Mental health well-being is a global concern, with disparities in treatment services being a challenge. Though, digital mental health interventions are proposed to bridge the gaps and supplement support and assistance. Yet, many individuals still struggle with mental health issues, particularly in regions encountering socio-political unrest, and face obstacles in seeking professional assistance. Situating our work in Kashmir, India, a region with a long history of socio-political unrest, we conducted 18 semi-structured interviews with participants seeking professional support to explore how individuals navigate mental health and professional help-seeking. Our findings identify the struggles in seeking support rooted in the context through socio-political and socio-cultural influences, strategies and methods adopted to navigate these struggles, and the role of technology in seeking support. Using a social-ecological approach to mental health care, we emphasize accounting for the socio-political realities that shape support-seeking in politically disturbed contexts and offer socio-technical design recommendations.
1 Introduction
The growing concern about the influence of mental health well-being on diverse demographics has elicited global attention, underscoring its significance on an individual’s overall well-being. The United Nations (UN’s) Sustainable Development Goals (SDGs) – SDG 3 addresses global mental health challenges [80]. This, aligned with varied initiatives from the World Health Organization (WHO), World Bank, and International Monetary Fund, emphasizes the need for improved mental health services and advancements [37, 75, 128]. Studies have reported various factors that influence mental health, including socio-economic [14], socio-political [9, 63], environmental [69], socio-cultural [81], biological determinants [95], and lifestyle choices [42]. Disparity in access to resources and mental health treatment services is also a crucial challenge influencing individuals and communities [57, 88]. The field of Human-Computer Interaction (HCI) is increasingly focusing on mental health well-being and its related provisions, as evidenced by various studies [88, 89, 90, 92, 113, 124]. With this, digital mental health tools are emerging as potential solutions to address mental health challenges, with numerous studies exploring their potential and application in providing effective care and support. For example, they have been utilized for early detection of mental health disorders [17, 120], health monitoring [41, 46, 77], online therapy [48, 101, 125], support groups [59, 96, 97], and psycho-education [4, 64]. Additionally, HCI research in mental health has employed ecological perspectives to emphasize and account for various ecological factors at varied levels, playing a role in mental health well-being and illness scenarios [8, 61]. Such research has investigated the roles of caregivers and family members [29, 114, 124], peer networks [15, 27, 30], socio-cultural [88, 90], and socio-political [116, 117] influences in an individual’s mental health care journey.
Despite these advancements in mental health care support, individuals still struggle with mental health issues, particularly in areas with limited resources and support [86]. Moreover, the literature on mental health-seeking practices of individuals originating from regions marked by socio-political unrest remains understudied. Furthermore, individuals in regions with prolonged socio-political conflict situations face obstacles to seeking mental health care and assistance. The existing efforts to address mental health care in conflicted regions become inadequate to meet the needs of the individuals in such regions as each conflict situation is distinct from another, especially when considering the diverse geographical contexts. Our research aims to highlight the distinctiveness of the context with a history of long-standing socio-political unrest, steering away from focusing solely on specific illnesses or specific disruptive events. With this our work underscores these challenges in the context of Jammu & Kashmir1, India, a region of territorial dispute for decades that has experienced prolonged armed conflict and socio-political unrest [79]. According to research reports, there are increased rates of depression, anxiety, and post-traumatic stress disorder (PTSD) [43, 44] among the population.
Situating this work in the context of Kashmir, our exploratory research aims to understand the experiences of people seeking professional help for mental health issues in long-term crisis context. To investigate this, we employed qualitative methods and conducted 18 semi-structured interviews (10 female, 8 male) with participants who were seeking professional support through a clinical psychologist for their mental health-related issues in Kashmir. This work focuses on a subsection of the Kashmiri population — individuals who had means and access to seek professional help. Our study focused on investigating the following research questions: RQ.1)What are the experiences of the people seeking professional mental health services in Kashmir?RQ.2)What barriers and facilitators exist in accessing resources and mental health services?, RQ.3)How does the use of technology, such as online therapy, helplines, mobile apps, or social media platforms, impact the experiences of the people in Kashmir seeking mental health services? Through our analysis, we identified three key findings: i) the mental health related struggles to seeking support through varied socio-political and socio-cultural influences rooted in and specific to the context, ii) individuals’ strategies and coping mechanisms to navigate the challenges and lack of access to mental health care, and iii) tech-enabled usage patterns and challenges for mental health support. Furthermore, we adapt the Ecological Systems Theory (EST) [12], a theoretical framework examining human development and behavior within interconnected interacting systems. We engage with EST to analyze our findings and explore the interconnected systems influencing an individual’s mental health support-seeking journey, which is crucial for our context.
Our work makes the following contributions. Firstly, we offer empirical insights into mental health support-seeking practices and the technological infrastructure in Kashmir, India and offer a deeper understanding of the nuances of the context by extending the HCI scholarship. Secondly, contextualising our findings in light of mental health literature through an ecological systems perspective, we present a comprehensive understanding of the multi-layered influences on the professional help-seeking behaviors of the people in the region. We identify the complexities and the interconnections between different systems helpful for designing effective interventions and considerations to improve mental health support seeking in the region. Finally, we offer socio-technical design recommendations for advancing mental health support seeking in our context.
2 Background
Jammu and Kashmir (J&K), in the northern Indian subcontinent, specifically Kashmir, has been a longstanding territorial conflict between India and Pakistan since 1947, leading to wars and complex political situations. It has affected various aspects of people’s lives, e.g., disrupted education and development [79, 126], increased unemployment [111], and substance abuse [47, 109]. The prolonged conflict has reported various mental health issues among people due to exposure to violence and uncertainty. According to a Médecins Sans Frontières (MSF) survey, around 1.8 million adults, nearly 45% of the population in the Kashmir Valley, suffer from significant mental health issues, including anxiety, depression, and PTSD [43, 44]. The prevalence rates for these conditions are approximately 41% for depression, 26% for anxiety, and 19% for PTSD, significantly higher than the global average [44]. Moreover, there exists a substantial treatment gap where only 10% of people with mental health problems in Kashmir receive treatment due to a lack of mental health resources, a significant barrier to getting help [44]. These gaps underscore the need to understand the context and its mental health state and present an opportunity to design technology solutions sensitive to the population’s unique needs.
3 Related Work
3.1 Mental Health and HCI
In recent times, the HCI scholarship has advanced in studying mental health and technology’s role in supporting mental health infrastructure. Research shows contextual factors such as social networks [21, 83, 132], gender and cultural identity [28], geopolitical location [65], and resource availability [6] influence attitudes towards mental health and help-seeking. Prior literature demonstrates the influence of social support and peer networks on individuals’ mental health suggesting methods to enhance support [15, 21, 27, 30, 94, 110, 132]. For instance, O’Leary et al. highlight the importance of peer networks in mental health care and advocate for technologies connecting those with similar challenges [83]. Park et al. showed that depressed individuals have smaller social networks and lesser interactions, indicating social communication[84] impact on mental health. HCI scholarship on socio-cultural identity ecosystems highlights how attitudes towards mental health vary among individuals and communities [62, 65, 82, 85, 91]. For example, a study demonstrated that cultural values in the Chinese community influence depression perceptions and management [65]. Pendse et al. studied the influence of various socio-cultural factors and colonization in the Global South on mental health technologies and strategies for more inclusive technologies [88, 91]. Choudhary et al. studied mental health data on Twitter, noting hesitancy in disclosing mental health, especially among male users[28]. Studies highlight mental health challenges of returning veterans [108], refugees [55], and under-represented communities [88], pointing to the influence of identity as a barrier towards the healing of individuals. HCI research has also explored factors like social or political norms, crisis, and access to technology affecting help-seeking among patients undergoing disorders like PTSD, eating disorders, and depression [16, 18, 22, 98]. Cobb et al. studied the role of technology in assisting crisis volunteers in raising situational awareness and curating digital aid and resources[22]. Evans et al. studied veterans with PTSD, noting the role of military experiences in help-seeking. Studies emphasize the impact of trusted peer accounts and discourse on PTSD healing [16, 33]. Rabaan et al. studied a transformative justice approach for trauma healing among Muslim domestic violence women victims in the US [98]. These studies bring forth the help seeking practices of individuals going through sensitive experiences like violence or crisis. However, there remains a dearth of research in HCI exploring the mental health-seeking practices of individuals coming from regions of socio-political unrest and unstable internet connectivity.
Furthermore, wide array of work has investigated the potential of technological solutions to supplement mental health assistance and care e.g., online therapy [48, 101, 125], digital health tracking [41, 46], and platforms for healing practices [102, 133] among others. Further, social media’s role in mental health awareness has been studied [3, 87]. Research has also explored technology-enabled helplines for inclusive support in low-resource areas [91, 93, 114]. Online mental health forums and help-seeking have been researched to understand the impact of online screening and information seeking on help-seeking journeys [59, 96, 97]. Technologies like chatbots and mobile applications have been developed to address challenges in help-seeking, including improving access to professional help and privacy concerns [13, 19, 29, 51, 58, 76, 103]. Moreover, emerging technologies and platforms, including large language models (LLMs), metaverse, wearables [50, 60, 73, 112], and TikTok [74, 105] are being assessed and leveraged for mental health support. While efforts have been made to address and account for various factors influencing an individual’s mental health care. However, regions with ongoing socio-political unrest face more nuanced challenges and barriers to accessing mental health services, where existing systems might not be adequately equipped to address the unique needs of the population, resulting in inadequate care. Our research fills the gap by highlighting these challenges to advance support-seeking for individuals from regions undergoing crisis.
3.2 Ecological Systems Theory Framework
The Ecological Systems Theory (EST) [12], developed by Urie Bronfenbrenner, is a theoretical framework that examines human development and behavior within multiple interconnected interacting systems. These systems span from personal environments to broad societal contexts, including: Microsystem the innermost layer includes the immediate environments in which individuals interact daily, such as family, peers, schools, health care services, and workplaces [12]. Mesosystem focuses on the connections and interactions between different microsystems [12]. Exosystem includes settings that indirectly influence individuals, even though they may not directly participate in them [12]. For example, community services, media, or policies that influence access to mental health services. Macrosystem encompasses the broader cultural, social, and economic contexts [12]. Cultural norms, values, beliefs, and historical events are part of the macrosystem that can shape help-seeking attitudes and practices. Chronosystem represents the dimension of time and how changes and transitions over time can influence individuals and their environments — e.g., historical events, political instability, impacting professional help-seeking behaviors [12]. Figure 1 depicts the model.
We build on the prior work that has employed social-ecological perspectives to emphasize the interplay between factors at various levels within health and illness scenarios [8, 61]. Studies across various domains have used EST to explain the impact of various influences in an ecosystem surrounding an individual. For example, studies have engaged with the ecological perspectives in the development of mobile technologies for children with asthma [49]. The studies in HCI scholarship taking an ecological approach have also examined the role of various environmental factors, e.g., veterans dealing with PTSD [33], substance abuse [107], serious mental health illnesses [78], fertility tracking data practices [24], mental health resilience in unaccompanied migrant youth [117]. Our findings reflect how the mental health help-seeking for individuals in Kashmir is rather complex and heavily influenced by multiple layers of varying factors which can be well represented by the EST framework. In this work we adapt the EST to draw our discussion from our findings and reflect on the interplay of influences at different levels in an individual’s mental health support-seeking journey, which is crucial to understand in our context. With that, we offer a comprehensive understanding of multi-layer influences and identify the complexities and the interconnections between different systems helpful for designing effective interventions and considerations to improve mental health support seeking in the region.
Figure 1:
Figure 1: Urie Bronfenbrenner’s Ecological Systems Theory model.
4 Methodology
4.1 Participants and Recruitment
For this study, we recruited participants through convenience and purposive sampling [23, 119] approach facilitated by a practicing clinical psychologist at a private clinic in Srinagar. To ensure clarity and alignment of objectives, the research team engaged in multiple online interactions with the clinical psychologist prior to commencing the interviews. Additionally, the first author visited the psychologist’s clinic in person to build rapport and gain a comprehensive understanding of the clinic’s environment. Based on the psychologists’ assessment and knowledge of the patient’s mental health situation, the psychologist contacted the participants telephonically regarding the study. They were first informed about the study’s aim and asked for their willingness to participate. All participants we interviewed for this study were interested in conversing about our context’s mental health-related issues and challenges. Table 1 provides an overview of the demographic characteristics of the participants. We provide a detailed description of the data collection process, ethical considerations, and data analysis approach employed in the following sections.
Table 1:
Name
Age
Gender
Occupation
Martial Status
Clinically Diagnosed
P1
26
Female
Employed
Single
Major depressive disorder
P2
31
Male
Employed
Married
Obsessive compulsive disorder
P3
23
Female
Student
Single
Generalised anxiety disorder
P4
28
Male
Employed
Single
Major depressive disorder
P5
35
Female
Employed
Married
Generalised anxiety disorder
P6
27
Female
Unemployed
Single
Major depressive disorder
P7
22
Male
Student
Single
Generalised anxiety disorder
P8
25
Female
Student
Single
Anxiety and PTSD
P9
21
Female
Student
Single
Generalised anxiety disorder
P10
33
Female
Employed
Married
Obsessive compulsive disorder
P11
26
Female
Employed
Single
Generalised anxiety disorder
P12
28
Female
Employed
Single
Major depressive disorder
P13
20
Male
Student
Single
Generalised anxiety disorder
P14
22
Male
Student
Single
Obsessive compulsive disorder
P15
29
Female
Employed
Married
Major depressive disorder
P16
32
Male
Employed
Married
Obsessive compulsive disorder
P17
25
Male
Student
Single
Generalised anxiety disorder
P18
27
Male
Employed
Single
Generalised anxiety disorder
Table 1: Demographics of the participants for the interview.
4.2 Data Collection
We conducted 18 semi-structured interviews (10 female, 8 male) with the participants from mid-February 2023 - April 2023. All the participants were already clinically diagnosed and were actively seeking professional support and have been seeing the same psychologist for over six months or more. All the interviews were conducted in person, face to face, at a clinic in Srinagar. Initially, three interviews were shadowed by the first author, where the psychologist conducted the interviews. The rationale behind shadowing the first three interviews, conducted by the psychologist, was to facilitate an observational learning process for the first author. This approach aimed to provide the first author with an in-depth understanding of the psychologist’s conversation-conducting techniques and question-asking approach. It served as an initial training phase, enabling the first author to grasp the nuances of participant engagement, probing formulation, and situational context. After this, with all the necessary precautions, care, and permission from the psychologist, the first author conducted all the other interviews. We asked questions around five distinct themes: a) their experiences with access to mental health services and resources, b) the cultural beliefs and attitudes towards mental health — e.g., the perception and stigmatization of mental health issues in Kashmiri society, c) barriers and facilitators to accessing mental health services, d) impact of political unrest and COVID-19 and, d) role of technology, social media (e.g., Helplines, Facebook, WhatsApp, etc.) in seeking mental health support. All participants were informed about the study’s purpose and assured of anonymity. Written informed consent and demographic data were collected from them. Participation was entirely voluntary, and no compensation was given to the participants; however, we paid approximately US$ 6 as clinical service charges per session. Each interview lasted between 1 to 2.5 hours. All the interviews were conducted in a mix of Kashmiri, Urdu, and English by the first author as per the participants preference. The first author’s mobile device was used to audio-record the interviews with the prior consent from the participants. Four participants did not let us record the conversation, as they felt comfortable talking and sharing more without getting recorded but notes were taken for these sessions. The data was collected in the form of audio notes and field notes with prior permission from the participants. To protect the participants’ privacy, the collected data was anonymized and then shared securely only with the research team involved in the study. For analysis, audio recordings were transcribed and, when needed, translated into English.
4.3 Ethics
Our Institute Review Board (IRB) approved this study in Delhi, India, and the study protocol underwent additional scrutiny by the practicing psychologist. We ensured that special attention was devoted to minimizing potential risks to the participants. Throughout the interview process, special care was taken to ensure the participants’ comfort before, during, and after the interviews. The participants were briefed about the study and informed that they could leave the conversation whenever needed. They were informed about the study, the nature of data collection, and how it will be leveraged in the future before the interview session. Post this, both written and verbal consent were received. After discussing sensitive details, we inquired about the participants’ well-being to ensure their emotional state was not adversely affected. Adequate breaks were provided between interviews when deemed necessary. After each interview, participants were asked to remain for a brief period in case they experienced any emotional distress, and they were informed of their right to seek support from the psychologist within 48 hours of the interview if they felt any discomfort due to the conversation. By adhering to these precautions and practices, we aimed to create a secure and supportive environment for the participant’s involvement in the study.
4.4 Data Analysis
For this study, we first transcribed the 38 hours of interview data and shared the data with the entire research team. The transcribed data was subjected to iterative inductive thematic analysis [10, 11]. The initial phase of analysis was carried out by the first two authors, who reviewed each transcript separately and performed line-by-line open coding of all the transcripts. The codes were then reviewed and aligned as a group to ensure consistency. Collectively, the research team was actively involved in this process. For instance, the example codes were, “stigma and secrecy around mental health issues”, “importance of social support networks”, “social media as a source of information”. These codes were clustered into the axial codes and met to discuss and generate higher level codes, for instance, — “impact of socio-political influences”, “recognition of the need for help”, “usage patterns, and challenges: role of technology in seeking support” etc., based on the observed and prominent patterns in data. Finally, we arrived at broader themes such as “mental health struggles rooted in context”, “moving forward and embracing support”, and “patterns, challenges and expectations of utilizing technology for mental health support”. Tools like Miro-board 2 and Google Sheets were employed to aid the brainstorming and theme construction process.
4.5 Study Limitations
We acknowledge the limitations of our study, and we discuss the same in this section. For this study, the participants were recruited through a qualified clinical psychologist. We employed purposive and convenience-based sampling methods, which relied on the psychologist’s assessment of each participant’s mental health condition and willingness to participate in our study. Our study sample consisted of individuals who had the means to seek support for their mental health concerns, possessed access to technology, and were familiar with online platforms. Due to the sensitivity of the subject, investigating mental health and well-being within a population with limited access to mental health support, technology, and awareness was not feasible. We acknowledge the need for a more expansive and diverse sample (e.g., varied socio-economic backgrounds, religious groups), encompassing a broader spectrum of perspectives, to yield further valuable insights, and we aim to investigate this in our future work.
4.6 Positionality
All the authors of this work are of Indian origin, comprising three females and one male having prior experience working with diverse communities in India. Our team includes a female practicing clinical psychologist and HCI researchers. Their work has focused on conducting research in the field of HCI to explore the utilization of digital technology in education and healthcare settings. Two of the authors of this paper, born and raised in Kashmir, have lived experience from the unrest and the political events that have shaped the region’s history. Fluent in the Kashmiri language and well-versed in its cultural nuances, the first author conducted the interviews for this study within the region. It is important to note that all the authors share a strong motivation to improve access to mental health services and raise awareness of mental health issues in Jammu & Kashmir. And the interpretation of the data is inherently influenced by our individual backgrounds and experience with safety. This shared commitment inevitably informs our analysis, and we request that our paper be read as such.
5 Findings
In this section, we offer an understanding of the unique socio-political and socio-cultural challenges in seeking mental health support in Kashmir, detailing individuals’ strategies to navigate obstacles and the use of technology for mental health support.
5.1 Mental Health struggles rooted in the Context
5.1.1 Impact of socio-political influences.
We observed that in our study context, the politically complex nature of the region has resulted in people normalizing and accepting their mental health situation as the norm, affecting their approach to seeking mental health support. All the participants highlighted that the region’s political unrest, disruptions, and uncertainty have significantly contributed to the prevailing mental health issues in the region. They emphasized that mental health issues often get overlooked and neglected because the situation demands immediate focus on other daily necessities and survival priorities. As explained by a participant —
“obviously, it (mental health) has been impacted because the focus is never on our mental health or well-being; it is rather on other things, so it has been impacted.” (P2, Male)
Our observations indicate the presence of embedded fear and profound concern among the people regarding security risks to their lives due to the ongoing political situation. The participants described that the influences of unrest and frequent shutdowns 3 have resulted in economic hardships, which, in turn, have led to mental health issues within the community. We found that these shutdowns not only have an economic impact but have contributed to feelings of isolation and disconnection from the outside world among the people, leading to adverse effects on mental well-being. Our participants mentioned that prolonged home-bound experiences during restricted movements due to lockdowns exacerbate the prevailing challenges and impact mental well-being. Additionally, the internet disconnection during the lockdowns has added to the burden of mental health issues among individuals in the region, making them adaptable to the region’s situations. Participants emphasized that these political complexities pose a threat to lives and give rise to insecurities, leading to constant worry and uncertainty surrounding their safety, heightened stress, anxiety, and trauma, making it increasingly challenging for people to seek and access mental health support. As described by a participant —
“…if you leave late from the office, you think you can be stopped anywhere; ID cards are often checked… checkings happen more often... Recently, a gun was pointed at one of my colleagues, so he was scared of coming to the office...and it scares me...these things always remain there subconsciously in my mind…” (P1, Female)
Furthermore, we noted that the individuals living in the region have had firsthand exposure to violent and traumatic events, contributing significantly to the community’s mental health challenges. As explained by a participant —
“...even when we used to go to tuition centers, I’ve seen firings and bullets…we used to go to hide in some neighbor’s places…those impressions are in my mind, and they affect you really deeply...” (P3, Female)
In addition to the exposure to violent, traumatic events, we found that the people in the region have witnessed grief, loss, emotional shocks, and the killings of people they know or someone close, leaving hidden but deep marks on their psychological health. As mentioned by a participant —
“my classmate in college got killed. I used to see him in the bus daily, which was shocking when I got the news. It does impact somewhere.” (P3, Female)
We also noticed that individuals who have personal lived experiences of exposure to violent, traumatic events experienced during cordon and search operations (CASOs)4 live at a considerable risk of developing PTSD and trauma leaving deep, long-lasting memories of emotional shocks and grief on individuals. As described by a participant —
“...we had this CASO in our area...my kid was in school...cordon in my area started everywhere...my kid had not reached home...during that period nobody is allowed to come inside to that area or go out from that area...that builds up stress and trauma in you…” (P5, Female)
We observed that among our participants, there is a general understanding and acceptance of disruptions’ direct or indirect impact on mental health within the community. They mentioned that threats and insecurity arising from the ongoing political situation outside Kashmir significantly impact mental health, raising serious concerns about their Kashmiri identity outside. As described by a participant —
“kashmiri’s are looked at with suspicion outside, then you have to prove your loyalty. So this unrest and trauma stays with you…crises spills beans on your psyche and affect you too much.” (P4, Male)
5.1.2 Impact of socio-cultural influences.
Besides the impact of socio-political influences on mental health in our context, we identified that cultural and societal conditioning also significantly impact mental health, leading to unnoticed and unaddressed mental health issues among the population. As reported in the prior literature, our observations also confirm the lack of awareness, limited availability of resources, and identification of symptoms contributing to the widespread non-recognition and trivialization of mental health conditions within the region’s general population. Our participants mentioned the challenges exacerbated by the general absence and lack of a localized community vocabulary around mental health disorders, resulting in constrained expression and communication surrounding mental health matters. As shared by a participant —
“…here, people didn’t even know that mental health issues can be treated…people are not even aware of the availability of services…the awareness is still lacking among the people.” (P2, Male)
We also noted that influences like societal understanding, cultural practices, and perspectives play a significant role in shaping help-seeking behavior for mental health issues, as reported by the literature. In our study context, inadequate awareness and understanding of mental health have been reported to result in initial family resistance and a lack of support when seeking help for mental health issues. This resistance is influenced by perceptions and guarded attitudes toward mental health problems. In our study context, we observed common reluctance to disclose mental health disorders due to stigma and taboos as discussed in mental health literature. The stigma, linked to labeling and stigmatization, compels individuals to keep their mental health issues hidden, contributing to broader community unawareness and misunderstanding of these concerns. We also identified that societal expectations and gender dynamics significantly contribute to mental health challenges. Stigma and cultural beliefs surrounding mental health exacerbate the difficulties faced by individuals, with females being particularly affected. For instance, if a female of marriageable age experiences mental health issues, it can hinder her prospects of finding a suitable match due to prevailing societal perceptions. As explained by a participant —
“an irony I recently realized, especially in Kashmir, if you are a girl of marriageable age, you are not supposed to say that you have some mental health disorders, then no one will marry you…” (P15, Female)
In addition to socio-cultural factors, personal preferences, religious beliefs, and practices significantly influence how the community perceives and responds to mental health issues. Any individual’s mental health issues are often attributed to the predominant belief that the individual is possessed, has had an evil eye, or has black magic-like influences instead of any mental health issue. We also noted that a lack of religious adherence, such as not praying five times daily or skipping prayers, is associated with mental health problems. People often interpret deviations from religious norms or sins an individual commits as potential reasons for mental distress. As described by a participant —
“if I tell my parents, I feel that I am having anxiety, they will tell me you should have offered Namaz (prayer); it’s because you don’t offer Namaz, that’s why it happens to you. Pray, and everything will be fine” (P7, Male)
We noted distinct personal and religious beliefs around psychiatrists and therapists influence seeking mental health support. We saw a dominant preference for male psychiatrists within the community, for them being considered more competent as doctors and prescribing medicines. However, female psychologists are preferred when it comes to therapists, primarily driven by personal choice and perception of them offering more empathetic care. We found that seeking support from a therapist was also mainly driven by religious considerations among females. We observed females associate discomfort with lengthy therapy sessions involving extensive communication, particularly with professionals of the opposite gender, influenced by cultural and religious norms. The predominant notion is that discussing personal and sensitive matters with someone of the opposite gender is perceived as inappropriate or against religious norms. Moreover, female preferences were also shaped by distressing experiences of inappropriate advances from male professionals taking advantage of their mental health conditions and vulnerabilities. A participant shared —
“I prefer a male psychiatrist...But for a therapist, you have very long sessions, you have to talk a lot, and a lot of times, you are not really comfortable talking about issues with the opposite gender. I think religion has to play a role and also the social context or the culture we are in…in Kashmir we have grown up where we are taught not to have male friends...and, I think religion also permits us to have the bare minimum contact and interaction with male people…in ample of cases the concept of transference and counter-transference, like eventually the client or the patient falls for the therapist or something, that’s very true, and I’ve seen in a lot of cases that happen. I tend to prefer a female therapist for me.” (P6, Female)
5.2 Moving Forward and Embracing Support
5.2.1 Recognition of the need for help.
As detailed above, the socio-political and socio-cultural context of our participants posed various challenges that can harm an individual’s mental well-being. Nonetheless, we also witnessed shared sentiments of hope and determination to strive for improved mental health and well-being through our participants. Our observations highlight initial coping strategies adopted by our participants when they first observed instability in their mental health. Several participants talked about disregarding initial signs and perceiving them as temporary challenges that could be overcome by ‘fighting’ them. Activities such as sleeping, staying composed, reading books, and using social media apps like Instagram were mentioned as coping mechanisms that helped individuals to distract themselves. A lack of understanding and acknowledgment of mental health disorders in their peer groups, as also explained before, discouraged them from treating their disorders seriously. A male participant emphasized that he told himself to stay strong and fight the signs of his degrading mental because he is a man and is supposed to face challenges head-on.
“I don’t just use any strategy I just used to you know going to my bed and just sleep not think about it. Sleep has been my coping mechanism to be very honest...” (P2, Male)
Following the coping strategies, our participants discussed that their journeys of seeking help began with acknowledging that they needed help and that their degrading mental health requires attention and care. We noted that our participants sought professional help at stages when their symptoms could no longer be ignored. With that, the importance of having a positive mindset about self-improvement, individual agency, and building resilience against potential negative opinions from peers was emphasized. Participants pointed out that the COVID-19 pandemic allowed them to learn more about mental health issues using social media. The pandemic led many to get exposed to examples of other people struggling with mental health, increased discussions and awareness and made them realize that they were not struggling alone. They emphasized the need to be exposed to such different opinions and examples while going through mental health disorders, as trauma and distress could significantly narrow a person’s perspective and prevent them from grasping the broader context. This exposure encouraged acknowledgment of the need for help and seeking information on appropriate actions to address their symptoms. A few participants also noted that they endured their symptoms until they reached a point where they had no choice but to recognize them and seek assistance.
“pandemic was a blessing in disguise at least this topic was touched multiple times. I think it has been a major topic being discussed in our society after these incidents. It might have reached many people during that time and many might have considered seeking help.” (P8, Female)
We noticed that individuals’ workplaces played a crucial role in recognizing the need for mental health support for some participants. Initiatives like well-being cells hosted in workplaces offer a curated list of counselors for mental health care. Participants expressed that they were initially concerned about the potential bias and judgment they would face if their mental health status were revealed to their colleagues and managers. However, later on, workplace initiatives became a vital source of information for identifying and obtaining assistance. As a participant explained —
“we had a project called “well being” at the organisation I am working at and I read that document once... I took the permission from lead to text her (psychologist) and that’s how I connected with her... At that time I only knew that there was something going on with me...I was clueless and had no idea regarding seeking help.That document triggered me to at least think about it...” (P1, Female)
5.2.2 Stigma, Privacy Concerns, and Personal Experiences: Navigating Help-seeking.
Participants discussed taking up multiple experimental routes towards help-seeking. It consisted of going to therapy to give it a try. Many participants expressed initial hesitation about taking prescribed medications due to concerns about potential addiction. They took them only when their mental conditions became intolerable. Patients, despite initial doubts, expressed a strong commitment to improving their mental well-being, taking proactive control of their journey. Emphasis was placed on the necessity of professional psychological assistance and improved access to resources to support the help-seeking process.
“I think you should go first to a clinical psychologist and only if, you know, you cannot, I think you overcome everything by only seeking help from a psychologist rather than going to a psychiatrist. Only if that doesn’t help you then only you can go to a psychiatrist and seek medical help.” (P5, Female)
Participants prioritized their privacy and preferred keeping their mental health status discreet. A participant mentioned not telling anyone about her medications and secretly consuming them. We noted that many participants preferred offline and in-person therapy sessions over online sessions as talking to a therapist personally was more helpful than online consultation. Some participants were also skeptical about online help, unsure if their privacy and identity would be kept confidential. It made many not use Government helplines out of the fear of their peer groups getting to know about their need to seek help through leaked information or detection of their identity through their contact information. As explained by a participant —
“I did not know who would be there on the other end of the call. I do know people can check through true callers whose number it is. I was scared what if it would be someone who would even remotely know me or know who I am. I did not want to take the risk of sharing my problem with anyone like that.” (P9, Female)
While participants emphasized the importance of going for therapy, they also recalled discouraging incidents that had an unpleasant impact on their mental health. A participant mentioned that her first therapist was cynical towards her symptoms and mocked her for reading too much on Google and concluding that she had a mental health disorder. It was despite her prior clinical diagnosis of the disorder by a psychiatrist. This distressed her further and made her mental health worse. With this, participants highlighted the need for proper licensing and training of therapists as patients are vulnerable to their treatment providers. Challenges with scheduling appointments and communication, unplanned unavailability of therapists, and a lack of seriousness towards their patients also degrade help-seeking experiences. Some participants also mentioned that only a few therapists in the region are well-qualified and genuinely helpful. However, the lack of infrastructure, like professional clinics, restricts their ability to assist their patients, often leading to the need for online sessions due to the unstable availability of supporting facilities. A participant shared —
“…everything to proper scheduling, there are no proper clinics, and the therapists I was seeking before she was taking these offline sessions. And then she switched to the online thing. So I went to no proper clinic here. So a proper clinical infrastructure is not here…” (P6, Female)
Apart from challenges in the therapy-seeking processes, we observed the religious influence on the participants willing to seek help. Participants talked about being asked to go to faith healers or seeing examples of their peers visiting them for treatment. They talked about being forced into going to a faith healer instead of seeking professional help because of limited knowledge about mental health disorders. A participant mentioned a rare positive experience where, luckily, the faith healer they were forced to go to had studied psychology, and they recommended that he visit a doctor instead. A participant described —
“I was forcefully taken to a faith healer, and luckily that faith healer was educated he had studied psychology, and he told me that this is not a matter of her being possessed by someone but rather take her to a doctor.” (P13, Male)
5.2.3 Aspirations and Hopes for a Better Future.
Despite challenges in accessing mental health care, we observe that the Kashmiri youth remain hopeful for a future with improved mental health infrastructure. Here, we report the suggestions and aspirations expressed by our participants. Many participants discussed the need to build an infrastructure that makes mental health support more accessible. They expressed the need for therapists to be commonly situated around the city with enhanced visibility and accessibility. More so, they suggested interventions should be specialized to the requirements and disorders of the patient to provide better treatment. Proposing the need for parallel services that the next generation can access for seeking entertainment and destressing themselves was also mentioned. They added that mental health disorders need as much attention and conversation as the issue of drug abuse in Kashmir to build more awareness. As explained by a participant —
“now there has been a lot of improvement I believe people are talking about it, people are not shying away from talking about mental health problems. But still, you know, a lot can be improved in this area.” (P1, Female)
Participants emphasized the need to improve the existing mental health infrastructure. They mentioned that one cannot find an able therapist easily in Kashmir. Even though helplines have been placed to aid individuals with unstable mental health, many pointed out their hesitation to take online consultations due to the fear of privacy violation. Expressing the need to design solutions considering these fears and usage preferences was emphasized. They also aspired to have such helplines available free of cost with a provision of trustable professionals through these helplines. As a participant explained —
“people don’t have that much reach, these resources are not accessible. No doubt people have got those helplines, or they have got those numbers, but they can’t take online consultations” (P6, Female)
We noted participants’ aspirations to have community-level initiatives to increase awareness around mental health. For example, they mentioned that Public campaigns and Public Health Initiatives similar to existing initiatives for cancer awareness should be placed for mental health awareness to educate communities about symptoms, precautions, and cure methodologies for degrading mental health. They recommended sharing positive examples of individuals suffering from mental health disorders and their journeys to be shared among communities to provide hope and awareness. More so, suggestions of community leaders and famous personas such as preachers or sermons talking about mental health awareness and giving motivational speeches also emerged as ways of creating a dialogue among community members and directing advertisements on television or radio broadcasts as potential vehicles to propagate information regarding mental health to reach a wider audience.
“community leaders giving a speech or sermon [on mental health] during Friday prayers might have a special impact... build clinic’s, infrastructure...introduce these concepts to more colleges so that people can learn and then eventually bridge the gap...not everyone can get education from outside...do something so that you can produce therapist and mental health professionals here...” (P4, Male)
Lastly, the aspirations and hopes for a better future remained constant among our findings. Our participants also emphasized the need for the destigmatization of mental health issues. They suggested that this destigmatization should begin right from school, where students should be educated about mental health with as much, if not more, emphasis as they are educated about physical health. Parents should be educated to have a healthy attitude towards the mental health concerns of their wards and pay the needed attention to their concerns. They also suggested that promoting understanding among various generations is essential to bridge the generational gap caused by differing attitudes and perceptions regarding mental health issues.
“I think elders should listen to the younger generation they might be experienced but they should be open to learn more understanding.” (P7, Male)
5.3 Patterns, Challenges and Expectations: Technology for Mental Health Support
5.3.1 Usage patterns: Role of Technology in seeking support.
We found that our participants utilize the internet and technology for mental health purposes. They often turn to online resources, such as Google Search and YouTube, to seek information about their symptoms, analyze their condition, and gain a better understanding of their mental health. We observed that through online platforms like YouTube, they watch videos to learn more about their symptoms. They talked about seeking comfort in relating to the experiences shared by others in the comments section of YouTube videos. Additionally, we saw that meditation applications and motivational videos are used as tools to promote relaxation and reduce stress. As a participant shared —
“I use an app called CALM its kind of related to nature sounds like waterfall, birds these kind of things you can use for meditate...I Just mainly use YouTube to see motivational videos for example some motivational videos of 5 minutes like of Jay Shetty, or psychology on YouTube...” (P13, Male)
Our data consistently indicates that social media plays a role in supporting mental health. Participants used technology and social media to temporarily divert their minds from stress, finding relief during tough times. Moreover, during the COVID-19 pandemic, the internet emerged as a vital resource for our participants, facilitating access to online activities previously unavailable during lockdowns. This digital shift offered new opportunities for engagement and helped ease the burden of isolation. We observed that social media became a valuable tool for mental health awareness, with many individuals following mental health-related pages and psychologists on platforms like Instagram. Furthermore, sharing mental health-related posts on their profiles allowed them to boost their mental well-being and contribute to fostering mental health dialogue within their social circles. As is explained by a participant —
“there are a lot of pages on Instagram from psychologists. I used to follow that and it used to give me a little pump for a few seconds only though, but still somewhere you feel a little better about it. But I believe the social media has drastically affected the mental health of people, especially Instagram” (P12, Female)
Participants highlighted using online therapy and helplines as accessible ways to seek assistance and guidance for their mental health challenges. They participated in online mental health discussions on platforms like Clubhouse by connecting with others and finding comfort in shared experiences and coping methods. These platforms emerged as important vehicles for reducing the stigma associated with mental health. Our observations also reflect that participants took the initiative to reach out to mental health specialists through texts or direct messages (DMs) on social media platforms (e.g., Instagram, Facebook). Engaging with professionals via social media allowed them to establish a first line of contact, making mental health support more approachable and readily available to those in need. As explained by a participant —
“before visiting the doctor physically, I listened to Dr. Aseem (psychiatrist) on a program on DD Kasher, and from that, I texted him on Facebook. Although I did not expect any reply back, I at least tried…” (P11, Female)
5.3.2 Struggles in Using Technology for Seeking Support.
Participants also reported some mental health challenges due to technology use beyond the previously mentioned benefits. Our participants consistently highlighted the recurring issue of unavailability of internet access during periods of shutdown as a major source of distress. We observed their heavy reliance on the internet for various activities, e.g., diverting their mind from stress and learning new things. The unavailability of the internet during shutdowns aggravated existing mental health issues and contributed to increased frustrations, thus exacerbating the challenges and affecting their mental well-being. As one of the participants explained —
“in 2019 I used to go insane...I stay stable by learning new things on the internet...2019 was very harsh and hard as compared to the pandemic.” (P11, Female)
Moreover, the participants shared apprehensions about social media. It included the negative effects of comparing their lives with others and promoting a perception of an idealized life. The participants also pointed out that inauthentic experts and the disseminating of misleading information on social media platforms contribute to the complexities of seeking accurate mental health resources online. As explained by a participant —
“there is a lot of misinformation and everybody these days has become a counselor or a psychologist. There are people who are making wrong claims and giving false information. I know a lot of people who do not even have medical background talk about being professionals and surprisingly these people have become influencers and are talking about whatever fits their narrative. And it’s sad for people who don’t really know anything and they buy that information.” (P10, Female)
5.3.3 Participants’ perspectives: Towards Technology-Enabled Support.
We observed that participants acknowledged technology’s positive role as a facilitator and catalyst for bringing about positive change and complementing the existing human infrastructure in mental health support. They highlighted the role of education and awareness through technology, suggesting displaying stories or inspirational content to raise awareness and promote mental health understanding among students at the college and university levels. As suggested by a participant —
“…schools and colleges now let other people come and give talks and any kind of awareness like we have drug abuse as an issue today…believe me, these university students are going through a hell of stress presently because of competition, unemployment… I think that is one of the platforms where you can introduce technology show them the impact of mental health or display inspirational stories…”(P5, Female)
Participants suggested leveraging social media platforms as an effective means to disseminate mental health information and combat the lack of awareness of mental health issues. While recognizing social media’s potential for addressing mental health awareness due to its wide reach, they emphasized involving trusted professionals to disseminate valuable information and promote better community understanding. As suggested by a participant —
“the people who have the platform who have the voice, they can talk about it. similarly, people who are following them, see or listen to that, they might feel that no, it’s not a problem with me. Other people are also facing the same issue.that’s what I believe could be done...talking about it, on platforms and social media.” (P16, Female)
Participants also recommended a push towards increasing the popularity of online counseling and making counselors and therapists more visible and recognizable through digital platforms while ensuring the privacy and security of patients. They emphasized the importance of prioritizing privacy and security in online counseling to address concerns about information sharing. They believe that ensuring a sense of confidentiality would be particularly beneficial for individuals who hesitate to seek professional help in traditional clinic settings due to the stigma and taboo around mental health. A participant suggested —
“there are a few apps like ACE online or Made Easy, if you purchase their prerecorded courses, and if you wish to screenshot or screen record the content, the app doesn’t allow that. Similarly, if online therapy or sessions have the same features, a person can ensure that the session can neither get recorded nor allow taking screenshots. That way, patients will get privacy, and they won’t hesitate to talk about everything…” (P11, Female)
6 Discussion
We adopt Ecological Systems Theory (EST) [12] to examine our findings, aligning with the calls in HCI and healthcare calls for ecological mental health approaches. Our analysis delves into diverse influences on individuals’ support-seeking journeys, crucial for understanding our context and uncovering factors contributing to successful sustainable mental health support design. Recognizing evolving needs amid contextual uncertainty, our study presents the multi-layered influences shaping professional help-seeking, aiding intervention design. We also identify the complexities and the interconnections between different systems helpful for designing effective interventions and considerations to improve mental health support seeking in the region. Through this, we discuss the non-linear nature of the ecological approach, influenced by socio-political and socio-cultural factors in our context. We direct our efforts toward how researchers, practitioners, and the HCI community can address and account for diverse challenges posed by our complex research context, offering socio-technical design recommendations for improving mental health support.
6.1 The interplay of Influences: Ecological Model of Mental Health Support Seeking
The individual seeking professional support is at the center of our model with the individual’s attributes, e.g., age, gender, common mental health condition type, and other demographics. Surrounding the individual are interconnected “layers" of relations, which reflect the individual’s nature of interaction within those varied compositions of influences in the ecology of an individual’s mental health support-seeking journey. The following sections provide a detailed description of the model depicted in Figure 2. We discuss how the interactions of the individual allied with the influence from the outer layers make this a challenging context for the individual at the center of this ecology.
Figure 2:
Figure 2: Social Ecological Model for Mental Health Support Seeking in our Context. The darker boxes highlight our recommended consideration at each layer.
6.1.1 Chronosystem Level Influences.
Our findings reveal the dominant influence of the chronosystem, spanning decades (e.g., ongoing socio-political context), shaping individuals’ behavior and mental health access. This influence permeates across ecological levels, directly impacting individuals and complicating support-seeking. Factors like prolonged political unrest, lockdowns, and internet disruptions profoundly limit access to mental health services in the region [25]. We noticed the chronosystem influences are deeply embedded over time, posing complex challenges for individuals within the system. This system’s unique characteristics and external factors compound complexities, requiring support-seeking individuals to navigate through disturbances and burdens across layers. Research in HCI and mental health interventions emphasizes the need for an ecological approach, incorporating social and environmental in mental health interventions [29, 113, 124]. Pendse et al. emphasize cultural, linguistic, and socio-economic considerations [88], while Tachtler et al. highlight considering political and legal factors among unaccompanied migrant youth [117] towards taking a social-ecological approach to mental health. However, much research has focused on the effectiveness of specific technological tools for mental health support, such as mobile apps or social media. These studies often overlook how a mix of these technologies can be utilized in a complicated socio-political landscape. Considering the challenges arising from historical events in our context, it is crucial to design technology-mediated solutions that coexist to function during technological breakdowns or periods of inaccessibility.
Implications for Chronosystem —Socio-political influences play a crucial role in the effectiveness of mental health interventions, especially in areas like Kashmir, where disturbances can worsen an already significant mental health crisis. These influences directly impact the accessibility of offline and online resources. Mental health solutions, even when grounded in HCI principles, can become ineffective or harmful if they fail to account for the unpredictable breakdowns or disruptions in such settings, as highlighted by the literature [115]. Unique challenges like the internet shutdown, e.g., the year-long shutdown after the abrogation of Article 370, which coincided with the COVID-19 pandemic [54], necessitate resilient and adaptive mental health solutions. This must entail anintegrated pathways requiring solutions to coexist, combining both tech-mediated interventions and the human and community infrastructure. We propose atech-human hybrid approach, where human resilience bridges gaps during connectivity disruptions, and technology is leveraged upon restoration. It is vital to realize that while normalcy does offer infrastructure support for tech solutions, the unpredictability demands an adaptive balance of both approaches to ensure continuous mental health support and prevent potential re-traumatization.
We propose a two-pronged design approach that leverages human community infrastructure [104] and tech-mediated solutions for crisis support. Emphasizing the need for contextual sensitivity, local community centers and local support groups should be established and equipped with basic mental health training, creating fallback networks for times of crisis. The need for having multiple adaptive solutions is also amplified by the Luk et al. [66], and Densmore et al’s. [31], work in Uganda and Ghana for healthcare. We saw in our context that individuals feel a reduced connection with therapists from different regions due to their lack of understanding of local challenges. Therapists from within the community inherently grasp these unique contexts, providing tailored counseling. Within our framework, the human factor concept takes on a distinct meaning – embodying not only empathy but also a comprehension of contextual histories to ensure effective and meaningful patient support. Cultural elements, emphasized by several works in the field [88], can be integrated by strengthening the existing assets within the region, e.g., using discreet technologies like local communication channels like community radio [53], use of IVR [38, 131]. A hybrid telehealth and in-person model [7] is suitable for contexts like Kashmir but engaging with the local community through participatory co-design is essential to understand specific needs and enhance its effectiveness. Government organizations can extend the ecosystem of care by mobilizing resources and support for mental health by integrating mental health interventions through partnerships with local NGOs on the ground as intermediaries, a concept supported by extensive research [5, 52, 126]. We recommend a tech hybrid system designed for adaptability with an emphasis on offline functionality as a default and constant option. Tech platforms should support offline data synchronization and switch to offline modes like SMS during internet outages. Such adaptable solutions in healthcare (e.g.,[71, 72, 118]), can enhance the resilience and adaptability of mental health support systems in socio-politically complex environments.
6.1.2 Macrosystem Level Influences.
Our research identified two main factors from the macrosystem that affect individual support-seeking behaviors for mental health: socio-cultural context and socio-political conditions. These greatly influence one’s perception and communication of mental health symptoms. Mental health topics often face stigma, reducing open discussions extensively discussed in the existing scholarship. Notably, gender and religious norms play a significant role in influencing support-seeking behaviors, especially among women. We saw that cultural and religious values often discourage females from seeking help and affect their choice in therapists. Political dynamics also impact the availability and prioritization of mental health care. For instance, due to political tensions, mental health has become a lower priority. Kashmiri identities further face risks, isolation, and suspicion, complicating their support-seeking. Further, individuals, exposure to violence and traumatic experiences add to challenges, highlighting the intertwined influence of socio-cultural and political factors on mental health practices in our study context.
Implications for Macrosystem — Drawing upon the salient challenges demonstrated in our findings, the macrosystem—encompassing socio-cultural and socio-political elements—significantly impacts how individuals seek and utilize mental health support. To address these challenges, we offer recommendations for tech-mediated interventions that can provide mental health support in a way that is sensitive to cultural and socio-political influences. One potential way is to draw from Value Sensitive design [35, 36] framework used in HCI literature to direct engagement with vulnerable populations. It emphasizes on integrating human values into technology by considering ethical, social, and cultural aspects throughout the design process. For example, create anonymous mental health platforms where users can seek advice without fear of judgment. This could be done by developing localized content that reflects users’ cultural norms and religious beliefs. Designs should also feature gender-sensitive interfaces that offer the option for users to speak to same-gender therapists, making the experience more relatable for users [35, 36]. In addition, mobile applications can be leveraged to improve symptom recognition, which is often trivialized or ignored due to prevailing socio-cultural attitudes, as corroborated by prior works [17, 120]. These applications could integrate emergency features to address immediate needs, especially with specialized care modules incorporating trauma-informed design paradigms [20, 45, 106] that provide specialized care for individuals exposed to violence or traumatic experiences. These should be highly accessible and prominently displayed in user interfaces. On the policy and governance front, data-driven policy advocacy tools can also be made to improve mental health support. For example, data-driven policymaking can be used to show policymakers the scale of mental health issues in different cultural and political contexts. This information can then be used to allocate resources more effectively. Political advocacy tools can also be created to make it easier to advocate for mental health services as a political priority. In line with Pendse et al.’s [88] suggestions, all these solutions should offer multi-language support for varied languages and regional dialects, ensuring accessibility to a diverse user base. Incorporating these nuances into the design systems would be one positive step towards an integrated, responsive digital ecosystem to help mitigate some of the challenges individuals face in seeking mental health support due to socio-cultural and socio-political influences.
6.1.3 Exosystem Level Influences.
The exosystem includes formal or informal systems that indirectly influence individuals. Our findings highlight various such systems like the technical infrastructure, healthcare infrastructure, government policies, and disruptions. Firstly, the technical infrastructure in Kashmir has been unstable and uncertain. However, when available, the technical infrastructure can empower individuals to recognize and address their disorders, as demonstrated in our findings. This is further detailed in microsystems. Secondly, we found that regional healthcare infrastructure is vital for healing individuals and promoting health awareness. The healthcare infrastructure of Kashmir remains weak with minimal to no support present to aid mental health patients as explained in the following section. Thirdly, various government policies like helplines have also been placed to support the mental health of citizens. However, despite the value of helplines to individuals to seek help by phone, concerns around privacy and lack of contextualization of helplines made individuals hesitate to use these services. Lastly, as detailed above, disruptions caused by the crisis influence the mental health of individuals. Accounts of witnessing violence firsthand and experiencing the loss of loved ones and peers owing to the unrest have left many with deep-seated traumatic memories resulting in disorders and distress.
Implications for Exosystem —Prior literature has explored the increasing risks of privacy violation and unintended breaches of confidentiality owing to the shifted focus on digital mental health[40, 67, 100]. There is a need to take fears and concerns of users into account when designing helplines and openly accessible resources. Helplines need to transparently communicate and inform the user that their data will remain confidential through special disclaimers and explanations [93]. More so, users can be given agency to control the exposure of their identities through features like voice-changing options. More so, for users from Kashmir, it remains essential to connect them to Kashmiri therapists and help providers to ensure and comfort users while providing contextually accurate and sufficient care to them. The popularisation of SMS-enabled helplines can also be useful during the unavailability of the internet.
6.1.4 Microsystem Level Influences.
Our findings reveal that the microsystem comprises the following: family and peers, healthcare providers, technology, workplace, and education. Among families and peers, disruptions foster fear and uncertainty and shape their dynamics. Our study found that concerns about employment and providing for one’s family amidst uncertainty led to mental distress. However, individuals often avoided seeking support from family and peers or kept their mental health a secret due to stigma, fear of judgment, and limited awareness about mental health. Our findings also bring the poor state of mental healthcare providers in Kashmir to light. Insufficiently trained professionals, lack of seriousness towards patients, and improper physical infrastructure like clinics significantly hinder and damage help-seeking and recovery. This ecosystem also interacts with families and peers. Families sometimes suggested faith healers over professionals or judged patients for seeking help. Technology as a system seems to have a very critical influence on an individual as it came up as an instrument of awareness, support, and inspiration. Mental health information sharing through Social Media and YouTube encourages help-seeking. Individuals also use online video conferencing for therapy and seek inspiration from mental health patient stories. Yet, the uncertain technology availability due to the unrest triggers feelings of isolation for many individuals. Harmful social media content, spreading misinformation and hate, also has adverse effects on mental health. Workplaces offer mental health support through initiatives like well-being cells, but concerns about degrading reputation on the reveal of poor mental health hinder open disclosure and sharing. Educational institutes also lack the needed information and education about mental health.
Implications for Microsystem —Even though technology access in Kashmir remains unstable and unpredictable, our findings highlight the potential for context-sensitive digital mental health for the times when the internet is accessible. To maximize the positive impact of technology on seeking help, we propose building upon existing assets like tech-dependent mental health practices [129]. We realize the need to facilitate open discussions around mental health to destigmatize it and raise awareness. Public movements and campaigns can be a medium to achieve the same as was also highlighted in our findings. Public mental health campaigns, similar to cancer awareness initiatives [130], can educate communities about mental health symptoms, precautions, and treatment, while influential figures can also promote its importance. Social media, contextualized applications, and websites, influential videos, SMS and call outreach, discussion forums, radio services, online crowdfunding, and virtual meetings can be leveraged to carry out such campaigns and movements as has also been observed in prior literature [32, 56, 99]. Educational institutions can establish wellbeing cells to educate students about mental health through interactive sessions and introduce beneficial technical resources. These well-being cells can also be online groups or platforms provided by workspaces to engage in discussions on mental health and connect to peers going through similar experiences as suggested by O’Leary et al. [83]. Such special spaces and support groups encourage conversations around stigmatized topics and provide a forum for individuals with shared experiences to offer each other support, as recommended by Tuli et al., [123]. These platforms can be made engaging to attract active usage by making them empathetic and interactive through gamification and personalization [2, 39, 58, 70, 121]. Online sessions conducted by professionals can also be introduced to increase awareness in schools and workplaces. More so, customized apps can facilitate anonymous help-seeking and shared experiences in workplaces and schools, enabling individuals to connect with peers anonymously, fostering support without the fear of judgment[34, 127]. Prior work has also suggested various technological solutions to address the lack of accessible professional help which include online therapy [125], empathetic chatbots[68], healing apps[26], mental health trackers [60], etc. However, it was shown in our study that Kashmiris prefer talking to therapists of their origin since they can understand their sensitive contexts better. Participatory design sessions [1] along with the affected population in Kashmir can help inform the design of such mental health applications in ways that cater to their specific needs and requirements owing to their non-normative context.Jo et al. explored LLM-powered chatbots as therapists [50], which presents opportunities for regions like Kashmir. These chatbots can be enhanced with Kashmir-specific context and language proficiency. Therapists, whether local or external, can also be sensitized to the Kashmiri context and connected to individuals through online platforms. However, it is also essential to control the potential harm technology might exert on users from sensitive contexts like that of Kashmir. Strict checks on fake information and hateful content around mental health should be enabled to avoid exposure of individuals coming from special contexts to misleading and adverse content [122]. Scores or markers can be provided to fact-check posts that advocate facts about mental health issues. More so, the existing development in the LLMs space can be explored to incorporate in-built-fact checks and explanations on social networking platforms so the users can get quick information about the validity of online information.
7 Conclusion
This qualitative study explores the mental health and professional support-seeking behaviors among the people in the region.Whilst many of the findings and areas discussed in our work are already known and implemented in many countries and regions, the holistic view about mental health-seeking behavior in areas of unrest is still understudied.Our work is a step towards offering crucial insights and findings that may apply to similar contexts while introducing the need for additional research in regions of unrest to validate and expand upon these initial insights. Our analysis offers a comprehensive understanding of the challenges faced in seeking support rooted in the context through socio-political and socio-cultural influences, strategies and methods adopted to navigate these challenges, and the role of technology in seeking support. We contribute to the growing body of scholarship in HCI on mental health by employing a socio-ecological perspective to emphasize and account for the various influences that play a crucial role in shaping and seeking mental health care and assistance. Our work presents a nuanced perspective on mental health interventions by introducing additional challenges for socio-politically disturbed contexts. With these challenges, our work necessitates understanding the unique navigation of support-seeking for these individuals at the center of the ecology. With this, we bring to the fore how design interventions need to take more nuanced integrated approaches and coexist to sustain the breakdowns in regions marked by disturbance. To this, we shed light on those complex contextual nuances and offer socio-technical design recommendations where mental health support is shaped by the unique challenges posed by socio-political realities.
Acknowledgments
We want to extend our sincere gratitude to the Institute of Physical Medicine and Rehabilitation Sciences (IPMRS), Srinagar, for their help and support throughout this study. We extend our gratitude to our participants for their willingness to engage in conversations with us. We thank them for openly sharing their stories, personal struggles, and challenging moments in navigating the journey of seeking professional support for mental health and care. We thank Anupriya Tuli for her very important feedback and support in writing this paper. We acknowledge the support provided by the iHub-Anubhuti IIITD Foundation. We would also like to thank our anonymous reviewers for their valuable feedback.
Shutdown here usually refers to a deliberate closing or cessation of everyday activities, often in response to political or social events. It can include curfew, internet and communication shutdown. We use shutdown and lockdown interchangeably in this paper.
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