Ethics statement

The study was approved by the UCL Research Ethics Committee (Ethics ID 22535/002). A formal written consent was obtained from all the participants. We followed the Standards for Reporting Qualitative Research [23] in this paper.

Study design and population

We have employed an exploratory qualitative study design to examine the views of mental health professionals and key stakeholders in South Asia. For this, we included mental health professionals who had qualified in a South Asian country, were of South Asian origin, residing in South Asia, at least 25 years of age (to complete qualifications), with at least two years of clinical and/or applied clinical research experience in a South Asian country. Other key stakeholders were eligible to take part if they were third-sector workers of South Asian origin, working specifically with people with CSA experiences in a South Asian country, at least 18 years of age, and with at least two years of work experience.

Recruitment of participants

We recruited participants purposively through LinkedIn and other professional networks of the research team members between 1^st January and 31^st August 2023. Participants were recruited from different regions and cultural backgrounds, at different career stages and working in varied settings, to invite variation in views and perspectives. We aimed for 8–15 participants to balance the anticipated challenges of recruiting professionals across South Asia. The first author, ST, provided a brief overview of the study to those who expressed an initial interest in the study and then followed up with an email explaining the study aims and attaching the participant information sheet. Those who were willing to participate then completed an online written informed consent form before they were interviewed which was then stored on OneDrive on a password protected computer.

Data collection

Semi-structured interviews were led by the first author, ST, on online platforms such as MS Teams, Zoom or Google Meet, depending on what was most accessible to the participant. The interviews were conducted in English and Hindi by ST who is fluent in both languages. A topic guide was used to steer the interviews; this was developed by ST, JB and RA (S1 and S2 Text). The questions enquired about the perceived needs of adult survivors of CSA and current treatments or support programmes available in the participant’s setting/organisation and country. Further, the interviewer asked participants for suggestions for cultural modifications in delivering those treatments and programmes.

The interviews were audio recorded through the video calling platform and transcribed using MS Stream. Any potentially identifiable information was deleted from the transcripts. Three transcripts in the early phases of data collection were reviewed by RA to assess whether the interviews were in line with the study objectives and to guide ST on the ongoing data collection process. To ensure retention of the meaning of data, three transcripts in Hindi were not translated to English, but any minor Hindi/Urdu phrases in the remaining predominantly English transcripts coded by TS and RA were translated.

Data analysis

We analysed the data using an inductive and iterative approach following the principles of reflexive thematic analysis [24]. We used MS Excel and MS Word throughout the analysis. Using an inductive approach, the first author (ST) led the coding, and all the coders immersed themselves in the data. This process was enhanced by using multiple coders wherein ST coded all the transcripts, TS coded four, and RA coded one of them.. ST, TS and RA agreed collaboratively on a the coding approach [24]. ST maintained a reflexive journal during data collection and coding to enhance the trustworthiness of the study and improve the quality of analysis [25]. Preliminary findings were also presented and discussed at a meeting with the other team members who are clinical academics and peer academic researchers. ST, RA and TS met separately to discuss provisional candidate themes identified from the data. ST, RA, JB and TS reviewed the candidate themes and agreed on the final themes and subthemes. The theme and subtheme names were refined to best capture the participants’ experiences. All authors reviewed the final analysis. A summary of the findings was subsequently sent to all the participants to inform them about the study findings and dissemination plan.

Quality and rigour

Our analysis followed an interpretative reflexive process wherein only one person collected the data, but three other members were closely involved during the analysis. Wider team were invited to contribute to the conceptualisation of the study design, reviewing and refining of the themes, and drafting of the manuscript.

We used a critical realist ontological position and a contextual epistemological position throughout the study. We chose this philosophical orientation to understand the views and experiences of our participants as connected by a common thread but also as individuals. This approach also enabled us to reflect on the data as clinicians and researchers. A critical realist orientation led to interpretation of the data beyond description.

Using maximum variation sampling [26], we aimed to recruit participants from different regions, from varied cultural and educational backgrounds and genders. We also situated the data within the context of the professional and their clients. This approach enabled us to facilitate transferability and demonstrate sensitivity of the context [27].

We collected the data using videoconferencing softwares to ensure that we were able to recruit participants from diverse backgrounds and regions. We acknowledge that this could have affected the participant-researcher relationship, however, this methodology enabled us to access a geographically wide group of participants with minimal participant burden.

Researcher characteristics and reflexivity

The research team comprised academic researchers and clinical academics in the UK and India. Table 1 describes the diversity and strength of all the authors informing the credibility of the results. All authors have mental health academic backgrounds with experience conducting research or working clinically with trauma-affected people and/or undertaking qualitative research. Our cultural backgrounds and professional experiences of working with people affected by trauma and/or working in South Asia (India) or people of South Asian origin informed the study design, topic guides and analysis.

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Table 1. Characteristics of team members.

https://doi.org/10.1371/journal.pmen.0000136.t001

1. Mental health symptoms as the tip of the iceberg

In our study, the professionals and stakeholders described that the mental health difficulties experienced by their survivor clients are often reported and are visible on the surface. Beneath the surface, the mass of the iceberg are their traumatic experiences.

2. Pragmatic approach to treatment and services

Our participants highlighted that they usually needed to deter from following a structured, standardised approach with their survivor clients. They tended to be pragmatic considering the limited availability of resources and diverse needs of their clients.

2.2 Bridging the gap between theory and client needs

Most professionals recognised that there was a gap between the published evidence developed in non-South Asian countries and the clinical presentation of trauma survivors in South Asia. Most mental health professionals explained that they adhere to the current non-South Asian evidence but adapt what would be required for their client. These adaptations were made according to survivors’ education level, region and mental health literacy. However, even after they made adaptations, personalising/tailoring treatments presented a professional challenge.

“Clinicians just sort of, umm, take the fundamental concepts and then without necessarily subjecting it to scientific study, that culture adapting in how they’re delivering for the individual clients…”

-Academic and Clinical Psychologist in Sri Lanka

Mental health professionals accepted that their informal adaptations were not validated in their cultures, and there is a need to formally establish the evidence base for treatments and services for trauma-affected people, including adult CSA survivors.

“I think we when we try to imitate or try to practice the way they (in the West) are, I think sometimes the things do not fit at that time (in our country).”

-Academic and Clinical Psychologist in Nepal

3. Systemic factors are often roadblocks to trauma services

According to our participants, the mental health, healthcare and wider national-level systems hinder offering the treatments and services for trauma-affected people, specifically CSA survivors.

3.4 Social, economic and political constraints

Some mental health professionals from Afghanistan, India, Sri Lanka, Pakistan and Bangladesh expressed their concerns about the inability of their clients to afford multidisciplinary professional help and/or long-term treatment and support.

“… .they cannot pay for psychologists or they cannot pay two fee for doctors and psychologist as well.”

-Psychiatrist in Afghanistan

Pakistani, Sri Lankan and Afghan professionals further elaborated on how the financial difficulties experienced by their countries, as a whole, have led to traumatic conditions. Clinicians from Afghanistan, Sri Lanka, Pakistan and some parts of India highlighted the impact of political conditions on the traumatization of their clients.

“…children here in Sri Lanka can be quite vulnerable to childhood traumas..but fact that in a developing country…mothers from the…lower socioeconomic strata leaving the country to work as housemaids in the Middle East. So leaving a lot of children population quite vulnerable…”

-Academic and Clinical Psychologist in Sri Lanka

4. Cultural beliefs and practices across communities

Our participants reported that working with trauma survivors, specifically CSA survivors, was impacted by cultural backgrounds, religious beliefs and community practices. They needed to take these factors into consideration to engage and plan the treatment.

Most mental health professionals stated that CSA survivors form an understanding of their trauma and CSA experiences in line with their cultural norms and mental and sexual health literacy. According to them, this personalised understanding could deter survivors from seeking professional help and lead to dropout.

“So depression, what is written in ICD-10 or 11 or DSM 5 might not be relevant to what we (in Bangladesh) understand about depression.”

-Clinical Psychologist and researcher in Bangladesh

Some clinicians from all the included countries suggested that following a less structured therapy process and including the family in treatment were important with their trauma-affected clients. Providing sexual health information in psychoeducation was a specific suggestion for adult CSA survivors. This was unlike what they had read in non-South Asian published evidence.

Specific to the northeast region of India, some clinicians spoke about the trauma related to military and political unrest and natural disasters precipitating and perpetuating mental health conditions. An Indian clinician practising in a northeast Indian city explained that middle-aged and older adults have traumatic memories of military conflicts experienced by their community within their state. Another clinician from a different northeast Indian state explained the traumatising impact on generations of locals due to annual floods and national registration.

A Pakistani clinician highlighted that adult CSA survivors who continue to experience abuse into adulthood (particularly with same-sex perpetrators) experience this as contravening their religious codes, which makes it harder for them to speak out.

“This is crime if we talk about Islam to have male-to-male relationship plus extramarital affair, be it bisexual…client considered it a huge crime…”

-Academic and Clinical Psychologist in Pakistan

An Afghan clinician mentioned how faith healing may take precedence over mental health support.

“…After some time when the patient became fine and got improvement, some of the colleagues of her mother said leave the treatment, please take your daughter to mulla (Muslim clergy)…they give some taaveez (religion pendant or bracelet to wear)…She left the treatment after 3–4 months. She came again… .I said why she got bad or worse from previous months. The mother cried…I left treatment.”

-Psychiatrist in Afghanistan

According to a clinician in Mizoram (a state in India with predominantly Christians having tribal ancestry), mindfulness and yoga have roots in other religions, and it would not be acceptable for survivors in Mizoram to practice these approaches. Hence, this clinician in Mizoram had to explain the rationale for mindfulness practices and modify them to accommodate the needs of their clients. A Nepalese clinician with work experience in Nepal and India highlighted how the excessive engagement of family members of their clients in India and Nepal are alike. A Bangladeshi clinician suggested the need for an “indigenous” approach to treating trauma survivors. Another clinician from Afghanistan spoke about the relevance of male family members in the treatment of female clients.

“…the doctor first convinced…husband or the brothers that we need to talk with this female alone. After that if he permit doctor can speak with female patients otherwise he say no doctor that is not allowed. Not important…she has no any problem with me…Everything is clear with us…In this case I say that 90% female say no no brother or no husband or son, I I dont have any problem but maybe 10% of female can talk with doctor alone in the room…”

-Psychiatrist in Afghanistan

Survivors’ initial presentation, expectations and reservations

This study’s findings suggest that trauma survivors in South Asia tend to disclose their traumatic experiences as the sessions progress. Disclosure of interpersonal traumatic experiences such as CSA is more stigmatised than violent and other traumatic incidents, for example, related to work [28]. Adult CSA survivors may struggle to disclose to mental health professionals due to issues like anticipation of disbelief [29]. In non-western contexts, religious and spiritual beliefs can impact the reporting of trauma [30]. Specifically in South Asian countries, collectivistic cultures are often linked to social integration, which could further limit the disclosure of interpersonal trauma [28]. Speaking about psychological trauma as an outcome of traumatic events may take a backseat due to anticipated shame [31]. It is worth noting that complex traumas like CSA often lead to ‘complex symptoms’ within CPTSD including low self-esteem which can discourage disclosure of abuse [32]. Despite growing literature globally, future research requires us to understand the barriers and facilitators of disclosures of CSA by adult survivors in the South Asian clinical settings.

Help-seeking for processing traumatic memories is limited by an inadequate understanding of trauma and its impact on mental health. Our study suggests that trauma-affected people prioritise seeking support for current symptoms causing functional impairment over processing their traumatic past. Mental and sexual health education in South Asian countries is limited [33] which may restrict survivors’ ability to articulate traumatic experiences like CSA. There is a pressing need to increase mental and sexual health awareness in a culturally appropriate manner. Future research could assess whether including mental and sexual health evaluations within general health evaluations could help identify sexual traumas and their impact.

The professionals commented that their clients prioritized a quick recovery over a complete recovery. Socioeconomic issues linked to inflation and poverty in the region and political conditions associated with communal riots, migration and structural stigma in South Asian countries [34, 35] would take precedence over multiple visits to a mental health professional.

Although our findings suggest that future research needs to aim at short-term treatments, the current evidence in the UK recommends psychological interventions lasting 8–12 sessions or more if needed [19]. There is limited evidence on single-session treatments for PTSD and other trauma-affected people following a single traumatic incident [36, 37]. Hence, before aiming for single-session or brief treatments, we propose conducting qualitative studies with adult CSA survivors to explore their views on the treatment needs and possible length of treatment. Then, conducting a feasibility trial would substantiate if we could proceed with the newly developed treatment informed by survivors’ views [38].

None of the mental health professionals in our study mentioned acute stress reactions while discussing any of their trauma-affected clients and instead diagnosed trauma survivors with other common and severe mental disorders. Before seeking professional help, trauma survivors, specifically adult CSA survivors, may seek informal support [39]. South Asians residing in the UK and the USA have reported structural stigma and culturally specific factors like subordination, encouraging informal support over formal ones [40]. Understanding treatment and support needs of adult CSA survivors in South Asia and the facilitators and barriers in seeking formal and informal sources of support warrants exploration.

We found that barring CSA, other forms of developmental trauma were not perceived by our participants’ clients as abuse. Notably, physical violence is the most reported form of violence against children in South Asia [41]. Parenting in South Asian culture has been labelled “authoritarian” in that cultural expectations require children to be obedient and follow a social hierarchy, and an increased need of the child to respond to parents’ demands [42, 43]. Considering that these are normative parenting styles in this region, critical comments and physical punishments to discipline the child could be blurring the boundaries between the accepted cultural norms of parenting and what is deemed to be physical abuse in non-South Asian cultures [44]. Various reports and articles have recommended increasing awareness about neglect and physical abuse in South Asia [41, 45, 46]. There is a need to include awareness about these other forms of abuse and neglect in childhood while endeavouring to increase awareness about the impacts of CSA in adulthood.

Establishing culturally sensitive, specialist services and training

Psychological help was voiced by the professionals as the most relevant formal support for trauma affected people, including CSA survivors. In the UK and the USA, treatment guidelines for PTSD and emerging evidence for CPTSD also recommend CBT and other psychotherapeutic approaches as first line interventions [19, 47] Whilst psychological treatments were unanimously recommended by the professionals in this study, there were varied views on the need to process trauma memories, despite this being considered a key component of PTSD/CPTSD treatment in Western contexts [48]. Avoiding ‘unpleasant’ distressing memories and thoughts as an outcome of exposure to trauma could also be related to resistance to trauma memory processing by the survivors [49]. Future work could reflect on the efficacy of processing trauma memories and phase-based treatment with trauma survivors, specifically adult CSA survivors in South Asian countries.

A significant finding was the professionals’ and stakeholders’ systemic approach to the treatment of trauma affected people, specifically adult CSA survivors. In a systematic review including 31 studies with racially and ethnically diverse samples on systemic interventions for exposure to traumatic events, [50] found strong evidence for youth-caregiver, group and couple interventions to reduce PTSD and related symptoms. Specifically for adult CSA survivors, interpersonal relationship difficulties in adulthood would mean a systemic approach to the treatment could be beneficial [51].

One Stop Centres for trauma-affected people cited by Nepalese clinicians emerged as an example of centralised services for gender-based violence. Such centres have been set up in other South Asian countries too, including Bangladesh, India, Maldives and Sri Lanka [52–55].

Current lack of evidence on effective treatments for people affected by trauma, specifically adult CSA survivors, in South Asia warrants attention [5]. Compatibility between trauma affected clients’ cultural values and adaptations of evidence-based treatments [56] is essential for offering legible services to trauma survivors. Despite culturally adapting interventions being an “ethical responsibility” [57], the paucity of resources and trained researchers could be creating obstacles to such adaptations for trauma survivors in South Asian countries. A recent briefing paper by International Association for Traumatic Stress Studies for treating trauma affected people in LMICs (including South Asian countries) recommends cultural adaptations and research being led or co-led by LMIC researchers [58]. In our study, all professionals proposed adapting the current trauma focused treatments for use in their countries and according to client needs.

The current ICD-11 diagnostic criteria for PTSD/CPTSD acknowledges the cultural variation in the presentation of symptoms [15]. Cultural variation specifically exists in the disturbances in self-organisation symptoms but lacks further supporting evidence [59]. Due to the scarcity of evidence on CSA, developing an understanding of what constitutes psychological trauma in South Asia would be foundational to furthering treatments for trauma-affected people in the region. Future research into the clinical presentation would be beneficial to inform treatment and support services.

Our findings suggest that mental health research and sectors in South Asia are under-resourced. A recent study identified building research capacity in South Asia as one of the priorities to promote mental health [60]. Our findings suggest licensure and legal requirements for practitioners in South Asia are still unclear. This could risk the retention of currently qualified professionals within South Asian countries, further weakening the services. In addition, South Asian population experiences multiple catastrophic events [31]. Lacking an understanding of the culture-specific needs of trauma survivors, specifically adult CSA survivors and systemic issues in this region warrants an evidence base for treatment that may not be completely independent of Euro-centric literature on psychological trauma, but which is developed or refined from within these countries.

Strengths and limitations

This is the first study, to the best of our knowledge, which explores the treatment and support needs of trauma-affected people, especially adult CSA survivors in South Asia, from the perspective of mental health professionals and key stakeholders. Further, we included professionals from six of the eight South Asian countries, who had varied qualifications and were at different career stages. The participants were practicing across Government and private institutes in diverse geographical regions, treating clients with varied socioeconomic statuses and from different communities. Although most participants were female, we did include four male and one gender fluid participant. Our research team was also diverse and included members from India, the UK and Europe, at different career stages with experience in trauma research and/or qualitative research. The interviews were conducted by an Indian clinician and researcher who was able to converse in Hindi as well as English.

Our study nevertheless has limitations. Whilst we included a diverse range of mental health professionals, some participants had limited experience of working with trauma affected people. Despite the best attempts of the research team to contact Bhutanese and Maldivian professionals, we were unable to recruit participants from these two countries, who continue to be underrepresented in mental health research. We were also only able to include two key stakeholders. A crucial perspective which is not heard in this study is that of trauma survivors themselves. This is an important next step in research in this field.

Implications for practice, research and policy

Practitioners, both clinical and non-clinical, in South Asia need to be trained to ask their clients about any history of trauma, especially CSA. Setting up multidisciplinary specialist teams or specialist centres could improve the management of treatments for trauma survivors, specifically adult CSA survivors. Clinicians could include sexual health literacy in psychoeducation and stakeholders in their awareness programmes and individual sessions if they suspect a CSA history. Finally, trauma survivors could be on both sides of the table; ensuring sensitive peer supervision could be instrumental in supporting practitioners who may be survivors themselves. Clinical supervisors need to develop a model of support for professionals and researchers working with trauma affected people.

For researchers, there are dual implications for survivors and professionals. There is a need to identify the mental health and support needs of trauma, specifically CSA, survivors; explore key facilitators and barriers in their help seeking; and develop culturally tailored interventions to best meet the identified needs of survivors. Future studies should also explore the psychological impact potentially on the trauma practitioners and researchers.

Policy makers need to improve the regulation of mental health professionals, their training and licensure requirements and increase the number of clinical training programmes in mental health in South Asia. This would need to include specialist trauma treatment training and allocating funds to set up services for trauma survivors but specifically for adult CSA survivors. There is a need for advocating policy development and implementation aimed at improving reporting mechanisms of CSA. In addition, enhancing legal protection for someone reporting CSA could prevent further incidents of CSA. Considering that many CSA survivors may not seek clinical help, there is a need to fund support services for the survivors in the non-statutory sector. Finally, there is a need to create awareness among children and their guardians about mental health conditions and the nature and impacts of abuse on children. This would include accessible visual materials and credible sources of support.