11758

Would Shadow Marketing Help Obviate Stigma Attached to

Depression in Fostering Social Inclusivity and a Sense of Workplace
Belonging?

ABSTRACT

The suffering of employees from mental depression and workplace alienation are matters of
critical concern to the staff and management of almost every organization today. These
afflictions lower work productivity, creative potentials, and qualities of life of all affected
individuals whose wellbeing and life satisfaction are essential for an inclusive organization to
function properly. We investigate this general issue by attempting to address problems associated
with mental depression and alienation of a sample of undergraduate students in the limited
settings of two educational institutions in India. We build a theoretical framework to identify
critical elements that contribute to the subjects’ wellbeing in terms of their sense of social
belonging within the institution. Drawing from Foucault’s work on epimeleia heautou (the care-
of-the-self), we suggest that integrating oneself with a nurturing social environment through an
anonymous platform that helps realize one’s true potential and bypass the stigma attached to
mental illness is the first step toward their self-management and personal wellbeing. Using a
mixed-methods approach, we interleave qualitative and quantitative data with theoretical
arguments to propose a connection linking social exchanges through affect-based, interactive
learning to improved self-care and wellbeing in life. Based on our findings, we design a web-
based intervention as an inclusive platform that is targeted at all individuals in an organization
and not solely at the affected ones to help them to develop an informed practice of self-
management. Calling this a shadow-marketing strategy, we propose that such an intervention,
which avoids an explicit focus on sensitive mental health issues, would circumvent the problems
of stigma attached to mental depression and alienation in the workplace. Consumer testing in two
educational institutions shows it to be a more effective way of addressing stigma, provided some
mental-health literacy efforts have been instituted, without which even a shadow-intervention
strategy might fail. At this time, more extensive testing of the platform in educational settings is
underway, and its adoption in a business environment is in active contemplation.
Keywords:
Social exchanges; Stigma; Shadow-marketing intervention; Self-care; Wellbeing
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“From the idea that the self is not given to us, I think there is only one practical
consequence: we have to create ourselves as a work of art.” --- Michel Foucault
(Foucault, 1997: 351)

What kind of workforce does an organization aspire to have? On the one hand, it is

generally the case that highly motivated and happy individuals exhibit high productivity at work.

On the other hand, there is also increasing evidence that melancholia is an inseparable part of

modern life with situations involving of bereavement, divorce, difficult health conditions, or lost

jobs. While often just a temporary setback, it can appear as a prolonged ailment, such as clinical

depression, which requires specialized resources for its treatment and management. One of the

common symptoms of depression is the inability to find the will to work; sufferers find it

difficult to go on with their daily activities, let alone exhibiting inspired, motived actions.

The dichotomy one encounters in this regard is that, while melancholia might actually be

a part of human existence in the modern society, no organization would consciously want to

engage low-productivity employees that are affected by mental and emotional problems, because

of their inability to keep up with the work pressure as well as to continue working productively

(Ahuja at al., 2007). In some cases, there could even be firing of such individuals (Singh et al.,

2012). To make matters worse, a personal stigma is also often attached to these conditions

(Corrigan and Watson, 2002). It is, indeed, this stigma that makes mentally depressed employees

suffer in silence and dissuades them from seeking help, professional or otherwise, for fear of

bearing the brunt of stigmatized workplace actions. This external stigma can also lead to an

internalizing consequence for the sufferers, with growing beliefs in the worthlessness of their

own selves. There might also be a complete denial of the suffering conditions in order to obviate

the negative effects of external stigma and consequent internalized self-stigma.

With increasing job stress from high environmental dynamism and turbulence, ill-

adjusted work-life balance, misalignment of career goals, declining life standards, and meager
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prospects for career advancement, instances of employee burnout and depression pervade the

environments of many organizations (Ahuja at al., 2007; Kreiner et al., 2006). The problem is

especially worse in firms that operate under highly uncertain and volatile market conditions, such

as in the financial sector (Moore, 2000). Struggling under extremely stressful conditions of time-

criticality in highly demanding projects, employees suffer from depression and burnout, which

lead to their rapidly declining productivity and high turnover rates (Singh et al., 2012). However,

many of these conditions are treatable, and if employers are supportive of and sympathetic

toward the affected employees during their most difficult times, the recovered individuals could

prove to be invaluable, productive, and loyal members of the organizational workforce.

Exclusive treatment of the conditions of the affected employees might run the risk of

separating them into marginal groups within the organization. This might, in reality, create a

situation akin to ‘us-versus-them’ and lead to feelings of marginalization and alienation in the

workplace. In other words, such employer actions might be perceived by many normal

employees as a special, preferential treatment accorded to a group of their peers, giving them, for

instance, less tiring work, more free time, work-from-home facilities, and so on. These normal

employees may feel alienated from their affected peers, whom they will, over time, come to

resent and even discriminate against. To deal with this situation, measures to ensure the self-

management and wellbeing of the affected employees are high on the agenda of the top

management in many organizations (Böckerman et al., 2011).

Self-harm and suicidality are often consequences of depressive conditions. Such actions

were categorized as a criminal offense in India until very recently (Sneha et al., 2018). No

concrete public policy was, therefore, in place to guide the actions of organizations with people

suffering from mental health issues. Although the legal state has now changed in India, the

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stigma attached to mental health issues is still a remnant of the earlier cultural tradition that is

unlikely to disappear anytime soon. Even when help is offered, fear of external stigma works as a

major deterrent to seek help.

Although prior research underscores the potentially devastating effects of depression,

stigma, and the resulting loneliness on the productivity and wellbeing of individuals in a social

setting (Ozcelik & Barsade, 2018; Singh et al., 2012), the organizational wellbeing literature is

not sufficiently clear as to how individuals, who are currently affected by these adverse

conditions, can actually develop ways and means to a better situation in life through an

appropriate management of the self. To address this issue of high social importance, we have

undertaken a research project to study the basic question of self-management of individuals who

suffer from conditions of depression, stigma, and alienation in a particular social environment,

such as that of a business organization or an educational institution. In this paper, we discuss this

problem as it affects a sample of students in two higher educational institutions (henceforth,

University X or UX and University Y or UY) in India.

In particular, we examine the individual preferences for three different interventions that

vary in the degree of their explicit reference to opt for the intervention that does not explicitly

mention mental illness. We argue that in a stigma-conditioned society, the way to achieve

inclusion is, in fact, to not to focus on stigma-inducing condition at all. We call this design

approach a shadow-marketing intervention. This design obviates the issue of stigma attached to

the exceedingly sensitive mental health issue by not making it explicit or manifest to the help-

seekers. Rather, it upholds inclusiveness of all individuals in the platform to bring out the best of

their productive and flourishing self. This purposeful lack of focussed explicitness in the highly

sensitive mental health issue in the present social context is meant to address the stigma attached

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to the issue and to ensure an inclusive platform wherein those that choose to use these features

are not categorized as the “others.” In short, an appeal that targets the general audience and has

mental wellbeing as a part of the offering may hold the key to handling both stigma as well

inclusion, without actually ending up excluding the stigmatized individuals.

Conditions of depression and loneliness similar to those of the students at UX also exist

today in many business environments, where employees work in organizations under highly

stressful conditions (Böckerman et al., 2011; Hessels et al., 2018). To provide a practical

solution to this problem, we are on our way to make use of the results of our study to implement

an IT-enabled, web-based intervention and campaign that is targeted at all individuals in the

organization and not particularly at the depressed ones and their caregivers. We hope that our

findings, and, in particular, the practical utility of the web intervention, will guide practitioners,

managers, and decision-makers in many organizations to ensure conducive working conditions

for their suffering employees, so that they can come out of their states of anxiety, burnout, and

depression to function in a fully productive capacity.

RESEARCH CONTEXT

With fierce competition in the educational and vocational sectors in India today, parents,

especially from the middle and lower-middle income families, routinely force their children to

enroll in programs that make the most financially rewarding professions in the present economy.

Students who lack motivation to study the concerned disciplines grow increasingly ill at ease

with the rigor of formal (that is, curriculum-driven) education and quickly lose interest in studies,

in particular, and in life, in general. Frequently, such forced, disciplinary education causes high

stress to build up in their life, causing poor academic performance and aspirational void.

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Subsequently, the stigma attached to the academic failure of these students leads to full-blown

mental depression or recurring episodes of anxiety for them.

Nevertheless, certain environment elements help an affected individual (a student in a

college/university or an employee in a business organization) to better manage their own life by

successfully contending with problems associated with personal stigma and depression. To

investigate these elements, we performed in-depth interviews and conducted surveys of a large

number of UG students in UX. This enabled us to identify the following five factors: (1) Access,

availability and quality of intervention in times of distress and discomfort; (2) A individual’s

informal, social interactions with their peers; (3) A individual’s interactions with their superiors

(for example, for students, their course instructors or university administrators); (4) An

individual’s participation in extracurricular/recreational activities; (5) An individual’s attitude

toward life. The objective of the present study, placed contextually around these elements, is to

build a framework for a process that leads, through an individual’s self-realization and subjective

care-of-the-self, to a balanced form of self-management and wellbeing.

THEORETICAL PERSPECTIVE AND CONCEPTUAL FOUNDATION

Today, an increasing number of individuals are confronting a crisis in their life as they

begin to cope with the pressing need to acquire employability skills to participate in a specialized

workforce (Brown et al., 2003). Frequently, the root of the crisis lies in the mismatch or

misalignment between one’s dreams and desires for personal aspirations and the socioeconomic

demands of financial security and professional success in life. In India, for example, parental and

societal pressures force many students to enrol, against their personal wish, in programs

providing marketable qualifications but for which they have no intrinsic motivation. Besides, the

catering to the strong demand for employability is manifested in the rigorous practice of

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disciplinary techniques of educational institutions to train their students to acquire employable

skills. Unfortunately, students who find themselves unable to cope with this disciplinary

mechanism often suffer from social stigma and develop mental depression, anxiety, and stress.

Disciplinary mechanisms can severely constrain and modify the normal behavior of

social actors (Foucault, 1994). Further, it makes the conditions of mentally depressed individuals

particularly worse. Controlled to be disciplined, and punished when deviant, not only the

depressed individuals but the non-depressed ones as well are molded to function in accordance

with what is deemed appropriate in society’s perception of high performance standard in terms of

employability. Most exploratory possibilities and alternatives that might otherwise be open to the

individuals would be squashed in this stranglehold. Students who fail to cope with this

disciplinary mechanism aimed for their professional success, followed by its punitive exercise of

power, begin to increasingly exhibit poor academic performance. In a highly competitive social

environment of the institution, stigma is attached to such failings and cases of hopelessness.

Goffman (1963) argues that individuals possessing certain attributes that invite social

disapproval must manage their behavior in public in order to handle their spoiled identity. In

particular, these individuals run the risk of being quickly discredited by society when their

identity with these attributes is revealed. Stigmatized individuals, therefore, exercise extreme

caution to manage their precarious identity in public (Henderson et al., 2013). Tensions arise at

work if colleagues and coworkers do not realize that the depressed individual has a stigma-driven

sense of suppression of existing conditions and is underperforming because of disturbed mental

health (Kanter et al., 2008). Deteriorating performance of these individuals, in academics or in a

business organization, leads the way to a shrinking spiral, in which they might fail to retain their

present standing, further damaging their self-confidence and self-esteem. It acts as a severe

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stressor in their life, which lowers their chances of recovering from their depressive mental

conditions or fight back against the scourge of stigma (Thornicroft, 2007).

There is an important difference, nevertheless, between those individuals who are already

discredited with manifestly stigmatized conditions and those discreditable ones that are likely to

be discredited when their conditions become publicly known. For the latter group, therefore,

there is always a pervasive fear of exposure. In addition, there is no acceptance permanency

awarded to the stigmatized by the so-called “normal” in the society, because the granted

acceptance of the stigmatized could be withdrawn at any time when their behavior steps beyond

the “comfort zone” of the normal. It therefore seems reasonable to suppose that the dependence

on and sanction granted by the normal might actually be counterproductive in the management of

stigmatized identity. Inadvertent exhibition of signs that betray the mental conditions of the

stigmatized, such as their inability to prosecute activities of daily routine, including eating,

sleeping, getting up from bed, taking baths, and so on, as well as sudden meltdowns in public

with sad or angry outbursts followed by bouts of crying, lamentations, or even self-harm make

them vulnerable and susceptible to discovery (Kanter et al., 2008; Thornicroft, 2007).

This argument leads us to hypothesize a design for our intervention to bridge the gap

between the stigmatized and the normal by giving anonymity in the seeking of help, but not

limiting such help to only psychiatric/psychological assistance. Instead, the design incorporates

diverse offerings (for example, meditation, yoga, gym training, nutrition guidance, career-related

discussions, and so on) that are equally beneficial to both the normal and the stigmatized,

depressed individuals. To avoid the serious stigma attached to mental health problems, the focus

is shifted from direct addressing of these issues to things that are more generally acceptable in

the Indian organizational culture and the society at large. We call this design a shadow-

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marketing intervention1. Specifically, the intervention attempts to achieve three objectives: (1) It

addresses the precariousness of dealing with a discreditable condition; (2) It helps the

stigmatized to cope with the associated shame and denigration; (3) It provides a way to

strengthen their care-of-the-self in a manner that the resultant resilience helps them to move to a

state where they can obviate the need to manage their spoiled identity.

We build on Foucault’s theory of the care-of-the-self to argue that the actual sense of

self-care stems from affect-based social exchanges between individuals. Whereas personal

stigma is attached to mental issues as an internalization of some forms of social exchanges, its

deleterious effects can nevertheless be mitigated also by means of elevating and expansive social

exchanges, where appropriate caution must be exercised to maintain anonymity in the concerned

exchanges. Exchange theorists maintain that the most effective channel for informal learning and

acquisition of knowledge by social actors involves exchange transactions of activities and

resources in the context of specific relationships among these actors (Homans, 1974). These

exchanges embed actions involving rewarding reciprocation that consolidates the bonds between

the actors (Blau, 1964). Whether it is the students in an educational institution or the employees

in a business organization, these exchanges are invariably affect-based (Lawler, 2001) and take

place, most frequently, in the free-mixing environments of cafeterias, clubs, and other places of

social gathering. These interactions have the potential to mitigate the debilitating effects of

stigma and depression on the suffering individuals, to impart a sense of self-realization to them,

and, most importantly, to help them search for alternatives to their normative, rationalized

existence (Luxon, 2008). Besides direct, face-to-face interactions among the individuals, the

existing social network of these individuals in their institutional environment is instrumental in

helping them to acquire social capital as their primary form of mental support (Mendieta, 2014).

1
Shadow, because of its camouflaging effect. Marketing, because the intervention will be provided as a web-based service to help-seekers.

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The social exchanges facilitate the process of building up intimate, affect-based

relationships among the social actors – a subjective sense of who they truly are as a human being

(Foucault, 1996; Lawler, 2001). In the absence of this subjectivity, the self-view in question

becomes static, fixed, and aggravated by prevailing stigma, oftentimes shaped and conditioned

automatically by the power of external disciplinary judgment. With a subjective sense of the self,

however, social actors are able to look inward for their truly authentic self to find thoughts,

memories, aspirations, and desires all personally meaningful (Foucault, 1996). The relationship

to their own self then becomes fully active and exploratory (McGushin, 2014), and its realization

is necessary for an individual in order to be able to focus, choose, and make better decisions in

life. As Foucault (2005) recognizes it, this is the true “care-of-the-self” (epimeleia heautou

(Greek) or cura sui (Latin)). For an affected individual in particular, it could truly work as an

open channel of self-expression and meaning in life (Vintges, 2014).

We consider this subjective self-management to be the most salient form of life

satisfaction and personal wellbeing for an individual, especially a stigmatized and depressed one.

The subjectivity encompasses personality elements, the socio-cultural environment, the specific

circumstances of personal experience, as well as the individual aspirations and the objectives

embedded in roles played within groups (Diener et al., 1999). However, it is also true that

feelings of depression and alienation of individuals in their workplace environment, when

additionally aggravated by heightened conditions of self-stigma, tend to thwart unassisted

attempts to build self-management measures. It is primarily with the intention to find a way out

of this dilemma for stigmatized and depressed help-seekers that we build our web-intervention

platform based on the shadow-marketing design. Instead of focusing directly on mental health

issues that tends to produce increasing social polarization of the workforce, it attempts to uphold

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inclusivity for both depressed and non-depressed individuals in the platform to bring out their

most productive and expressive inner self, thereby diverting or concealing all stigma-related

signals. Following the line of arguments suggested above, we hypothesize that the shadow-

marketing design should sufficiently anonymize stigmatized identity of individuals, encouraging

them to use or utilize the benefits of our web intervention platform. To this end, we used samples

of students from UX and UY and set about to empirically test whether our platform would be

more acceptable to stigmatized individuals than other platforms that specifically focused on

mental health and wellbeing but did not utilize the benefits of shadow marketing. Figure 1

presents the conceptual framework described above.

-------------------------------
Insert Figure 1 about here
-------------------------------

METHODS

Research Setting and Data Collection

The study was conducted in two universities, UX and UY. The residential campus of UX

was located in a semi-rural area of a northern state of India at an approximate distance of 15

miles from the nearest metro city. UX had about 200 faculty members and a student population

of approximately 2000 consisting of UG, masters, and doctoral students. It provided education in

engineering, natural sciences, social sciences, humanities, and management through five

different schools divided in more than 20 departments and more than 5 research centres. At the

time we commenced data collection, UX had just introduced its mental health support system

and was experimenting with different models to see to what extent they were able to alleviate the

depressive conditions that continued to exist among a fraction of their students. However, the

problem of spoiled identity attached to the stigma of some of the students, which had continually

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been aggravating the depressive mental states of these students, was not addressed by any of the

models used by the UX authorities. In addition to qualitative depth-interviews (DIs) and focus

group discussions (FGDs), snowball sampling was used to collect relational data on students

enrolled in various UG and PG programs in UX. All student participants completed our informed

consent form.

UY was a large public university located in one of the largest metropolitan cities of India

with more than 60 affiliated UG colleges offering programs in humanities, natural and social

sciences, and commerce. Because a very small number of students could be accommodated in its

limited hostel facility, some students lived as paying guests or in privately operated hostels,

while others commuted from their homes. The students had a multitude of options for

socialization inside UY as well as outside. UY’s attendance policies were not strict, however;

although most class sizes were around 70-100, about 30-70% of the students skipped classes

without having any major effect on their academic performance. Evaluation systems were

primarily based on performance in end-semester, written tests for which the questions were

generally predictable, and the answers, based mostly on rote learning, were expected to be

written following a definite template. There were no significant mental health awareness

programs or free counselling services offered to the students by the university authorities.

Mixed-methods Approach

-------------------------------
Insert Figure 2 about here
-------------------------------

In this study we employed a two-pronged, mixed-methods approach (Tashakkori &

Teddlie, 1998) to establish a connection between primary observations and a theoretical

framework grounded upon a set of sociological theories. The basic schema is presented in Figure

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2. Within this framework, we identified a number of critical antecedents to personal wellbeing of

an individual functioning in a certain environmental setting (for example, the workspace of an

educational institution or a business organization). Concurrently, using observations derived

from DIs and FGDs of subjects in this setting, supplemented with primary data collected from

survey questionnaires, we identified pertinent themes in the patterns of struggles of the

individuals and explored new directions which facilitate triangulation with the theoretical model.

The use of mixed-methodology is appropriate for this study on both ontological as well as

epistemological grounds. First, the actual population of all subjects for potential investigation

were unknown to us. We, therefore, needed to conduct in-depth interviews of an initial sample of

students, instructors, and administrators at UX to understand what ideas made sense for this

specific problem and what critical variables and parameters needed to be included in order to

effectively deal with it. Second, quantitative surveys prepared on the basis of this initial

information (T8) were used to collect relational data to capture the informal social network

interactions of the subjects for their mutual support and help within the UX community (T6). A

quantitative, in-depth analysis of this social network based on the quantitative survey data (T5)

unravelled emergent, characteristic patterns of behavior for deeper investigation (T3).

Concurrently, qualitative interviews helped to acquire pre-understanding for a more elaborate

quantitative analysis (T4). The emergent characteristics identified from the latter in turn

influenced and restructured the qualitative interviews and our further understanding of the

problem (T4). This analysis helped us to formulate the theoretical framework (T9). Interestingly,

it also pointed to some new theoretical directions (T1) which were further explored to enhance

the theoretical framework (T2). Besides, our understanding of the specific problems involving

the stigmatized existence of some of the subjects, their depressive mental conditions and

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alienation as well as those features of life that contributed to ameliorating the conditions of their

mental states (T8) also helped us to bolster the theoretical framework (T7). Third, at almost

every stage, the qualitative and quantitative studies were interleaved. In the instances where they

were not uniformly compatible, they were found to complement each other. These opportunities

for triangulation were enriched by the coexistence of both methods in the study. Fourth, and

finally, both approaches were knowledge-driven, and mutually fulfilling, which benefited from

the complementary skills and expertise of the researchers involved in this study.

Research Process

With stigma attached to mental health issues causing reluctance of prospective

participants to open up, it was not easy to gain access for inquiry to students suffering from

depression. To address this challenge, we collected data with the help of students who could gain

confidence of the depressed peers. Data was collected through a series of studies conducted in

UX and UY. Before any qualitative or quantitative fieldwork was conducted by our students, the

authors provided intensive training to them in order to ensure that they had the required

competence and sensitivity to deal with socially sensitive issues. For the purpose of analysis of

qualitative data, DIs and FGDs were transcribed, and after initial coding, broad themes were

developed based on grounded methodology (Charmaz, 2006; Creswell, 2007). We thoroughly

examined the data to identify emerging themes to ensure accurate triangulation. The steps

involved in the research process, with research questions, methods and sample details are

explained in Table 1.

-------------------------------
Insert Table 1 about here
-------------------------------

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Step 1: An MBA student who was trained in interviewing using Zaltman Metaphor

Elicitation Technique (ZMET) (Zaltman & Zaltman, 2008) for an unrelated corporate project2,

performed a deep metaphorical exploration of five depressed students on campus to gain insight

into their thoughts and feelings when they were sad or depressed. Step 2: We appointed a UG

student research assistant, who had excellent interpersonal skills, was a good listener, and had

close connections in the student community. Having initially assured them of complete

confidentiality, he requested them for appointments to participate in the study. Beck’s

Depression Inventory (BDI) was then administered for collecting relational data for social

network analysis. Additionally, as a part of their class projects, two graduate student teams were

deployed to collect BDI data by snowballing. Step 3: Two independent UG and MBA student

teams, as a part of their course studies, did the fieldwork to understand how the depressed coped

with their condition, the role of stigma in help-seeking behavior from the free university-

provided professional and peer-counselling services, as well the experiences of caregivers and/or

peer-counsellors. One of the authors conducted follow-up interviews of a few students. Step 4:

Based on the above steps, a concept card for the web-intervention was prepared by two UG

students who were doing a non-credit research thesis project on student wellbeing. Step 5: One

of the two UG students involved in step 4, a computer science major, did fieldwork on

understanding the elements of the web-intervention that would be relevant to the self-care of

both normal and depressed students. Step 6: A team of MBA students worked on the positioning

of the web-intervention as a part of their class project. Step 7: The survey instrument was

administered by the above UG computer science major student and a research intern from UY

with a keen interest in social issues.

2
Olson Zaltman Associates, the proprietary patent holder of ZMET, had a corporate project in India, and this student was trained by one of
the authors to conduct that fieldwork.

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Exploratory Network Study (Step 2)

When existing conditions became difficult for a student to cope with, they would rely

exclusively on resources and personal support from their informal social network within UX. As

an endowment of trust for this support, a depressed student’s degree centrality included their

direct contacts with caregivers, peer-counselors, and other depressed students. Simultaneously,

the network’s large-scale density and centralization provided information about the extent of

convergence of a student’s dependence on these contacts. This helped us to identify popular

actors to whom others might turn for support, advice, or assistance in times of mental distress.

Furthermore, a student’s betweenness allowed us to locate trust-brokering actors in the network

who served as bridging links between other support-seekers, caregivers, or peer-counselors to

access help and support which might be remote from the seeker. The design of our intervention

platform was highly influenced by the role these actors played to enhance the network’s large-

scale connectivity. As a robustness check, we computed the network’s global clustering

coefficient (CC) and compared its value with that of a random network (Newman, 2003;

Wasserman & Faust, 1994). A supplementary check employed the Watts-Strogatz (1998) CC.

During times of emergency, it is critical that the necessary resources be made available to the

support-seekers. However, individuals who had stigma attached to pre-existing conditions of

mental depression become psychologically overwhelmed and emotionally drained, so much so

that they became excessively withdrawn and would shun external help. The average closeness

gave an indication of the ease with which the necessary resources could be accessed. This

process is most effective in a small-world network (Newman, 2003; Watts & Strogatz, 1998).

Measures (Step 7)

Unless otherwise noted, 1 = “strongly disagree” to 7 = “strongly agree” scales were used.

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Stigma. Prior studies have confirmed that there is a social stigma associated with

depression (Henderson et al., 2013; Thornicroft, 2007). A previous depressive episode in the life

of an individual does not stop the affected person from entertaining negative opinions about

depression that reflect the views of the community, and the particular social and cultural milieu.

Because of stigma and shame attached to depression, personal weakness often becomes an

ingrained self-prejudice that leads an affected individual to avoid problem acknowledgment and

to decline offers of help, support, or potentially beneficial assistance (Kanter et al., 2008). We

measured stigma by five-item scale of Komiya et al. (2000). An example item from the scale

reads: “It is a sign of personal weakness or inadequacy to see a psychologist for emotional or

interpersonal problems.”

Wellbeing. Wellbeing is commonly understood in terms of subjective happiness as a

positive emotional condition of an individual and their satisfaction with life. It is as much as

matter of individual personality as it is an element of the socio-cultural environment in which the

individuals find themselves (Diener et al., 1999). We measured wellbeing using a 5-item scale

adapted from Lyubomirsky & Lepper H.S. (1999) and Diener et al. (1985). An example item

from the scale reads: “The general conditions of my life at the present stage are excellent.”

Depression. We measured the depression levels of students using the BDI scale (Beck et

al., 1961). Out of all students who completed the BDI, those who scored 17 or above were

administered a survey that was used to capture relational data for constructing their informal

social network, along with several demographic information. In our samples, students in UX and

UY were found to be 30% and 24% depressed respectively.

Analytical Method (Step 7)

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In order to examine the efficacy of our web intervention platform to alleviate depressive

conditions of stigmatized individuals with respect to their wellbeing, we tested the intention of

the respondents to use three different platforms, which were all designed to facilitate wellbeing

of individuals. Our platform was named “Cocoon,” and the other two platforms, both of which

had already been in production when the responses were collected, were called “Site 1” and “Site

2” to conceal their real identity. Site 1 was a platform to promote wellbeing through meditative

and self-reflective practices. It did not explicitly mention mental illness but was based primarily

on the idea that wellbeing was a skill-based practice. Site 2 was specifically aimed at those that

wish to speak anonymously to a trained peer-listener or a psychologist. Our choice of these two

sites was motivated by their primary difference that, Site 2 is helpful for emergencies and was

targeted at those suffering from stress, anxiety, or depression, whereas Site 1 was intended for

use by those who believed that they could improve their mental states with mindful practices.

A proxy variable was employed to gauge the intention of the respondents to use the

services provided by each of the three platforms. This variable was a hypothetical amount of

investment made by a prospective user over a period of three months, where a monthly

subscription fee in the amount of $300 was charged to avail of the services offered by the

platform. The idea was that, users with particular stigma and wellbeing scores would venture out

to make a definite investment decision that was directly associated with their intention to use the

services offered by the selected platform. Thus, our dependent variable (DV) is the total amount

(𝑎𝑚𝑡) earned by each platform (or the investment amount made by a single user) over the

complete period. Because the DV is restricted to a finite range from $0 to $900 (inclusive), the

assumptions of ordinary least square (OLS) estimation are clearly violated for such a limited DV.

Thus, the continuous, censored DV is a good candidate for a Tobit model. Since there was no

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panel structure evident in the data, there was no need to compute a cluster-corrected covariance

matrix for the adjustment of standard errors for intragroup correlations among the users.

However, we employed heteroskedasticity-robust standard errors to minimize the effect of

heteroskedasticity and heteroskedasticity-robust 𝑡 statistics for testing the individual

significances of the coefficients (Wooldridge, 2010). To safeguard against of multicollinearity in

the regressions, we computed the variance inflation factor (VIF) and found that the average VIF

was 7.1. This was well below the recommended cutoff of 10 (Cohen et al., 2003), so

multicollinearity was unlikely to be a major concern in our estimation method. Besides, Stata

automatically drops covariates from a model when multicollinearity affects the concerned

computations. No covariates were dropped in our regressions. All of the computations were

carried out using standard routines in the Stata 14 package, and the VIF computations were

performed using the Collin multicollinearity diagnostics command in Stata.

RESULTS

-------------------------------
Insert Figure 3 about here
-------------------------------

Step 1. The results are summarized in Figure 3. Our ZMET analysis suggests the

existence of three stages that students move through.

First Stage. When probed on their thoughts and feelings as they feel depressed,

respondents show images of silhouetted, dark rooms with shadows of drooping, solitary human

figures, and masks of fake smiles. These visual metaphors indicate the deep metaphorical (DM)

experience of a closed and disconnected container3 (Zaltman & Zaltman, 2008) that is

characterized with feelings of hopeless sadness and attempts to hide true mental states. There are

3
A container refers to the concept of being in (or out) of a place (such as, house, room, etc.). It is a reference to keeping things “out” or “in”;
being wrapped up or out in the open.

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prolonged periods of sadness that catch one unawares and leave them confused. The initial

apathetic, low-energy phase makes even regular limbic movements difficult to accomplish.

Sometimes, the sadness is overwhelming; at other times, it is numbing. As a defence mechanism,

individuals tend to build walls around themselves and prefer to believe that such a state is

temporary and struggle to come out of it.

Second stage. While the container at the first stage can be debilitating in its dark

confining imprisonment that seems impossible to escape, there is also a lack of desire to make

efforts of connecting with others. One vacillates between staying in the container for seeking the

apparent comfort of its isolation and slipping into the depths of misery. Consequently, there is a

dilemma between the quest for human companionship and the solitary struggle for their

existence. The image of a person inside a jar attempting to get out of it symbolizes this struggle,

while a cracked mobile phone and a drowning hand desperately seeking help captures the

difficulties in making the connection. This stage characterizes the DM of paradoxical

connection4 (Zaltman & Zaltman, 2008).

Third stage. The final stage resolves the paradox that the respondents feel between the

two opposing pulls of the container and the connection through the DM of balance5 (Zaltman &

Zaltman, 2008). Showing visual metaphors of a multi-coloured hut in an island and starry nights,

the element of balance turns the metaphorical container experience from a black hole of

miserable nothingness to an expanding galactic universe – respondents talk about seeing

themselves in gazing at a galaxy of stars, as they learn to become comfortable with their own

4
A connection refers to feeling included and kept in loop, against feeling excluded and kept out of loop. It is a reference to connecting with
things or people, conveying a sense of making an association, linking or attaching as well as to be a part of and to not be isolated from. It also
signifies liking or loving someone or something.
5
Balance signifies equilibrium, equalization, or compensation. It is a reference to reciprocity and corresponds to stable (such as calm, relaxed,
or serene) emotional states, and feeling “right” (that is, in harmony) with the world.

19
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self. We discuss the process of how individuals achieve this balance using coping mechanisms in

the findings related to step 3.

------------------------------
Insert Table 2 about here
------------------------------

Step 2. An analysis of the student network macrostructure gave us definite indications of

problematic areas of institutional life of students and helped us to explore avenues where

improvements can be made through our web intervention. Table 2 provides summary statistics

for the metrics of this network with short supporting explanations. Depressed students, their

caregivers, and the peer counselors constituted 148 actors in this network. With 34 clusters

(including six isolates), the leading cluster spanned about 10% of the network’s entire volume.

The network’s disconnectedness showed up in its large fragmentation fraction of nearly 23%.

Triangulating with our qualitative data indicated that this problem was rooted primarily in the

social stigma that was attached to their mental depression syndrome. Severe withdrawal and

alienation caused their help-seeking tendencies to be grossly subdued as they began to cut off

external interactions. Our web intervention addresses this problem by providing links among the

currently disconnected students through the identified broker-actors in the network. In addition,

the network’s non-centralized structured was revealed in its low mean centralization and mean

degree (just 26% of the highest degree in the network). Ordinarily, we expected that the peer-

counselors, whose job it was to assist students to seek professional help, would function as trust

brokers in the network. However, depressed students often perceived them as an extended arm of

the university’s surveillance mechanism to identify depressed students who indulged in

substance abuse. Swati reported thus: “[Peer-counselors] were expected to tell everything to the

[administration] and… there are times when people come to us and ask us not to say anything to

20
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them, and (the UX-appointed professional) has zero concept of privacy.” This resulted in a large

degree of disconnectedness in the student network.

The density and the associated clustering metrics in Table 2 indicate the network’s low

cohesiveness. This seemed rather surprising at first. Initially, we expected considerable cohesion

introduced by the peer-counselors owing to their special status as regular university students.

However, this did not seem to be the case here. Deeper investigation revealed that the

fundamental element of trust between these individuals, as a prerequisite for support-seeking

behavior, was missing in the relationships. More critically, however, the network did not have

the configuration of a small-world community, as evident in Table 2 in the disparate magnitudes

of its mean geodesic distance and that of its random counterpart. Thus, when emergencies arose,

quick access to relevant resources from the right but distant network actors was problematic.

The individual actor-level betweenness and closeness distributions (not shown) identified

two students as key players in terms of intermediation and resource-access relationships. They

were the same two individuals, one of which was a caregiver and the other was a caregiver, who

was also depressed. This seemed to suggest that the caregiver role as a symbol of trust was a

critical one. However, since the network was constructed using cross-sectional data, the time

factor embedded in most trust-based relationships could not be directly captured. Instead, we

used tie strength as a proxy for time. Our results showed that the strong-tie connections

converged on the “popular” students who had been in the university for at least three years. Our

web intervention was designed to identify these actors as individuals in the network who could

infuse more hope and trust into the depressed students’ social support system.

In this connection, our qualitative data indicated that caregivers played a critical role in

the process of self-realization of affected students. Bunny explained thus: “This friend of mine…

21
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would mostly be around when I was in a long-term crying state. I started indulging in art… in

music. Then I told her this is really not changing anything… she told me your problem is

whatever interest you had is in a dying state now… you work on your personality problems

which hurt you more than your physical problems…and I myself realized that my personality

problems have taken over everything… I understood whatever depression is doing to me. So, in

order to get better, I need to take up those things one by one and work on them.” Peer-

counselors, however, were not of immediate help beyond encouraging affected students to seek

professional assistance, because it always took time for these students to build trust with them.

-------------------------------
Insert Table 3 about here
-------------------------------
Step 3. We discuss this step from the perspectives of the depressed individuals and the

caregivers. The themes and supporting quotes from respondents are presented in Table 3.

Phase 1. Surfacing of Depression: From Denial to Disbelief. As discussed earlier, the

container stage is characterized by a sense of denial as individuals fail to come to terms with

their present conditions marked with prolonged, sad phases accompanied by the inability to do

basic self-care like leaving bed, eating food, taking bath, and getting ready for class. The high

achievers are also reluctant to show themselves as weak and vulnerable to others. When these

conditions begin to deteriorate, and students inadvertently start displaying the tell-tale signs of

depression including uncontrollable crying or self-harm, they can no longer ignore them or hide

them from others. In UX, some students coped by cutting themselves off from the world, some

sought professional help, while others took to substance abuse.

Phase 2. Curse of Stigma: Better Suffer in Silence than be Sorry. Individuals exhibit a

great resistance to social or professional help-seeking, because of a lurking fear of being labelled

as mentally unsound. In our UX sample, instances of mockery and desertion by friends or

22
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acquaintances surfaced when the symptoms of mental illness became evident to the community.

With the long history of criminalization of suicidality in India and the associated lack of concrete

public policy concerning mental health support services, there is a complete lack of trust of

individuals in institutionalized efforts. For example, when UX offered free psychological or

psychiatric services as well as student-initiated voluntary peer-counselling by those specifically

recruited and trained for this purpose, there was intentional non-consumption triggered by the

perception of a lack of care of the institutional authorities as well as a suspicion of the loss of

confidentiality when the affected individuals talked to peer-counselors, psychologists, or

psychiatrists. Students suspected that it was a mechanism of panoptic gaze (Foucault, 1977)

aimed at watching them using multiple “eyes” of the administrators apparently trying to help, yet

actually intending to penalize when they confessed about their coping mechanisms involving

alcohol or drug-consumption or, at the very least, making themselves susceptible to public

stigma We explain our findings about non-consumption of free psychological/psychiatric/peer-

counselling services offered by UX in Figure 4.

-------------------------------
Insert Figure 4 about here
-------------------------------

Phase 3. Connection: From Cause of Pain to Safe Space-Holding. Many of our

respondents initially slid into depression as they were unable to adjust to their existing

conditions, to which prevailing social comparisons contributed. These social comparisons often

arose during their high school days characterized by long hours in coaching institutes that

prepared them to get into professions that were chosen by their families, sometimes against their

own will. The inability to cope at that stage often pushed them into the container of isolation and

23
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distress that continued beyond high school to college6. When the pressure of pent-up emotions

started to exhibit external manifestations, even when the individuals attempted to suppress them

in fear of stigma – sometimes a friend or a teacher played a Good Samaritan to facilitate their

move to the connection stage. The nature of social connections, therefore, change, from being

suffocating and painful, to healing and safe space-holding. Sometimes, however, when such help

is unavailable, self-reliance comes to the fore, and the struggle for mental peace becomes

essentially an individual effort.

Phase 4. Away from Societal Expectations: Finding Balance in my Container of Self-

realization. In the acceptance of a depressive stage, individuals seek relief in matters outside of

their personal universe, as they move out of their restrictive distressful container-spaces.

Connections through conversations with close friends and intellectually stimulating discussions

in classes or outside, as well as physical or self-reflective, centering exercises (for example,

walks; biking; meditation; yoga; painting, etc.) often prove to be expansive and elevating for the

inner being. In many ways, the healing that happens through safe space-holding in the earlier

stage is transformative, and the path to recovery gradually evolves from one that depends on

others to a personal journey where one learns the art of self-care. We found that individuals who

had previous depressive episodes are able to cope with the problems better than those who were

affected the first time. Healing, in this regard, is actually a continuum of increased self-

understanding through practices of self-care.

For the care-givers, on the other hand, it turned out to be a double-edged sword. There is

an underlying paradox in their sense of compassion that frequently results in being overwhelmed

6
We report this in a separate communication that is currently under preparation.

24
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by care-receivers’ expectations. They genuinely intend to help but often themselves feel drained,

exhausted, and helpless in the process of caregiving.

Step 4. We developed a concept card for the proposed web-intervention, based on our

findings from steps 1-3. Given the high stigma attached to mental health issues which affect an

individual’s intention of help-seeking from friends, professionals, or peer-counsellors, we

decided against directly positioning the intervention on mental illness or wellbeing. Instead, we

designed the intervention to better serve as a platform in which one can accept challenges in

taking up wellbeing activities individually or with other community members. The intervention

platform prepares an individual to engage in career-related activities including, for instance,

doing internships; participating in contests; interacting with or listening to podcasts by invited

speakers on recent research topics or contemporary issues; taking up centering challenges;

talking anonymously to a peer-counselor or friend for getting information on helpful

nutritionists, yoga-instructors, gym-trainers, psychologists or psychiatrists. This inclusive

intervention design provides a path toward self-fulfilment of all individuals, non-depressed as

well as depressed. There is an intentional lack of focus on mental health issues, and anonymous

chatting with or search for a wellbeing activist/psychologist/psychiatrist is just a part of the

overall offering, thus reframing help-seeking as a part of an overall self-development and career

progress efforts of an individual. This is precisely the idea of shadow marketing, in which the

focus is shifted from mental health to a different but challenging path of pursuing career-related

goals and the use of associated self-management tools. This strategy helps to normalize and

destigmatize individual help-seeking behavior and facilitate adoption of self-care practices that

contribute to wellbeing.

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Step 5. We tested the concept card with FGDs and DIs of normal students, depressed

students, and faculty. Subsequently, we made the necessary modifications based of the feedback

received. The web-intervention design is displayed in Figure 5.

------------------------------
Insert Figure 5 about here
--------------------------------

Step 6. This step involved developing the correct positioning for the platform. A short

video of the proposed intervention was shown to the students, and they were asked to show

metaphorical images to describe the features that worked best for them. The tabs that were most

popular were “take a Challenge” and “talk to someone.” The images that the respondents

described were deep metaphors of self-expression7, connection, and open container8 (Zaltman &

Zaltman, 2008). Consequently, the intervention was named “Cocoon”9 with the tagline “paint

your wings your colors.” It conveyed the idea of both self-expression and container – a safe

space for a caterpillar to turn into butterfly. Table 4 provides details of the images associated

with a few key tabs on the web intervention platform.

------------------------------
Insert Table 4 about here
--------------------------------

Step 7. We checked the platform for its effectiveness in handling stigma vis-à-vis two

other popular interventions. However, before moving to this step, we developed a prototype of

the intervention to reflect the positioning and tagline. A snapshot of the prototype of the web-

7
Self-expression refers to things that express one’s personal goals, values, points of view, and so on, to one’s self or to others.
8
A container is open when it helps one feel a sense of being free and expansive.
9
Swati, a depressed respondent, beautifully stated it: “I mean the blackness at the same time feels cozy and extremely empty . . . the blackness
could be like a cocoon, like a warm blanket; at the same time the blackness also reminds me of the expanse of the universe. So, it’s everything,
my sense of fear, my sense of acknowledgement, my sense of self, my disassociation with self, my association with others, my disassociation
with others … it’s just me, but at the same time there is no me … you just become more comfortable [with the] nothingness and … it’s
something that starts off with extreme negativity becomes something positive.”

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intervention is provided in Figure 6 and the website design may be accessed at

https://kp2288.wixsite.com/cocoon.

-------------------------------
Insert Figure 6 about here
--------------------------------

Empirical Analysis of Intention to Use Platform (Step 7)

---------------------------------------
Insert Tables 5 and 6 about here
---------------------------------------

Table 5 provides the basic statistics pertaining to the scales for stigma and depression.

Table 6 reports the maximum likelihood estimates of the coefficients in the Tobit model. Our

hypothesis asserts that stigmatized individuals suffering from depression will show a greater

likelihood to avail of wellbeing-related services offered by an intervention platform that utilizes

a shadow marketing strategy rather than by one that does not adopt such a strategy. The results

show that the hypothesis is supported with a high significance (𝛽 = 0.28, 𝑝 < 0.001) for the UX

sample. For the UY sample, however, although stigma is significant (𝛽 = −0.32, 𝑝 < 0.05), the

directionality of the association is opposite. The implications of this result are discussed in the

next section. However, in neither of the samples, wellbeing was found to be significant. This is

not surprising, of course, in view of the fact that the actual benefits provided by the sites

pertaining to the improvement of wellbeing of an individual have not been put to the test in

actual practice by any of the respondents in our study. It was only their perception of the

wellbeing services offered by the sites that have been revealed in their choice of subscription.

DISCUSSION AND CONCLUSIONS

Theoretical Contributions

Although, at this time, we used samples from only two educational institutions in India to

test the theoretical model introduced in this paper, our framework, grounded in sociological
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theories, develops a sufficiently general understanding of subjective self-care and wellbeing for

an individual suffering from alienation in the workplace, who are personally stigmatized because

of their prevailing conditions of mental depression. We argued that the strategy of shadow-

marketing intervention can obviate the deleterious influence on them of the stigma that is

attached to their depression. In large measure, it imparts a sense of self-care to the individuals.

Affected individuals, on account of high personal stigma attached to their depressive

mental conditions, become fearful, over time, of public exposure of their weak and unmanaged

mental states, which contribute to their poor performance when compared to that of their peers,

coworkers, or colleagues in the workplace. In this regard, the inclusivity of all individuals on the

platform as well as its explicit avoidance of a direct focus on mental health issues helps the

stigmatized, depressed individuals to become integrated with others in sharing their thoughts,

ideas, career goals, as well as personal problems within an exclusively anonymous setting.

The network analysis revealed its excessive disconnectedness, where many local clusters

had coexisted in the network without any large-scale connectivity. As our data from the

interviews substantiated, this lack of connectivity comes about because students, who are already

stigmatized because of their conditions of mental depression and consequent declining academic

performance, are constitutionally shy, withdrawn, and too distrustful of others to open out and

share their feelings and sentiments in times of severe mental distress. Consequently, emotional or

physical help, when they need it most urgently, is not readily available.

Goffman (1963) contended that stigma leads to spoiled identity of an individual. Building

on this view, we argued in this work that the identity, even when it is spoiled, can be resuscitated

into its rightful state by establishing the inclusivity of stigmatized individuals with normal ones

but, at least initially, under protective observance of anonymity. The freedom inherent in

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anonymous social exchanges and communications normalizes stigmatized, depressed individuals

and gradually builds in them a sense of self-knowledge and an interest in renewing lost

engagements or commencing new ones in life. This essential form of self-care leads, over time,

to personal wellbeing of the individual.

Our shadow-marketing intervention platform, with its explicit avoidance of the focus on

mental health issues, positions itself as a safe container-space to express the best version of an

individual’s ideal self. It works better than the forms of direct interventions implemented in the

other two sites at handling stigma in a social environment that has some exposure to

conversations, interventions, or efforts to alleviate mental illness (in our case, UX).

Unfortunately, our respondents in both UX and UY did not have the time nor the opportunity to

practically use the services of any of the sites offered to them during the course of our data

collection for this study; the empirical tests for wellbeing, therefore, did not completely

materialize, which is, of course, not an unexpected result10.

On the other hand, the tests for stigma between UX and UY reveal an interesting

difference between the two samples. For Cocoon, the UX behavior is highly significant,

convincing, and support our hypothesis, imparting confidence in our model to design the

intervention platform. By contrast, it seems that more stigmatized respondents in the UY sample

appeared to have somewhat lower intention to invest in Cocoon. There are primarily two

explanations for this apparently anomalous behavior exhibited by the UY sample. First, the

underlying institutional structures of UX and UY are different. Students in the fully residential,

semi-urban setting of UX spend more time together in a tightly knit community. Consequently,

the stigma effects are stronger and more immediate on them that on the students at UY, where

10
We initially decided not to include the results of this test in this paper, because they are at best incomplete. Nevertheless, we at least wished
to record them in order just to confirm that we did not obtain any spurious results in the statistical analysis in the empirical tests.

29
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students spend much less time together on the average in an urban environment and perhaps

more time with their friends and families outside of the university environment. The inclusive

setting of the Cocoon platform may not therefore hold any particular appeal for them. Second, in

a setting with no awareness efforts or campaigns to alleviate conditions of mental health of

individuals (as it was the case of the students in UY), even a shadow intervention could backfire

and produce an undesirable effect of aggravating stigma. The same strategy, therefore, does not

work at dissimilar levels of acceptance of mental illness in the general population. In the

complete absence of mental health literacy efforts, even providing tools that facilitate wellbeing

and anonymous chatting may also trigger stigma, although the intervention explicitly focuses on

career- and self-growth.

Practical Implications

The stigma attached to mental health issues has not be addressed in many nations

primarily due to the lack of governmental action and public policy measures on it. One of the

primary reasons in this regard was the necessity to maintain sufficient confidentiality and

anonymity in this process. This is indeed so, because since colonial times in India, any suicidal

attempt by an individual, which often results from depression, was a criminal offense punishable

under law. While the British colonial law in existence as section 309 of the Indian Penal Code of

1860 that criminalized attempts to suicide was recently repealed in India, in much of south and

east Asian countries, such as Pakistan, Bangladesh, Singapore, and Malaysia, the situation has

remained unchanged (Behere et al., 2015). Our study has practical implications for business

organizations as well as for educational institutions, where workplace stress or personal distress

results frequently in depressive conditions in individuals, and there has been a history of stigma

attached to such conditions that force Goffmanian (1963) management of spoiled identity. We

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find that our shadow-marketing intervention, which avoids explicit focus on mental health issues

but positions the platform as a safe container-space to express the best version of one’s ideal self,

works better than the forms of direct interventions implemented in sites 1 and 2 at handling

stigma in a social environment that has some exposure to conversations, interventions, or efforts

on mental illness (in our case, UX). Interestingly, even such camouflaged intervention might

backfire and produce the undesirable effect of aggravating stigma in a setting that has no

awareness efforts pertaining to mental health (UY).

Limitations and Future Directions

The present paper provides just a short glimpse of the findings of our ongoing research

project pertaining to the understanding of the nature of the path from self-realization to the

attainment of a state of wellbeing in the life of individuals who are suffering from adverse

conditions of existence. As it stands at this time, the work has several limitations and

inadequacies that leave room for further research in the future. First, a preliminary examination

of this material suggests that the additional information will provide fresh insights into the

problem. In particular, it will help us explore some of the present domains in a new light and

thereby enrich the scope and quality of the intended web-intervention platform. The results we

got from UY also suggest that if the social ecosystem has no mental health awareness at all, even

a shadow marketing intervention will not be fully efficacious. Only after intensive, initial efforts

of creating awareness can the effects of stigma be abated. Additionally, in order to be sure of the

causality connecting mental health literacy and efficacy of shadow marketing, a separate study

using experimental design must be undertaken.

Second, in addition to UX, we are currently investigating the educational environments of

several other universities, UG and PG colleges in India, some of which are private and some

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public. The private university culture is relatively recent in India and, as such, is different in

several ways from the environments of the major public institutions of higher education, which

are large bureaucratic bodies with highly rigid and controlled curriculum structure.

Consequently, the nature of student wellbeing will differ in specific detail between the two types

of institutions in India11. At a more fundamental level, however, the nature of the path from self-

realization to the attainment of wellbeing is ubiquitous, irrespective of the nature of the

governance structure of institutions. Future work will examine the robustness of our framework

against structural variations between the two systems and substantiate its generalizability.

Third, we did not explicitly focus on the cultural dimensions of wellbeing. Many aspects

of cultural dissimilarities are markedly pronounced between the Indian and the Western concepts

and individual recognition of wellbeing. A deeper investigation of the cultural characteristics,

even within India, will prove fruitful, and our future work will report on this issue in more detail.

Fourth, at this time, we are unable to study the temporal dimension of the students’ relationships.

An important aspect of this concerns the investigation of “role evolution” of the network actors.

There is already some evidence in our data that a depressed student may herself play the role of a

caregiver to another depressed student at one time or a caregiver may become depressed herself

at another time. Studying the role-evolution phenomenon will bring to light the dynamic nature

of the network relationships.

Finally, a worthwhile and exciting challenge for us is to extend our framework beyond

the domain of educational institutions into the realm of business and industrial organizations. As

already mentioned before, employees in many of these organizations, especially in the IT service

sector in India, suffer from conditions of distress, disillusionment, burnout, and mental

depression. Working conditions in corporate India are different from those in the educational

11
We have not specifically examined the role of the structured education system in student depression in this study.

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institutions in the country. With appropriate modifications, our proposed framework and the

accompanying web-based intervention program can contribute to the personal wellbeing of the

employees in these organizations. In particular, the study can benefit the managers and

executives of these firms to learn from and use some of our findings in order to ensure working

conditions in their organizations in which their employees find themselves in the best of mental

health and in the finest state of productivity.

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TABLE 1 Steps in the Research Process, with Research Questions, Methods, Sample
Details, and index of Findings

Research Question: What

intervention would help depressed
students cope with their condition? Method Sample Findings
Steps
Research Sub-Questions
Step 1
What do depressed ZMET on thoughts and feelings when sad
students think and feel? or depressed 5 depressed students Figure 3
Step 2 Whom do depressed Survey on relational data for social
students confide with network analysis
when they feel low? 148 students Table 2
Step 3 Depth-interviews: for the depressed we
assessed their coping mechanisms,
whether they sought paid external help or
Figure 4,
free professional/ peer-counselling 5 depressed students, 5 peer-
Table 3
What helps depressed services offered; for care-givers/peer- counsellors of whom 3 are depressed,
students cope with their counsellors we tried to understand what 2 caregivers one of whom is
condition? strategies help the depressed depressed
Step 4 Developed Concept Card for Web-intervention
Step 5
Depth-interviews (DI) and Focus Group 3 FGDs and 5 DIs of students (of
What would normal and whom 2 were depressed, 2 suffered
Discussions (FGD): Consumer-testing was
depressed students find from anxiety but not depressed, 1
done on the features of the web- Figure 5
relevant to them for self- normal); 2 DIs of faculty with
intervention, and changes made after
growth? reputation of being engaging and
incorporating the suggestions received
student-centric
Step 6 Depth-interviews (DI) and Focus Group
What would be the right Discussions (FGD): Video on the concept
positioning for an card was made and students were
Table 4
inclusive platform interviewed on the features that work best
targeting both normal and for them, image-based exploration was 1 FGD, 10 DIs (of whom 5 were
depressed students? done depressed)
Step 7
200 students from two universities:
100 from a university in a remote
How would the developed location with residential campus, that
web-intervention fare vis- had some student and university-led Figure 6,
à-vis other interventions Survey on stigma, well-being and activities around mental health; 100 Tables 5
targeting mental health in intention to subscribe in another university located in a and 6
terms of addressing major metropolitan city with no
stigma? significant awareness around mental
health, and no strict attendance
requirements

TABLE 2 Network Macrostructure Metrics

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Metric Value Description***

Size (𝒏)
Number of ties (𝒎)
Mean degree (𝝑)
Largest degree
Largest betweenness (scaled)
Largest closeness (scaled)
Density (𝝆)
Degree centralization (𝝈)
Average geodesic (𝒍, 𝒍𝒓𝒂𝒏𝒅)
Diameter (𝒅)
Clustering (𝑪𝑪, 𝑪𝑪𝒓𝒂𝒏𝒅)
Watts-Strogatz CC (𝑪𝑪𝑾𝑺 )
Number of clusters
Largest cluster’s size (%)
*** Detailed descriptions are given in Wasserman & Faust (1994) and Newman (2003).
148 Total number of nodes
116 Total number of edges
1.568 Average centrality of direct connections
6 Largest centrality of direct connections
4.300 Largest level of intermediation between actors
5.910 Largest reach in terms of path connectedness between actors
0.011 Measure of how dense or sparse the network is
0.031 How centralized an actor’s degree position is
1.911, 11.110 Average shortest length in network and in its random counterpart
4 Largest shortest length
0.015, 0.011 Global cohesiveness in network and in its random counterpart
0.036 Average local cohesiveness
34 Total number of connected components
10.135 Size of the largest connected component

TABLE 3 Coping with Depression

Depressed Examples
Phase 1: Surfacing ‘I think it was a gradual change; maybe if I could have realized this was happening, my parents or I could have done
of Depression: From something about it’ Bunny
Denial to Disbelief ‘I just wake up in that stage you know and you are aware of what’s happening, you are aware of everything but not aware at
the same time … it was April 28th and my breakdown had happened in 7th January, 2014 and I had spent that amount of
time locked up in my room . . . This is this, absolute lack of energy, absolute lack of animation. You know, for example, look
at it like you know those kathputli [puppet] …. those dolls … when you stop caring about others. Its fine, because you still
are caring about yourself. It’s when you do not care about yourself and you know that, “Oh! We are in the bad area now!”.’
Swati
‘I have this image on campus that I am very chirpy active and extrovert type, I can’t have such problems and even I thought
the same I mean extroverts are the least depressed people because it’s very hard for an extroverted person to feel that way,
the way a mentally unwell person would feel and I never thought I would get into something serious like this, I have a very
overconfident nature also but then there was one time when I had to accept it, it took me like 4 months to accept that I am
ill’ Ankit
‘I thought of things that I felt like during that time, like being trapped, not able to move anywhere, just feeling tired and
exhausted, just feeling alone so these were the things I felt so I searched through them and these are the keywords that I
typed on google that too on incognito, it shouldn’t, like I didn’t want it to be in my history’ Ankit
‘There were thoughts of killing myself so that was like the main, like that was the threshold when I realised that shit I am
thinking of killing myself, this is big thing, that’s when I realised that I am in depression’ Reema

Phase 2: Curse of ‘I was extremely afraid of getting judged … I think may be all of them will leave me at one point of time, and if I don’t want
Stigma: Better that to happen I’d like hide things’ Reema
Suffer in Silence ‘I think you need a lot of guts to do it (visit a professional)’ Blaze
than be Sorry ‘I used to cry, I used to self- harm, she did not know how to deal with this, so she left the room . . . Like we were kind of best
friends’ Bunny
‘there was this girl in my year . . . maybe she was depressed . . . so these girls . . . they were just like hawwwwww hawww
she did this hawww (mocking) . . . I would advise people not to trust anyone . . . from our (students’) side . . . I heard her
(psychologist) speaking about others’ problems and laughing about it . . . I told the warden that I can be depressed so she
was like . . . if you become depressed, you can talk to the dean and you can go the psychiatrist, so I asked her ‘do you really
want me to become depressed’?’ Shruti
‘whenever I go to hospital they also know what psychiatric medicines am I talking about. They used to view me as I am
asking for drug or something. You know they used to stare at them’ Bunny
‘Nobody wants to talk about depression. I mean the other mind-set is I will be fine I will be okay’ Muskan
‘sometimes some family condition is like they are not supportive enough, the student doesn’t reveal anything to the family
and suffers within’ Nilesh
Phase 3: ‘‘I was hanging out with these people because of which I had this impression k everybody does it everybody gets into a
Connection: From relationship, everybody has sex everybody smokes up and everybody drinks, drinking is so casual but then I realized no I
Cause of Pain to mean I have a certain group of people back home who don’t do it, it’s ok to not do it’ Ankit
Safe Space-Holding ‘She was someone you know, who would understand. There were two percent who would really understood what I am going
through, she herself used to understand better, she used to read about it, then be there like I used to get dreams like someone
hugged me and I really needed it. She would mostly be around when I was in a long term crying state, like I could not
control, and she would come by’ Bunny
‘I have been absolutely, absolutely unable to just leave my bed in the morning. I mean of all the classes I have taken I have
been attending only one class and that because I know a woman, she has always been one of my favorites and she is leaving
after this semester and they are like she is leaving. So like… I will go and can’t keep me way of the situation’ Swati

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Phase 4: Away from ‘I don’t want anyone around me, but still I want the people to be close to me to fight for me, like you know this thing about
Societal you know, I want two things at the same time and I don’t know in which I will be’ Reema
Expectations: ‘You don’t try to fit into someone else’s way of thinking, so that’s something I thought, so you think of yourself as a puzzle
Finding ‘Balance’ in and think of it as an entire puzzle thing and you are trying to fit in you are trying to cut your edges and trying to fit into
my ‘Container’ of them, now I decided to start my own puzzle and that I am going to take people I like I am going to hang out with people the
Self-realization way I like I think about and who have similarities’ Ankit
‘Like Tinkerbell is gonna come and sprinkle you with fairy dust that’s not how it works. There has to be this consciousness.
You have to be self-conscious, be aware of what’s happening and actually really want to get into that bettership . . . You are
the only one who could take you out of it, you are the one who can enhance the power. The world does not have the power . .
. So ya, but every depressed person I think like the only way anyone has ever been able to get out of it is through sheer
stubbornness. Nothing else … I am tired of being sad I wanna feel happy again and umm my break with apathy was exactly
like that and that did not happen when I was asleep, that actually happened when I was awake’ Swati
‘Now when I feel that loneliness, I just end up calling my brother and talking to him for a few hours, I meditate like you
know like even if I am, like trying to consciously pin my thoughts now, you know if I see I am drifting off, I force myself to
start thinking of something else again … when I am sad I think of what I wanna eat and I make a point to eat it, you know
like small childs, it’s all about like not letting yourself go anywhere near that black door’ Swati
Caregiver Examples
Paradox: ‘I felt like a child like I didn’t know what I was getting into. I was just, I just had a maybe you can call it a passionate feeling
Compassion vs about getting rid of this . . . Like at the start of monsoon the fragrance of rains on parched earth is beautiful, but then after 5
Overwhelming months of monsoon it’s very bad right . . . (you need to be like) a cat. Because it has the perfect balance of ignoring you and
Care-receiver loving you. It like when one moment he will come and love you and be nice with you and doesn’t want food that you are
Expectations eating it will just go and sleep in a corner that’s how, that’s the kind of friend you need’ Neha, care-giver
‘I think learning to draw a line is very important about putting yourself first and if they are a good friend they will
understand that you can’t, you can’t give your entire day to them and you can’t give all your time all your attention to them’
Pavi, depressed and care-giver

TABLE 4 Finding the Positioning for the Web-intervention (A Few Examples)

Tab Images Deep Metaphor

Spring season, A box with a question Running a marathon: First step of

Walking with a lots of flowers. mark on it and outside marathon is the easiest thing to do
head up in the Not too hot not the box it has jagged but the last step in the victory
crowd after too cold, edges like in comic ground you get an awesome
Take a completing the perfectly books “boom” is feeling of conquering it although
Challenge challenge balanced. written on a box you are in pain Self-expression

Standing on a It would be him

sea shore, calm putting out Just like opening a dam (your
and peaceful or some weight Talking Diary: I write, problems) which floods for a
Talk to seeing sunrise (excess weight) and it listens to me moment(frustration) and the
Someone sunset from his bag since it doesn’t pass entire situation calms down after Connection, Open
(friend) (mind basically) opinions on me it has been flushed out Container

TABLE 5 Stigma and Wellbeing Statistics

Measure Mean KMO Alpha Variance Explained (%)

UX UY UX UY UX UY UX UY
Stigma 3.02 (1.04) 2.13 (1.08) 0.71 0.75 0.72 0.84 43 48
Wellbeing 3.75 (1.28) 2.42 (1.37) 0.78 0.84 0.77 0.86 54 65

TABLE 6 Coefficient Estimates for Cocoon, Site 1, and Site 2

Variable Cocoon Site 1 Site 2

UX UY UX UY UX UY
Age -0.03 (0.02) 0.03 (0.06) -0.08 (0.06) -0.03 (0.03) -0.02 (0.02) 0.02 (0.09)
Gender 0.05 (0.10) 0.22 (0.22) -0.08 (0.09) -0.11 (0.15) -0.16* (0.09) -0.13 (0.21)
Year 0.01 (0.06) -0.11 (0.14) 0.11 (0.07) 0.03 (0.09) 0.03 (0.05) -0.01 (0.16)
Stigma 0.28*** (0.04) -0.32** (0.11) 0.01 (0.04) 0.13* (0.07) -0.04 (0.05) 0.05 (0.10)
Wellbeing 0.07 (0.05) -0.15 (0.10) 0.01 (0.04) 0.07 (0.06) -0.04 (0.05) 0.02 (0.09)
*** 𝒑 < 𝟎. 𝟎𝟎𝟏; ** 𝒑 < 𝟎. 𝟎𝟓 * 𝒑 < 𝟎. 𝟏𝟎. 𝑵 (𝑼𝑿) = 𝟏𝟎𝟓; 𝑵 (𝑼𝒀) = 𝟏𝟎𝟎.

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FIGURE 1 Conceptual Framework

FIGURE 2 Mixed-method Schema

FIGURE 3 ZMET Analysis of Depressed Students

FIGURE 4 Negative Trust and Non-Consumption of Mental Health Support Service

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Non-
consumption of
social/
professional
support

FIGURE 5 Web-Intervention

FIGURE 6 Prototype of Web-Intervention

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