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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 105-112

Nonsuicidal self-injury and family environment among college students in Kolkata, West Bengal: Mixed method explanatory sequential design


1 Unitedworld School of Liberal Arts and Mass Communication, Karnavati University, Ahmedabad, Gujarat; Department of Social Work, Visva-Bharati, Birbhum, West Bengal, India
2 Department of Social Work, Visva-Bharati, Birbhum, West Bengal, India

Date of Submission09-Jan-2022
Date of Decision11-Feb-2022
Date of Acceptance19-Feb-2022
Date of Web Publication13-Jan-2023

Correspondence Address:
Ms. Arkita Pal
Department of Social Work, Visva Bharati University, Birbhum, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_11_22

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  Abstract 


Background: Nonsuicidal self-injury (NSSI) refers to intentional, deliberate, and socially unexpected harming acts to oneself without any intention to die. It is a growing concern among recent mental health professionals. NSSI behaviors have an impact primarily on the individual, family, and ultimately on society. This problem is prevalent among the clinical population, but it has also become a threat to the general population, specifically adolescents and the young population. Aim: In this present study, we have explored the relationship between family environment and NSSI and investigated the predictable family factor for NSSI. Materials and Methods: Mixed method sequential research design was used for this research work. First, we did quantitative data collection; a total of 535 college students aged 18–26 years were selected and assessed using the Family Environment Scale and Functional Assessment of Self-Mutilation Scale. Second, thematic analysis was performed, followed by interviews with six participants. Results: There is a significant relationship between family conflict and NSSI χ2 = 33.47 (P < 0.001). Family conflict can be most reliable to predict NSSI, χ2 (16, n = 499) = 57.78, P < 0.001. In addition, the Thematic Analysis highlighted family interpersonal relationship, lack of expressiveness, and lack of sense of belongingness in the role of NSSI. Conclusion: Family conflict can be a crucial factor in detecting NSSI. This study can be a good source of information for clinicians and social scientists, but more studies should be conducted to control and prevent NSSI.

Keywords: Family conflict, family environment, nonsuicidal self-injury


How to cite this article:
Pal A, Roy P. Nonsuicidal self-injury and family environment among college students in Kolkata, West Bengal: Mixed method explanatory sequential design. J Mental Health Hum Behav 2022;27:105-12

How to cite this URL:
Pal A, Roy P. Nonsuicidal self-injury and family environment among college students in Kolkata, West Bengal: Mixed method explanatory sequential design. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Feb 3];27:105-12. Available from: https://www.jmhhb.org/text.asp?2022/27/2/105/367734




  Introduction Top


The emerging death of a youth in India has been a great concerning area of both clinical and social research. There has been a radical change worldwide regarding the causal factors of suicide and self-harming behaviors. On the other hand, the 21st century has seen a flurry of changes in family domains such as family relationships, family systems, and personal growth. Hence, in our study, we have explored the most recent phenomena called nonsuicidal self-injury (NSSI) and its relationship with the family environment. NSSI behavior can be considered deliberate destruction of the body tissue without the intent to die, and the acts are socially unacceptable. The gradual advancement of research and experiments has given well understandable phenomena related to NSSI behaviors. In our study, we have used quantitative and qualitative research designs. The qualitative research gained recognition for understanding mental health needs for the last two decades though primarily it was regarded as unscientific.[1] People generally use multiple methods like cutting, hitting, scratching, and compulsive head banging.[2] The massive discussion and study result supported that NSSI behaviors are prevalent in the community and clinical samples[3],[4] To get more knowledge about NSSI behaviors, the distinction between suicide attempts with NSSI behavior needs to be clarified. A study on 390 students reported strong evidence supporting the difference between suicide attempts and NSSI behaviors.[5] Different studies have been done to identify the relationship between suicidal attempts and NSSI behaviors.[6],[7] In this regard, differences between NSSI behavior with suicidal attempts can be observed in terms of lethality. The individuals engaging in NSSI behaviors are less lethal, and the low inevitability of death has been observed compared to suicide attempters.[8] The most common methods of NSSI behavior include burning, scratching, hitting, burning, biting, picking skin, and obstruction to wounds.

In contrast, the standard techniques used by suicide completers and attempters are hanging, poisoning in most cases.[9] Considering the chronic and distressing emotion, people often use NSSI acts to get relief from it with less or no intention to bring an end to life.[10] In some cases, engagement of NSSI behaviors is performed to avoid suicide.[11] Suicide attempts can be associated with a long history of NSSI where the youth use multiple methods without any painful sensation.[12]

Results given by Cash identify suicide as the third important cause of death for youth and for which one of the risk factors can be a history of NSSI behavior.[13] However, we have seen that various changes in the family environment are responsible for the development of emotional regulation. It is essential to explore the recent family factors in terms of either self-injury or NSSI. Hence, we investigated the relationship between family environment and NSSIs behaviors among college students.

Objective

The present study assessed the relationship between family environment and NSSI and the predictable family factor of NSSI.


  Materials and Methods Top


This was a mixed-method sequential study conducted in the colleges of Kolkata, a metropolitan city of India.

Quantitative research

In the 1st stage, the initial sample was six universities (three states and three private) of Kolkata, selected by random sampling method. University Grant Commission approved, and 3 years of the establishment were the inclusion criteria for university selection. In the 2nd stage of sampling, the Stratified Random Sampling method was used. The strata used were private and public colleges to stratified random sampling in selecting colleges. From the colleges' list under the universities, six colleges were selected. In the 3rd stage of sampling, 630 responses were obtained proportionately from different departments. The inclusion criteria were the students between 18 and 26 years, those residing with family, students who are giving consent, and those who can read and write English. We excluded the college students undergoing psychiatric treatment and taking psychiatric medication. The final 535 responses were considered fulfilling the inclusion and exclusion criteria. We used a semi-structured sociodemographic data sheet, Functional Assessment of Self-Mutilation (FASM), and Family Environment Scale (FES) for data collection. The reliability of FES was ranged from 0.48 to 0.92. It has eight family domains, i.e., cohesion, expressiveness, conflict, acceptance and caring, independence and active recreational orientation, organization, and control. On this scale, there were some positive and negative items. Positive items and negative items were rated on 5-point Likert scale, respectively. FASM scale was used to assess the frequency, functions, and other characteristics of self-mutilation behavior. FASM consisted of two sections. The initial section of the scale was a specification of 12 self-injury behaviors. Those who recognized at least one NSSI behavior were asked to complete the second section, which comprised 22-item questions about the motives for self-injury. The items were valued on a 4-point Likert scale, ranging from 0 “never,” 1 “rarely,” 2 “some,” to 3 “often.” Two experts commented on the validity of the scale on the Indian population. The data collection process continued from January 10, 2020 to September 01, 2020. The written consent was obtained from all the participants. [Figure 1] shows the design for mixed-method sequential research.
Figure 1: The design for mixed method sequential research

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Qualitative research

In-depth telephonic interviews were conducted with six (three males and three females) participants who had multiple forms of NSSI behavior for the qualitative data more than once. We stopped interviewing six participants for qualitative design because the data were saturated. All the participants reported family issues triggering their NSSI acts. Purposive sampling was used for qualitative data. Thematic analysis using open coding and axial coding was done based on grounded theory, followed by quantitative data analysis. The researcher developed the interview guide outline on self-injury intention, frequency of NSSI, common stressors of NSSI, family relation and NSSI, suicide plan in future, support, and NSSI. The interview was continued from December 01, 2020 to March 15, 2021. We followed six guidelines given by Braun and Clarke for thematic analysis.[14] The corresponding researcher, a trained (M.Phil.) and experienced female Psychiatric Social Worker from the Institute of Psychiatry (COE) conducted the qualitative interview after establishing the rapport, and the interview language was English.

Study procedure

Six colleges from Kolkata were selected for data collection after getting permission from the college authority. A semi-structured datasheet, FASM scale, and FES were used as data collection tools. Proper instructions were provided, and the objectives of the research were explained to the participants. Out of 630 data, 535 responses were considered final data. After the quantitative analysis, six (three females and three males) participants were interviewed after taking consent. The final analysis was done on both qualitative and quantitative data.

Statistical analysis

This study used descriptive statistics, mean, frequency, and percentage. This study used inferential statistics such as Chi-square and Binary logistic regression. The study used a statistical package for social sciences 27 version for compulsory descriptive and inferential statistics. In this study, selected covariates were cohesion, expressiveness, conflict, acceptance, independence, organization, control, and active recreation. The covariates were categorical in type and selected based on the dependent variables' clinical implication, i.e., NSSI. We categorized covariates like cohesion as Low Cohesion (0), Average Cohesion (1), High Cohesion (2) based on the scoring manual. In this same manner, other covariates were categorized as low (0), average (1), and high (2), respectively. We selected the first (0) as a reference group by changing in the SPSS, Version 27.0. IBM Corp., Armonk, New York, and the rest two (1 and 2) were comparison categories. We intended to see the relationship between the NSSI group coded as 1 with the No NSSI group coded as 0 in the SPSS.

Ethical consideration

The institutional ethics committee for human research, Visva Bharati (A Central University) approved the research work with reference No. VB/IECHR/2021/11. The ethical values of research were considered during the present research work. No students were disregarded or disempowered through this research. The purpose of the research was explained to the participants and written consent was obtained from the college authorities. Participants were informed that the data obtained will be kept confidential and will be used exclusively for research purpose. Only the researcher and the statistical consultation services of the university will get the access of the data. Freedom of withdrawing the data and the participation was given to the participants.


  Results Top


Description of sociodemographic variables of nonsuicidal self-injury participants

[Table 1] shows the participants' sociodemographic details of their age, sex, socio-economic status, family type, and different non-suicidal self-injurious behaviors. It also represents the brief family dynamics of each participant.
Table 1: Detail of sociodemographic profile, nonsuicidal self-injury and family dynamics of participants

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[Table 2] describes the frequency and percentage of NSSI and non-NSSI participants. The research result shows 68.03% (364) participants did not perform any self-mutilating behaviors out of the total sample (535). Thirty-two percentage (171) participants engaged in self-mutilating behaviors among the total sample. By analyzing the data, we found 6.8% (36) participants engaged in self-mutilating behaviors with suicidal intent, and 25.23% (135) participants performed self-injurious behaviors without suicidal intent. The suicide intent was assessed by an item of the FASM “While doing any of the above acts, were you trying to kill yourself?” The mean age of the NSSI participants was 21.48, and the mean age of the participants who did not perform any NSSI behavior was 22. For NSSI participants, 12.4% (62) were male, and 14.6% (73) were female. 18.6% (93) participants belonged to nuclear family type, 8.2% (41) participants belonged to join family, and 2% (1) was from extended family among all the NSSI participants. Regarding the monthly family income of NSSI participants, 2.6% (13) had less than Rs. 10,000, 8.4% (42) had between 10,000 and 50,000, 9.6% (48) had rupees between 50,000 and 2 lakhs, 3.2% (16) had between 5 and 10 lakhs and 2.2% (11) had more than 10 lakhs.
Table 2 Frequency and Percentage of Non-Suicidal Self-Injury and Non-Suicidal Self-Injury participants

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[Table 3] describes the types of NSSI, number of incidents, and reasons of NSSI. Among all other types of NSSI behaviors, 10.3% (55), 14.0% (75), and 1.1% (6) participants engaged in biting, and the percentage was high compared to other forms of conduct for those who performed it once, 2–5 times and more than 10 times respectively during the past 12 months. Considering the number of incidents of NSSI, the percentage of hitting was high, 8.0% (43) of them did it once, 11.8% (63) did it 2–5 times, and 5.0% (26) did it 6–10 times. Among all other NSSI behaviors, hitting, biting, cutting, and scraping picking areas for blood are the most common acts performed once or multiple times. Most often, the reasons of the NSSI participants were to relieve feeling numb or emptiness (8.2%), to stop bad feelings (8.2%), to punish oneself (6.6%), to feel relaxed (5.3%), to get parents understood (4.1%), and to get a reaction from someone (4.1%).
Table 3: Details of Non-Suicidal Self-Injury types and number of Incidents

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[Table 4] shows the relationship between NSSI and the domains of family environment. The result showed a meaningful positive relationship between NSSI and Family Conflict χ2 = 33.47 (P < 0.001), so the null hypothesis is rejected. However, there was no relationship between any other family domains like cohesion, family expressiveness, independence, organization, acceptance and caring, control, active recreational orientation with NSSI.
Table 4. Relationship between Non-Suicidal Self-Injury and the domains of Family Environment

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Effect of family environment domains on nonsuicidal self-injury

[Table 5] shows the effect of family environment domains on NSSI. Binary logistic regression was done to assess the effect of the domains of family environment on NSSI. The model had eight independent variables like cohesion, expressiveness, conflict, acceptance, independence, organization, control, and active recreation. The full model (Omnibus Test of Model) containing all predictors was statistically significant χ2 (16, n = 499) = 57.78, P < 0.001, showing that the model was able to distinguish between participants who performed NSSI and who did not perform NSSI. Nagelkerke R2 was 159, which indicated the variation in the dependent variable by the independent variable. The strongest predictor of NSSI can be family conflict among all other domains.
Table 5. Effect of Family Environment domains on Non-Suicidal Self-Injury (Binary Logistic Regression)

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Thematic analysis of the participants' responses

Inadequate family interpersonal relationship

Most of the participants disclosed that they experienced disturbing family communication with family conflict, which precipitated their urge for self-harming behaviors. The consistent pattern of aggression, critical comments, hostile behaviors caused emotional disturbance among the participants.

(Participant 1, I have been exposed to conflict and disagreement every time in my family since my childhood, my mother used to criticize me as I am a girl child, she did not even give me food at times).

(Participant 3, I used to get physical punishment on small issues and my parents always had high expectations from me).

(Participant 4, my mother was very aggressive and used to rebuke me all the time. She used to slap and hit me).

(Participant 5, I am staying with my parents, but I seldom talk to them. My parents are always having conflict and showing aggression on me, they throw and break my artistic works, paintings).

The participants revealed that inadequate and noncordial relationships often led to negative self-image-related ideas. Ineffective family relationship is the most common factor to aggravate negative emotion among the family members. The evaluation of the family interpersonal relationship was done according to the perception of the participants.

Lack of family expression

The theme was primarily characterized by the expression of ignorance that every participant experienced. The lack of family validation theme was created when most of them reported that family members never gave assurance and validation to the participants.

(Participant 3, My opinions were not valued like my other siblings).

(Participant 4, At times I want to get attention from others to understand my point or my interest because my parents always insisted me to follow their interests only).

(Participant 6, There were huge difference of opinions with my family members).

(Participant 5, I was not even allowed to choose my subject for Graduation, still now they do allow me to make independent decisions).

The participants could not express their thoughts and feelings. The participants felt they had no choice in making decisions or even sharing their problems with their parents and family members.

Sense of lack of belongingness

The third theme illustrated the experience of the emptiness of the participants. A secure and supportive, healthy relationship is key to having positive, healthy emotions. But, for the participants, isolation, and feeling of rejection, which ultimately led to developing emptiness, was the primary concern of ending life.

(Participant 3, I was ignored by my parents because they were busy all the time. I was alone).

(Participant 2, I felt nobody was there to support me or help me. I get so irritated when my parents did not fulfill my demands).

(Parent 1, My mother used to care my sister and always wanted a son as her first child, she used to neglect me always).

(Participant 5, I feel so lonely all the time, I frequently visit temple and from there I get some positive vibes).

Experience of lack of belongingness was the potential aggravating factor of intense negative emotion. To relieve the empty feeling was the standard trigger to take prompt action to self-harming behavior.

Intention to die

The last theme emerged to determine the lethality of suicide. All the participants mentioned that they had no intention to commit suicide successfully. The main reason for performing self-injurious behaviors was to relieve the overwhelming negative emotions such as anger and guilt. However, some reported that they do not feel like doing injurious behaviors after releasing the emotional tension and do not have further death intentions.

(Participant 1, I am not ready to hear any negative comments from anyone and if I could not fulfill my demands, I feel so dejected but no. no suicide).

(Participant 2, I cannot control myself injurious behaviors when I am sad or angry, but I don't want to end my life).

(Participant 3, Suicide is a Gunah (a form of sin). I can't end my life due to our religious belief).

(Participant 5, I get some relief when I visit temple and I wish to live more days to help people).

(Participant 6, I am against suicide and I never had suicidal intention and will never think of it.)

(Participant 4, No I don't want to end my life).

Participants are willing to know more to control their emotional impulsivity in their emotional stability state.


  Discussion Top


The present study explored the relationship between NSSI and other family domains like cohesion, expressiveness, conflict, acceptance and caring, independence, active recreational orientation, family organization, and control. A significant positive relationship has been established between family conflict and NSSI among the eight family environment variables. A study done by Cassels reported how family functioning intermediates the link between childhood adversity and adolescent NSSI acts.[15] In this study, the thematic analysis on inadequate interpersonal relationships showed more than half number of participants reported their NSSI behaviors due to family conflict experiences. A study done by Martin et al. demonstrated that parents' persistent poor relationships and physical maltreatment could be related to NSSI.[16] It also reported participants having a bad experience in childhood and negative relations with other family members were more prone to have NSSI thoughts and behaviors. Baetens et al. examined the relationship between parental expressed emotion and NSSI on adolescents.[17] The outcome of this study demonstrated high rates of NSSI behaviors found among adolescents who reported prominent self-criticism through the increased depressive level. There was a positive relationship between NSSI acts and perceived parental environment. Analysis from the path model showed that a perceived lack of emotional support affects NSSI. The binary logistic regression of this present study showed that family conflict could predict NSSI. Di Pierro et al. studied the effects of personality traits, family relationships, and maltreatment on NSSI behavior. It was found that anxiety, aggressiveness, and impulsivity have a strong link with NSSI.[18] In another study, researchers assessed NSSI behaviors in interpersonal and social roles, result depicted perceived social support or recognition by other family members was low for individuals with a significant level of repetitive NSSI behaviors.[19] The initiation of NSSI behaviors was more often related to interpersonal reasons. The other two themes, like lack of expression and lack of sense of belonging, played a relevant role in NSSI. According to biosocial theory emphasized on emotional dysregulation, which is specifically persistent in invalidating environment given by Linehan (1993), acceptability sense and sense of belongingness are dominant.[20]

Dysregulation of emotion within the family environment can manifest self-harming behaviors or suicides. A study conducted on adolescents reported high cases of self-harming behaviors because of ignorance toward children's personal experiences, and sometimes they are being criticized and punished.[20] In a healthy family system, it is essential to understand the extent to which family members are being encouraged to express their feelings and emotions directly to others. It is necessary to build up trust among the family members regarding expressiveness. Lack of trust among the family members might cause NSSI.[21] Other domains related to the quality of family relationships; disruptions of family bonds can also contribute to NSSI. In further research, results reported that parents who show a lack of affection and over-controlling nature where children cannot express themselves could lead to NSSI behaviors.[22] Other research studies have shown a similar result: Individuals who engage in self-injurious behaviors have trouble developing positive social solutions and significant problems in their family environment.[23] The findings from the paper implicate family intervention in the management of NSSI, which is quite different from conventional individual psychotherapy or dialectical Behavior Therapy. All the participants mentioned that they had no intention to die. However, they showed interest in stopping their NSSI behaviors. This study explores the association between NSSI and family environment and identifies the predictor variables to decrease the prevalence of NSSI in the community. This paper has emerged persistence of inadequate family environment causing NSSI, which is a new phenomenon in college students of Kolkata, despite extensive mental health awareness in the 21st century.

Limitation

Personality assessment could not be done to identify the participants' traits, but personality traits could contribute to NSSI. Family members were not interviewed due to time constraints.

Future direction

A longitudinal study with participatory behavioral observation may provide a clear picture of the NSSI behavior. In addition, a future study might be conducted on the family members to explore more specific family domains related to NSSI.


  Conclusion Top


This study shows significant association with NSSI with family conflict. The research study can contribute significantly to mental health professionals and social workers. Due to the emerging rate of death of youth in India, various studies are required to identify self-injurious and NSSI behaviors among adolescents and young adults to control the sudden loss of family and the community. Scarcity and unawareness of information led to the development and persistence of diseases. Considering the various changes in expectations and roles in families that are instrumental in raising behavioral problems related to suicide and self-harm, NSSI behaviors need to be addressed with proper care.

Acknowledgment

The authors are grateful to Visva Bharati University and Colleges at Kolkata for conducting and supporting the research work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hauber K, Boon A, Vermeiren R. Non-suicidal self-injury in clinical practice. Front Psychol 2019;10:502.  Back to cited text no. 4
    
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Cash SJ, Bridge JA. Epidemiology of youth suicide and suicidal behavior. Curr Opin Pediatr 2009;21:613-9.  Back to cited text no. 13
    
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    Tables

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