study utilized a cross-sectional exploratory design. The sample included two groups of distressed participants who could be considered potential users (and thereby the stakeholders) of a mental health app under development for common mental health concerns: distressed treatment seekers (D-TS) and distressed non-treatment seekers (D-NTS). The D-TS group included 10 individuals (average age: 33 years; six men) with self-reported or clinician-reported depressive and anxiety symptoms at intake who were seeking help from mental health professionals. The D-NTS group included 10 distressed individuals (average age: 23 years; five men) who were recruited from the local community through an announcement. The announcement called for participants who were experiencing anxiety and low mood but had not yet sought help for their distress. A semistructured interview schedule was used to explore the nature of barriers encountered and the perceived utility of the content of the proposed app. The questions that aimed at understanding the perceived barriers were open-ended. The perceived utility of various components of the proposed app was explored via 11 items, with a 5-point Likert scale.

Results

Personal barriers frequently reported by both groups were doubts about treatment and fear of social consequences. The role of inadequate self-awareness about one’s mental health concerns as a barrier to reaching out for professional help was articulated more frequently by the D-TS group than the D-NTS group. Proposed app components such as self-assessment with individualized feedback, informative videos by mental health professionals, testimonials from mental health service users, and a platform for an online connection with a professional were rated as potentially useful in reducing barriers to professional help-seeking. Insights based on stakeholder perspectives have implications for further research and are being utilized for the development of a mental health app for common mental health concerns.

Development of vocational potential assessment tool and counseling module for persons with severe mental disorders

OBJECTIVE

To develop and validate the vocational potential assessment tool and counselling module for persons with severe mental disorders (SMD).

METHOD

The tool and the module were developed through review of existing assessment tools, individual interviews and focused group discussions with key stake holders- persons with SMD, caregivers, expert mental health professionals and employers. The developed tool and module were validated by experts.

RESULT

The process of tool and module development was conducted simultaneously and included 11 persons with SMD, 9 caregivers, 9 experts and 9 employers. A total of 38 themes were obtained through individual interviews and focused group discussions. The developed tool and module along with a scoring key were validated by 6 mental health experts.

CONCLUSION

The tool is easy to use and comprehensive, takes approximately 45 min to 1 h for assessment. The module provides a framework for vocational counselling. The scoring key provides a guideline for professionals during assessment.

Explanatory models of mental illness among family caregivers of persons in psychiatric rehabilitation services: A pilot study

BACKGROUND

Understanding the explanatory models of family caregivers is particularly important in interdependent contexts like India, where they often play a significant role in the help-seeking behaviours, treatment decision-making and long-term care of those diagnosed with mental illness.

AIMS

This study was planned to explore the diversity of explanatory models among family caregivers at a centre for recovery-oriented rehabilitation services in South India.

METHODS

The sample for this study included 60 family caregivers of patients referred to Psychiatric Rehabilitation Services within a tertiary-care hospital for mental health and neurosciences. Bart's Explanatory Model Inventory, including a semi-structured interview and a checklist, assessed the family caregivers' explanatory model of distress on five domains: identity, cause, timeline, consequences and control/cure/treatment.

RESULTS

The results indicated the coexistence of multiple causal explanatory models including psychosocial, supernatural, situational and behavioural contributors. While 36.7% of the caregivers displayed two explanatory models, 33.3% of the caregivers held three explanatory models and 16.6% of the caregivers endorsed four explanatory models. Caregivers shared their concerns about varied consequences of mental illness but less than half of them were aware of the name of the psychiatric disorder. While they accessed various forms of treatments and adjunctive supports such as prayer, medication was the most frequently used treatment method.

CONCLUSIONS

The findings have implications for collaborative goal setting in recovery-oriented services for persons with mental illness and their families.

"End-of-Life Care is more than Wound Care": Health-Care Providers' Perceptions of Psychological and Interpersonal needs of Patients with Terminal Cancer

Aim

People diagnosed with cancer and in end-of-life care may have a range of needs. These needs may be inadequately expressed, recognized, or responded to by family members and health-care providers. The present study aimed at exploring health-care providers' perceptions of the interpersonal needs, psychological needs, and unfinished business among terminally ill cancer patients during the end-of-life care.

Methods

The sample consisted of 11 health-care providers, including physicians, counselors, social workers, and nurses from the end-of-life care settings in Bengaluru, India. A cross-sectional qualitative design was used and involved semi-structured interviews and focus group discussions.

Results

Thematic analysis identified themes related to health-care providers' perceptions of patients' prominent interpersonal needs, psychological needs, and expressions of "unfinished business" and their perspectives and experiences. There were three themes related to psychological needs and concerns: (i) experience and expression of negative emotions, (ii) mental health concerns, and (iii) confronting mortality. Three themes emerged in the domain of interpersonal connections: (i) support and closer connections with family, (ii) disconnection from family relationships, and (iii) building new connections at the hospice. Two themes were identified related to unfinished business: (i) types of unfinished business and (ii) addressing unfinished business. The findings also highlighted health-care providers' perspectives and experiences: (i) need for expanded end-of-life care training and (ii) experiences of emotional labor.

Conclusions

The findings have implications for comprehensive training of health-care providers and for assessment, support, and care services in palliative care settings in India.

Pattern of social cognition deficits in individuals with borderline personality disorder

BACKGROUND

Social cognition deficits have been implicated in the affect regulation and interpersonal difficulties seen in borderline personality disorder (BPD). The study examined patterns of social cognition abilities, using self-report and task-based measures, among individuals diagnosed with BPD.

METHODS

The sample included a clinical group of 20 patients diagnosed with BPD and 20 age and gender-matched control group participants from the community with no psychiatric diagnosis. The measures included the Mentalization Questionnaire, the Reading the Mind in the Eyes Test and the Social Cognition Rating Tool in Indian Setting.

RESULTS

Results indicated that the clinical group had lower self-reported mentalizing ability. Facial emotion recognition ability was significantly lower for the clinical group, particularly for photographs of the eye region with positive and neutral valences. The clinical group had significantly higher personalizing bias, and greater difficulties in social perception. The two groups did not differ on first and second order theory of mind, recognition of faux pas and externalizing bias.

CONCLUSIONS

The results point to the links between social cognition deficits and interpersonal difficulties among persons with BPD. Implications include the need for pre-therapy assessment of the magnitude and patterns of social cognition difficulties in BPD, the development of culturally and ecologically valid assessments and the evaluation of interventions for social cognition vulnerabilities among individuals with BPD.

Predictors of non-suicidal and suicidal self-injurious behaviours, among adolescents and young adults in urban India

BACKGROUND

The complex intersections between non-suicidal self-injurious (NSSI) behaviours; like cutting, burning or self-hitting, and suicide attempts, are an important domain of enquiry among vulnerable adolescents and young adults. A cross-sectional survey in urban schools and colleges assessed the rates of self-injurious behaviour among Indian adolescents and young adults. Predictors of NSSI and of self-injurious behaviours with associated suicidal intent, were also examined.

PARTICIPANTS AND METHODS

The sample comprised 1571 male and female students, from 19 private and government aided high schools, pre-university colleges and undergraduate colleges in an urban city in South India. Participants completed the Functional Assessment of Self-Mutilation which assesses the methods, characteristics and functions of self-injurious acts in the past 12 months. The measures of psychopathology included the Youth Self-Report and the Young-Adult Self-Report.

RESULTS AND CONCLUSION

The results indicated that rate of NSSI was 33.8%, with minor forms of self-injury reported more often (19.4%) than the moderate/severe forms (14.6%). A smaller proportion (6.8%) reported self-injurious acts with associated suicidal intent. Certain self-injury characteristics and levels of internalizing and externalizing problems differentiated self-injuring youth with and without suicidal intent. Logistic regression analyses identified predictors of any self-injurious behaviour and of self-injury associated with suicidal intent. The implications for assessment and intervention frameworks for self-injuring youth are discussed.

Development of a Social Skills Assessment Screening Scale for Psychiatric Rehabilitation Settings: A Pilot Study

CONTEXT

Deficits in social skills may present in a range of psychiatric disorders, particularly in the more serious and persistent conditions, and have an influence on functioning across various domains.

AIMS

This pilot study aimed at developing a brief measure, for structured evaluation and screening for social skills deficits, which can be easily integrated into routine clinical practice.

SETTINGS AND DESIGN

The sample consisted of 380 inpatients and their accompanying caregivers, referred to Psychiatric Rehabilitation Services at a tertiary care government psychiatric hospital.

MATERIALS AND METHODS

The evaluation included an Inpatient intake Proforma and the 20-item Social Skills Assessment Screening Scale (SSASS). Disability was assessed using the Indian Disability Evaluation and Assessment Scale (IDEAS) for a subset of 94 inpatients.

STATISTICAL ANALYSIS USED

The analysis included means and standard deviations, frequency and percentages, Cronbach's alpha to assess internal consistency, t-tests to assess differences in social skills deficits between select subgroups, and correlation between SSASS and IDEAS scores.

RESULTS

The results indicated the profile of social skills deficits assessed among the inpatients with varied psychiatric diagnoses. The "psychosis" group exhibited significantly higher deficits than the "mood disorder" group. Results indicated high internal consistency of the SSASS and adequate criterion validity demonstrated by correlations with select IDEAS domains. Modifications were made to the SSASS following the pilot study.

CONCLUSIONS

The SSASS has potential value as a measure for screening and individualised intervention plans for social skills training in mental health and rehabilitation settings. The implications for future work on the psychometric properties and clinical applications are discussed.

Assessment of Self-Reported Emotional and Behavioral Difficulties Among Pre-University College Students in Bangalore, India

BACKGROUND

The understanding of youth mental health needs and development of service delivery models is a national public health challenge.

OBJECTIVES

The rates and predictors of emotional and behavioral problems among 1087 youth were assessed in a pre-university college in Bangalore, India. Variations in rates of disturbance, identified by using different cut-off points, were also examined.

MATERIALS AND METHODS

The Strengths and Difficulties Questionnaire was used as a self-report screening tool.

RESULTS

Results indicated that 10.1% of adolescents had total difficulty levels in the abnormal range, with 9% at risk for emotional symptoms, 13% for conduct problems, 12.6% for hyperactivity/inattention and 9.4% for peer problems. Select gender differences were present. Cut-off scores derived from the sample yielded lower estimates of disturbance than the published cut-offs. Regression analysis identified predictors of total difficulty levels.

CONCLUSIONS

Implications for assessment of youth mental health and planning targeted services in educational institutions are discussed.

Self-injurious behavior, emotion regulation, and attachment styles among college students in India

CONTEXT

Intentional self-directed acts of injury are the most common among adolescents and young adults. Developmental psychopathology theories that conceptualize pathways to self-injurious behaviors (SIBs) implicate insecure attachment representations and inadequate self-regulatory skills to cope with emotional distress.

AIMS

The study aimed to examine relationships between SIBs, attachment, and emotion regulation among college students.

MATERIALS AND METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the functional assessment of self-mutilation questionnaire, attachment style questionnaire, and the difficulties in emotion regulation scale.

RESULTS

Results indicated that 31.2% of the participants reported SIB in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of self-injury (e.g. cutting, burning) were reported by 19.8% of the sample. Self-injuring youth reported higher levels of anxious attachment, preoccupation with relationships and need for approval in relationships, and difficulties in all domains of emotion regulation. Logistic regression analysis identified preoccupation with relationships and impulse control difficulties as predictors of SIB.

CONCLUSIONS

The findings have implications for comprehensive interventions for self-injuring youth.

Ethical dilemmas experienced by clinical psychology trainee therapists

Ethical dilemmas are inevitable during psychotherapeutic interactions, and these complexities and challenges may be magnified during the training phase. The experience of ethical dilemmas in the arena of therapy and the methods of resolving these dilemmas were examined among 35 clinical psychologists in training, through an anonymous and confidential online survey. The trainees' responses to four open-ended questions on any one ethical dilemma encountered during therapy were analysed, using thematic content analysis. The results highlighted that the salient ethical dilemmas related to confidentiality and boundary issues. The trainees also raised ethical questions regarding therapist competence, the beneficence and non-maleficence of therapeutic actions, and client autonomy. Fifty-seven per cent of the trainees reported that the dilemmas were resolved adequately, the prominent methods of resolution being supervision or consultation and guidance from professional ethical guidelines. The trainees felt that the professional codes had certain limitations as far as the effective resolution of ethical dilemmas was concerned. The findings indicate the need to strengthen training and supervision methodologies and professional ethics codes for psychotherapists and counsellors in India.

Assessment of Autobiographical Memory Narratives in Psychotherapy with Borderline Personality Disorder: An exploratory study

Autobiographical memory narratives that emerge in therapeutic discourse can aid the understanding of the client?s narrative identity and the identification of cen-tral themes or conflicts. The study aimed to examine the structure and thematic content of autobiographical memory narratives of five clients with Borderline Personality Dis-order (BPD), during the early phase of individual psychotherapy. The Biopsychosocial Interview gathered narrative material about the clients? life experiences in childhood and adulthood and explored the history of psychological difficulties and/or disorders. The interview and the first five sessions of psychotherapy for each client were audio record-ed, transcribed and coded for analysis. The Coding System for Autobiographical Memory Narratives in Psychotherapy was used to identify autobiographical memory narratives from the clients? life experiences, rate the narrative complexity, specificity and integration, and derive narrative patterns or themes. Analysis indicated that the narra-tives had a moderate level of complexity, low levels of specificity, were predominantly autobiographical, poorly integrated and revealed dominant themes of contamination. Narrative themes of agency, communion and redemption were relatively lower among the clients. The implications for therapeutic practice, training of clinicians and future re-search are discussed.

The Question is the Answer: concerns and queries raised by patients and caregivers referred to rehabilitation services

BACKGROUND

The philosophy of recovery emphasises consumer participation and engagement in developing effective rehabilitation services. Assessment of consumer perspectives and concerns lies at the heart of responsive and relevant rehabilitation frameworks.

AIM

The study aimed to document and examine patient and caregiver queries, at their first contact with Rehabilitation Services.

METHODS

The sample consisted of 124 consecutive inpatients and their accompanying caregiver/s, referred to Psychiatric Rehabilitation Services, within a tertiary care psychiatric hospital in India. The data were collected using the semi-structured Inpatient Intake proforma during the intake session. The spontaneous queries raised by patients and/or caregivers were documented and content analysis identified themes, separately for patients and caregivers.

RESULTS

The results indicated both similarities and differences in the frequency of themes that emerged from questions asked by patients and their caregivers. Two prominent themes centered on specific queries about rehabilitation services and the treatment and prognosis of the psychiatric illness.

CONCLUSIONS

The findings have implications for training, practice and research in the field of psychosocial rehabilitation. Recommendations are made for training and practice frameworks to facilitate consumer-service provider communication towards the development of responsive recovery-oriented services.

Patterns of non-suicidal self-injurious behaviours among college students in India

BACKGROUND

Non-suicidal self-injurious behaviour (NSSI) is a growing concern among youth and rarely reaches the attention of mental health and medical services.

AIMS

The study explored the occurrence, methods, characteristics and reported reasons for NSSI among a sample of college students in India.

METHODS

A total of 470 participants from undergraduate and postgraduate colleges completed the Functional Assessment of Self Mutilation (FASM) questionnaire.

RESULTS

Results indicated that 31.2% of the participants reported NSSI in the past year, with the mean age of onset being 15.9 years. Moderate/severe forms of NSSI were reported by 19.8% of the sample. The most common method was self-hitting (15.2%) followed by cutting or carving skin (13.2%). A majority of self-injurers endorsed multiple methods of NSSI, and there were no significant gender differences in NSSI rates. The NSSI was performed both to regulate internal emotional states (automatic reinforcement) and to influence others in the environment (social reinforcement).The most commonly endorsed reasons for NSSI were 'to feel relaxed' and 'to get control of the situation', while the least frequently endorsed reasons were 'to make others angry' and 'to avoid college, work, or other activities'.

CONCLUSION

The findings underscore the need to increase the awareness and understanding of NSSIs and to plan targeted interventions among college youth.

Medication Adherence, Work Performance and Self-Esteem among Psychiatric Patients Attending Psychosocial Rehabilitation Services at Bangalore, India

CONTEXT

Work benefits mental health in innumerable ways. Vocational rehabilitation can enhance self-esteem. Medication adherence can improve work performance and thereby the individuals' self-esteem.

AIM

To test the hypothesis that there would be a significant correlation between medication adherence, work performance and self-esteem.

SETTING AND DESIGN

A quantitative, descriptive correlational research design was adopted to invite patients attending psychiatric rehabilitation services to participate in the research.

MATERIAL AND METHODS

Data was collected from a convenience sample of 60 subjects using the 'Medication Adherence Rating scale', 'Griffiths work behaviour scale' and the 'Rosenberg's Self-esteem scale'.

STATISTICAL ANALYSIS USED

Analysis was done using spss18 with descriptive statistics, Pearsons correlation coefficient and multiple regression analysis.

RESULTS

There were 36 males and 24 females who participated in this study. The subjects had good mean medication adherence of 8.4 ± 1.5 with median of 9.00, high mean self-esteem of 17.65 ± 2.97 with median of 18.0 and good mean work performance of 88.62 ± 22.56 with median of 93.0. Although weak and not significant, there was a positive correlation (r = 0.22, P = 0.103) between medication adherence and work performance; positive correlation between (r = 0.25, P = 0.067) medication adherence and self-esteem; positive correlation between (r = 0.136, P = 0.299) work performance and self-esteem. Multiple regression analysis showed no significant predictors for medication adherence, work performance and self-esteem among patients with psychiatric illness.

CONCLUSIONS

Medication monitoring and strengthening of work habit can improve self-esteem thereby, strengthening hope of recovery from illness.

A Study on First Intake Assessments of In-patient Referrals to Psychiatric Rehabilitation Services

BACKGROUND

Psychiatric rehabilitation is an important component in mental health services. The rehabilitation needs of patients with mental illness have been highlighted in various studies. The studies on in-patient referrals to rehabilitation services however are sparse. This study describes the clinical and demographic details and the reasons for referrals to rehabilitation services during the in-patients stay.

MATERIALS AND METHODS

A semi-structured pro forma was used for the assessment of in-patients referred for the psychiatric rehabilitation services. The pro forma included socio-demographic details such as background, family resources, illness related details such as symptom status, risk assessment, medication details. The total number of referrals for a period of 5 months was collected and coded.

RESULTS

The total number of referrals for a period of 5 months was 216 and there were 197 forms available for the study. The mean age of the sample was 31.48 ± 10.46 years. Vocational rehabilitation was the commonest reason for referral to the in-patient services. Severe mental disorders were the most common diagnosis of patients refereed to the services.

CONCLUSIONS

Patients with severe mental illness were most often referred to the in-patient services. This indicates that we need include to rehabilitation in the management plan at the earliest. Vocational rehabilitation is the most common reason for referrals and there is a need to develop services to cater to these needs.

Self-reported suicidality and its predictors among adolescents from a pre-university college in Bangalore, India

There is increasing concern about suicide rates in the vulnerable developmental stage of adolescence. The experiences and expressions of suicidality among adolescents are often "hidden" and occur due to complex and cumulative interactions of multiple factors. A cross-sectional survey assessed self-reported suicidal ideation, suicide attempts and helpseeking behaviour among adolescents attending a pre-university college in Bangalore, India. This formed part of a 2-year teacher training project for Adolescent Mental Health and Suicide Prevention in the college. 1087 male and female adolescents aged 16-18 years, completed the Columbia Teen Screen which assessed self-reported suicide attempt/s (lifetime, past 3 months) as well as suicidal ideation (current, past 3 months) and associated intensity, severity and duration. Adolescents' perceptions about the need for help and mental health consultation were also assessed. Emotional and behavioural difficulties were reported on the Strengths and Difficulties Questionnaire. The results indicated that 25.4% of the adolescents reported suicidal ideation (past 3 months) and 12.9% of the total sample expressed their need for seeking help. The rate of suicide attempt was 12.9% (lifetime) and 6% (past 3 months). Logistic Regression analysis identified factors associated with recent suicidal ideation and attempt. Females had higher rates of suicide ideation and attempts than males (Ideation OR = 1.4, CI = 1.04-1.9; Attempt OR = 2.2, CI = 1.0-4.5) and adolescents with abnormal emotional and behavioural problems were at higher risk for suicidal ideation (emotional difficulties OR = 4.6, CI = 3.2-6.6; hyperactivity/inattention OR = 2.1, CI = 1.3-3.2). The findings add to the limited database on youth suicidality in India and have implications for prevention and intervention.

Psychological vulnerability, burnout, and coping among employees of a business process outsourcing organization

BACKGROUND

The business process outsourcing (BPO) sector is a contemporary work setting in India, with a large and relatively young workforce. There is concern that the demands of the work environment may contribute to stress levels and psychological vulnerability among employees as well as to high attrition levels.

MATERIALS AND METHODS

As part of a larger study, questionnaires were used to assess psychological distress, burnout, and coping strategies in a sample of 1,209 employees of a BPO organization.

RESULTS

The analysis indicated that 38% of the sample had significant psychological distress on the General Health Questionnaire (GHQ-28; Goldberg and Hillier, 1979). The vulnerable groups were women, permanent employees, data processors, and those employed for 6 months or longer. The reported levels of burnout were low and the employees reported a fairly large repertoire of coping behaviors.

CONCLUSIONS

The study has implications for individual and systemic efforts at employee stress management and workplace prevention approaches. The results point to the emerging and growing role of mental health professionals in the corporate sector.

Epidemiological study of child & adolescent psychiatric disorders in urban & rural areas of Bangalore, India

BACKGROUND & OBJECTIVE

There are limited data on child mental health needs in our country. Therefore, an epidemiological study to determine the prevalence rates of child and adolescent psychiatric disorders was initiated as a two-centre (Bangalore and Lucknow) study by the Indian Council of Medical Research. It also aimed to study the psychosocial correlates of the psychiatric disorders. We present here the findings of Bangalore Centre.

METHODS

In Bangalore, 2064 children aged 0-16 yr, were selected by stratified random sampling from urban middle-class, urban slum and rural areas. The screening stage was followed by a detailed evaluation stage. The ICD-10 DCR criteria were used to reach a penta-axial diagnosis.

RESULTS

The results indicated a prevalence rate of 12.5 per cent among children aged 0-16 yr. There were no significant differences among prevalence rates in urban middle class, slum and rural areas. The psychiatric morbidity among 0-3 yr old children was 13.8 per cent with the most common diagnoses being breath holding spells, pica, behaviour disorder NOS, expressive language disorder and mental retardation. The prevalence rate in the 4-16 yr old children was 12.0 per cent. Enuresis, specific phobia, hyperkinetic disorders, stuttering and oppositional defiant disorder were the most frequent diagnoses. When impairment associated with the disorder was assessed, significant disability was found in 5.3 per cent of the 4-16 yr group. Assessment of felt treatment needs indicated that only 37.5 per cent of the families perceived that their children had any problem. Physical abuse and parental mental disorder were significantly associated with psychiatric disorders.

INTERPRETATION & CONCLUSION

Prevalence rates of psychiatric morbidity in 0-16 yr old children in India were found to be lower than Western figures. Middle class urban areas had highest and urban slum areas had lowest prevalence rates. The implications for clinical training, practice and policy initiatives are discussed.

Child and adolescent psychiatric epidemiology in India

The increasing focus on child mental health in developing countries like India points to the importance of epidemiological data in developing training, service and research paradigms.This review attempts to synthesise and evaluate the available research on the prevalence of child and adolescent psychiatric disorders in India and highlight significant conceptual and methodological trends. It identified 55 epidemiological studies conducted between 1964 and 2002 in the community and school settings. Despite considerable progress, various methodological lacunae continue to limit the value of the epidemiological surveys. These include issues related to sampling, case definition methods, tools, multi-informant data and data analysis. The importance of a socio-culturally relevant research framework has been highlighted. The review suggests directions for future research to guide planning of services that meet the mental health needs of vulnerable children and adolescents.