Self-Harm Behavior, Emotion and Spirituality towards Undergraduate Student’s Mental Health ()
1. Introduction
Self-harmed behavior reaches 13.2% - 46.5% in the young adult population worldwide, not only aimed at suicide (suicidal self-injury) but also non-suicide (nonsuicidal self-injury) in a conscious or unconscious state (Muchlenkamp, Cowles, & Gutierrez, 2010). Self-harm behavior can recur throughout life and interfere with the quality and mental health (Robinson, 2017). Psychiatric cases involve the young adult population linear with increased efforts to seek psychiatric guidance by undergraduate students. Their age ranges with quite mature emotional lability and inability to cope with their stressors. As individuals, they want to be treated as adults but still have limited responsibilities, which also bring out their childish side. This problem often becomes a source of frustration in their life and social relationship and creates other competition burdens in themselves and their environment (Ulya, 2017).
Emotional turmoil and inability to cope with ongoing stressors impact their mental health, leading to feelings of hopelessness, helplessness, and self-harm behavior. Emotional expression becomes the primary aspect to recognize self-harmed behavior which can evaluate from affective changes by direct observation and daily behavior. Even it’s not only emotional expression that is the main of mental health evaluation. We all understand that mental health is integrated by biopsychosocial-spiritual components that appear at all age levels. Still, there are limited research studies that explain spiritual aspects of self-harmed behavior of young adults’ population.
Spirituality is related to transcendence without reference of particular religion (Davis, Kerr, & Kupius, 2003). Spirituality often looked similar to religiosity as a measuring point for a person’s perspective on self-belief in God and one’s religion, making a person try to find the meaning and purpose in life through or without faith (Tanyi, 2006). Spirituality is expected to help people have good mental health stability and become an approach to patients with a history of self-harm behavior. This paper will analyze evaluating self-harm behavior, emotional expression, and aspects of spirituality towards mental health in undergraduate students, representing the young adults’ population.
2. Method
This research was a descriptive analytic observational study with a cross-sectional approach conducted at the Psychiatric Unit of Universitas Brawijaya Hospital during March-August 2020 with purposive sampling. Sample met the inclusion criteria such as undergraduate students who received treatment or psychotherapy by psychiatrist or clinical psychologist, age limitations 18 - 24 years old. Exclusion criteria for this research such as the patient reject and decide to not contribute in this research. Drop out criteria were students with a history of significant head trauma or certain neurological diseases that deteriorated cognitive function. Evaluation with anamnesis technique to establish psychiatric diagnosis followed by psychometric evaluation using Millon Clinical Multiaxial Inventory (MCMI-IV); questioner of Non-suicidal Self Injury Assessment Tool (NSSI-AT) (Whitlock, Exner-Cortens, & Purington, 2013); questioner Positive and Negative Affective Scale (Watson, Clark, & Tellegen, 1988); questioner spirituality (Hardt, Schultz, Xander, Becker, & Dragan, 2012). Statistical analysis made with JASP version 0.14.1.
Ethics
This research permitted by ethics committees in Medicine Faculty University of Brawijaya provided full ethical approval for all aspects of the follow-up (Ethical Clearance No. 135/EC/KEPK/07/2020). All participants gave consent for their data to be used in research.
3. Results
There were 150 subjects who matched with inclusion criteria, 42 male (28%) and 108 (72%); obtained of 93% (139) with history of self-harm behavior; 52% (78) with suicidal behavior; 63% (95) gave their threats aimed at others that they would commit acts of violence (to themselves or others to vent their emotions); 47% (71) with moderate spirituality and 51% (76) with negative emotional expressions (Table 1).
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Table 1. Baseline data mental health condition towards undergraduate students at Psychiatric Unit Universitas Brawijaya Hospital.
Psychiatric examination towards 150 people showed that most diagnoses were depressive disorders 31% (47); bipolar affective disorder 29% (44); schizoaffective disorder 20% (30); schizophrenia spectrum 11% (17); anxiety disorders 7% (11). Researcher found only 1 respondent with Tourette Syndrome which will worsen when felt anxious or under excessive stress. Up to 69% (103) had borderline personality disorder. Self-harmed behavior analysis to psychiatric conditions had p = 0.015 (sig); suicidal behavior p < 0.001 (sig); threat of self-harm p = 0.003 (sig); emotional expression p = 0.007 (sig); spiritual towards psychiatric condition p = 0.062.
4. Discussion
The proportion of undergraduate students occupies range of 40% - 60% of total patients at Psychiatric Unit Universitas Brawijaya Hospital. This unit has begun to form and active in providing curative mental health services for a period of 2 years (2019-2020). There was 100% increasing in sum of patients which starting around 59 patients/month in early 2019 which eventually became 130 patients/month. There are 6 - 10 patients/week with self-harm behavior. Increasing number of outpatient visits at Psychiatric Unit led the author to think about iceberg phenomenon. Patients will come to Psychiatric Unit with various needs such as examination, medication, psychotherapy, etc. Nowadays, patients already learned from social media, health platform which educate more about mental health.
This finding is related with research by Lipson et al. (2019) which traced the trend of increasing the need of mental health services in United Stated over a period of 10 years (2007-2017) involving 196 campuses (155.026 undergraduate students who registered as patients). Up to 19% students need treatment, and it increase in 2017 to 34%. While the diagnosis of mental disorder which long-life treatment increased from 22% to 36%. The prevalence of depression and suicide attempts is increasing but stigma in society has decreased considerably (Lipson, Lattie, & Eisenberg, 2019). In line with Fenwick-Smith et al. (2018) that mental health promotion programs that focus on stressor resistance and coping abilities deal with daily stressors, how to seek mental health professional help patients to find and choose their need (Fenwick-Smith, Dahlberg, & Thompson, 2018). Apparently, a similar condition also occurred in Psychiatric Unit Universitas Brawijaya Hospital.
Not all undergraduate students have total insight into their mental health conditions. Up to 139 from 150 students had history of self-harm behavior. This involves disturbance in thought processes, psychomotor, affect, emotion and other mental state abilities. Author got information about kind of self-harm behavior which often done such as banging head against the wall, injuring their body with sharp weapon, causing injury or bleeding around their skin, trying to take certain drugs to feel like overdosing, opening fingernails or toes, pulling hair, etc.
Based on terminology, self-harm behavior is distinguished from suicidal behavior in terms of the desired goals. Self-harm behavior and non-suicidal self-injury aimed at their body to feel pain which symbolize of transferring form of psychological pain to physical with lower mortality rate (Halicka & Kiejna, 2018). In this research, we found that 93% patients with self-harm behavior also aimed about ending their life (with suicidal intention up to 52%). It needs to be followed as early alarm to find another psychopathology from patient. Self-harm behavior needs to be treated as soon as possible. This is consistent with the findings of Whitlock et al. (2013) which suggests about self-harm behavior becomes a “gateway” to suicidal behavior in the future if it does not immediately get help, find meaning of life, relationship and clinical improvement (Whitlock et al., 2013).
Another research which involving of 597.548 participants from 41 countries revealed that onset of a person committing self-harm behavior at the age of 13 years, 47% had 1 - 2 episodes of slicing their extremities (45% cases) (Gillies et al., 2018). Person with non-suicidal self-injury will try to seek help but have difficulty expressing what they are experiencing. Research in Southeast Asia reveals that injury due to non-suicidal self-injury more likely to cause death than direct suicide attempts (Greydanus & Shek, 2009).
This research had significancy of self-harmed behavior (p = 0.015); suicidal behavior (p < 0.001); threat of self-harm (p = 0.003); emotional expression (p = 0.007) to psychiatric diagnosis. This leads to understanding that when someone had a predisposition of self-harm behavior, there is a tendency had psychiatric problem or personality disorders or both of combination in same situations. Although not all of patients had suicidal behavior, they still had chance of self-harm, gave threatening aimed at other people or oneself; providing specific notes on what to do which expected certain forms of attention that may not be shown immediately, encourages person to get impulsivity or took action without careful consideration.
Emotional expression becomes a description of feelings that appear with mood, objective as response to external stimuli and connected with experiences or various situations, whether pleasant or not (Rottenberg & Gross, 2007). This research revealed significance between emotion expression with mental health condition. If someone has a predominance of negative emotions expressions (disappointment, sadness, withdrawal, anger, etc.), then mental health problems will follow. In this study, even 49% subjects had positive emotion expression, these conditions have not let go the risk of experiencing mental health problems, especially if they are in a situation that places someone under high pressure, the urge to self-harm, unable to resolve their external stressor completely.
There is no significance about spiritual towards psychiatric condition p = 0.062. Although spirituality contributes in mental health conditions, in low and moderate levels of spirituality tends to be a lot of psychiatric and personality problems. Limitations in managing the meaning of life and spiritual values are not formed in their daily concept of life. This often leads to a spiritual emptiness which is often interpreted as a situation of being far from having a belief, having no belief in religion or God, etc. About 17% (25) with high level of spirituality still have a vulnerability of psychiatric problems. This still requires evaluation related to spirituality in different aspects.
Participants with moderate spirituality level (71 from 150) raise an assumption that a person which knows the meaning of their existence regarding spirituality aspect, religious and moral values but did not effective enough to suppress conditions that lead to psychiatric problem or personality disorders. Understanding the meaning of spirituality is not fully implemented in daily life. Even though they had high spiritual level; it still had a chance to get risk of mental health problems.
These findings support various mental health intervention efforts that have been running around the world. Detection about self-harm behavior, early detection and recognize the symptoms will help to cut down another mental health problems. Mental health interventions are not limited to individuals but also groups and entire populations who can take advantage of media and various communication technologies (Sharma, Sharma, & Sharma, 2017). Efforts that already done by author as psychiatrist in curative matters can be continued with promotion and prevention to make people more be aware of the importance of maintaining mental health before experiencing psychiatric problems or personality disorder.
The limitations of this research are small amounts of subject involved, it makes difficult to draw conclusions that can be broadly applicable. However, this study can be used as a basis for long-term follow-up in the same unit in the future. Improvement that we can suggest divide at clinical, follow-up and data improvement. From clinical improvement perspective, we can ask all the patients to bring their best adherence compliance for the psychopharmacy they got. Then, it will bring us to next direction research in the future and got follow-up and increases the number of subject and fulfill the data.
5. Conclusion
Self-harm behavior leads to psychiatric problem and/or personality disorders which can disturb their mental health conditions that arise from young adult age. Self-harm behavior can be followed by suicidal intention, threatening and become early sign that someone is at risk of psychiatric disorder. Focus of therapeutic effort no longer leads to curative aspects but emphasizes prevention, starting from recognizing sign symptoms and education when they realized or experience changes in psychological condition.
Disclosure Statement
No potential conflict of interest was reported by the author.
Acknowledgements
Author expresses appreciation to all the patients, psychiatrist and clinical psychologist team from University Brawijaya Hospital. This research was supported by PNBP Faculty of Medicine Brawijaya University (No. 214.10/SK/UN10.F08.06/PN/2020). The funding sources did not partake in the design, data collection or analysis.