“I’m a Prospective Professional Helper, but I’m Vulnerable”: A Mixed Methods Study of the Self-Regulation of Psychology Students with Adverse Childhood Experiences

Abstract

Prospective professional helpers particularly in psychology are at great risk when they have had adverse childhood experiences (ACEs). Their self-regulation as survivors may endanger their profession in the future. A mixed-methods sequential explanatory study aimed to gain an in-depth understanding of the self-regulation of emerging adult students majoring in psychology who survived ACEs. The first study with a cross-sectional survey method identified negative correlation between ACEs and self-regulation. The domain of childhood maltreatment was more strongly negatively associated with impulse control than goal setting. The opposite applied to the domain of family/household dysfunction. Meanwhile, the second study with a narrative method among participants with at least four types of ACEs generated ten narrative themes (i.e. intense self-criticism, excessive self-dedication, awareness, meaning reconstruction, compensation or avoidance, competitiveness, independence, family orientation, social relation patterns, and social support role). Integration of the two results generated four forms of survivors’ typical self-regulation. Two forms were in line with previous concepts (i.e. impulse control and goal setting), the rest were two survivor-specific findings (i.e. cognitive functioning and the value of the other’s presence). There were three groups of participants produced from correspondence analysis. The results indicate that despite their survival, their setting goals and striving for the future, psychology students with more ACEs are still hindered by the terrible memories and their impacts. Self-insufficiency and interpersonal issues particularly may cloud their future profession as helpers. The psychology students themselves or other parties can help improve self-regulation by understanding the possible connections between their ACEs and their current difficulties, separating lingering emotions caused by past history, and improving abilities gradually, intrapersonally and interpersonally.

Introduction

Helping professions are important fields of work and in great demand. For example, the Bureau of Labor Statistics (BLS) reported that helping professions occupy the second after management occupations of all occupational groups in the United States in 2020 (Department for Professional Employees, AFL-CIO, 2021). Furthermore, the BLS (2022) also reported that helping practitioners show the highest projected percent change of employment between 2021 and 2031. In Indonesia where the current study was conducted, data from the Ministry of Health processed by BPS-Statistics Indonesia (Badan Pusat Statistik/BPS Indonesia, 2023) shows that professional helpers in the health sector reach 1.4 million out of the nearly 276 million population in 2022. The largest number of professional helpers in Indonesia is nurses with a total of 563 thousand people. Medical personnel are in the third place with 176 thousand people. Meanwhile, psychologists (in this case in the field of clinical psychology) are in the second lowest position after traditional health workers, namely with 1,247 people (BPS Indonesia, 2023). One of the very important variables for these professions is the ability to self-regulate (Skovholt & Trotter-Mathison, 2016). Precisely, self-regulation is the ability to regulate the response in the individual in goal setting, both behavioral responses and biological responses (Neal & Carey, 2005; Thomson & Jaque, 2017). Professional helpers, such as workers in the fields of physical/mental health, therapy, education, or social, are required to be skilled in interacting between humans intensely and continuously, namely in caring for others (Skovholt & Trotter-Mathison, 2016). Their central strength lies in the ability of perspective taking, as well as good and sustainable coping to balance self-care and other-care.

The strength of the professional helpers is determined long before the professions take root, even since childhood. In a normative situation, students who study in fields with job prospects as professional helpers still face challenges of emerging adulthood, namely a unique developmental phase that bridges adolescence with adulthood (Arnett, 2000). This period (18 to 29 years of ages) is characterized by identity exploration, emotional instability, self-focus, feeling in-between, and sense of possibilities (Arnett, 2004; Arnett et al., 2014). According to Arnett (2000), most emerging adults explore the various options and possibilities in the fields of education, romance, work, accompanied by an increase in the expectations and roles of the social environment. Self-regulation affects their ability to pass the period optimally (Rollins & Crandall, 2021). Emerging adults generally have completed the school period, chosen to continue their studies and become college students. They generally begin a phase that demands a process of adaptation towards independence in being both in the academic environment and the social environment (Tao et al., 2000).

However, self-regulation among emerging adults is particularly determined by their earlier experiences (Murray & Rosanbalm, 2017). Their adjustment during emerging adulthood as well as being students is exacerbated by adverse childhood experiences (ACEs; Borgese, 2019). Those who have experienced childhood adversities (e.g. childhood maltreatment, family/household dysfunction, and other violence outside the home) show disturbances in regulatory domains so that behavioral and psychiatric problems develop in emerging adults at various degrees of severity (Balkis & Duru, 2015; Murray & Rosanbalm, 2017; Newbury et al., 2018). In addition to symptomatic and intrapersonal burdens, ACEs are also associated with severe and profound interpersonal distress (Van Nieuwenhove & Meganck, 2017; Van Nieuwenhove et al., 2018). On the other hand, the reason for choosing further studies with job prospects as a helping professional may be ironic. Kottler (2010) explains that they need to overcome their own problems, namely fulfilling their unconscious motives because of the emotional wounds they have experienced, including due to ACEs. Further, Skovholt and Trotter-Mathison (2016) explain that failure in coping ultimately causes several problems, namely burnout, compassion fatigue, vicarious trauma, ambiguous ending, as well as professional uncertainty that endanger themselves and their profession. The ability to self-regulate well while being a student can ameliorate the impact of ACEs on the professional quality of life (Harris, 2020).

A correlational study alone to clarify the negative relationship between ownership of ACEs and self-regulation is not enough to understand the dynamics of self-regulation among those who have experienced ACEs. Meanwhile, prevention of worsening impacts, support for capacity building, or more appropriate treatment can be done by understanding the conditions of self-regulation in depth. Thus, this mixed methods study was conducted aiming to provide in-depth and comprehensive understanding about the self-regulation in emerging adults as helping profession students with a history of ACEs. This research combined the two strengths of quantitative and qualitative research. Specifically, the quantitative research, namely a correlational survey, aimed to examine the hypothesis that there was a negative relationship between ACEs and self-regulation. Meanwhile, the qualitative study, namely a narrative approach, aimed to answer the research question of how emerging adult students with a history of ACEs interpreted their current self-regulation. Each phase was carried out alternately which was continued by combining quantitative and qualitative findings to obtain a deeper understanding of the phenomenon under study (Othman et al., 2021; Bowen et al., 2017).

Materials and methods

This research was a mixed-methods research with sequential explanatory and nested design. There were two stages of research with different methods where the quantitative phase (cross-sectional survey) was followed by the qualitative phase (narrative approach), and involved the same sample or sample parts as studies at other stages (Creswell & Plano Clark, 2011). This method is able to optimize the advantages of quantitative and qualitative approaches, including measuring a specific construct with accurate operationalization, contextualizing quantitative data with detailed data rich in individual experiences, including emotions, beliefs, and attitudes and behaviors, in-depth analysis of complex human beings, family systems, and cultural experiences in a way that cannot be fully captured with the measurement scale and multivariate models (Castro et al., 2010; Creswell et al., 2003; Mason, 2006; Othman et al., 2021; Plano Clark et al., 2008).

Participants

The participants were helping profession students, particularly majoring in psychology from a state university in Indonesia. Their age range was 18 to 29 years (Arnett, 2000). Participants were obtained through a convenience sampling technique by informing the research of 186 students. A detailed explanation of the information about the study was given before participants voluntarily engaged marked by a statement of willingness in informed consent. There were 71 students who were willing to access the online survey within a 2-week period, but only 58 of them voluntarily expressed a willingness to be involved in the first phase of the survey (M_age=20.21; SD_age=0.91; Male = 8.6%). The majority of participants were Javanese (67.2%), Muslim (86.2%), and achieved a GPA above 3.5 on a scale of 4 (77.6%). Only 3.4% of them had a GPA below 3. Demographic data of survey research samples are shown in Table 1.

Table 1.

Demographics of participants

Category of demographic	n	Prevalence (%)
Sex
Male	5	8.6
Female	53	91.4
Age
19 years old	14	24.1
20 years old	23	39.7
21 years old	16	27.6
22 years old	5	8.6
Race
Javanese	39	67.2
Non-Javanese/Mixed	19	32.8
Religion
Islam	50	86.2
Protestant	5	8.6
Catholic	3	5.2
Year of Study
2st Year	25	43.1
3st Year	33	56.9
GPA (scale of 4)
x < 3	2	3.4
3 ≤ x < 3.5	11	19.0
x ≥ 3.5	45	77.6

Note. N = 58

Of the 58 survey respondents, there were eight people (13.7%) who met the qualifications in the number of ACEs, namely a total score of at least four, for the next stage of the study (see Table 2). However, only four of the eight respondents who met the ACEs score qualifications were involved in the drafting of the narrative essay, as the remaining four declared resignation. Participants with a minimum score of four based on measurements using WHO ACE-IQ were determined based on the cut off used by Agbaje et al. (2021) and Felitti et al. (1998). The total score of at least four could contain a combination of ACEs from any domain. The variety of self-regulation scores was not limited so that this variable could be observed in depth in people with a set number of historical ACEs.

Table 2.

ACEs and distributions by types

Number	n	Prevalence (%)	SSRQ Score
			Mean	Std. Deviation
ACE(s)
0	16	27.6	100.38	12.14
1	16	27.6	95.31	13.70
2	9	15.5	93.56	15.22
3	9	15.5	89.00	14.05
4	6	10.3	88.00	13.89
5	1	1.7	96.00	.
10	1	1.7	73.00	.
Childhood Maltreatment Type (out of 5)
0	24	41.4	98.42	14.14
1	14	24.1	94.93	13.53
2	9	15.5	89.67	9.41
3	9	15.5	89.33	15.84
4	1	1.7	96.00	.
5	1	1.7	73.00	.
Family/Household Dysfunction Type (out of 5)
0	40	69.0	97.20	13.04
1	16	27.6	88.38	14.13
3	2	3.4	84.50	16.26
Violence Outside the Home Type (out of 3)
0	49	84.5	94.59	13.00
1	8	13.8	95.38	18.53
2	1	1.7	73.00	.

Note. N = 58; SSRQ scores represent self-regulation

Data Collection

Demographic Data

Demographic data was asked at the beginning of the questionnaires. These data, namely gender, ethnicity, study period, and GPA, were taken into consideration in the quantitative analysis. Previous studies have proven differences in ACEs among emerging adults based on the demographic data, such as Badr et al. (2018) in terms of gender, Girresch (2018) in terms of ethnicity, as well as Gresham and Karatekin (2023) in terms of study period and GPA. Differences in self-regulation have also been found based on gender (Pasha-Zaidi et al., 2020), ethnicity (Rollins & Crandall, 2021), as well as study period and GPA (Gresham & Karatekin, 2023).

The World Health Organization Adverse Childhood Experiences International Questionnaire (WHO ACE-IQ)

ACEs were measured using WHO ACE-IQ by the World Health Organization (WHO, 2018) which contains 29 questions to represent 13 types of adverse experiences of childhood up to age 18. The types of experiences represent three domains, namely childhood maltreatment, family/household dysfunction, and violence outside the home. All difficult childhood experiences are tiered so that each type will get a score of “1” if experienced, or “0” if not experienced.

The total score of the ACEs ranged from 0 to 13. WHO ACE-IQ has been adapted into Indonesian with the internal reliability of Cronbach’s α 0.74 and positively correlated (p < .01) with the ACE-Questionnaire of 0.81 (Rahapsari et al., 2021). Cronbach’s α in this study was 0.63. The alpha in this sample was not satisfactory because the r_ix ranged from − 0.09 to 0.57 (with the mean of 0.29). Furthermore, this may occur because of imbalances in response to types of ACEs (Kadam & Bhalerao, 2010), or because of the small number of points of the response scale given their binary choices (Liu et al., 2010).

A Short Version of the Self-Regulation Questionnaire (SSRQ)

Self-regulation was measured using SSRQ by Neal and Carey (2005). This scale is a Likert scale with 21 items, namely 11 items representing the impulse control aspect and 10 items representing the goal setting aspect. Respondents were asked to respond to how the items represented their circumstances. There were six-tiered score response options from 1 (strongly disagree) to 6 (strongly agree). A negative item would be suspended otherwise. The total score ranged from 21 to 126. SSRQ has been adapted into Indonesian and tested on undergraduate students with internal reliability of Cronbach’s α 0.90 and positively correlated (p < .01) with career aspirations of 0.49 (Sawitri & Dewi, 2018). Cronbach’s α in this study was 0.91 with r_ix ranging from 0.31 to 0.77 (with the mean of 0.54).

Narrative Essay

The narrative study was used to answer the research question of how emerging adult students with a history of ACEs interpret their current self-regulation. The narrative was set forth in the form of an essay typed in a soft file (Microsoft Word) by answering questions within a week and a half of essay drafting timeframes. Researchers provided support through social media groups periodically every 1 to 2 days to monitor, provided important information and the widest possible questioning space for participants. The questions in the narrative essay consisted of two kinds of questions, namely life story questions and reflective questions. These questions were based on a modified version of the Biographical Narrative Interview Method (BNIM) (Wengraf, 2001). The BNIM uses a single broad narrative inducing question to prompt participants to tell the story of their experiences. The questions compiled were general in nature to reveal self-regulation in emerging adult students without considering aspects of the existing instruments used in this study (SSRQ; Neal & Carey, 2005). The aim was to provide an opportunity for response development beyond existing aspects so as to enable new findings and a more thorough understanding. Next, participants were gradually prompted with several additional questions directly related to their self-regulating experiences if the subsequent questions had not already been answered.

Participants were encouraged to respond more broadly to the topics that were told in sequence through the question “Tell us about the challenges in your daily life and how you deal with them. You can describe in general terms how your management has been, followed by specific examples of managing daily life.” Some additional questions were also asked regarding the sustainability of the experience, namely “Tell me about difficult problems that you may have encountered in recent times or are the long-lasting impact of a particular experience. Tell me how you deal with it?” Participants’ responses in the form of essay were continued by answering reflective questions that aimed to dig deeper into the participants’ stories, namely “Tell us about important things that you think have contributed to the management of your daily life or in solving difficult problems. How does it affect?” In addition, the researcher also encouraged participants’ open and in-depth response by adding the instruction, “You are free to say anything about the GOOD or BAD thing you did according to the theme raised in the given question, as far as describing yourself as you are. Provide information on what you think and feel, as well as the things you do as a form of support for your statement. You can relate your story to areas of your life (to the extent necessary as appropriate) such as physically, academic, social, work, family, etc.”

Five principles and strategies to maintain qualitative research results have been sought to be achieved, namely credibility, dependability and confirmability, transferability, reflexivity, and reliability for content analysis (Othman et al., 2021; Hollway & Jefferson, 2000).

Data Analysis

Quantitative analysis was first carried out by identifying descriptive statistics to get an idea of the variables, including the prevalence of ACEs and their domains. Second, researchers confirmed the fulfilment of the assumption test. Third, independent sample T-Tests were run to ascertain whether control over demographic variables was needed. The results of the independent sample T-Test showed that neither gender, ethnicity nor study period distinguished the score and therefore did not need to be controlled. Finally, researchers considered these results and used the Pearson Correlation statistical test for quantitative analysis. The correlations between the variables and GPA were also examined for exploration. All statistical examinations were carried out with SPSS 22 software.

Qualitative analysis in this study was carried out by taking into account two types of analysis, namely narrative theme and narrative form. A certain narrative part of the essay will be identified, coded and analyzed thematically. The next analysis was carried out related to the structure that is interpretive or narrative meaning-making narrative which is carried out by inductive coding methods to develop themes that appear in the encoded essay (Reissman, 2008). The themes themselves were formulated from sub-themes which were previously generated from narrative essay codes. Finally, narrative forms and language choices were inferred to encourage enlightenment beyond what can be learned from participant meaning alone (Reissman, 2008). How participants construct narratives can provide interpretive understanding that shows the participatory emotional struggle of retelling and recalling painful and difficult experiences (Hollway & Jefferson, 2000; McAdams, 1998).

Researchers used interactive strategies to combine both separate outcomes (Creswell & Plano Clark, 2011). The goal was to compare, contrast findings, look for contradictions, convergence and complement each other to improve the understanding of phenomena (Robinson et al., 2016). By considering the depth of narrative data compared to quantitative data, the researcher further conducted a qualitative-dominant crossover mixed analysis to integrate the two analysis results, namely extracting meta-themes (Bernard et al., 2016) using correspondence analysis strategies (Onwuegbuzie & Hitchcock, 2015). The meta-themes themselves were identified because of the thematic proximity between themes that have previously been developed. Furthermore, correspondence analysis was conducted to combine the results so that latent patterns could be revealed.

Results

Descriptive Quantitative

There were 13.7% (n = 8) of samples who had at least four ACEs (see Table 2), namely at least one in the childhood maltreatment domain of 58.6% (n = 34) of the sample, in the family/household domain of 31% (n = 18) of the sample, and in the violence outside the home domain of 15.5% (n = 9) of the sample. Based on the mean of the SSRQ score which can be observed in Table 2, self-regulation tended to decrease with the addition of ACEs as well as the domains of childhood maltreatment and family/household dysfunction, but was less observed in the domain of violence outside the home. In addition, descriptive statistics (see Table 3) showed that the empirical mean of ACEs (x̄=1.72) and their domains (x̄ respectively from the domains of childhood maltreatment, family/household dysfunction, and violence outside the home, namely 1.17, 0.38, and 0.17) were below the hypothetical mean (x̄=6.5, 2.5, 2.5, and 1.5 respectively) or tended to be slightly experienced. Meanwhile the empirical mean of self-regulation (x̄=94.33) and its aspects (x̄=47.83 for impulse control and x̄=46.50 goal setting) were above the hypothetical mean (x̄=73.5, 38.5, and 35 respectively) or tended to be high (good) in regulation.

Table 3.

Pearson correlation coefficients among variables

	1	1a	1b	1c	2	2a	2b	3
1. ACEs	1	0.89***	0.70***	0.43***	− 0.35**	− 0.31**	− 0.32**	0.07
1a. Childhood Maltreatment		1	0.37**	0.14	− 0.31**	− 0.31**	− 0.26*	0.11
1b. Family/ Household Dysfunction			1	0.26*	− 0.29*	− 0.23*	− 0.32**	− 0.02
1c. Violence Outside the Home				1	− 0.10	− 0.10	− 0.09	− 0.01
2. Self-Regulation					1	0.94***	0.91***	0.08
2a. Impulse Control						1	0.70***	0.09
2b. Goal Setting							1	0.05
3. GPA								1
Minimum (Empiric/Hypothetic)	0/0	0/0	0/0	0/0	67/21	32/11	31/10	2.34/0
Maximum (Empiric/Hypothetic)	10/13	5/5	3/5	2/3	122/126	63/66	60/60	3.96/4
Mean Empiric	1.72	1.17	0.38	0.17	94.33	47.83	46.50	3.60
Std. Deviation Empiric	1.79	1.27	0.67	0.43	13.88	8.13	6.91	0.25

Note. ***) Correlation is significant at the 0.001 level (1-tailed),

**) Correlation is significant at the 0.01 level (1-tailed),

*) Correlation is significant at the 0.05 level (1-tailed)

Correlation between Variables

Pearson’s correlation coefficients (1-tailed, see Table 3) showed that in general ACEs were negatively and significantly correlated with self-regulation as well as its aspects (r_xy=-0.31 to − 0.35; p < .01). The childhood maltreatment domain had a greater correlation with the impulse control aspect (r_xy=-0.31; p < .01) than the goal setting aspect (r_xy=-0.26; p < .05), while the family/household dysfunction domain had a greater correlation with the goal setting aspect (r_xy=-0.32; p < .01) than the impulse control aspect (r_xy=-0.23; p < .05). These coefficients can be categorized as weak-moderate (Akoglu, 2018).

The domain violence outside the home is not correlated with self-regulation and any aspects, presumably due to the very little exposure of this domain in the sample (15.5%). Finally, the examination of correlations of any variables with GPA is not significant.

There were four participants involved in the second phase of the study (see subsection of the Participants). Details of the ACEs and self-regulation scores are shown in Table 4 (pseudonyms are used). The self-regulation (and its aspects) scores from the highest to the lowest were respectively owned by Bella, Clara, Alvin, and Diana. Furthermore, the comparison of mean scores between the aspects has shown that the goal setting scores were always higher than the impulse control scores.

Table 4.

Qualified sample for qualitative analysis*

Nama, Pseudonym (Sex, Age)	ACEs				Self-Regulation
	CM	F/HD	VOH	Total	IC (Mscore)	GS (Mscore)	Total (Mscore)
Alvin (M, 22)	5	3	2	10	35 (3.18)	38 (3.80)	73 (3.48)
Bella (F, 21)	3	1	0	4	53 (4.81)	50 (5.00)	103 (4.90)
Clara (F, 20)	3	1	0	4	48 (4.36)	44 (4.40)	92 (4.38)
Diana (F, 19)	3	1	0	4	32 (2.90)	35 (3.50)	67 (3.19)

Note. *) Information is restricted to maintain the confidentiality of personal identity; scores as measured using the WHO ACE-IQ (ACEs) and SRRQ (self-regulation) which are described later; M = male; F = female; age are in years old; CM = childhood maltreatment; F/HD = family/household dysfunction; VOH = violence outside the home; IC = impulse control; GS = goal setting

Qualitative Findings

Narrative essays from participants ranged from 650 to 2322 words (average of 1381 words). The results of the analysis were divided into narrative themes and narrative forms as follows.

Narrative Themes

Narrative essays were read repeatedly and filtered out relevant parts to answer questions, coded, and then analyzed thematically. There were 46 sub-themes obtained for Alvin, 24 sub-themes each for Bella and Clara, and 35 sub-themes for Diana. Inductive coding methods were then applied and generated ten main narrative themes (see Table 5, Column 1) that are typical of the participants:

Table 5.

Formation of meta-themes

Narrative themes	Meta-themes
− Terrible memories lead to intense self-criticism and destructive patterns	Impulse control
− Excessive self-dedication
− Awareness of having problems and their associations with possible causes and solutions	Cognitive functioning
− Reconstructing meaning or being stuck
− Switching to compensation or avoidance	Goal setting
− Being competitive and self-intolerant or giving up easily
− Independence and decision making ability
− Family orientation	Value of other’s presence
− Debilitating social relationship pattern − Social support role

1. Terrible Memories lead to Intense self-criticism and Destructive Patterns

All participants showed strong self-criticism, connected to repeated, chronic, and/or profound past bad memories. This resulted in a variety of strong negative emotions, sometimes fluctuating and directed inward.

Intense self-criticism also influenced responses to situations that demanded performance because sensitivity to external judgments increased. This led to a sense of inferiority and fear of making mistakes as well as the preoccupation of failures that were anticipated by feeling oneself bad, would be humiliated, disrespected, and considered incompetent. As one of them stated by Bella:

My growth went through many difficult events, even my mother once said that she was afraid that my growth would be disturbed because I used to often get physical and verbal abuse from my father and often saw my parents fighting. I grew up to be a person who often mentions the word ‘fear’ because I am so afraid that my behavior will be wrong and then be publicly humiliated, I am afraid that my behavior will not be liked by others.

At the extreme, these pressures seemed to result in susceptibility to both destructive behaviors (such as destructive lifestyles, substance abuse, suicide attempt) and physical complaints (such as irregular menstrual cycles, fatigue even for minimal physical activity).

2. Excessive self-dedication

There are two forms of excessive self-dedication, one directed at others and the other directed at oneself. Alvin and Bella tend to take the first form, which is self-sacrifice to prioritize others. Alvin admitted that he made the efforts to benefit others over himself. He also contemplated and tried to get happiness from his sacrifice but it was not easy. Bella obviously dedicated herself to others precisely to her family. This was not an easy thing. She did this because of her feelings of responsibility as the only child who has to take care of the family and make her parents proud. Alvin typed about excessive dedication to others:

I just value real results impacting someone else and this I don’t want to get results for me. From the development of my thinking orientation, there are new problems in my life that result in some parts of my body and internal organs not working properly, because of what I have done and only concern with work regardless of my own care.

Clara and Diana tend to take the second form of excessive self-rumination. Clara strived to be competitive representing a great deal of attention to self-performance and to get the attention of others. Hence she focused on personal limitations instead of dedicating herself to others. Meanwhile, Diana contemplated herself because of her low self-management, so intensively that she was unable to solve her problem.

3. Awareness of Having Problems and Their Associations with Possible Causes and Solutions

Participants may be aware or clueless about having problems, as well as their associations to possible causes including childhood-adolescent adversities and to possible solutions. Awareness was observed in Alvin, Bella, and Clara. All three reflected on their problems and limitations and felt discomfort as a result, yet reflection became the starting point for understanding the cause, clarifying and determining the next more constructive goals, thinking about possible efforts, and acting to try to achieve the goals set.

On the contrary, Diana clearly knew that she had problems including possible consequences of an unpleasant past. Based on the advice, she also tried to address her complaints but ended up having trouble capturing the exact association of how the effort might work. Diana repeatedly expressed confusion, ending up blaming herself and feeling worthless, as one of the quotes: “I actually feel that I don’t envy my friends’ achievements and experiences. I feel good for their achievements. However, I am confused as to why I end up blaming myself and feeling small compared to my friends.”

4. Reconstructing Meaning or Being Stuck

Reconstructing meanings were obtained through insights as individuals proceed with events or as results of the external situational supports. Reconstructing meanings included reinterpreting negative events that lead to gratitude, hope, appreciation of small achievements, evaluation of positive relationships, positive self-evaluation, positive self-talk, or concrete efforts. Alvin, Bella, and Clara reconstructed meanings with different intensities, but Alvin and Clara clearly had external support. Ali experienced changes in better facilities compared to his childhood, and Clara received help from close people including a religious community. For example, Clara interpreted the presence of those around her which was God’s intervention:

I think God sends people around me to take care of me. I am given a boyfriend who is very patient with me, ready to reassure me whenever I suddenly think some useless things. I am given some friends who are always ready to listen to my stories whenever I need them.

All participants, including Diana, also felt the support of their educational background in Psychology, thus evaluating the benefits of studying this science. However, Diana still seemed to need a longer process even though she also got supports from parents and friends, did positive self-talk and concrete efforts. Her efforts were often countered by worries that came later.

5. Switching to Compensation or Avoidance

Self-complaints require channeling – or nothing. It will be explained later on the narrative theme of competitiveness. Alvin, Bella, and Clara compensated in the form of trying hard to excel with achievements in certain areas. Each of them also realized how these efforts were still not in line with personal desires because they were manipulations in the midst of unpleasant events. Especially in Alvin and Bella, their personas were shown as a tough figure and having good social skills. However, both admitted that their true selves were not so, as one stated by Bella:

My schoolmates always say that I am a cheerful and friendly person. However, behind it all, my life is actually not as beautiful and colorful as other people imagine… … when I’m alone or at home I become a different person, I’m not as cheerful as when I’m with friends, I become more silent.

Another thing happened to Diana who actually chose to avoid it. Despite receiving esteem supports and suggestions, intrusive thoughts and feelings about failure and criticism pulled her back from trying new things, but on the other hand she knew how important it was for her future.

6. Being Competitive and self-intolerant or Giving up Easily

Alvin excelled in academics and careers, decorating life with achievements and finances. Bella demanded herself at her age, should come to terms with (bad) memories, could manage herself well, and be reliable. Clara became competitive to keep up with her more proud sibling. As typed Clara:

I often feel envious and want to be her [older sister]. My father frequently compares me with her… … My father was disappointed [with my failure] and accidentally takes his anger out on me. My father got angry and said [painful things]. From then on, I felt I became a very scared individual of failure and became very competitive.

Competitiveness is generally positive but does not apply to these three participants due to their low self-tolerance. Alvin, for example, highlighted for ignoring the perceived effects, while another participant, Diana chose to give up easily. She was preoccupied with pressures so that she felt intense fatigue, found it difficult to manage activities even for minimal routines more than most of her peers. These things turned out to be enough to make her stop any further efforts despite having started them.

7. Independence and decision-making Ability

Independence and decision-making ability are connected with other narrative themes. Alvin and Bella had strong independence while Clara and Diana had weak independence. Strong independence is characterized by the ability to make decisions that are mostly driven by personal will, make independent considerations, be able to persist in their efforts, and direct their orientation outwards. As Bella typed:

I am an only child who has been keeping many stories alone, I have nowhere to share, I swallow all the bitter events by myself, and I have to grow up by myself… … I am now 21 years old,… … I should be able to manage myself better, over time I realized that I had to be a reliable person and not give up even though there were many unpleasant events and sometimes there was a feeling that my life was in vain, so far my reason for surviving and fighting for my life is because I am an only child,

On the contrary, those with weak independence gain real and continuous social supports to start and maintain efforts, as well as strengthen their intrapersonal through both emotional and esteem supports, as well as informational supports.

It is concluded that external support is important. However, for those with strong independence, Alvin for example, accessing professional psychologists did not necessarily help. He sought for help from different professionals and was still trying to develop himself based on his own reflections and choices.

8. Family Orientation

Apart from similar experiences of childhood maltreatment and family dysfunction, family orientation can lead to two tendencies, namely being responsible for the family, and being distant from the family. Alvin and Bella felt responsible by directing achievements for the family even when they still felt discomfort.

Although Clara became competitive with her sibling, she became less responsible because of the sharing of burdens with others. In addition, she came from a wealthy family. Meanwhile, Diana, who was actually aware of the family’s financial limitations, was unable to manage her attention to help parents build the family economy. This was considered as the poor self-management so that it was enough to be directed to obligatory academics only. Diana typed in her essay:

Since my parents decided to sell some food [at certain events, redacted], it made me feel a bit ‘tired’ when I knew the time [redacted] was coming… … I always felt dizzy, what should I do first. And to at least be able to do those activities, I finally chose not to do any of those main activities [helping parents, taking care of personal needs].

9. Debilitating Social Relationship Pattern

Social relationship patterns in all participants tended to be debilitating, that is, the distance type or as a result of trust issues, and the fear of abandonment/rejection type. Alvin and Bella experienced trust issues for different reasons. Alvin felt hatred as a result of his childhood adversities –from psychological and physical abuse to death threats– so he could not adapt properly. Regarding this Alvin typed: “In this phenomenon, I am increasingly convinced that I really hate people until now, events that make me unable to adapt correctly to people… until now I have always manipulated all forms of circumstances.”

Meanwhile, Bella considered the world to be competitive and did not hesitate to bring her down when she made a mistake – regardless of her persona that was easily liked.

Clara and Diana experienced fear of abandonment/rejection. Repeated experiences of family disharmony and rejection made Clara need a great external support. She couldn’t help but share and get recognition that she was important in the eyes of her significant other outside the family. Meanwhile, Diana felt afraid of being abandoned/rejected because of similar experiences in the past, and if she couldn’t meet others’ expectations of having a brighter future that seemed to be imposed on her. Procrastination or avoidance became her anticipation of more painful events.

10. Social Support role

The role of social support is quite consistently in line with other narrative themes and leads to two forms, namely denying or otherwise needing and gaining social support. Denial was observed in Alvin and Bella with different patterns. Alvin felt that sharing problems was not a solution, instead it created more unwanted feelings. Meanwhile, Bella was used to struggle alone in her family and felt that she had to show good things of herself.

Clara and Diana prominently needed, sought, and obtained social support from their environment whether they were individuals, families, or close communities. Complaints for reinforcements (such as emotional and esteem support) and suggestions of direct action (such as informational support) must be obtained to initiate and sustain. The following quote explained how social support meant to Clara:

I seem to tend to be a person who can’t keep my problems to myself. When I’m having a problem, I tend to share it with others because I love getting different points of view from my friends… … I feel like I have a place to share, tell stories, and encourage each other. I also join a small group where in that group I can tell whatever I feel.

Narrative Forms

There were three narrative forms inferred from the four participants, namely ‘I’m struggling with all these things alone’ for Alvin and Bella, ‘There are people I turn to whenever I’m down’ for Clara, and ‘Most of the time I fail, but I’m confused why’ for Diana. The narrative form in Alvin and Bella was inferred from stories and word choices that indicate independent efforts, though hard, to deal with the challenges of their lives. Actions taken or demands on themselves are embedded by nullifying the need for social support. The narrative form in Clara was inferred because of the recognition and narrative support that she cannot keep her problems to herself so that she tends to tell others. Clara was actually similar to Alvin and Bella who can’t share openly about their burdens and past, but she was more fortunate because she has close people (outside of her family) who were ready to stand by her if she started to fall. Meanwhile, the narrative form in Diana tended to contain preoccupations with confusion about regulatory failures and doubts in making decisions even though on the other hand, she had received parental understanding and friend support regarding the problems in managing activities.

Analysis Integration

Study 1 proved that ACEs are negatively and significantly related to self-regulation, as well as its aspects, with correlation coefficients in the weak-moderate category. There is no difference in scores based on gender, ethnicity, and study period. The childhood maltreatment domain is higher correlated with the impulse control aspect than the goal setting aspect, while the family/household dysfunction domain applies the other way around. The domain of violence outside the home is not correlated with self-regulation and any aspect of it. Furthermore, the participant score profile of Study 2 showed that with at least four ACEs, self-regulation scores could vary i.e. with a majority below the empirical mean (Table 3) –from the farthest (or the lowest self-regulation) to the nearest successively i.e. Diana, Alvin, and Clara (see Table 4). Only Bella had a self-regulation score above the empirical mean (or the highest self-regulation).

The meta-theme analysis of the ten narrative themes above resulted in four categories, namely (1) impulse control, (2) cognitive functioning, (3) goal setting, and (4) value of other’s presence (see Table 5). They were formed using interactive strategies between the narrative themes and the concept of self-regulation from Neal and Carey (2005), in terms of definitions, aspects and indicators. The strategies were carried out carefully to compare, contrast findings, look for contradictions, convergence and complement. Therefore, more appropriate meta-themes could be developed. For example, “terrible memories” might be the theme that would intersect with cognitive function because it led to cognitive distortions. However, low “impulse control” as a result of these memories was more prominent because it ended in destructive patterns. Meanwhile, “cognitive functioning” was more likely to represent the ability to “process understanding” and “reconstruct meaning”; both of which were also not yet possible to be part of “goal setting” completely even though they appear to be intersecting. Another meta-theme, “value of other’s presence” specifically characterized participants and needed to be established. The theme “excessive self-dedication” might intersect with “value of other’s presence” but including it within this meta-theme might also indicate a lack of caution in observing out-of-control behavior (related to “impulse control”).

The strategies used in forming the meta-themes were also used in the correspondence analysis. Moreover, it took into account the personal profile of participants based on the grouped themes. The results of the correspondence analysis shown in Table 6 reflect the self-regulation profiles of emerging adult students surviving ACEs. The definitive finding was that intense self-criticism is associated with persistent bad memories of the past, hindered performance, and even leads to self-destructive patterns. However, the important thing that then determined whether self-regulation was better or worse is cognitive functioning, namely the presence or absence of broad awareness to understand the problem and how this was connected to the possible causes and solutions that could be done. Awareness was followed up by reconstructing meaning so as to ease the burden.

Table 6.

Partially ordered meta-matrix

Name (Pseudonym)	Impulse control		Cognitive functioning		Goal setting			Value of other’s presence			Total in group
	1	2	3	4	5	6	7	8	9	10
Alvin	Yes	Sacrificing self for others	Aware	Yes	Compensation	Competitive, self-intolerant	Strong	Being responsible for	Trust issues	Denying
Bella	Yes	Sacrificing self for others	Aware	Yes	Compensation	Competitive, self-intolerant	Strong	Being responsible for	Trust issues	Denying	2
Clara	Yes	Ruminating self	Aware	Yes	Compensation	Competitive, self-intolerant	Weak	Distancing from	Fear of abandonment/ rejection	Needing, Gaining	1
Diana	Yes	Ruminating self	Not aware	No	Avoidance	Giving up easily	Weak	Distancing from	Fear of abandonment/ rejection	Needing, Gaining	1

Note. 1 = Intense self-criticism; 2 = Excessive self-dedication; 3 = Awareness; 4 = Meaning reconstruction; 5 = Compensation or avoidance; 6 = Competitiveness; 7 = Independence; 8 = Family orientation; 9 = Social relation patterns; 10 = Social support role

However the process of better self-regulation took time because deep self-criticism need to be further facilitated. Those who appeared independent needed compensation, displayed a tougher persona, and be competitive even if they had to be self-intolerant. They also directed their compensation goals to those outside of themselves even in the midst of unpleasant situations. Instead, they undervalued (denied) the importance of the presence of others as social supporters; one of the reasons was strongly suspected to be due to trust issues caused by the past. Alvin and Bella were at this level of self-regulation (Group 1; see Table 6) which quantitatively had the third (Alvin) and highest (Bella) levels of self-regulation.

Clara (Group 2), who quantitatively had a second level of self-regulation, basically had weak independence despite having shown awareness and reconstruction of meaning. Instead of directing the goals of compensation to those outside of herself, she was preoccupied with self-rumination. Despite adopting the fear of being abandoned/rejected by her family, she was actually distant from the family instead approaching significant others outside her family who were far comforting. Theses social supports made her persevered with goals that compensated for her weaknesses, remained competitive and self-intolerant.

Only Diana (Group 3) had the lowest level of self-regulation quantitatively. Her awareness regarding the exact relationship of problems with possible causes and solutions was low. Diana’s independence was weak and social supports from close acquaintances were definitely obtained, but self-rumination and preoccupation with limitations especially cognitive function reinforced fears of being abandoned/rejected so that she chose to avoid or give up easily. She also distanced herself from a sense of responsibility for others including family.

In general, the results of the correspondence analysis showed the participants’ vulnerabilities at different levels depending on the problems being maintained, such as trust issue and self-intolerance in Group 1; social support role and fear of being abandoned/rejected in Groups 2 and 3; and cognitive functioning in Group 3. These results also confirmed a significantly negative relationship between ACEs and self-regulation, including based on impulse control and goal setting aspects. The higher the number of ACEs followed by lower self-regulation, specifically weaker impulse control and less mature goal setting.

This study can conclude the aspects of self-regulation in the general instruments used (SSRQ; Neal & Carey, 2005), both impulse control and goal setting. However, as findings, the researchers also conclude that there are two other forms of self-regulation, namely cognitive functioning and the value of other’s presence in the participants of this study, namely emerging adult students surviving ACEs. Thus this study also complements and provides a deeper understanding of the topic.

Discussion

The results of the quantitative study prove the hypothesis of a negative and significant relationship between ACEs and self-regulation, in this case among emerging adults who are helping profession students majoring in psychology. These results are in line with previous studies that have been conducted in emerging adult populations (Shin et al., 2019). Furthermore, the domain of childhood maltreatment is more related to the impulse control aspect than the goal setting, but the opposite applies to the domain of family/household dysfunction. Ten narrative themes were produced with the support of three narrative forms. There were three profile groups of participants. The meta-themes of qualitative study results are also in line with the previous concept of self-regulation by Neal and Carey (2005), which includes the form of impulse control and goal setting. Moreover, this study finds forms of cognitive functioning and the value of other’s presence in self-regulation of emerging adults and helping profession students who have survived ACEs.

One narrative theme on the meta-theme of impulse control that is agreed by all participants is bad memories that result in intense self-criticism which represents internalizing symptoms and destructive patterns such as substance abuse behaviors which represents externalizing symptoms. Both internalizing and externalizing symptoms have been shown to be associated with ACEs (Muniz et al., 2019). Responses to potentially traumatic events including ACEs can be debilitating in emerging adults depending on whether they are interpreted as central to one’s identity (Boals & Schuettler, 2011). The results of the current study indicate that participants interpreted their ACEs as central to their identity. As a result, they experienced problems in controlling the urge to hate themselves.

Intense self-criticism is actually excessive self-dedication directed inward (self-rumination) – another narrative theme of the impulse control meta-theme. Participants showed excessive self-rumination because it was closely related to the fear of being abandoned/rejected, but on the other hand they did not feel competent enough to prove themselves with the expected performance. But there were also participants who might experience problems in setting boundaries so that they actually over-dedicated themselves outward. In line with control-mastery theory, people can normally think reflexively. However, distortions can occur due to pathogenic beliefs that support interpersonal guilt and make self-punishment a subconscious goal, causing pathological worries and ruminations (Gazzillo et al., 2020). Prospective professional helpers with a history of ACEs, who prioritize care for others as the precious commodity, struggle with this. They should be the ones who take perspective in their dedication to others. However, they are actually busy evaluating themselves and are self-intolerantly proving that they are worthy.

The narrative themes of the goal setting meta-theme are interrelated but influenced by other narrative themes. Participants can compensate in actions and achievements, or otherwise avoid because they are not unsure of their abilities. A common theory that can explain this is cognitive appraisal by Lazarus and Folkman (in Carpenter, 2016). This theory explains the process of evaluating the meaning and significance of potentially stressful events for individual well-being, containing primary and secondary appraisals. Individuals take into account the level of pressure (danger/loss, threat, challenge) and are influenced by personal–situational factors in the primary appraisal. Individuals with trauma may perceive events as threats and potential harms/losses. The secondary appraisal then evaluates the relevant sources and coping options by taking into account the physical, social (support system), psychological, and material. Attention to opportunities of changing situations, having to accept, seeking further information or even withdrawing are important things in secondary appraisal (Carpenter, 2016).

Participants who decide to struggle to initiate or continue efforts to compensate, have assessed the situation as possibly approached with the available resources. They are characterized by strong independence and being competitive. However, attention needs to be given if strong competitive efforts to encourage compensation are accompanied by low tolerance and even self-intolerance, namely maintaining intolerance for continued compensation. Those with this condition, as observed in the participants, seem to show low/no flexibility in their effort to compensate. Meanwhile, flexibility is important for prospective professional helpers. Their highly skilled perspective taking is crucially determined by perceptual flexibility and tolerance for ambiguity (Skovholt & Trotter-Mathison, 2016). They may fight to deal with ‘caring for other’ situations along with their unfinished business. However, exhaustion can occur when inflexibility persists, resulting in complaints such as fatigue and burnout (Skovholt & Trotter-Mathison, 2016; Taylor & Stanton, 2021).

A strong argument supports the phenomenon for example using the perspective of self-forgiveness. Self-forgiveness that is close to self-love is considered to have dark sides, namely reducing negative emotions (such as guilt) that are actually needed to maintain compensating behavior (Wohl & McLaughlin, 2014; Wohl et al., 2017). Forgiving oneself for self-intolerant behavior is feared to reduce negative feelings so as to weaken competitiveness and compensatory actions. In participants with high self-criticism, this weakening can be threatening because it allows a shift in channeling to a more destructive direction (Wohl & McLaughlin, 2014). On the opposite as a result of inflexibility, shame is another phenomenon that may occur when survivors of ACEs fail to compensate themselves even when they have been self-intolerant. Survivors experience shame as a form of negative emotion due to the belief that they themselves are flawed and are not worthy of acceptance and belonging (Brown, 2006). If participants become professional helpers, this will lead to self-preoccupation with themselves instead of caring of others, sympathy and even defensive reactions instead of empathy, and a lack of affective sensitivity to be able to appropriately take another’s perspective (Gibson, 2016).

The new findings from the study are two other meta-themes related to self-regulation in emerging adult students who have survived ACEs, namely the value of other’s presence and cognitive functioning. The competitiveness of participants who are not independent enough can only be facilitated with sufficient social support. The results of this study showed that there were assumptions that social support become meaningful for participants who were afraid of being abandoned/rejected as a result of past parenting. A previous study by Schimmenti and Bifulco (2013) supports this, namely the presence of rejection, criticism, negative interactions in parenting during childhood–adolescence results in emerging adults developing patterns of insecure anxious attachment characterized by fears of rejection and separation. Participants in this study became intensely self-ruminating and desperately needed encouragement from social support, even if it was outside their own nuclear family. While gaining outside social support, they became distant –but insecure– from their nuclear family.

Among survivors of ACEs, it turned out that they also experienced denial of the need for social support because strong trust issues developed from difficulties in their childhood. Still in line with the study from Schimmenti and Bifulco (2013), neglect in the form of antipathy during childhood-adolescence parenting causes emerging adults to develop anxious–ambivalent attachment patterns. Trust issues and denial of the need for social support in the study participants made them more independent, competitive but self-intolerant, but then directed their goals outward, sacrificing for others, including being oriented or feeling responsible for their families – as they were with anxious–ambivalent characteristics. This pattern of attachment that tends to be pessimistic can have impacts on long-term process but allows for participant recovery (Konieczny & Cierpiałkowska, 2020).

Specifically, as prospective professional helpers, the value of others’ presence is important besides their own intrapersonal capacities. Kottler (2010) explains that the career path as a helping professional for those with ACEs is a phenomenon of the wounded healer, namely individual who goes through his/her own struggles in life and then heals the wounds of others. These current results show that those with ACEs actually have strong conflicts in social needs, including their own family. They may need dependency and fear abandonment or rejection. Or if not, they experience trust issues and deny the need for social support. All of that may cloud their future profession as helpers. Difficulties in establishing attachment to caring for others can be real obstacles (Skovholt & Trotter-Mathison, 2016). Especially given the experience of deficits in relationships and attachment (Alexander, 2013; Kliethermes et al., 2014). WHO (2019) has even explicitly stated that ‘disturbances in relationships’ are one of the three symptoms that must be met for post-traumatic stress disorder due to complex trauma such as ACEs, in addition to ‘affective dysregulation’ and ‘negative self-concept’.

The last is the meta-theme of cognitive functioning which largely determines the participants’ regulatory ability. Participants who had sufficient awareness about the problem at hand, including being able to see their relationship with possible causes and solutions, could reconstruct meaning so as to ease the burden of their thoughts and emotions. This ability is in line with appraisal-focused constructive coping as suggested by Weiten et al. (2018), namely the ability to change the perceptions of threatening situations, including cognitive reinterpretation and even finding the meaning of the situation. This phenomenon is completely in contrast to those who are less aware because they find it difficult to take the benefits of cognitive function continuously so that repeated failures of efforts will result in giving up more easily. Participants agreed that their educational background in psychology had been supporting their recovery, starting with gaining knowledge and understanding of themselves, or at least teaching them practical steps that could be taken in the short term. However, the journey seems to be just beginning and requires a longer process than just acquiring knowledge in this field.

The results of this study represent the state of ACEs survivors among emerging adult students, particularly those who are majoring in psychology, who constantly process bad memories and their consequences, as well as maladaptive self-regulation both rigid and inhibited. Maladaptation can be repeated and become a vicious cycle to increase chances of psychological disorders. The vulnerabilities due to a history of childhood-adolescence cannot be ignored even though emerging adults usually have their own qualities. Obstacles – or conversely insightful processes – can end up stagnating and leading to hopelessness; or even adaptive solution. Hopelessness in people with ACEs can have implications for depressive symptoms due to the development of a negative attributional style in evaluating events (Liu et al., 2015). Correspondingly, depressive states in people with ACEs also occur due to cognitive dysfunctions that contain maladaptive schemes, negative automatic thoughts, as well as avoidant behaviors and resilience disorders (Zhao et al., 2022) which also affect emotions. In this way, their future as professional helpers will only be an unrealized discourse.

The results of this study provide a deeper understanding for scientific and practical interests. However, its limitations need to be taken into account in order to use it appropriately. Scientifically, academics can carry out further studies as offered in this paragraph after each limitation is explained. This study involved Indonesian respondents limited to psychology students from all fields of helping professions. The results have alluded the influence of educational background in responding to bad memories and their consequences on respondents where psychology courses allocate a large proportion in teaching skills of understanding and managing self in addition to coping with interpersonal interactions. Future research can take into account samples from more diverse and broader fields of helping professions (e.g. nursing, medicine, midwifery, teaching, or social work) as well as samples from different countries (e.g. countries with individualistic cultures/other countries with collectivistic cultures, developed/developing/underdeveloped countries with potential differences in service facilities by the helping professions), both in quantitative and qualitative studies, to better represent populations (i.e. with a larger number of participants) and enlarge the domain variation of ACEs (i.e. covering less commonly found types, or targeting specific types of ACEs separately). The limitation of this research also lies in narrative essays. The instructions were judged clear by the participants, the time, information, and reinforcement given were appropriate to produce an optimal essay, but the essay was only applied one time in one direction so no further information can be retrieved. Member-checking of research results to participants is carried out, but subsequent research can still increase credibility by member-checking the raw data of narrative essays (i.e. confirming or getting more in-depth information) before being processed further.

Practically, these results can provide insight for the society. It is important to provide interventions by educating psychology students with/without ACEs since they are prospective professional helpers. Educational policy makers need to pay attention to the curriculum that can be implemented in classrooms. ​If intensive treatment is needed, then an individual treatment can be arranged by a practitioner to prevent the worsening impacts and improve the self-regulation by understanding the student’s psychological dynamics in depth. The students themselves or other parties can help improve self-regulation, overcome self-insufficiency and interpersonal issues by (1) encouraging self-understanding by studying and using this study results that relate to the self (e.g. by understanding the possible connections between their ACEs and their current difficulties), (2) increasing self-tolerance or allowing themselves to own/accept their shortcomings but also believing that these can be overcome gradually, (3) finding strengths from everyday life and appreciating them, (4) setting realistic goals to improve the capabilities gradually, (5) practicing empathy within interpersonal contact by understanding and separating lingering emotions caused by past history from current contact, and (6) monitoring and improving the efforts that have been made.

Funding

None.

Declarations

Compliance with Ethical Standards

The authors declare their adherence to ethical standard based on Declaration of Helsinki in this study. They document informed consent from participants and ensure data confidentiality.

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Consent to Publish

Research participants have consented to the submission of the manuscript to the journal for publication.

Competing interests

The authors report there are no conflict interests to declare.