Poornima Bhola

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.

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.

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.

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.

Services for Enhanced Recovery with Intensive and Continued Engagement (SERWICE): An outpatient psychiatric rehabilitation model from India

The long-term outcome of patients with psychiatric disorders is likely to be better with rehabilitation inputs (DeSisto et al., 1995). In India, there is paucity of psychiatric rehabilitation facilities. Formal rehabilitation settings are lacking in most teaching institutes too, and hence, postgraduate trainees in psychiatry lack training in psychiatric rehabilitation. In this context, a specialized service ‘Services for Enhanced Recovery with Intensive and Continued Engagement (SERWICE)’ was conceptualized to provide (a) an outpatient, family-assisted, comprehensive rehabilitation for patients with severe mental disorders and (b) much-needed training for trainees in psychiatric rehabilitation. SERWICE is being run at the National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore over the last 3 years. SERWICE is offered to patients [preferably those with severe mental disorders (SMD)] who have not attained satisfactory recovery with medications. All 6 adult psychiatry units of the Department of Psychiatry refer patients to SERWICE. Only such patients and families, who agree to take active role in the recovery process (i.e., more frequent follow-up visits, implementing homework assignments and consenting to be contacted by phone/email/home visits), are recruited under SERWICE. These patients are allotted to postgraduate psychiatry trainees – on an average, each trainee has about 2–4 SERWICE patients. The trainees assess patients with SERWICE proforma, which includes a comprehensive assessment of rehabilitation challenges and opportunities of the patients. Under the supervision of a consultant psychiatrist, the trainee provides individualized management, comprising of pharmacotherapy and a host of services, including psycho-education, individual psychotherapy for residual symptoms, family therapy, cognitive retraining, social skills training, training in self-help skills, study skills, behavioural modification, vocational counselling and vocational training. In most cases, a family caregiver is actively involved through the planning and implementation of the plans. Trainees proactively contact patients by phone/e-mail and coordinate multidisciplinary interventions. Follow-up

‘Power positions are embedded in our minds’: focus group discussions on psychotherapy ethics in India

ABSTRACT Background: Ethical issues are ubiquitous during therapeutic work, despite the presence of professional ethics codes that guide ethical decision making. This exploratory research looks at how mental health trainees and practitioners, across various mental health disciplines, perceive and experience ethical dilemmas in the therapy space. Method: The sample included 12 mental health practitioners from varied mental health disciplines (clinical psychology, psychiatry and psychiatric social work), and practising counsellors, from an urban city in India. Three focus group discussions were conducted, where participants expressed the ethical issues and challenges encountered during their sessions with clients. Results: Content analysis of the narratives of the focus group discussions highlighted prominent ethical dilemmas in these domains: negotiation of boundaries or frames of the interaction; involvement of family in therapeutic decisions; negotiation of issues of gender and power in therapy; value conflicts in working with sexuality issues; therapist competence; and method of resolution of ethical dilemmas. Personal and cultural values emerged as impacting the perceptions, interpretations and experience of ethically challenging situations. The findings have implications for the development of culturally sensitive and value-based training methodologies.

Through a glass, darkly: ethics of mental health practitioner-patient relationships in traditional societies

ABSTRACT Assumptions about the universality of ethics and the use of dominant ethical frameworks of mental health care may obscure the differences and contextual realities in traditional societies. The ‘culture’ of the encounter between the mental health practitioner and the patient can be viewed through three dominant perspectives; paternalism, autonomy and reciprocity. Culture strongly influences how persons construct and negotiate their autonomous identities and the concept of relational autonomy may be more relevant in traditional societies like India. In this article, research studies and practitioner viewpoints are brought together to highlight the debates related to patient-practitioner communication, confidentiality and disclosure, informed consent and decision-making capacity, involuntary admissions and discharge processes, use of covert medication, advance directives and cultural influences on the definition of professional boundaries. Understanding the complex interplay of cultural beliefs and processes, culturally embedded practitioner value systems, economics, social justice paradigms and existing mental health care systems in traditional and resource-poor societies can provide a deeper understanding of the ethics of mental health care. A view of reality as interpretative and contextual can enhance our understanding of the ethical playing field in mental health care in both traditional and modern societies.

Intersections Between Ethics and Technology: Online Client–Therapist Interactions

With the growing technological advancement, the paradigms of client–therapist interaction are also changing. There is an emerging trend of practising e-therapy in India. The chapter discusses the possible ethical issues that might arise in the context of client–therapist interaction in the digital world. It enlists the steps of deciding if a client is suitable for e-therapy and how to think about the therapeutic frame in the context of e-therapy. It highlights issues related to confidentiality and electronic security, boundary management particularly with respect to time, payment and fees, contact between sessions and multitasking with e-therapy. It also highlights the ethical concerns with respect to client–therapist encounters in the online space. The ethical codes and guidelines are analysed and recommendations are made to help mental health practitioners address the ethical issues arising in this context.

Navigating the Ethical Landscape: Critical Issues in Practice and Training

Counsellors and therapists must provide a safe space and walk the ethical line during their psychotherapeutic interactions with vulnerable clients. Ethical practice is informed by several philosophical positions; deontological, utilitarian, the widely used principle-based framework, feminist care ethics and other post-modern perspectives. Expanded frameworks of ethics encompass context, culture, and personal values and embrace the complexity of ethical dilemmas encountered in the therapy room. Research has identified common ethical dilemmas; confidentiality and its limits, boundary violations, therapist self-disclosure, but this has also raised questions about the intersections of culture and ethics. Various professional bodies have delineated ethical codes and guidelines but there are inevitable gaps in their translation to the arena of therapeutic practice. The application of ethical principles may be influenced by a range of client, setting, therapy (theoretical orientation or therapy modality), and organisational variables as well by extant legal frameworks and socio-political contexts. Training in ethics for mental health professionals is inconsistent and often inadequate. A critical evaluation of ethical codes, innovative training methodologies, the need for training in ethical decision-making models, and the value of therapist self-reflection are discussed, with a special focus on the Indian context.

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, Cronbachs 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.