GRATITUDE THERAPY IN CHRONIC LOW SELF-ESTEEM IN SCHIZOPHRENIA PATIENTS: CASE STUDY

Schizophrenia can cause negative symptoms such as delusions, hallucinations, disorganized speech or behavior


INTRODUCTION
The incidence of mental disorders continues to increase every year.According to (WHO, 2022), in 2019, as many as 1 in 8 people who experience mental disorders or the equivalent of 970 million people worldwide experience mental illnesses.Meanwhile, in Indonesia, the prevalence of mental disorders is 6.7% or 282,654 individuals experiencing severe mental illnesses (Riskesdas, 2018).According Stein et al. (2021), mental disorders are syndromes characterized by clinically impaired understanding, emotion regulation, or individual behavior.The most common types of mental disorders are anxiety disorders, depression, bipolar disorder, PTSD (Post Traumatic Stress Disorder), and Schizophrenia.Schizophrenia is a chronic mental health disorder characterized by several symptoms, including delusions, hallucinations, disorganized speech or behavior, and impaired cognitive abilities (Patel et al., 2014).
One of the individual barriers to schizophrenia is negative symptoms such as minimal speech, limited experience and emotional expression, inability to feel interested or pleasure, and social withdrawal (WHO, 2022).In addition, individuals with schizophrenia often receive stigma from their families and the surrounding community, causing many to be shackled.According to Riskesdas data (2018), in Indonesia, 14% had been shackled for a long time, and 31% had been shackled for three months.This makes people living with schizophrenia experience chronic low self-esteem, namely the presence of symptoms such as feeling worthless and lacking talents and abilities (Irawati et al., 2019).So that, therapy or treatment is needed for people with schizophrenia.
The goals in treating schizophrenia include relieving symptoms, preventing relapse, and increasing the individual's adaptability to blend back into society (Patel et al., 2014).Thus, the treatment will not be short and requires long-term care.Pharmacotherapy is the main thing in managing Schizophrenia, but some symptoms can persist, such as isolating behavior and always having negative thoughts.Therefore, non-pharmacological treatment, such as providing several nursing actions that help determine and train the positive things that the client has, and the nurse can do psychotherapy which is also essential for people with schizophrenia.
Psychotherapy is a treatment method used to treat mental disorders in therapy using several skills based on theoretical knowledge (Pawlak & Kacprzyk-Straszak, 2020).Psychotherapy has been used for a long time, more than 100 years ago.According to Niveau et al., (2021), types of psychotherapy that can be used for chronic low self-esteem problems are Cognitive Behavioral Therapy (CBT), reminiscence-based intervention, group therapy, art therapy (music, coloring, theater, etc.), compassion therapy, and gratitude therapy.One of the psychotherapies that nurses often use is cognitive behavioral therapy.The results of research by Langford et al., (2022) explained that CBT can improve self-esteem and coping of individuals with chronic low selfesteem.However, CBT interventions take a long time to achieve the desired results because this therapy is targeted and problem-oriented.So, researchers are looking for therapies that can be easily implemented quickly, such as gratitude therapy.It is hoped that with gratitude therapy individuals can see more of their positive abilities and no longer focus on negative things.
Gratitude has a strong bond with mental health and satisfaction with life because with gratitude we become easier to deal with everyday stress and provide resilience to negative emotions (Emmons & Stern, 2013).Lin (2015) in his research explained that individuals who are often grateful have high self-esteem because they focus on the positive things in themselves.Meanwhile, individuals who have a negative self-view can easily become depressed because they have low self-esteem.Gratitude therapy is one of the interventions that can be given to treat chronic low self-esteem.This therapy targets gratitude as a way to increase positivity and happiness each day.Dickens (2017) presented the results of his research that gratitude therapy interventions can improve various outcomes including happiness and do not affect other people.Based on research conducted by Cunha et al., (2019), gratitude therapy can increase enthusiasm, comfort, and life satisfaction and reduce sadness, feelings of being put down, and symptoms of depression.In addition, it was stated that the intervention was only given for 14 days, with the task of recording the moments they were grateful for throughout the day on the paper provided.Besides that, according to Kirca et al., (2023) in his research proved that gratitude therapy has significant value in increasing psychological well-being including happiness, life satisfaction, and positive influence.Of the various benefits of giving this gratitude therapy intervention, of course, it can help individuals with low self-esteem to focus on positive things.
In addition to providing many positive benefits and can be carried out in a short time, gratitude therapy offers many other conveniences.According to Davis et al., (2016) in his research, it was stated that gratitude therapy could be applied to other types of psychotherapy because it is aligned so that it can be given together, such as yoga and butterfly hugs.It is known that patients with schizophrenia sometimes experience anxiety, so yoga is suitable for reducing anxiety (Telles et al., 2018).Therefore, gratitude therapy needs to be given to patients with chronic low selfesteem symptoms.Thus, this case study aims to describe the provision of gratitude therapy to chronic low self-esteem in schizophrenic patients.The provision of gratitude therapy interventions in this case study was only given for five days, due to the short practice time in the psychiatric nursing station and the need for more time to build a trusting relationship between the researcher and the patient.

METHOD
This study uses a case study descriptive method in patients with schizophrenia with chronic low self-esteem.Written informed consent was obtained from the patient.The study was conducted for 13 days, starting June 25, 2022, to July 9, 2022.Data was collected primarily using interview and observation methods and reconfirmed to the nurse in charge of the patient.

Patient Information
The patient, Mrs. N, is 50 years old and not married.The patient was diagnosed with paranoid schizophrenia.The patient entered mental rehabilitation because, according to the nurse there, according to the confession of the patient's family, she often laughed to herself in her room and always said she would go to college again to continue her education.At that time, the younger sister explained to the patient that this was not true, and the patient did not accept it, which made the patient relapse.Therefore, in April 2022, the patient was treated at the Nur Ilahie Mental Rehabilitation Center, Garut, West Java.
The first time the patient was brought to the Mental Hospital was in 1991, or when the patient was 19 years old, because the patient argued with a neighbor.Until 2000, patients were still in and out of the Mental Hospital frequently because patients were always angry and arguing with family members at home.The patient said she was always angry when her parents ordered her to do household chores like washing dishes.The patient always feels she is constantly being called.According to the patient, her parents were like that only to her, not to her other brothers or sisters.The patient thinks that because she is the only one who is not successful, she always orders challenging tasks for the patient.
The patient said that she had experienced failure to enter the dream state university he aspired to be in 1991, the patient had passed the state university through PMDK but was not allowed by her parents, so she was not accepted.In the end, in 2005, the patient was studying D1, majoring in PG TK at a private university.In 2003 the patient had worked at several banks in the credit department and had been a PG TK teacher, but the patient always felt that someone was sexually attracted to her, so the patient was uncomfortable and left his job.
Until 2019, patients were in and out of different mental hospitals because when the patient's symptoms recurred, such as anger and hallucinations, her family always took the client to a mental hospital or mental rehabilitation.Meanwhile, as long as the patient is at home, she cannot regulate the use of drugs.The patient said that he rarely took the pill.According to the patient, there is no family or caregiver to manage drug consumption.The patient moved and lived with her married younger sister.The patient stated that she was often locked in a room when she lived there.Then in 2020, he was moved to a bamboo house behind his sister's house.In 2021 outpatients at a rehabilitation clinic and drugs are rarely consumed.
The patient was traumatized by being beaten by his father.In addition, the patient had experienced two attempted rapes while living in the bamboo house.Fortunately, the patient was able to fight off the stranger.The patient said that none of her family members had mental disorders.However, her second sister seems to have a mental illness because she often threatens patients with scissors.So far, the patient's father has always carried out the decision-making pattern.The parenting style that has been obtained from the patient's parents is authoritarian, in which the patient receives a strict and fierce upbringing, and the parents control everything.

Clinical Findings
Based on the study results, when meeting the patient for the first time, she felt embarrassed, worthless, had no abilities, and was difficult to communicate with, and the patient's voice was very low.The patient said her family did not appreciate him, especially if he had a mental disorder.The patient said he was suffering, and the family never responded, making her even more depressed.The patient's self-concept, such as the patient's body image, accepts all forms of her body and is grateful.Her identity as a woman is lacking and dissatisfied because she is not married.The patient's role as a child is dissatisfied because she is one of the unsuccessful children.The patient's ideal self wants to have a steady job and income.The patient's self-esteem feels inferior because she is not married and is ashamed that she is the only one who is unsuccessful in her family.This proves that the client has signs and symptoms of chronic low self-esteem.
While at the mental rehabilitation house, the client rarely chats with other patients because patients find the chat boring.The patient feels she is smart, so she wants to chat on tough topics such as politics with people with higher education.Therefore, clients find it challenging to find good friends to communicate with within this rehabilitation house.From the results of this study, it appears that the patient has a thought content disorder, namely delusions of grandeur.The patient's thought processes are circumstantial because they answer a long way when asked questions.The patient's memory or memory has impaired long-term memory, always confused when examining history.The patient's self-inclination always blames things outside himself.
The hope is that the patient says he wants to be appreciated and responded to by the family.Apart from that, the patient also hopes to go home but not to be locked again in a room.The patient's stress coping from before entering the mental rehabilitation house until now is eating like biscuits and listening to music.Related to spirituality and beliefs, the client's religion is Islam.Clients rarely pray 5 times a day because at dawn the client is still asleep and it is too cold when ablution and walking to the prayer room, the client only performs midday, afternoon, evening and evening prayers.
Routine activities carried out by patients while at the mental rehabilitation house include sports such as gymnastics and yoga, besides playing marawis, and there are always recitations.In addition, the schedule for bathing and eating has been determined by the mental rehabilitation house regular basis.Then there is a schedule for routine health checks by general practitioners and psychiatrists visiting more or less once a month.In addition, vital signs are checked every morning before breakfast.
The pharmacological therapy that the patient received was haloperidol 1.5 mg (3x1), hexymer 2 mg (3x1), clozapine 200 mg (1x1), and frimania 200 mg (2x1).The patient consumes all medicines after eating and given directly by the nurse.These drugs make patients calmer, reducing their hallucinations due to pharmacological therapy.The side effects of the medications the patient is taking are often feeling drowsy, and the lips looking dry.

Therapeutic/ Nursing Intervention
Patients were given gratitude therapy interventions for five days at the sixth meeting with the same intervention daily.The intervention of gratitude therapy in this case study is to write down moments that have been grateful for throughout the day, according to research by Cunha et al., (2019).Before the intervention is given, it is explained how to fill it in and what things need to be recorded in the list.Patients are advised to set aside 10-20 minutes of free time before going to bed, then write down five things to be grateful for every day on the sheet of paper provided and train patients to say thank you to themselves.
In this case study, patients were given additional interventions, namely butterfly hugs and yoga, to reduce patient anxiety and negative feelings.The patient is given a butterfly hug intervention, namely by crossing the patient's arms around the chest until the shoulders are adjusted according to the patient's comfort then the patient pats with a gentle clap of hands (Girianto et al., 2021).Patients are advised to do the butterfly hug when they are lonely, feel excessive anxiety or fear, and have negative emotions.The butterfly hug intervention was only given once for six meetings, namely at the fifth meeting.The patient is also given yoga therapy with other patients in the mental rehabilitation house.Yoga is done in the morning for about 30 minutes and a yoga instructor from students.Yoga is given once in the fourth meeting.The patient is used to doing yoga because mental rehabilitation schedules yoga to be done 1-2 times a week at home.

Follow-up and Outcomes
Every day the patient is followed up on whether to do gratitude therapy.Follow-up in the form of asking and reminding patients to write things they are grateful for on the paper that has been given.After five days, an evaluation is carried out regarding how the patient feels after being given the gratitude therapy intervention.
After being given the gratitude therapy intervention, the patient feels happier every day.Then, the patient shows the tasks that have been recorded, containing things that the patient is grateful for every day.The patient mentioned several things she was grateful for, including being thankful for being able to breathe, being able to read, listening to music, chatting with nurses, winning games, being able to make friends, knowing people who respected each other, still being able to worship, and being grateful for having the plan to sell cakes when they come home.
Patients also seem to be more cheerful and active.Every day, patients seem to open up more and invite others to chat and tell stories, play games, become confident of appearing in front of others, and are enthusiastic whenever they meet.The patient said she would continue to write down things to be thankful for every day, even after the intervention.
In addition, the results of the butterfly hug intervention indicated that the patient felt calmer and would practice it if she was feeling negative emotions.In addition, the patient also understands how to do the butterfly hug.Furthermore, the patient said her body relaxed after the yoga intervention.The patient looks happy and smiles while talking.Even though yoga is often done every week, patients don't do it outside of the schedule provided by the mental rehabilitation house.

RESULT
After the assessment, the nursing diagnoses were chronic low self-esteem and thought process disorder: delusions of grandeur.Patients are given generalist nursing interventions according to the strategy of implementing chronic low self-esteem, namely discussing the patient's positive things, helping to assess positive things, and helping to choose positive things to practice.The positive thing desired is cooking.However, practicing cooking skills while in a mental rehabilitation house.Finally, the author provides psychotherapeutic interventions such as gratitude therapy, butterfly hugs, and yoga.
Of the three interventions given, namely gratitude therapy, butterfly hug, and yoga, the patient chooses to do gratitude therapy every day.Patients say they are happy because they write things they are grateful for daily.In addition, giving gratitude therapy for five days makes the signs and symptoms of chronic low self-esteem in patients decrease daily.
The patient, in this case, reports a triggering stressor, namely pressure from the environment, especially the family, unpleasant experiences, and poor drug management.According to Stuart (2016), stressors that trigger schizophrenia include biological characteristics, environmental pressures, and several triggering symptoms.Therefore, if the trigger appears and the schizophrenic patient does not have a suitable coping mechanism, repeated periods will occur.

DISCUSSION
There are positive and negative symptoms of patients with schizophrenia.According to Stuart (2016), positive symptoms include delusions, hallucinations, and confusion in speech and behavior, while negative symptoms of anhedonia are where a person cannot feel pleasure and flat affect.According to this concept, patients also experience grandiose delusions where patients think they are intelligent, detailed, and unhappy.Patients with schizophrenia may experience maladaptive symptoms, namely poor appearance, agitation and aggression, difficulty concentrating, forgetfulness, and repetitive behavior (Stuart, 2016).The patient, in this case, experienced the same thing, namely untidy clothing and anxiety.
The stigma that the patient gets from the family and the surrounding environment makes the patient withdraw.In theory, the signs and symptoms of chronic low self-esteem, according to Keliat et al. (2019), are negative self-assessment, feeling ashamed, feeling unworthy, lacking eye contact when speaking, and rejecting positive self-assessments.This is to the patient's condition when studied.The patient feels ashamed and feels she cannot have any abilities, while the patient has several talents, such as cooking and playing marawis.But the patient is unaware of these advantages and only withdraws and continues to feel insecure.
Generalist nursing actions are by the strategy of implementing chronic low self-esteem, according to Keliat et al. (2019), namely discussing the positive things the patient has, helping the patient to assess the abilities they have, helping the patient choose the powers to be trained, practicing the abilities they have, giving praise each activity carried out, facilitate the patient to tell about his success and help make a practice schedule.After selecting the ability to be trained, namely cooking.However, strengths such as cooking are challenging to train in mental rehabilitation homes, so patients are given other nursing actions to complement gratitude therapy.
Gratitude therapy intervention is a therapy that can make patients recognize and respond with feelings of gratitude for the positive experiences and results obtained (Iqbal & Dar, 2022).We have to be grateful every day, but sometimes individuals forget to be thankful for something they already have and events that have happened.Research related to gratitude therapy is growing in various easy-to-apply ways, such as making a list of things to be grateful for every day on several sheets of paper and keeping a daily journal (Davis et al., 2016).So Gratitude therapy is straightforward to apply and understand and practical.
Giving gratitude therapy in the research of Emmons & McCullough (2003) proves that this intervention can improve the welfare of patients in their daily lives.The patient looks comfortable carrying out his activities at the mental rehabilitation house and begins feeling confident.When we express gratitude to someone else or ourselves and receive the same appreciation, the brain releases dopamine and serotonin, two important neurotransmitters responsible for emotions, and make us feel good by elevating our mood and making us feel happy (Fox et al., 2015).
Negative thoughts, such as patients feeling that other people don't like them are also reduced.According to the results of research conducted by Cunha et al. (2019), that gratitude therapy can reduce the negative affect and symptoms of depression.There are benefits of gratitude therapy other than in psychological terms.The results of research conducted by Jackowska et al. (2016) stated that gratitude therapy has physical benefits, namely increasing individual well-being with better sleep quality and can reduce blood pressure.This was appropriate, when conducting meetings for follow-up interventions, the patient stated that he had a good night's sleep.Gratitude therapy also provides social benefits, namely improving (Chowdhury, 2019).
Gratitude therapy can be applied to other types of psychotherapy because it is compatible (Davis et al., 2016).So the authors decided to provide butterfly hugs and yoga interventions to reduce patient anxiety.The butterfly hug gives a comfortable sensation when breathing and is done until the feeling has calmed down.Butterfly hugs can activate the Hypothalamus Pituitary Adrenal Axis (HPA) and stimulate the secretion of hypothalamic hormones and corticotropin-releasing hormone (CRH).Adrenocorticotropic hormone (ACTH) is activated and stimulates the production of serotonin and endorphins, making the body feel relaxed and safe, thereby reducing anxiety (Girianto et al., 2021).Like the butterfly hug, yoga can also relax the body and reduce stress, depression and anxiety (Shohani et al., 2018).According to Dalgas et al. (2008)yoga is not like other sports because it controls the mind and the central nervous system, such as reducing the hormone cortisol and regulating nerve impulses and physiological responses.Therefore, yoga is effective in alleviating depression and mental disorders.
Various studies on gratitude therapy interventions have been carried out, one of which was in research conducted by Dickens (2017), explaining that gratitude therapy provides perceived convenience and benefits that can increase various positive aspects, such as happiness and does not affect other people.The patient, in this case, report realized that he had many advantages to be grateful for.It can be seen that gratitude therapy has many beneficial and valuable effects for building positive emotions, and this gratitude therapy intervention is very promising (Kerr et al., 2015).Therefore, it is hoped that more and more patients with chronic low self-esteem will receive gratitude therapy interventions.
Some limitations in this case study only involved one patient and the short intervention time was only five days.This is due to the limited time for mental nursing practice.Searching for literature on gratitude therapy that is directly related to low self-esteem is difficult to find, it would be better for future researchers to determine the search keywords even better.In addition, gratitude therapy has not been widely used in nursing as an intervention.So that nursing research related to the benefits of gratitude therapy is still lacking.

CONCLUSION
This case study reveals that giving gratitude therapy interventions can reduce chronic low self-esteem in people with schizophrenia.When we express gratitude to others or ourselves as a form of gratitude, the brain releases dopamine and serotonin, which makes us feel good by elevating our mood and making us feel happy.The results of this case study patients look happier and more confident than before.This is indicated by the patient starting to open up to other people and being able to appear in front of many people.Therefore, giving gratitude therapy interventions is recommended for health workers, especially the psychiatric nursing team as a nonpharmacological intervention in reducing chronic low self-esteem in schizophrenic patients.Suggestions for further research, so that you can apply gratitude therapy interventions with more samples and carry out follow-ups in sufficient time.So it is hoped that in the future more and more nurses will use gratitude therapy interventions as evidence-based practice to overcome chronic low self-esteem in patients with mental health problems.