Abstract

Background: Delivery of mental health interventions to youth in schools requires a cadre of community mental health workers (CMHWs) in addition to psychiatrists. Literature is sparse in the India context on the ethical and professional challenges faced by CMHWs, especially those working with youth. Hence, the aim of the study was to understand these challenges faced by CMHWs working in schools in urban Chennai and explore ways to overcome them.

Methods: A qualitative study was done with CMHWs involved in the delivery of youth mental health (YMH) interventions, including mental health literacy, screening for mental disorders and mental health support to youth in schools in urban Chennai. Focus group discussions (FGDs) were conducted with the study participants and audio recorded. Transcription of the recording was done verbatim and coded for themes using a thematic analysis approach.

Results: Two FGDs were conducted with a total of eight participants. The mean (± standard deviation) age of the participants was 27 ± 3.7 years; all having a master’s degree in either psychology, social work, or public health. The major themes that emerged were the meaning of ethics and professionalism, confidentiality, dilemma in decision making, incongruence between the requirements of student and school administration, and personal and professional challenges faced by CMHWs. Recommendations to overcome these challenges were also explored.

Conclusion: The results indicate CMHWs face significant ethical challenges with confidentiality, and decision making while delivering YMH interventions in schools, highlighting the need for designing and implementing a framework to address these challenges.

Keywords: ethics, professionalism, community mental health, mental health professionals, youth, schools, challenges, recommendations

Introduction

The World Health Organization (WHO) defines young people and youth as individuals in the age group between 10-24 and 15-24 years, respectively [1]. India is one of the countries with the highest number of youths — comprising nearly 30% of the total population — under 24 years of age [2], distributed in workspaces in both organised and unorganised sectors and communities, and educational institutions [3], who are viewed as a potential focus for mental health services [4].

Most mental health disorders start usually in mid- and late-adolescence or early adulthood [5]. Various biological, psychological, and social risks, and protective factors play interactively in the emergence of mental disorders among youth [6]. A meta-analysis from Indian studies estimated the prevalence of child and adolescent psychiatric disorders at 6.46% in the community and 23.33% in schools [7]. The variation in the prevalence among youth could be due to differences in settings, age groups studied, methodology and tools used to assess mental health disorders. Similarly, a meta-analysis of 13 psychiatric epidemiological studies from India estimated the prevalence of mental morbidity at 22.2 per 1000 population among 15 to 24 years [8]. This highlights the need for mental health services for youth early on, ranging from mental health literacy, promoting positive mental health, screening for mental disorders, and safe access to treatment.

Many mental health services for educational settings like schools and colleges have been developed by community mental health workers (CMHWs) trained in youth mental health (YMH) [9, 10]. Delivering mental health services and interacting with youth in educational settings brings in a specific set of ethical and professional challenges other than those faced by community health workers in general. While many Indian studies have explored the ethical and professional challenges faced by community health workers delivering health services in the community [11, 12], a very few have examined the challenges faced by them while delivering mental health services to the youth [13].

It is important to explore ethical and professional challenges such as safety concerns for women, providing a safe milieu for the delivery of youth mental health services and building a framework to safeguard ethical principles and professionalism, both from the CMHWs’ and youth’s perspectives [14]. Similar findings were observed from one of the studies conducted by the authors (unpublished data). Hence, we aimed to qualitatively explore the ethical and professional challenges faced by CMHWs while delivering mental health services to youth in educational settings in urban Chennai and discuss recommendations to overcome those challenges.

Methods

Schizophrenia Research Foundation (SCARF) is a not-for-profit mental health organisation involved in mental health services for persons with mental disorders at clinic and community level. SCARF has various departments including a department of YMH, involved in clinical and community services and research pertaining to youth in urban Chennai. Various community-based projects have been initiated by SCARF beginning 2019 [15], ranging from promoting mental health and mental health literacy, screening for common mental health issues and referral to mental health services. Most activities are carried out by trained mental health professionals.

The current study was part of a larger project where YMH interventions were delivered in schools by CMHWs in Chennai between January 2020 and December 2021. In brief, the objective of this project was to impart mental health literacy (MHL) to youth in schools, using a youth MHL module from Canada adapted to suit the local context with the support of youth in schools, and delivered by CMHWs. A total of six MHL sessions were delivered on a weekly basis to the students and their knowledge, attitude and stigma regarding mental health was assessed before and after the delivery of the MHL module.

The larger project was conducted in five schools in urban Chennai, which were a mix of government (N=2), government aided (N=2) and private schools (N=1). All the schools used English as the medium of instruction, but Tamil (vernacular language) was heavily relied upon and used in the classrooms during the delivery of the interventions. The age range of the targeted students was between 13 to 16 years.

Institutional ethics committee approval was obtained before the start of the study (SRF-CR/08/AUG-2019). The current study was conducted between April and May 2022.

A qualitative study design involving focus group discussions (FGD) was used to explore the research question. The Ethical Framework for Global Psychiatry (EFGP) developed by Katz et al was used as the theoretical basis [16]. The EFGP framework summarises prominent ethical issues that arise in global health psychiatry including obtaining informed consent in the face of language barriers and diagnosing and treating mental illnesses where such conditions are heavily stigmatised. The framework suggests a multi-step process for the resolution of ethical dilemmas that fit into the wider context of global health outreach and helps in identifying ethical challenges and evaluating potential courses of action based on their respective ethical merits.

Out of the 10 CMHWs that were part of the larger project, only 8 were accessible. All eight of them provided written informed consent and were recruited into the current study. These CMHWs were research assistants, intervention facilitators, school counsellors, psychologists, and psychiatric social workers, involved in the delivery of YMH interventions in educational settings in Chennai under the larger project.

The authors would like to acknowledge the power dynamics between the researchers and the researched. The first author, involved in the design and implementation of the larger school intervention programme, is one of the staff working under a principal investigator (PI) along with CMHWs in the delivery of the intervention. Moreover, the first author and CMHWs were trained as one cohort by the PI and hence seen as equal from the group point of view. The second author, involved in the process of obtaining consent and conducting interviews, was one of the CMHWs involved in the larger project. She has extensively worked with the other CMHWs as a peer with a good working relationship and is seen as equal from a power perspective.

Two FGDs were conducted, with eight CMHWs (four in each FGD). After a thorough review of the literature and discussions based on our experience from larger studies on YMH, we developed a topic guide for the FGDs [Supplementary file 1]. Questions to CMHWs fell broadly into four domains: (a) how they perceived ethical and professional challenges in their daily work; (b) the nature of the issues faced; (c) how they resolved these issues; and (d) the principles and guidelines they considered while facing these issues. The participants were not provided with a definition of an ethical issue; instead, they were asked to discuss what they perceived to be ethical challenges in their work, their understanding of the concept, and to explain why the issue they provided was an ethical issue for them. The guide was deliberately non-directive to allow participants to discuss areas that could be relevant, such as virtue ethics or the moral inquiry of oneself.

The FGDs were conducted at SCARF by two researchers trained in qualitative research with experience in conducting FGDs. All FGDs were done in English, lasting for an hour or more, and were audio recorded. Two individuals took notes during the FGDs.

Both FGDs were transcribed verbatim to allow for thorough qualitative thematic analysis [17]. The coding scheme was developed based on detailed reading and interpretation of the transcripts and through discussion among the researchers. The initial codes were revised, expanded and collapsed as the analysis progressed. The Ethical Framework for Global Psychiatry was also simultaneously referred to while coding, and hence, an inductive-deductive approach was utilised. GS did the preliminary analysis by performing open coding of the narratives obtained from one FGD in Microsoft Excel Spreadsheet. VR then reviewed the codes, and both discussed the coding of the data. The coding method led to the discovery of subthemes and themes that best explained the data. Sifting through the data and choosing appropriate quotes to illustrate the themes was part of the indexing and charting stage. The mapping and interpreting stage of analysis entailed combining the quotes, categories, and themes, as well as discovering relationships between them, to create a comprehensive picture. Coding tree is provided as Supplementary file 2.

Results

Socio-demographic details of the study participants are described in Table 1.

Following the thematic analysis approach, the themes below were identified that best explained the data.

The CMHWs expressed the view that ethics was an important aspect of their job. While some considered ethics to be norms for the protection of participants, others believed they were dependent on the situation and a way to improve credibility as a researcher. Some participants reported that ethics was respect and morals held by an individual.

“Ethics to me is what should and shouldn’t be done. It is having certain boundaries for yourself and doing something you are capable of, within those boundaries.”

“Ethics are a set of rules and norms that exist within a setting.”

The aspect of confidentiality was a recurring concern for many CMHWs. Most felt it was not conducive to have a teacher or school staff present during the mental health sessions as the students were hesitant to disclose their mental health problems and emotional disturbances in the presence of school staff. Some school staff sought personal details of students or showed interest in knowing their problems, even though it was clearly explained to them that such information about the students will not be divulged without the consent of the students.

“When the teachers are present in the class during the session, students won’t interact at all, they become very silent. It then becomes a one-way conversation.”

On the other hand, some CMHWs said that having a staff member during the sessions was beneficial as it helped the teachers to better understand the mental health issues of the students, recognise mental health symptoms early, and provide appropriate referral to those students with mental health needs. One way to address this issue was by providing a separate training session on youth mental health to teachers alone.

“I’ve found teachers can help identify students who could have ADHD or IQ related issues. They express concern about the student and mention how it affects his or her academic related performance.”

A majority of the CMHWs in our study believed that there is a likelihood of the teacher labelling the student or alienating them, which breaches confidentiality and poses an ethical dilemma. When communicating with the school staff about the notions of confidentiality and disclosure, some of them felt it should be mandatory to inform the school administration about the mental health issues of the students in order to help the students more effectively. Participants felt that even if that was the case, the information could be divulged only with the student’s consent.

“And also, I think we will have to ask the students if they are okay with teachers being there. They will have to have that voice, right?”

One of the concerns hindering the decision-making process for CMHWs was the inability to intervene when a child expressed a perceived need for help and the family members refused to give consent, especially in the context of school interventions. In some cases, CMHWs had tried to reach the parents through the school teachers and management after explaining the same to the students. Though some parents consented to further treatment, many did not consent to treatment or follow-up of the students by CMHWs. The CMHWs further identify stigma and lack of knowledge and awareness on mental health as important factors that hinder consent from the parents.

“In some cases, the staff takes good efforts, even if it is one student, to get the required help and the principal also shows support. But the parents are not willing to seek help.”

CMHWs were faced with conflicts in the perceived needs of the school administration and the youth. They expressed the view that some schools had certain requirements that are incongruent with the needs of the youth. The requirements of the school administration were usually centred around stress management or well-being. Some of the health workers were requested by the school management to avoid using the term “mental health” and “mental illness”, while providing mental health literacy to the students. However, avoidance of words related to mental health may perpetuate the stigma against mental health and mental illness at the community level and exacerbate the existing gap in mental health.

“Can it be like mental well-being or can it be like any sort of activity-based stuff? Can we have a fancy name?”

The students felt the need for more relevant and prevalent topics such as interpersonal issues, bullying and ways to support a peer undergoing mental health problems. The school administration refused to grant the necessary permission if the sessions could not cater to their needs and objectives. Though the topics suggested by the school management were not harmful, most of the youth found them irrelevant and not helpful in improving their mental health. Moreover, the school management did not approve of topics such as relationship issues and sexual health to be delivered in the classroom, thus denying information that is most needed by the youth. During such situations, complying with the school system was the only option and posed a dilemma for most CMHWs.

“We discussed with both the students as well as the teachers. The teachers emphasise on topics such as stress management, work and personal life balance, academic pressure. But the topics that interest students are relationship issues, family issues…”

CMHWs face an array of ethical challenges such as concerns that they are leaving some students without sufficient support, especially those at risk of self-harm, harm to others, those undergoing any form of abuse or neglect, problems around masturbation and sexual concerns. The reasons range from practical challenges such as limited time with the students, lack of appropriate infrastructure such as a separate space to maintain privacy or even inadequate training of CMHWs to address these issues. As the research project is for a defined time and the number of sessions the CMHWs work with the youth is limited to 5 or 6, CMHWs found it difficult to gain rapport with and trust of the youth in such a short time. Also, CMHWs were aware that it will not be possible to go back to the youth in the schools to provide help after the research project was over.

“One of the students opened up about how she feels really uncomfortable around her father. And then she expresses undergoing abuse. This conversation happened right after the session. So how do I handle? Firstly, I did listen to her, and then, gave her SCARF’s number, and a consultant psychiatrist’s number. What are we doing at that point? This student opened up now, after six sessions and I’m not going to be able to provide longer support to her. So, the space is being created, but it becomes of no use after the six weeks.”

“The one who is working with children, should know like, how to handle immediate crisis. That sort of training should be provided. Suddenly, if there is an instance of suicidal idea expressed by the student. What is one to do?”

The strength of students in each classroom varied between 35 and 60 in different classes and schools. This posed a challenge to the CMHWs to work individually with each student and understand and address their unique needs through personalised and tailor-made interventions. Though it is an operational challenge to overcome this issue in the existing real-life settings, it can be a personal challenge for the CMHWs to find an appropriate, safe, and private space within the school to discuss the mental health issues of the students.

Being asked personal and intimate questions by students, such as marital status, age, phone number, and residential address also jeopardises the professional relationship with them. Female CMHWs felt uncomfortable being stared at, or at the receiving end of unsolicited comments, especially in an all-boys institution.

“The students wanted to get my contact number, my house details, and many personal details to get to know me. They would ask if they could meet me out or how they can continue contact. They express that they want to keep talking to me.”

“When I was a facilitator, boys distracted my class making very unnecessary and uncomfortable remarks. And I feel like that personally affected me.”

CMHWs reported requiring practical and tailor-made guidelines to further enhance their engagement with youth. They showed an active interest in building a network of youth-engaged researchers and health workers for knowledge sharing. The participants felt that the existence of a network of researchers working with youth will lead to continued discussions on the challenges faced and ways to address them. There was mutual agreement on the building of peer group discussions to provide them with multiple perspectives on a particular topic and facilitate more informed decisions about how to act.

“I was thinking before we get into communities, a proper safety policy for the clients or children should be developed. How are we going to safeguard the children from anything which would happen as part of this project?”

The areas of concern and mitigation measures suggested by the CMHWs are summarised and presented in Table 2.

Table 2: Areas of concern while delivering youth mental health interventions to youth in schools and potential mitigation measures suggested

Discussion

The Results indicate that CMHWs face critical ethical and professional challenges when delivering YMH services in schools.

While CMHWs had mixed interpretations of what ethics meant, there was a collective agreement that ethics is about what should be done or not done in each situation. Similar perspectives about ethics have been observed in previous studies [18, 19]. The familiarity of the terms related to ethics among the CMHWs indicates that they are aware of and highly concerned about the need to observe ethical principles while carrying out their roles, even though ethics as a subject is not extensively covered in the undergraduate and postgraduate curriculum of psychology and social work [20]. Sustaining ethical integrity among CMHWs requires significant reflection upon personal values and the professional imperative to work in the best interests of youth. Our study results indicate that the concept of professionalism did not emerge as a distinct theme from ethics even when specific enquiry was made; participants viewed ethics and professionalism as a unitary concept.

Youth seek help and advice from a wide variety of sources to address their stress and distress, including health professionals [21], and prefer to talk in confidence about their feelings and behaviours in response to stress [22]. One of the unique challenges faced by mental health professionals providing care to youth is breach of confidentiality, especially regarding sharing of information with parents. Youth might prefer to keep their discussions with the CMHWs confidential and request them not to divulge the information to their parents especially regarding interpersonal relationship issues the youth face with their parents. Whereas parents insist that the CMHWs share information provided by the youth so that they will be in a better position to help their child. This outlook might be related to Indian culture and might be more prevalent in collectivistic societies in the South-East Asian region when compared with the western world [23].

A dilemma frequently arising when dealing with the youth is that CMHWs are mandated to disclose information — such as cases of youth with suicidal ideation and those with child protection concerns — to parents and/or the school management [24]. However, the legal stand in these circumstances is unclear. For example, the Mental Health Care Act (MHCA), 2017, of India [25] is limited in its scope regarding the right of the child/adolescent to be an active participant in their own mental healthcare, with overarching powers given to the parent/guardian [26]. Moreover, there is also mandatory reporting on sexual abuse among minors under The Protection of Children from Sexual Offences Act (POCSO) Act, 2012 [27], which further complicates the role of CMHWs.

The perspective on mental health differs between youth and educational institutions/teachers/parents, and the same has been observed in other studies [28, 29, 30]. While handling emotions and relationship issues have been indicated as the major focus of YMH interventions by the youth, school managements suggest topics such as mental health literacy, better studying skills and time management, which infringes on the autonomy of the youth. Though YMH interventions try to comprehensively address topics suggested by both — youth and school administration — the pressure exerted by the schools on the CMHWs to include only the suggested topics and to avoid covering relationship issues and sexual health — which are equally related to youth mental health — is ethically problematic.

The stigma against mental health and mental disorders among the general population is a barrier for the dissemination of mental health information to the youth and general population [31, 32]. Even though stigma as a construct has not emerged as a theme from the data analysis, it can be seen from previous literature that stigma could be playing an underlying role in the emergence of the ethical issues observed in the current study. More work needs to be done in India to address stigma associated with mental health.

Some major strengths of the study are: It is one of the first studies from India that has specifically investigated the ethical and professional challenges faced by CMHWs working with youth in schools. The participants in the study were mental health professionals with psychology or social work backgrounds who are deeply involved in the delivery of YMH interventions at different educational and community settings, with first-hand knowledge of the challenges.

Some of the limitations are: A single site study in urban Chennai schools may not be representative of the challenges in rural and other settings of India. Challenges faced by CMHWs providing mental health services to adults and the perspectives of the school students and the ethical challenges posed by the CMHWs on them were not explored. While gender, religion, and caste could have an impact on the mental health of the youth, these were not explicitly explored in the current study.

Conclusion

When working with youth in educational settings, CMHWs face tough ethical challenges that have the potential to pose harm to the parties involved and hinder the delivery of the YMH interventions. Future studies should explore not only the ethical challenges faced by CMHWs, but also those related to the laws, policies and systems around mental health and contribute to the development of a framework to facilitate ethical delivery of mental health services in the community.

Acknowledgement: We are grateful for the guidance and support provided by Dr Varalakshmi Elango, a freelance consultant currently working for Global Antibiotic Research and Development Partnership (GARDP) as a Microbiology consultant for a Phase 3 clinical trial, in writing this manuscript. We also thank the community mental health workers who took part in the FGDs and shared their experiences. We are grateful for participation in the WriteShop on public health ethics organised by Rural Women’s Social Education Centre (RUWSEC) and funded by Thakur Foundation, and the mentor-mentee interaction in the WriteShop which formed the basis for this manuscript.

Contribution

Vijaya Raghavan (VR): Conceptualisation, obtaining permission, project management, data collection, data analysis, and manuscript writing.

G Sanjana (GS): Conceptualisation, data collection, data analysis, and manuscript writing.

Funding: None.

Conflict of interest: Authors declare no conflict of interest.