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Child and adolescent mental health
Explanatory style in youth self-harm: an Indian qualitative study to inform intervention design
  1. Shilpa Aggarwal1,
  2. George Patton2,
  3. Deepika Bahl1,
  4. Nilesh Shah3,
  5. Michael Berk4,
  6. Vikram Patel5
  1. 1 Department of Mental Health and Non-Communicable Diseases, Public Health Foundation of India, New Delhi, Delhi, India
  2. 2 Department of Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  3. 3 Department of Psychiatry, Sion Hospital, Mumbai, Maharashtra, India
  4. 4 Department of Psychiatry, Deakin University School of Medicine, Geelong, Victoria, Australia
  5. 5 Department of Global Health and Social Medicine, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Shilpa Aggarwal, Public Health Foundation of India, New Delhi, Delhi, India; shilpazq{at}


Background There are very few studies that have examined the effectiveness of psychological interventions (PIs) that have been developed and tested in high-income countries to reduce self-harm in low and middle-income countries.

Objective To evaluate the perspectives and explanatory styles of youth with self-harm and their caregivers to inform the design of an evidence based PI in a non-Western cultural setting. An additional objective was to suggest ways of integrating local practices and traditions to enhance its acceptability.

Methods We conducted 15 in-depth qualitative interviews with youth with self-harm and four interviews with the caregivers in the psychiatry department of a tertiary hospital located in Mumbai, India. Data were analysed using phenomenological thematic analysis.

Findings Five themes were uncovered: (i) contextual factors related to self-harm including interpersonal factors, intrapersonal factors and socio-cultural factors; (ii) formulation and current feelings about the attempt (iii) family members and friends as the perceived supports and deterrents for future self-harm attempts; (iv) treatment related experiences with counselling, in-patient and outpatient treatment and barriers to treatment; and (v) coping strategies. Recommendations for key areas of adaptation include therapist adaptation, content adaptation to accommodate for cultural considerations and broader social context. Gender based socio-cultural norms, beliefs and stigma attached to self-harm need to be specifically addressed in South Asian setting. Interpersonal conflicts are the most common triggers.

Conclusion and clinical implications To our knowledge this is the first study in the South Asian context evaluating explanatory styles of youth with self-harm and their caregivers to inform the design of an intervention to ensure its cultural congruence. Cultural adaptation of an evidence based PI results in competent delivery and ensures best results in diverse ethno-cultural populations.

  • suicide & self-harm

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  • Contributors SA was involved in conceptualising and designing the study, analysis and drafting the manuscript. GP was involved in designing, analysis and drafting the manuscript. DB was involved in data analysis. NS was involved in designing and execution of the study. MB and VP were involved in guiding the study design, analysis and drafting the manuscript.

  • Funding This study was funded by The Wellcome Trust DBT India Alliance (IA/CPHE/16/1/502664).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was reviewed and approved by two ethics committees: Institutional Ethics Committee Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai-IEC/684118 and Institutional Ethics Committee Public Health Foundation of India, Gurgaon, Haryana IEC-366/17.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.