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Advances in Social Science, Education and Humanities Research, volume 494
Joint proceedings of the 3rd International Conference on Intervention and Applied Psychology (ICIAP 2019) and
the 4th Universitas Indonesia Psychology Symposium for Undergraduate Research (UIPSUR 2019)
Combining Counseling Techniques With Acceptance
and Commitment Therapy to Alleviate
Psychological Distress and Non-Suicidal Self-Injury:
A Single-Case Study
1 2*
Vira Andalusita Mulyaningrum , Sali Rahadi Asih
1Faculty of Psychology, Universitas Indonesia, Depok, Indonesia
2Department of Clinical Psychology, Faculty of Psychology, Universitas Indonesia, Depok, Indonesia
*Corresponding author, Email: sali.rahadi@ui.ac.id / sali.asih@gmail.com
ABSTRACT
High level of psychological distress is prevalent among university students. This is because they are
faced with numerous challenges, not only their academic performance but also conflicts with family
and friends. In some cases, high level of psychological distress may co-occur with non-suicidal self-
injury (NSSI). This research aimed to evaluate the effectiveness of a four-session intervention for a
client who reported a high level of psychological distress and NSSI tendency. A combination of
counseling techniques and several acceptance and commitment therapy (ACT) strategies was applied
as a four-session intervention. This study used a single-case, pre-test/post-test design, and the study
participant was a 22-year-old woman with depressed mood and NSSI tendency. The counseling
techniques, including active listening, encouragement, confrontation, reflection of feeling and content,
and positive asset search, were used to help the patient reduce her intense emotions and feel better
about herself. The ACT techniques, including acceptance, cognitive defusion, and committed action,
were applied to help the patient cope with unpleasant feelings and stay committed to her goals. The
result of the intervention revealed a decrease in psychological distress, as reflected in the reduction of
Hopkins Symptom Checklist-25 (HSCL-25) score from 2.72 to 1.60. The participant also reported a
decrease in NSSI tendency from 8 to 1 on the scale of 1–10. In addition, she managed to reduce her
intense emotions and discover new, more effective behaviors that align with her goals. These findings
suggested that counseling techniques combined with ACT strategies can be an effective treatment to
reduce psychological distress and NSSI tendency.
Keywords: acceptance and commitment therapy, counseling, depression, non-suicidal self-injury,
psychological distress.
1. INTRODUCTION stressors, these students often experience
University student populations are at a high levels of stress as well as chronic
high risk of psychological distress stress due to repeated demands for
(Stallman et al., 2018; Sugiarti et al., performance and evaluation (Stallman &
2018). This is because they are faced with Hurst, 2016). University students are also
numerous problems, not only their undergoing important and potentially
academic performance but also their stressful life transitions during this time,
conflicts with family and friends (Dreger which may cause them to experience
et al., 1991). In addition to normal life loneliness, isolation, and identity loss
Copyright © 2020 The Authors. Published by Atlantis Press SARL.
This is an open access article distributed under the CC BY-NC 4.0 license -http://creativecommons.org/licenses/by-nc/4.0/. 204
Advances in Social Science, Education and Humanities Research, volume 494
(Curtis, 2010). According to Arnett and meaningful life while accepting the
(2011), the college years are a time of negative experiences that unavoidably
transition from late adolescence to early occur (Harris, 2009). The aim of ACT is
adulthood, which is termed emerging not about eliminating difficult feelings but
adulthood. An individual is demanded to rather about being present with what life
fully become an adult during this emerging brings and moving towards a behavior that
adulthood period. However, at this point in aligns with individual goals (Hayes et al.,
life, an individual has only a limited 2011). The use of ACT has been
capacity to be truly independent. These recognized as a potentially effective
conflicts between demands and abilities at treatment for psychological distress
the emerging adulthood period make (Fledderus et al., 2012) and NSSI tendency
individuals vulnerable to the development (Washburn et al., 2012).
of various psychological problems. The For this study, the research team
prevalence of depression among young sought to adopt several ACT strategies and
adults aged 18–25 years is quite high, combine them with basic counseling
which is 25% higher compared with other techniques to help a client with
age groups (Kuwabara et al., 2007). psychological distress and a NSSI
Furthermore, college students nowadays tendency over a relatively brief duration.
are at a higher risk of psychological The ACT techniques used in this study
distress compared with 15–20 years ago were acceptance, defusion, and committed
due to increasing tuition fees that lead to action (Harris, 2009). In addition, the basic
financial problems, higher demands for counseling techniques used were
success, and difficulty in finding a job in a attending, encouragement, reflection of
highly competitive market (Sharkin, feeling, and reflection of content (Aladag,
2013). 2013). The main focus of the current
Psychological distress is defined as “a intervention was to help the client become
particular relationship between the person more aware of, and able to accept, her
and the environment that is appraised by negative experiences. Furthermore, the
the person as taxing or exceeding his or sessions aimed to teach the client not to
her resources and endangering his or her allow negative experiences to be an
well-being” (Lazarus & Folkman, 1984). obstacle to achieving her goals.
Psychological distress can take the form of The purpose of this study was to
depression and anxiety (Mirowsky & examine the effectiveness of combining
Ross. 2003). According to Richmond et al. counseling techniques with ACT strategies
(2017), the symptoms of psychological for a client who reported a high level of
distress often co-occur with non-suicidal psychological distress as well as a NSSI
self-injury (NSSI). Over the past few tendency. It is important that the
years, NSSI has emerged as a significant intervention was brief as it allowed the
issue for university students (Richmond et therapist to alleviate the symptoms of
al., 2017). psychological distress and NSSI tendency
Acceptance and commitment therapy in a setting with limited resources, thereby
(ACT) is a form of psychological avoiding the development of more serious
intervention aimed at creating a rich, full,
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Advances in Social Science, Education and Humanities Research, volume 494
problems, such as clinical depression and about 5 years ago, when she was in high
suicide attempts. school. She was distressed over a conflict
with her best friend who suddenly moved
1.1. Case Presentation away without saying anything. She blamed
1.1.1. Initial Presentation herself for somehow disappointing her best
NA was a 22-year-old woman who friend. At the same time, her family started
was a final-year undergraduate student in experiencing quite serious problems that
psychology at a public university in began when her family decided to buy a
Jakarta, Indonesia. She came to Beji house. During the first year of new home
Community Health Center (Puskesmas ownership, the family was able to pay
Beji) and reported being in a very bad mortgage. However, in the second year,
mood and an urge to do self-harm without her father’s business started to have
the intention of actually killing herself. problems, thus disrupting the mortgage
She also experienced other symptoms of payments and prompting NA’s mother to
depression, such as feeling worthless, lack borrow money from numerous sources.
of energy, having trouble concentrating, The debt of NA’s family continued to
feeling irritable, experiencing social accumulate, without them being able to
withdrawal, and having a decreased pay the debt or the mortgage. NA was
appetite. At the first meeting with the eager to do something to lessen her
therapist, NA immediately cried when the family’s financial problems, but she could
therapist asked how she was feeling. Her not do much. This inability made her felt
voice tended to be small and weak, and her useless and that she was just a burden on
eyes were often downcast. She said she her family.
had been “buried too much, for so long” Not long after this financial crisis
that she could not even bear to cry. After began, NA had to face the fact that her
being given time to calm down, NA began parents were on the verge of divorce. She
to talk about the urge for self-harm that believed it was because her mother could
she was experiencing. She said that she
had a strong urge to cut her wrist every not tolerate her father’s harsh behavior. He
time she felt herself to be under a lot of often spoke rudely and rarely showed
stress, and she was exposed to a needle or affection to his family. Moreover, the debt
problems added to the tension between her
a scissor. However, she “never really did parents. Apparently, in the midst of
it,” and instead just cried herself to sleep.
considering divorce, NA’s father became
1.1.2. Background information ill due to his nicotine dependence. His
NA was the second child in a family of illness caused NA’s mother to cancel the
three children. She described that her divorce, and she decided to take care of
family tended to be emotionally distant. her husband until he was healed.
Her father was perceived to be a hard and Unfortunately, within 1 year, NA’s father
tough man as he came from a family that died. His death occurred not long before
was less well-off and had no formal the university admission tests that NA was
education. Meanwhile, her mother was scheduled to take. Due to the
said to be a compassionate but somewhat complications from her family problems,
she was unable to focus on the test
sensitive person. NA’s problems began in
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Advances in Social Science, Education and Humanities Research, volume 494
preparation. She failed the tests several NA said that she felt better when she
times and was finally admitted to a was able to spend time on her hobby,
university that was not where she had which was writing. She liked to write
hoped to attend. about self-care and self-improvement on
her own blog. She said that she had been
Meanwhile, NA’s older sister had been regarded as a wise person and that the
married and often told NA about her people around her often confided in her.
domestic problems. The sister had such Therefore, she wanted to spread her words
serious problems with her husband that of wisdom to more people by writing a
they were at the verge of divorce. The blog. NA was very pleased when friends
series of negative events that happened to or blog readers admired her writing and
NA’s family made her think that she did felt motivated by her blog. Thus, she felt
not deserve good life experiences. NA felt important and capable when she was
desperate, to the point of thinking about
suicide and doing self-harm. She had a writing. However, NA’s confidence
strong urge to cut her wrist every time she dropped immediately when she saw a
saw a needle or a scissor. As a psychology negative comment on her blog, to the point
student, NA realized that something was she did not want to write anymore because
wrong. Therefore, before actually hurting of sadness. NA said that she had not been
herself, NA tried to find help to reduce the able to write over the past year and did not
tendency. She had tried to find self-healing have enough confidence to try to write
modules on the Internet and took online again, although she wanted to. She felt
counseling sessions; however, due to her doubtful about whether she was really
low level of commitment, none of these capable of writing and whether people
methods worked. NA finally decided to truly liked her writing.
take a counseling session in person at the
Beji Community Health Center.
an individual setting.
2. METHODS
2.1. Design 2.3. Approvals
This study was a single-case design The study participant agreed that the
with repeated measurements that were data collected from the intervention
conducted at the first session (pre-test) and process would be recorded and published
at the last session (post-test). The in an educational setting. The counselor
intervention was conducted in four (first author) maintained anonymity of the
sessions, with one session per week. Each study participant’s name by using only the
session lasted 90–120 min. initials. The counselor explained the
purpose of each session and debriefed the
2.2. Context study participant at the end of each
This study was conducted in Beji session. In addition, the study participant
Community Health Center (Puskesmas signed the informed consent.
Beji), Depok City, Indonesia. The sessions During the intervention process, the
were performed in a counseling room with counselor was under the supervision of a
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