REALITY ORIENTATION MODEL FOR MENTAL DISORDER PATIENTS WHO EXPERIENCED AUDITORY HALLUCINATIONS Orientasi Realita pada Pasien Gangguan Jiwa yang Mengalami Halusinasi Dengar Arum Pratiwi, Enita Dewi Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta Email:
[email protected] ABSTRAK Pendahuluan. Jumlah penderita penyakit mental meningkat setiap tahunnya. Penelitian ini bertujuan untuk mengembangkan model terapi orientasi realita pada pasien skizoprenia yang mengalami halusinasi dengar. Manfaat praktis dari penelitian ini adalah meningkatkan kemandirian pasien dalam mengendalikan halusinasi. Metode. Desain penelitian ini adalah sequential exploratory research yaitu mengkombinasikan kualitatif dan kuantitatif untuk mengevaluasi model terapi kognitif orientasi realita. Responden yang dilibatkan dalam penelitian ini adalah pasien schizophrenia yang mengalami halusinasi dengar dan resisten terhadap antipsikotik. Responden yang memenuhi kriteria berjumlah 10 pasien ditetapkan sebagai target populasi dalam uji coba prosedur terapi. Lima orang perawat yang mempunyai pengalaman merawat pasien di rumah sakit jiwa ditetapkan sebagai expert dalam ujicoba instrument ini. Pada tahap awal dilakukan identifikasi isi halusinasinya dengan menggunakan “Beliefs about Voices Questionnaire (BaVQ)” melalui wawancara, kemudian hasil wawancara dianalisis menggunakan analisis kualitatif yaitu thematic analysis. Hasil. Nilai kecemasan pasien adalah t 1,078 dengan P value 0,309 yang bisa disimpulkan bahwa tidak ada perbedaan kecemasan pasien antara sebelum dan sesudah diberikan terapi kognitif orientasi realita. Diskusi. Perbaikan model sampai validasi akhir berhasil dilakukan dan lebih terelaborasi untuk diaplikasikan pada pasien yang negatif mengalami halusinasi dengar. Kata kunci: Terapi kognitif, orientasi realita, Halusinasi dengar ABSTRACT Introduction. The number of patients with mental illness increased every year. This research aim was to develop a model of reality orientation therapy in patients with schizophrenia who had auditory hallucinations. This research aimed to develop a model of reality orientation therapy in patients with schizophrenia who had auditory hallucinations. Methods. This design of the study was a sequential exploratory research which combines qualitative and quantitative approach. Respondents were involved in this study were patients with schizophrenia who experience auditory hallucinations. Ten respondents who met the criteria were used as a population target in trials of therapeutic procedures. Five nurses who have experience treating patients in a mental hospital established as an expert on trial of instrument development.Initially, the contents of the hallucinations were identified using “Beliefs about the Voices Questionnaire (BaVQ)” through interviews, and then were analysed using thematic analysis. Results. The level of the patient’s anxiety was statistically significant 1,078 (P 0.309). It can be concluded that there was no difference between the patient’s anxiety before and after cognitive therapy reality orientation. Discussion. This process of the study has finished until accomplishing of repair model in the final validation. The model more elaborate to be applied for patients who experience negative voices hallucinations. Key words: Cognitive therapy, reality orientation, auditory hallucination
patients who have been cured from the hospital relapse and then had to be re-hospitalized. There are many reasons why the patient should be re-admitted to psychiatric hospitals. Faozi (2011) found that the patients show signs and symptoms during recovery. In developed countries, patients were re-admitted back to stabilize their mental state (Romansky, et al 2013). Research Wahyuni, S., Yuliet, S. N., & Elita (2012) concluded that there was no differences in cure rate between intervention
INTRODUCTION The number of patients with mental illness increased every year. Based on the survey in 2007, the total number of people with mental illness in Indonesia reaching more than 28 million. In 2013 the estimated of mental disorders in Indonesia more than 57 000 live in rural areas with a shackle (Diatri, H. and Maramis 2014). Indonesia is a developing country that has not been able to reduce the incidence of mental illness. In addition, many
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Reality Orientation Model For Mental Disorder Patients (Arum Pratiwi, Enita Dewi) (Morrison 2001; Penn, D. L. 2009). This study, development of cognitive behavioural therapy orientation of reality that has the advantage changing the patient’s beliefs through cognitive therapy orientation of the reality, this behavioural cognitive therapy can be continued by patient independently. Between therapist and the patient make an agreement on the new beliefs of patients that later made a card of therapy that will be applied by patients independently. In addition to the advantages of the patient’s perspective, the advantages can be highlighted from the nursing perspective. The procedures applied in this study are simple, easily understood by a nurse in a psychiatric hospital, including non-professional nurse and professional. Guidelines in the form of this procedure are very important because there are many non-professional nurses who work in psychiatric hospitals that need simple guidelines to develop their knowledge gradually according to their background and be able to evaluate the patient’s recovery. Based on the issues above, it is important that the nurse modifies a nursing care which one of the nursing care is the application of cognitive therapy reality orientation for patients with auditory hallucinations. To prove the effectiveness and efficiency the implementation, this needs to be analyzed its significance. This research can be used as a consideration to replace the old procedure. Some purposes of this study that have been achieved comprised of describing the personal characteristics of the patient, assess the beliefs of auditory hallucinations patients, analyze the patients’ beliefs toward hallucinations using thematic analysis, applying the model of development of cognitive therapy orientation realities on patients with auditory hallucination, and analyze the differences patients’ anxiety between before and after therapy as a target population of developing models.
groups by rebuke the voices and control group, so this shows that the model of the old nursing care therapy is still less successfully applied. One of the important initiatives that can support the successful implementation of nursing care to control hallucinations is testing an effective and efficient nursing therapy based on the patient’s unique problems. Videbeck (2010) states that mental health nurses in hospitals should develop nursing care in accordance with the environmental condition of the patient, including assessment, planning, action and evaluation of the success of nursing. One of the activities in the nursing action is to provide the intervention on how to control auditory hallucinations patients and then evaluate its success. The patients who underwent inpatient care, they got the intervention on how to control the auditory hallucinations using the standard operation of the procedure. It can be concluded that there is still a misperception of standards among the nurses in a psychiatric hospital on the implementation of the nursing care to the patient with hearing voices. Furthermore, it is due to lack of a simple guideline for auditory hallucinations that can be applied through nursing intervention. There is a reason why it needs new and simple procedure and evaluation of the results as well as focusing on the patient’s recovery. The current procedure is a complex nursing care that can only be understood by professional nurses, so misperception by a nonprofessional nurse when applying the nursing actions can be very dangerous for patients. The case study reported many professional students increased severity patients with auditory hallucinations after getting therapy how to control hallucinations. Yuniartika (2010) describes the patients after were given way of control of auditory hallucinations with turn a deaf ear, has consequently that they have increasingly heard the sound and voice growing louder as perceived by the patient. Si m ila r resea rch on cog n it ive behavioural therapy is to reassure the patient that there are no voices, and then developed the skills to build relationship to others, the study carried out by the individual therapist
METHODS This study utilized a mixed method with a sequential exploratory design to analysis 83
Jurnal INJEC Vol. 1 No. 1 Juni 2016: 82–89 stages. First, the researcher was tried out the instrument that has been conceptualized based on themes found in patients and literature review. The test was applied by five nurses with different educational backgrounds that professional nurses, graduate nursing, and senior diplomat. Second, the test results were analyzed the advantages, disadvantages and possibilities for improvement. The third phase, after the instrument repaired then applied again (initial validation). Some notes about obstacles and disadvantages were discussed through peer group with the method of focus group discussion. At this stage was called verification. The fourth stage was the final validation that re-application of instrument which has been repaired. In the last stage was dependent analysis test. Analysis of dependent test was conducted to measure the level of patients’ anxiety before and after therapy cognitive reality orientation. Five nurses who apply the procedure perform measurements using instrumental HAD anxiety. The procedure applied for one month, once a week the patient trained with cognitive therapy reality orientation. After that, the patients’ anxiety was carried out repeated measurement with the same instrument.
cognitive orientation reality procedure and compares the patients’ anxiety as a procedure target. Qualitative analysis was used to find a theme and test of content’s validity and to enhance the model therapeutic procedures in patients with hallucinations. While quantitative analysis was used to measure the anxiety of patients before and after giving reality orientation therapy. Respondents were recruited for this study was patients who were hospitalized in a psychiatric hospital of Surakarta numbered 10 people. The characteristics of the respondents were schizophrenia patients, experiencing auditory hallucinations at least once a week, aged 25–50 years, able to communicate and literate. Sampling technique is purposive that take all of the patients who met criteria for inpatient care. This study used three instruments. First, the instrument was BAVQ-R from Chadwick and Birchwood (2000). Second, it was anxiety and depression instrument (HAD) that was the Hospital Anxiety and depression questionnaire from (Zigmond, AS; Snaith 1983) Third instrument was an instrument designed by the researcher. The instrument was in the form of therapeutic procedures for patients with auditory hallucinations. Instrument has modified from Psychiatric nursing theory about therapeutic communication techniques for orienting the reality of NANDA (1990). Data collection techniques were conducted with interviews and observations. In the first stage of data analysis was using thematic analysis. In this study, data was collected from interviews for participants then transcribed the records into a narrative. After that the data in the form of a narrative were read to build the meaning of the data. In the second stage was content validity test. The test of content validity procedure was applied to enhance the cognitive therapy reality orientation. The researcher measured the procedure and then analyzed the meaning and relationship of words and concepts. After that, the researcher made conclusions about the message in the text. In this study, the content validity test of the instrument was carried out in several
RESULTS The Patients’ Beliefs of Voices Identification of the themes performed on all participants based on quotes on texts that were stated by the patients through interviews. This theme below is the part of participants that is identified from five respondents. Patient statements presented in the table already through the data reduction. The five patients were as follows (Table 1): In Table 1 above illustrates that the first respondent (P1) is male, 35 years old, suffered auditory hallucinations, He believed that the voices insulted him. The second respondent (P2) was male, 38 years old, experience commanding hallucinations. The third respondent (P3) was female, 41 year old suffered auditory hallucinations. She believed that the voice insulted the patient. The fourth (P4) respondent was male, he is 43 years old, 84
Reality Orientation Model For Mental Disorder Patients (Arum Pratiwi, Enita Dewi) Table 1. Quotes, Keywords, and Themes Participant P1 M 35 P2 M 38 P3 F 41 P4 M 43 P5 P 28
Quotes The voice my mother in law said that I was not able to do anything, I was stupid I was fired I really the poor people I was getting angry when I heard the voices The voices said that he insulted you, hit them I follow the voices automatically Its voices tell me like that, My husband having affair , he went to another girl I am getting old, I am not beautiful anymore I was angry and would like to hit my husband with the beam Many voices, friend of mine at junior high school said that I was stupid Nobody willing to my girlfriend The voices also said that I was bad and had black skin There was a voice’s man that said that people pass in front of me insulted me. The voice said that someone tell me stupid, bad. Later the voice command me to hit them
Keyword • stupid • unable • poor
Theme Hallucinations insulting the patients
• • • • • •
Hallucinations commanding the patient Hallucinations insulting the patients
insult hit command stupid angry hit
• stupid • Bad
Hallucinations insulting the patients
• stupid • Bad • Command
Hallucinations commanding the patient
Table 2. The Results of Analysis of Patient Anxiety Before and After Cognitive Therapy of Reality Orientation
Before - After
Paired Differences 95% Confidence Interval of Sig. Std. Std. Error t df Mean the Difference (2-tailed) Deviation Mean Lower Upper .80000 2.34758 .74237 -.87935 2.47935 1.078 9 .309 are replaced by the voice that is heard by the patients, the patient’s beliefs, and the ability of the patient. And then was conducted the initial validation. Some findings after initial validation were the ability of nurses to apply the use of therapeutic communication techniques. At the stage of verification were added examples of therapeutic communication that should be applied by nurses at every stage in the procedure of the therapy. Lastly is the final validation. In this stage applied procedures that are already using the operational language and examples of therapeutic communication without changing the content and purpose of reality orientation therapy.
and he believes that hallucination insulted him. The last is respondent five (P5), he is a man 28 years old, have belief that the hallucinations derogatory and govern him. Instrument Improvement Process Cognitive therapy of reality orientation procedure was piloted by five nurses in several rooms where there were cases of auditory hallucinations. At this trial stage, which the procedure was applied, the team found several obstacles such as lack of operational language these were the content of hallucinations, perception, orient, and insight. The words
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Jurnal INJEC Vol. 1 No. 1 Juni 2016: 82–89 front of the patient. In this case was experienced by P5, he heard a different voice, a voice that sounds derogatory and another voice ordered him. Research conducted by Cole, M. G., Dowson, L., Dendukuri, N., & Belzile (2002) found that 12.6% of 190 patients experiencing auditory hallucinations two different voices, and one of the voices is command type. T he t heme t hat eme rged wa s combination of insulting and commanding hallucinations. This theme deduced from some patient statements and categorized keywords. Some keywords that lead patients on the theme of hallucinations insulting the patient like “ugly”, “stupid”, “poor”. According to Chadwick (2006) type of hallucinations is called Malevolent hallucination, these types of hallucinations have the feature of which penalizes the patients, mistreat a patient, insult the patient, endanger the patient and destroy the patient. Another theme is “hallucinations command the patient”. In this study, the voices were performed that voice commands tend to injure the patient and the environment. While keywords that have a tendency to become hallucinations commanding the patient is “boxing him”, “break the window” and “hitting him”. Chadwick (2006) categorizes the type of hallucination is the name of omnipotent hallucination, these types of hallucinations have the characteristics forcing the patient to do something, it cannot be controlled by the patient, if the patient reject of the orders, the voices threat the patient.
The Level of Patients’ Anxiety Before the cognitive therapy of reality orientation was applied, the nurse measured the level of patients’ anxiety. The anxiety levels were measured before treatment begins and lasts a month after therapy. The results of the analysis are as follows (Table 2): In Table 2 above shows that the t test of the difference in anxiety levels between before and after the intervention was 1,078. This score indicates that the significance value of 0.309, which is a value greater than 0.05. So the hypothesis fails to reject and can be concluded that based on statistical analysis, there was no difference between the patient’s anxiety levels before and after the application of reality orientation therapy. DISCUSSION The Content of Hallucinations In general, the auditory hallucinations’ patient heard of negative words. According to several studies in which the patients generally experienced auditory hallucinations was hearing voices of negative contents (Waters 2010). Feeling or belief of the negative voice called negative insight. Insight is the awareness of mental patients experience different realities (Stuart 2013). Hallucinations was experienced by patients is the voice of a person who had ever known, like his/her mother, his/her schoolmates, or a neighbor. Therefore, for example, like the case of P9 (Respondent 9) often broke the neighbor’s window, according to the patient because he heard his neighbor insulted him, then followed by another voice told him to hit the window glasses. Waters (2010) in his study found that many patients heard the voices with two kinds of different voices; the two different sounds are not the same with the patient’s own voice. The patient has a hallucination portray the characteristic of command hallucinations. Some types of hallucinations a negative voice is heard by the patient and then proceeds to govern to do negative behaviour. For example the voice instructs to hit someone passing in
The Application of Reality Orientation Therapy Based on the contents of the patient’s hallucinations, then researchers designed appropriate therapeutic procedures. This procedure was applied to 10 patients who experienced auditory hallucinations with the negative voices. Several important events are worth noting in the process of validation test is the response of the nurse as an applicator and the response of patients as subjects who were given treatment. Sproule (2009) states that the content validity test of the procedure is a
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Reality Orientation Model For Mental Disorder Patients (Arum Pratiwi, Enita Dewi) that the contents validity process for evaluating items, and reaching an agreement to achieve saturation, should be conducted by several experts.
kind of test of the validity for the questions to validate the structure where each item needs a response from some individuals to revise it. According to Fitzpatrick and Wallace (2012) the content validity test not only conducted by a panel of experts to refine but also the target population is used as a test instrument, such as a procedure or therapy programs. There were several conditions that must be fulfilled in the process of the content validity test. The nurses who applied to the model of reality orientation therapy should have background education a psychiatric nurse, had skill and experience took care of mental illness patients in psychiatric hospital. Some of the obstacles encountered with the application process take place are the difference in all three of these components above. So, there were various times needed to get a response from nurses. Expertise must be owned by nurses at the application of this procedure is therapeutic communication techniques and the nurseclient relationship to mental illness patients. During the validation process, the capability of nurses ‘ communication is different each other, especially on ability of therapeutic communication techniques to the mental illness patients. This makes the report on the nurses ‘ response require interpretation of the researcher as an expert on the concept of psychiatric nursing science. Based on the interpretation, the next were continued to do interpretation sharing using to focus group discussions. In this study, expert is limited, so, rely on clinical experience. The verification processes were undergone with discussion groups. Each applicant contributes some opinions. All experts had active communication in this phase. Some expert commentaries such as: “Sometimes patients argued for therapy”; “the patient decided to stop when therapy was ongoing “. The two examples cannot be solved by an expert on how to overcome them in the improvement on procedures, but the experts just decided that if such events were occurred during therapy, they stopped and repeated on other occasions wait for the patient’s stable condition. Brink, P. J., & Wood (2001) argues
The Patients’ Anxiety Level The anxiety patient levels before and after the intervention was severe anxiety level. I can be concluded that HAD questionnaire showed abnormal anxiety both before and after cognitive therapy reality orientation. This is probably due to the process of therapy focus on the procedure, not the patients as subject therapy. Therapist just concentrates on improving the validity of the procedure. In addition to the factors of the patients ‘anxiety level was not changed due to the unstable patient’s condition. The patient’s condition that could be described when performed cognitive therapy intervention reality orientation is: patients sometimes angry feel tired, want to stopped, and no concentration. This makes the cognitive therapy should be repeated by starting from the earliest stages back. Townsend (2014) explains that the patient’s anxiety happened as a process of emotional response when the patient felt a fear. And then will be followed by some of the signs and symptoms such as tension, fear, anxiety and vigilance. Videbeck (2010) explains that anxiety is a response to internal or external stimuli that involve cognition that appears in the physical and behavioural symptoms. There is an interesting point of the condition of the patient’s anxiety level. The average of patient anxiety levels after the intervention had higher scores than before applied reality orientation therapy. This illustrates that the target population of the content validity is not the main goal, so that the nurses more articulated on the procedure, however, it does not mean the level of anxiety is not important to be noticed. There were various factors that affect why the condition of the patient’s anxiety level did not abate when cognitive therapy is given. If the main goal of this research is to reduce the patient’s anxiety, the patient’s condition should be controlled such as contact with the environment, visitors, 87
Jurnal INJEC Vol. 1 No. 1 Juni 2016: 82–89 REFERENCES
other patients and nurses, because it is a confounding factor that make biased a therapy experiment. Creswell (2009) says that if we want to do research experiment, some main components that must be considered to reduce the bias, such as randomness and control group. In addition, the treatment group should be completely protected from the influence of confounding variables. Furthermore, Johnson, B. and Christensen (2010) argues that in order to obtain the valid results in experimental studies the researcher must consider of potentially confounding variables that will make the bias dependent variable, therefore confounding variables must be controlled.
Brink, P. J., & Wood, M.J., 2001. Basic Steps in Planning Nursing Research: From Question to Proposal, Jones & Bartlett Learning. Chadwick, P., 2006. Person-Based Cognitive Therapy for Distressing Psychosis, John Wiley & Sons Ltd. Cole, M. G., Dowson, L., Dendukuri, N., & Belzile, E., 2002. The Prevalence and Phenomenology of Auditory Hallucinations among Elderly Subjects Attending an Audiology Clinic. International Journal of Geriatric Psychiatry, 17(5), pp. 444–452. Creswell, J., 2009. Research Design; Qualitative, Quantitative, and Mix Method Approach, Los Angeles: SAGE. Diatri, H. and Maramis, A., 2014. Indonesia Aims to Free The Mentally Ill from Their Shackles. Available at: http:// theconversation.com/indonesia-aimsto-free-the-mentally-ill-from-theirshackles-30078. Faozi, E., 2011. Laporan Praktik Pofesi Keperawatan Jiwa, Johnson, B. and Christensen, L., 2010. Educational Research: Quantitative, Qualitative, and Mixed Approaches 4th ed., London: Sage Publications LTD. Morrison, A.P., 2001. The Interpretation of Intrusions in Psychosis: An Integrative Cognitive Approach to Hallucinations and Delusions. Behavioural and Cognitive. Psychotherapy, 29(3), pp. 257–276. Penn, D. L., et al, 2009. A Randomized Controlled Trial of Group CognitiveBehavioral Therapy Vs. Enhanced Supportive Therapy for Auditory Hallucinations. Schizophrenia Research, 109(1), pp. 52–59. Romansky, J.B., Lyons, J.S., Lehner, R.K., West, C.., 2013. Factors Related to Psychiatric Hospital Readmission among Children and Adolecents in state Custody. Journal of Psychiatric Services, 54(3). Sproule, C.F., 2009. Rationale and Research Evidence Supporting The Use of Content Validation in Personnel
CONCLUSION This research is very complicated 37,5 the target population that is used as a because 50,0 development model is a mental illness patient 12,5 who had unstable conditions. Nevertheless, the 100 orientation models of cognitive therapy reality for schizophrenic patients who have auditory hallucinations are successfully carried out until the final validation. The important weakness to be noted deriving from expert factors. These are the ability of the psychiatric nurse and the target population is the patients who are mentally ill. RECOMMENDATION Warm Compress F %process of the study has finished This until accomplishing of repair model in the 1 6,3 final validation. The model more elaborate 1 6,3 1 6,3 for patients who experience to be applied 0 negative 0,0 voices hallucinations, however, the 13 81,3still need to be repaired and reinstruments repaired,100 consider the individual is unique, so 16 the response to the illness is special, primarily the mental illness patients. This study can be repeated of content validity. The repeated test more appropriate with preparing adequate expert and control the target population. Besides, it can be used as a discourse to develop a cognitive therapy with the other beliefs of hallucinations.
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Reality Orientation Model For Mental Disorder Patients (Arum Pratiwi, Enita Dewi) Assessment. International Personnel Assessment Council Monograph. Available at: http://www.ipacweb.org/ Resources/Documents/monographs/ monograph_0901_sproule.pdf. Stuart, 2013. Principles and Practice of Psychiatric Nursing, Elsevier Health Sciences. Townsend, M.C., 2014. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice 6th Ed., FA Davis Company. Videbeck, S.L., 2010. Psychiatric-Mental Health Nursing, Lippincott Williams & Wilkins.
Wahyuni, S., Yuliet, S. N., & Elita, V., 2012. Hubungan Lama Hari Rawat dengan Kemampuan Pasien Mengont rol Halusinasi. Jurnal Ners Indonesia, 1(2). Waters, F., 2010. Auditory Hallucinations in Psychiatric Illness. Available at: http://www.psychiatrictimes.com/ schizophrenia/auditory-hallucinationspsychiatric-illness/page/0/2. Yuniartika, W., 2010. Laporan Praktik Profesi Keperawatan Jiwa, Zigmond, AS; Snaith, R., 1983. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), pp. 361–370.
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