Journal of Psychology & Psychotherapy
Open Access

Family Psychoeducation: Effect of Enhancing the Knowledge of Controlling Violent Behavior of People with Schizophrenia Pilot Study

Sulastri Basirun¹, Andi Thahir^2* and Anisa Mawarni^{2 *}Correspondence: Andi Thahir, Department of Guidance and Counseling, Lampung, Indonesia, Tel: +6281369906130, Email:

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Introduction

The increase in the proportion of mental disorders in Indonesia in the data obtained by the results of basic health research in 2018 is quite significant when compared to the results of basic health research in 2013, up from 1.7% to 7%. Lampung Province was 1.40/00 in 2013, increasing to 5.60/00 in 2018 [1,2]. Violent behavior is a condition where individuals experience behavior that can be physically harmful to themselves and others [3]. Anger is an irritation that arises in response to an unfulfilled anxiety/need that is perceived as a threat [4]. Violent behavior is one of positive symptoms which experienced by the mental disorder patients. This condition is a burden for its family [5]. Some of the families decided to do shelter and some of them referred to the mental hospital to be treated. Hence, the mental hospital conditions which have limited treatment capacity often make the family have to bring the patient home. The disability and ignorance of how to treat make the patient often relapse. Post treatment service cannot be disobeyed in order to handle this condition. Family is the main unit which holds the important role to treat the patient [6,7]. Independent patient is the aim of the treatment in order to decrease family burden. Patient empowerment inside the family and community must be done as early as can be even on hospitalized patient [8,9].

The Commitment to the empowerment of patients or people with mental disorders (ODGJ) is strengthened by the issuance of Laws Number 18 year 2014 about Mental Healthy, to guarantee every person to achieve better quality of life, also to give integrated healthiness service, comprehensive, and sustainable through promotive, preventive, curative and rehabilitative efforts. On the headline, those issuance mandated on the importance of role and community on protecting ODGJ in the form of aids: energy, fund, treatment facility for ODGJ and protection towards act of violent, create conducive environment, provide skill training, also supervise service providers at the ODGJ service facility [10].

The World Health Organization states that the costs incurred for drug expenditure in developing countries are between 20-40% of total health costs while in developed countries between 10-20%, it is mentioned that 50-90% of patients in developing countries pay for medical expenses by self-help (not covered by insurance). Especially for Indonesia, the price of drugs is quite expensive caused by more than 90% of raw materials must be imported from abroad [11].

Events that can cause psychiatric disorders in family members affect other family members [12]. This condition makes family members become burdened materially and immaterial. Losing the productive days does not only happen to the ODGJ, but to other family members, as it has to take care of sick family members. Caution should be given intensively especially in patients who exhibit aggressive symptoms / violent behavior, as it may threaten his or her safety, others also the environment [13].

Patients who behave aggressively usually ignore the rights of others. The patient feels the need to struggle, for him life is a battle [14]. Research that has been done shows that there is a connection between schizophrenic sufferers and violent behavior, although not all schizophrenia does violent behavior. Systematic review to see the risk of violent behavior in psychotic diseases, there are 20 studies including 18,423 individuals with schizophrenic disorders showing an increased risk of violent behavior, violent behavior carried out by clients with schizophrenia is 13.2% compared to the general population of 5.3% [15].

Violent or aggressive is a form of behavior that aims to hurt someone physically and psychologically. Angry doesn't have a specific goal, but rather refers to a set of certain feelings [16]. Research that has been done shows that there is a connection between schizophrenic sufferers and violent behavior, although not all schizophrenia does violent behavior. Systematic review to see the risk of violent behavior in psychotic diseases, there are 20 studies including 18,423 individuals with schizophrenic disorders showing an increased risk of violent behavior, violent behavior carried out by clients with schizophrenia is 13.2% compared to the general population of 5.3% [15].

Family as the primary care giver of the patient plays a role in determining the way or care that the patient needs at home. Otherwise family dysfunction is one of the causes of disturbance in members. The existing mental health service is a facility that helps patients and families in developing their ability to prevent problems, to cope with problems and to maintain adaptive state [17]. One of the factors that cause mental disorder relapse is a family who do not know how to handle patient behavior at home.

According to Sullinger [18], the recurrence rate of patients with mental disorders is quite high. It is estimated that the risk of recurrence is 50% in the first year, 70% in the second year, and 100% in the fifth year after returning home from the hospital due to mistreatment at home and in the community. Proper handling is the solution to this problem. Several previous studies have demonstrated the benefits of family psycho-education. The psychoeducation program aims to achieve the family's ability by educating the family about the disease, teaching families about techniques that will help them overcome the behavior and symptoms of the patient [19]. This will give the family strength to take care of the patient. Consistently administered family psychosis in approximately 9 months with adequate instruction can provide patient support, knowledge, and behavioral support to patients [14].

Patients with mental disorders; there are 70 people who have mental disorders, 70% of them with a history of violent behavior and 4 of them ever shelter. Based on preliminary survey, conducted by the family is much burdened with the condition of the patient. Families should incur additional costs for patients, even to care sometimes; families have to leave their jobs. This condition is of course very disturbing the family economic conditions. The family says there is not much to do but to follow the patient's wishes as much as possible, to avoid angry patients. Besides, neighbors are also disturbed if the patient's wishes are not met. The family said they were getting counseling about how to take care, but not yet applied.

Most patients have been admitted to a mental hospital. Family says it is convenient if the patient is away from family; family is not disturbed and can do activities completely.

Based on observations made on 10 patients who made the initial visit, 7 of them said saturated with daily routine. They want to do something like selling or other activities, but there is no chance and the family does not allow for fear of disturbing others. Those conditions make patients feel upset because they cannot meet their own needs and families become the target of anger if the desire is not met.

There has been no specific intervention provided by the Puskesmas to anticipate the dropping of drugs experienced by the patient. Family as the primary nurse plays an important role to avoid patient recurrence. Therefore, it is necessary to deal with problems faced by families and members who are sick. One of the CMHN (Community Mental Health Nursing) service programs that can be performed for families with mental disorder strategies for the implementation of individual and group nursing actions for patients and families. One of family activities for their family is Psychoeducation.

Research Methods

This is quasi experiment research that apply pre posttest design with control group with family psycoeducation intervention which compare two groups of ODGJ that faced violent behavior in the area of Puskesmas Kedaton Bandar Lampung. This research is done in order to know the change of patient ability in controlling violent behavior after the family given psycoeducation. The intervention is given only to intervention group after pretest. Then, the ability will be compared between intervention and control group.

The study population was all people with schizophrenia in the work area of the Kedaton Bandar Lampung Health Center, amounting to 70 people. Respondents in this study were 20 people. Sampling of respondents is done by purposive sampling technique. Respondents involved as many as 20 people according to the criteria prepared by the researcher. The respondents were divided into two groups, namely the intervention group and the control group. Each group consisted of 10 people for the intervention and 10 people for the control group. This research is a quasi-experimental study. Psychoeducation given in 5 sessions, to provide knowledge to the family, so that patients know and are able to control violent behavior. The family was given a booklet as a guidebook and workbook so that it would give the family easy to handle patients. Data analysis was performed with U withney and Wilcoxon tests, to compare the mean scores of the pre test and post test of the intervention and control groups and the results of interviews with patients.

The collecting data were done with using the quissionaire A consists of respondents ’ data and quissionaire B consists of statement about violent behavior knowledge and how to handle it, that must be filled by the patient with the help of the family. The respondents were chosen with the following criteria:

• Person with mental disorder who have violent behavior background,

• Patient who live with the family that is the main care giver,

• Family ages 20-55 year,

• Family able to read and write,

• Family with minimum High School (SMA) education.

The therapeutic process is done by giving psychoeducation to the family for 5 sessions in 5 visits. Families are also given knowledge of how to treat patients with the help of booklets and workbooks. Furthermore, families are given the opportunity to care for patients for 2 weeks according to the booklet and workbook provided.

Booklet contains: recognize the problem violent behavior, how to give support to the patient, how to control violent behavior, Follow up to the nearest health service, signs of relapse, and when the family made a referral.

The workbooks containing sessions to be followed during Psychoeducation are given in 5 sessions, namely:

• Identify the problem,

• Management of family knowledge about violent behavior,

• The development of patient ability,

• Benefits of therapy,

• Empowerment of family members.

After the therapy is done, then the two groups are re-measured to determine the ability to control the behavior of symptoms and symptoms after therapy.

Results

The result of the analysis was carried out in the control group and intervention group to determine the patient's ability to control violent behavior.

The results of the analysis in the intervention group can be seen that at the pretest and post test there were significant differences with the difference of 10, the analysis results obtained p-value 0,000 (<0.05), so it can be concluded that there are significant differences in the ability of clients to control violent behavior in intervention group between before psychoeducation and after psychoeducation (Table 1).

Table 1: Distribution of patients ability to control violent behavior in the Intervention group before and after family psychoeducation.

The results of the analysis after the intervention showed significant differences in family knowledge between the intervention group and the control group (p=0.001). Knowledge of the intervention group in the control group is higher (mean=14,7) than the control group (mean=6,3). These results reinforce the Wilcoxon test results between the intervention and control groups after the intervention which showed no significant difference (0.012). These results suggest there is an increased knowledge of how to control violent behavior in families who are psychoeducated.

While in the control group, the difference in ability score between pretest and post test was very small, the analysis showed no significant difference with p-value 0.163 (>0.05), so it can be concluded that there was no significant difference in the client's ability to control behavior violence in the control group between before psychoeducation and after psychoeducation (Table 2).

Table 2: Distribution of patients ability to control violent behavior in the I control group before and after family psychoeducation.

The results analysis of differences of patient’s ability to control violent behavior in the intervention group and the control group showed significant differences. This can be seen from the mean difference after the intervention with the bivariate test results obtained p-value 0,000 (<0.05), so it can be concluded that there are significant differences of patients ability to control violent behavior in the control group and intervention group (Table 3).

Table 3: Distribution of patient's ability to control violent behavior in the intervention group before and after family psychoeducation.

Discussion

Mental disorder is a description of the syndrome with a variety of causes, many of which are not yet known with certainty and the course of illness is not always chronic, generally characterized by fundamental deviations, characteristics of the mind and perception, and the presence of unnatural or dull affects [20].

Mental disorder is a syndrome of a person's behavioral pattern typically associated with something of a distress or an Impairment in one or more of the most important functions of a human being: the function of psychology, biological behavior and disorder lies not only in the relationship between the person But also with society [21]. The response displayed by mental patients 24-44% is the violent behavior perpetrated by individuals with schizophrenia during the acute phase of the illness [22]. The burden that caused by mental disorder includes the economic burden to pay the treatment and medicine.

Based on the research conducted [23], about the influence of Family Psycoeducation on the ability of family care of mental disorder patient in Work Area of Public Health Center in Natar Lampung Selatan, using Quasi Experiment Pre Post Test design in intervention and control group showed the influence of family psychoeducation on the ability of caring for mental patient. This is evident from the increased ability of caring for mental patients in the intervention group.

From the research result [24], The Influence of Family Psycoeducation Toward Family Psycosocial on Family Member With Leprosy Illness in Pekalongan District. The results of the statistical test obtained psychological support p value of 0.019 (p<α), and social support p of 0.035 (p<α) so it can be concluded that there are significant differences in family psychological and social support between the intervention group and control group in caring for family members who suffered from leprosy after providing family psycho-education.

The result of the research that done by [25], Showed significant results in his study, patients who received psychoeducation had better knowledge and awareness of the disease than the non-interventionist group.

Kedaton District is a fairly dense area in Bandar Lampung. Kedaton is divided into 7 sub-districts and 1 sub health center (pustu) Sukamenanti, Kedaton in Bandar Lampung, on 2014 Kedaton has 45,808 inhabitants, on 2015 the population increase to 47,399 people.

Family psychosis is able to increase the patient's knowledge to control violent behavior. These results are in line with the study [26] which states that psychoeducation given to patients is able to reduce the recurrence rate of schizophrenic patients.

The results of the study [27], Which states that psychoeducation given to patients is able to reduce the recurrence rate of schizophrenic patients. The results of the study, showing psychoeducation results in the elderly can improve knowledge of adolescent sexuality mental retardation mild. States that the elderly and caring closest people are vital elements in caring for mentally retarded patients. There is an increase in family support and compliance with taking patient medication after family psychoeducation [28].

According [29], family psychosis is one form of family mental health care therapy by providing information and education through therapeutic communication. The results showed that families who have received psychoeducation showed an increased knowledge of disease and treatment. Psychoeducation allows families to learn more both cognitive and psychomotor through role play.

The provision of this method indicates that psychoeducation is more effective than health counseling or only supportive therapy, many advantages of family psychoeducation such as reviewing the constraints experienced by the family under review in the early review process, then the therapist will inform about mental disorders starting from Understanding, symptom signs and treatment that must be followed by the patient.

This result is in accordance with the opinion [30] that the principle of learning is a process done for a lifetime of human beings have the ability to learn from birth until the end of life. Provision of education is to provide information on the family about how to treat the patients on mental disorders through this activity occurs the learning process conducted by the family by absorbing the information provided and apply directly to members of his family.

Based on [29], Family psychosis is one form of family mental health care therapy by providing information and education through therapeutic communication. The results of the study showed that families who have received psychoeducation showed family knowledge about the role of the family in improving medication adherence in patients, and assisting patients in the treatment routinely. According to these results it is evident that the provision of family psychoeducation is more effective in comparison with health counseling or only supportive therapy, many advantages of family psychoeducation such as reviewing the constraints experienced by the family is more deeply studied in the process of assessment that begins the session, then the therapist will inform about mental disorders Starting from the understanding, signs of symptoms and medication are mandatory in taking medicine.

According to [18,31], Families have basic functions in fulfilling their life needs. The basic functions are divided into five functions, one of which is affective function, the family function for the formation and maintenance of children's personality, adult personality consolidation, and the fulfillment of the psychological needs of its members. If this effective function cannot run properly, then there will be psychological disturbance that affects the psychological of the whole family unit.

According to the research that done by [23], about the influence of family psychoeducation on the ability of the family to care for the patient of mental disorder in the working area of Puskesmas Natar Lampung Selatan, there is a significant effect with the result of the significant increase in ability, namely pretest 13.63 and posttest of 30.5. There was a 16.67 capacity increase (p value = 0.06). The result of paried test of t-test sample in the intervention group obtained p-value = 0,000 which means there is pre-post difference, in p-value control group 0,889 there is no difference during pre-post.

According to Buckley, as cited by Hidayati [32], shows that supportive therapy improves cognitive abilities and behavior of schizophrenic clients who experience violent behavior. Patients’ ability increases by more than 90% after therapy.

Lawrence & Veronika, in his study obtained results of an increase in the ability of families in caring for social isolation patients by 33% after family psychoeduation [33]. Through family psychoeducation is not only taught cognitively but psychomotor is also a target through role play activities. This allows the family to apply directly the skills already taught. Results can also be seen directly in patients by increasing the ability of patients in social relationships. Other results in family psychoeducation applications can improve the ability of families because families obtain information coping skill, knowledge, and psychomotor [34].

Duran & Barlas, in his study of psychoeducation in psychiatric patients the results obtained a significant improvement in the welfare and affection of the elderly in the patient after giving eight sessions of psychoeducation (p <0.05) [35]. Psychoeducation is a method of providing information, and psychological counseling to parents with family members of mental disorders can help patients better adapt to their environment.

Referring to the results of research conducted by Goldenberg & Goldenberg, based on the quoted by Wiyati, et al, and based on evidence based practice, family psychoeducation is a therapy used to inform families to improve their skills in Caring for family member ’ s mental disorders [36,37]. This condition is expected to give a positive impact with the increase of family coping so as to overcome the stress and burden experienced [38].

Increased family knowledge has an impact on the increased ability to care for. The results showed that the patient's knowledge of how to control violent behavior increased in groups whose families were given psycho-education. These results suggest that learning can be done not only from direct experience, but can be accomplished by imitating and viewing positive models. Behavior is the result of the adoption of information that is reflected in the psychomotor response. Families who are able to have knowledge and skills in caring for patients who experience violent behavior will apply their abilities to family members who are treated. The family is expected to always give praise and appreciation to the patient so that the patient does not feel ostracized and feel as part of the family.

Based on the results obtained, nurses are expected to perform psychotherapy, especially family psychoeducation. As well as necessary support of health and community workers such as family mental health cadres so that families can regularly attend meetings, especially family psychoeducation therapy for families to obtain information in a sustainable manner in increasing the knowledge of family and patients, especially those with mental disorders. Patients feel valued and will respect others, including the environment in which the patient lives.

Conclusion

There is a significant influence on the provision of family psycho-education to patients about how to control violent behavior. It is advisable to the holders of the mental health program to be able to schedule regular meetings on the family for the implementation of psychoeducation for the family. Install posters in health facilities such as District Puskesmas and practice on how to prevent and treat patients with violent behavior.