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I have spent almost four years of my life in the University of the Philippines Diliman. Typically, applying for internship gives you the liberty to get out of your comfort zone and explore the working world outside college. In my case, however, I chose to spend the past two months of my supposed vacation working in an office located within my very own department. As I count down my few remaining hours, I looked back and realized that working within your own university has its perks, particularly allowing you to see a problem within the university through a whole different set of lens. In particular, I was able to have a better understanding of the problems occurring within University Health Service (UHS), specifically the unwillingness of some of their admins and staff to handle students at high suicidal risk during emergency situations.
Now, before I proceed, here’s a little background on how I perceive the staff of the University Health Service. As a clumsy student, my visits to the emergency room have always been for physical concerns such as an irritated ear or the third sprained ankle of the semester. The emergency personnel I have encountered were stubborn and hot-headed, and the stories I hear from my friends and acquaintances did not debunk any of my assumptions towards them. In terms of assisting students at high suicidal risk, however, I was not aware of how they deal with them.
I found out about this during the Lifeline workshops, arguably one of most memorable parts of my internship. Created by Dr. Violet Bautista, these workshops aim to provide university faculty and staff the skills necessary to deal with students and co-workers undergoing mental health problems. During my internship, I was able to attend two workshops. However, one workshop in particular stuck with me. While the other workshops were definitely longer and had more participants, the one coordinated for the staff of the UHS was an eye opener for me.
Before the workshop, I wasn’t aware of the details of the established referral system within the university and the role that UHS plays in it. Since PsycServ was just established the previous year, I guess it was understandable that students like myself wouldn’t be aware of the new protocol. According to the referral system, which was printed out in bright yellow bond paper, where students will be brought will depend on the nature of the emergency. For students at low and medium suicidal risk, usually referring to students that they have ideations but no concrete plans for suicide, they can be brought to the Office of Counseling and Guidance (OCG) or PsycServ. In case of emergency, particularly with students who self-harm or students at high suicidal risk, meaning they have concrete plans for suicide, they should be brought immediately to the UHS emergency room. In short, the emergency staff of the UHS is tasked to give at least first-level aid to clients experiencing extreme emotional distress. The reasons for choosing UHS was new to me as well. Apparently, according to the people from PsycServ, the UHS emergency room is the safest place for anyone who is at high risk. First of all, they are situated on the first floor, which removes any threat of the patient to suddenly jump from a high place to hurt themselves. Second, unlike PsycServ and the OCG, their emergency room was open 24/7, meaning cases that occur during night time can still be handled even if the other offices are closed.
However, during the workshop, some of the health practitioners voiced out their complaints regarding the referral system. Some wished to clarify their roles, while others were saying that they shouldn’t be the ones tasked to take care of these kinds of patients, given that for one, PsycServ exists, and two, when the workshop was being held, the UHS did not have an in-house psychiatrist. Even after the completion of the workshop, there have been instances wherein the emergency staff at the UHS refused to take in a high risk student. Personally, I did not expect that the members of UHS agreed that they needed training for psychological first aid. I thought that, as health practitioners, they should have learned these skills when they were in medical school, or at least through experience with patients with mental illness.
Understanding and clarifying the roles of health practitioners and mental health professionals within the university is important in making sure that constituents are safe and given proper treatment. All universities aim to take care of the mental state of their students, given that college is considered to be an extremely stressful environment. In one study by Firmante (2017), anxiety and depression were found to be common problem areas in Filipino college students. Common factors that attribute to depressive symptoms among students include academic workload and interpersonal problems with significant people in their lives. Having a strong and reliable referral system is needed to ensure their safety. In this regard, this report aims to explain the role of psychology in this issue by discussing possible factors influencing these kinds of behaviors from health practitioners and suggest solutions that can help them become more open to accepting this kind of responsibility.
Psychology, despite not exactly being a hard science, still follows the scientific method and values research and evidence. Based on my personal experiences with the UHS, which are honestly mostly negative, I could just take the easy way out and assume that the health practitioners act this way simply because they are not kind to others or that they hate their jobs. Well, research doesn’t always guide you through the easiest routes. Instead, it may lead you to effortful yet organized and efficient ones. In our case, we can use psychology, as a discipline that studies human behavior, to become aware of the possible factors that contribute to the UHS staff’s unwillingness to handle cases of suicidal students.
In this case, the behavior we’re focusing on is handling suicidal students. In order to shed light the factors, we should discuss few of the determinants of behavior discussed in psychology. One of the most notable determinants of behavior is attitude, which involves multiple elements including one’s thoughts and feelings toward certain people, objects, ideas, or even behaviors. Whether or not behavior changes because of attitude may depend on the stability of the attitude, which may differ based on several factors.
Glasman and colleagues (2006) mention that “People who doubt their attitude should be more likely to attempt to reconstruct it than people who think that their attitude is correct,” emphasizing the importance of one’s confidence in their attitudes (p. 782). Some health practitioners, particularly nurses, reported that they are not confident in working with self-harming and suicidal patients (Anderson, et al, 2000). This lack of confidence may lead to less stability for positive attitudes towards self-harming and suicidal patients.
Knowledge also seems to have a positive impact on facilitative attitudes among health practitioners. Many studies have pointed out that health practitioners’ knowledge on self-harm has positive associations with having more favorable attitudes towards people with mental illnesses and self-harming tendencies, such as exhibiting less negative feelings, less stigmatizing attitudes and committing less acts of social discrimination and restriction. In particular, one study found that nurses showed highly negative attitudes and suggested that this could be due to lack of training.
However, attitude is not always believed to directly impact one’s behavior. According to Ajzen’s study (1985), this role belongs to intention. Human beings take note of the implication of their actions, whether consciously or subconsciously, which is one of the main assumptions of the theory of reasoned action. Basically, behaviors are done because the person intends to do so, and attitude, in turn, is one of the determinants of intention. These attitudes are molded by the belief systems a person has regarding that particular behavior. More than general knowledge, how people understand and make sense of suicide and mental health in general matters as well. People may have different sets of beliefs and perceptions, and these have been said to have an impact on their behavior. One of the main things I noticed during the lifeline workshop with UHS was how doctors and nurses viewed suicide compared to psychologists and psychosocial supporters.
Doctors and nurses spend more than 10 years of their lives in medical school before they get into the profession, and for the most part, they deal with physiological issues. In some ways, this affects how they view the problems experienced by suicidal patients. At times, since the medical perspective focuses much more on the biological aspect of the person, health practitioners fail to take into consideration the personal biographical context of the patient. While this in no way generalizes the views of the entire population of the UHS, I did notice that, during the lecture part of the lifeline workshop, some health practitioners were more focused on helping alleviate the physiological problems experienced by the student, especially for those who physically harm themselves. Similarly, a study on experiences of accident and emergency doctors in dealing with self-harming patients showed that, because providing emotional support was not within their line of work, they would focus more on treating the physical problems of the patients.
This problem is also seen in medical students, with one study claiming that medical students in their first year were less stigmatizing towards patients with mental disorders compared their fifth year seniors. In contrast to this, there is literature on positive attitudes of medical students towards these patients. Compared to freshmen, medical students in their last year of school mostly improve on how they interact and deal with mentally ill patients, despite retaining problematic beliefs regarding their mental health.
The lack of psychological first aid or processing training in the medical field is not the only issue. Suicide is a sensitive topic, and for some people, their response to people at risk ties in with their moral standpoints. This is reflected in the results of a qualitative study done on nurses and psychologists regarding their views on suicide. Findings listed two perspectives: suicide as a moral issue and suicide as a pathological issue. Compared to psychologists, who treated it as a mental health problem, nurses outside the field of psychology mostly acted based on the former perspective, having their moral values and ethics heavily influence the way they treated suicidal patients. This usually led to pushing feelings of guilt and shame onto the patients, because some of them deem suicide to be a crime. In contrast, there are emergency staff nurses that were more accepting of patients’ suicidal tendencies and behaviors. However, they only do so for patients with incurable illnesses, since the nurses view these behaviors as a normal response to their patient’s situation. Unfortunately, this highlights the conditionality that comes with trying to understanding suicidal behaviors. Viewing the problem as a pathological issue would remove responsibility from the suicidal patient, since the “improper behaviors”, such as self-harm, would not be perceived as the result of their morals and principles, but of an illness, which is something they cannot control.
These sets of beliefs that could propagate the stigma against people with mental health problems can also be rooted in culture. For instance, developing countries in Asia are usually the home of traditional societies, ones that hold conservative views. People from developing countries in Asia generally view mental illnesses as the product of spiritual or religious curses, describe emotional and psychological distress through means of physical symptoms, and exhibit fear around people with mental illnesses.
After looking through my experiences and the literature, we can narrow down our focus to a few points: lack of knowledge on self-harm and how to handle these incidents, lack of confidence, and misconstrued beliefs about suicide and mental health based on either medical background or sociocultural factors. However, these cannot be conclusively generalized to the members of the UHS since there are notable differences between them and the samples found in the studies. For one, the UHS is a public health institution that is based within a university, meaning that most of their patients are students. Aside from this, it is important to note that the UHS currently lacks a psychiatrist and any other mental health professional in their institution. One of the possible research options would be examining their attitudes towards suicidal patients, or the attitudes of institutions with similar features to fill in the gaps.
Given these problem points though, the seemingly simple yet complicated answer would be to provide them education, like the lifeline workshop. A randomized controlled trial of this workshop comparing attitudes and skills development between health practitioners that attended that workshop and a control group would be beneficial to see if the workshop does have a significant impact on the participants. Also, since the lifeline workshop is modified for both university faculty and health practitioners, there could also be a comparison study between the outcomes of these two groups, since the perspectives of faculty may differ from health practitioners, since they most likely don’t have medical background. However, since there were some instances wherein the emergency personnel still rejected a high risk patient despite going through training, changes can be made to the workshop as well.
For one, there can be a focus on both gaining knowledge in self-harm and suicide and building confidence among the practitioners in dealing with these incidents. Both knowledge in self-harm and confidence in dealing with incidents have been considered predictors of how effective practitioners perceive themselves to be after handling a crisis situation and this perceived effectiveness is linked to less negative feelings towards patients who do self-harm (Egan, et al., 2012). With this in mind, it is important that at post-training, health practitioners have high self-efficacy in dealing with these clients, since it may lead them to act more favorably towards them in the future.
Several evaluations of training programs similar to the lifeline workshop have resulted in higher levels perceived knowledge in suicide and confidence among their participants, most of which consisted of both lectures on suicide and interactive role-playing activities. Interestingly, one study highlighted the discrepancy between the participants’ perceived confidence and the actual improvement of skills in identifying pupils with depression, which implies that measuring confidence, is not a reliable outcome measure on its own. Although, only one of these programs had health workers as samples, so modifications may need to be made in order to be contextualized for health practitioners.
Improving the attitudes of personnel towards patients with mental health problems is also essential. The workshops in its current form do educate the participants on the state of mental health within the university, highlighting the true weight of the situation when someone does have suicidal ideations. Attitudes can also be restructured based on the information given about a certain behavior, particularly if one is taught two sides of a particular issue. For medical personnel that may have negative attitudes towards suicidal patients, being presented contrasting views will help them rethink and reevaluate their attitudes, and hopefully, behavior towards them.
Another way to lessen negative attitudes towards patients would be providing personnel with more experience in order to increase familiarity with emergency situations. While this may apply more to the curriculum in medical school rather than a workshop, role-playing activities could also suffice, since participants will be able to practice their skills. However, gaining more experience may not be sufficient on its own. Contradictory to previous studies, Anderson and colleagues (2000) found that emergency staff with fewer experiences in handling crisis situations actually had more confidence compared to those with more experience, with the more experienced staff mentioning that this was due to lack of training and sufficient time to deal with these patients.
In conclusion, there is still a problem among the different institutions in the university regarding the referral system that seems to be rooted in the attitudes of the health practitioners towards patients with mental illness or suicidal tendencies. Looking at it from a psychological perspective, the issue can be tackled better if analyze these attitudes further and refuse to brush them off as just bad behavior. Instead, we discussed the behavioral beliefs, personal stand points and sociocultural factors. Psychology allows us to look into multiple aspects of human behavior, which gives us a more holistic view of the phenomenon. Appropriate and engaging education, which has already been started by PsycServ, will be helpful for both the health practitioners and the university students, as long as the several factors discussed earlier are taken into consideration. Further research on the attitudes of health practitioners in the school setting and evaluations of the workshops is recommended.
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