Reassurance supportive therapy for reducing depression in paraplegic patients due to Bantul earthquake

Background Bantul earthquake caused about 350 people got spinal cord injury that made their lower body paralysis. Because of that, they became a person that not function as used to. Depression symptons appears then due to their condition. Aims This study aimed to determine the role of reassurance supportive therapy to lower levels of depression in patients with paraplegia Bantul earthquake survivors. Depression can be seen from the symptoms that shown during the research include the manifestation of emotional, cognitive, motivational, physiological and vegetative. Method ABAB single subject design applied to experiment. First, few survivors with paraplegia selected by Beck Depression Inventory (BDI). Then, interviews were conducted to six survivor, two of them participated as the study participants. The main phase of research conducted over four weeks. The data obtained during the study period ie self-monitoring records, recording the process of providing reassurance and supportive therapy daily reflection records. Self-monitoring data were analyzed using visual inspection. Data recording process reassurance therapy and daily reflection notes were analyzed qualitatively using a phenomenological approach by Cresswell. Results & Conclusions The results showed that reassurance supportive therapy may decrease levels of depression with varied patterns between one to another symptoms. This variation also occurred among participants with one another. Qualitative research results indicate reassurance supportive therapy can change the consciousness of participants in self understanding, and affect they attitude to face the problems. All participants in this study were women. Problems are often experienced conflict with husband. Reassurance supportive therapy help participants understand the source of the problems that happened. Moreover, they are aware of their potential that they have at this time so as to reduce dependence on others. This study does not free from influence of external factors, so that the dynamics change of the environment that occur and influences the participant should get special attention. * Corresponding author. Tel.:+6281250199212; fax: +625114774405 E-mail address: rahmirahman12@yahoo.com http://dx.doi.org/10.15405/ejsbs.125 R. Fauzia & Q. Sholihah / EJSBS 1411 © 2013 Published by C-crcs. Peer-review under responsibility of Editor or Guest Editor of the EJSBS.


Introduction
The earthquake that strike on May 27, 2006 in Yogyakarta and Central Java caused many people have disabilities.
And estimated that not less than 500 people got spinal cord injury (SCI), 350 of them had paraplegia caused the accident.Paraplegia resulting in an acute disease and sufferers experience a psychological problem.This is due to that paraplegia have is very small cure rate.(Kishi, Robinson & Kosier, 2001).Sharma (2005) stated that the psychological problems that arise in survivor with paraplegia in the form of emotional disorders such as anxiety, depression, fear, anger, hostility and feelings of helplessness.23% -30% of patients experience depression predicted paraplegia after a few months and had anxiety for at least two years after being diagnosed paralyzed.Some triggers that cause depression include a fairly long period of rehabilitation, very limited mobility, sores pressure (sores like burning on the surface of the skin due to prolonged pressure on parts of the body have a disability), bladder and bowel tract infections, medical treatment spent a long time and considerable cost, also self-care process that must involve other individuals such as family members or professional caregivers.
Symptoms of depression include a greater dependence on others, especially in the aspect of self-care, feel insecure when meeting with others, haunted by a sense of despair, and a desire to commit suicide.This condition is expected to be experienced by people ranging from first year to nine years after the diagnosis of paralysis.
Patients with depression generally have an error in perceiving the conditions that they experienced.As a result, become more sensitive to stimuli that are connected with these conditions.Based on the theory proposed Beck regarding negative cognition or depressive triad, depression can occur due to: 1) the emergence of negative cognitions against him were marked by the emergence of self-belief that he or she is worthless, incapable and not expected.Then the individual will interpret negative events caused the failure and inability of self, 2) emergence of a negative outlook on the environment or the outside world.Individuals who are depressed feel that all the bad things happening to them, the world and the environment are not considered sensitive, frustrating and demanding.
Furthermore, he will see the world in a pessimistic and cynical, and 3) the emergence of a negative outlook on the future and assume that there will be a change, consider future is hopeless and believe that negative events will continue to occur.Depressed individuals who believe that they are helpless and do not have the power to improve the situation or the future (Beck, 1985).
In paraplegic patients survivors of the earthquake, the disaster is experienced as loss of health due to disability, loss of property and loved ones, hope to be able to recover back that has not materialized, and the economy state has not returned to normal, can bring up feelings no luck, feeling very miserable , not precious, which is the crushing poverty, despair resulting in the emergence of psychological problems.This condition will more accumulate with the rehabilitation process that must be followed.In the early stages of rehabilitation is less than a year after the earthquake, the government financing and also borne by the health agencies of foreign aid.But now, most people have to spend their own money to finance the process.This greatly affects the stability of the economy that has not recovered after the earthquake.Accumulation of these problems in the future can lead to emotional distress in patients.Might even have an impact on interpersonal relationships with husbands, children and the environment in which people live.
Other factors that also play a role determining the severity of depression in people with paraplegia is pain attacks (Ravenscroft, Ahmed & Burnside, 2000;Budh, Hultling, & Lundeberg, 2005).Most of the patients with SCI paraplegia and tetraplegia (30% to 90%) experienced this.In his research, Budh et al (2005) stated that 99 people or 51.38% of the 191 study participants were depressed.The attacks of pain described as a burning sensation that seemed to attack the nerves in the body that is paralyzed, and even pain can also be felt on the body that are not paralyzed.Appearance was not predictable, because it is not dependent on the time and conditions (Almeida, Arizala, & Widerstrom-Noga, 2005).
Psychotherapy is often used to reduce the level of depression in patients with SCI.Research conducted Joiner-Junior et al. (1999) about the supportive therapy with a focus on providing reassurance, can provide a substantial contribution to reducing symptoms of depression, and may reduce the adverse effects such as depression and conduct disorder effects on the environment.Cottrell et al (2006) in Drawing on the Evidence states that supportive therapy have an equal with cognitive therapy as an effective treatment to cure depression.These data prove that supportive therapy has a considerable influence to help reduce the severity of depression.Donovan & Blake (2007) in his study of patients with rheumatic complaints (rheumatoid arthritis) were conducted using a qualitative approach to the results of consultations between patients with physicians produce, skill in delivering reassurance diagnosis did the doctor do greatly affect the mental status of the patient in dealing with the disease suffered.Wolberg (1967) in his book The Technique of Psychotherapy stated that reassurance can help couples who are divorcing, people with severe depression will commit suicide, as well as individuals with psychosis.

Problem Statement
Most of the survivors of the bantul earthquake who suffers from praplegy does also have depression.
Because of that, research has been done to determine the effects of rassurence against depression they suffer from.

Research questions
How does reassurance supportive therapy for reducing depression in paraplegic patients due to Bantul earthquake?

Purpose of the Study
Determine the role of reassurance supportive therapy to lower levels of depression in patients with paraplegia Bantul earthquake survivors.

Research Methods
The design of experiments used in this study is within the subject ABAB single subject design models.
Number of study participants two women who are survivors of the earthquake who suffered paraplegia and depressed when the study was conducted.Depression criteria defined according to standard categories of depression on the measure of depression the Beck Depression Inventory (BDI).Data collection methods used in this study were 1) interview, used at the beginning of the study to reveal symptoms of depression using the Beck Depression Inventory as a tool to determine the level of depression as well as an interview guide (interview's guidance), 2) sheets of self-monitoring, based on rigorous interview, then used to reveal the effects of a given therapy for symptoms of depression to be monitored during therapy development.Besides, it also included a reflection sheet to confide during the study period.The entire process of collecting data from interviews to the therapy process is documented in the form of audio-visual.
Depressive symptoms were monitored directly by study participants include symptom manifestation emotionally with sadness, crying, anger, discontentment; manifestation of cognitive symptoms consider unsuccessful, consider yourself guilty, expectation of punishment, the impression of the body, not like the self, self accusation, difficult decisions; motivational manifestation with symptoms pessimistic, tend to suicide, withdrawal from the environment, slow work, depend to other people; manifestation of physiological and vegetative symptoms of sleep disorders, fatigue, loss of appetite , loss libido, pain and headache attacks, one responsive to the body.

Findings
Visual inspection of analysis results indicates reassurance supportive therapy can reduce the intensity of the symptoms of depression.Decrease the symptoms of having a positive impact on depression scores were shared by all participants.There are different patterns between symptom reductions.Similarly, with each participant, showing different dynamics decreased with each other.Decreased levels of depression dynamics can be described in table 1.
Table 1.Score Dynamics of the decrease in the level of depression in participants

Participant Y5
Participant Y6 Baseline 1 17 30 Treatment 1 32 13 Baseline 2 22 13 Treatment 2 12 5 Y5 experienced all the symptoms of depression are sadness, pessimism, consider unsuccessful, dissatisfaction, consider guilty, expectation of punishment, dislike of self, of self-accusation, tend to suicide, crying, anger, withdrawal of the environment, difficult decisions, the impression of the body, slow work, sleep disturbance, fatigue, loss of appetite, one of the body's response, loss libido, depend to other people, pain and headache attacks.
Y6 experienced symptoms of depression is anger, difficulty in making decisions, the attacks of pain, fatigue and sleep disturbances, whereas other symptoms under controlled conditions.
Overall, symptoms of depression experienced by participants decreased intensity, but the attack symptoms of pain, fatigue and sleep disturbances showed fluctuating conditions.There is a distinctive pattern of symptoms between attacks of pain and sleep disorders that are associated with each other.This is due to a sleep disorder suffered by one of the participants is experienced as pain attacks occur almost any time (Budh et al., 2005).The pain attacks greatly affect the quality of sleep participants (Almeida et al., 2005;Ravenscroft et al., 2000;Young, 2003).
Similarly, fatigue, physical condition resulted in participants limited movement can only use the upper body as a pedestal.That is why fatigue often occurs (Pentland et al., 2002;Gianini et al., 2006).
Qualitative analysis of the results showed that the appearance of most of the symptoms are quite emotional and cognitive manifestations triggered by external issues that are less harmonious relationship with her husband, so the impact of the increase in intensity of symptoms.
Anger is one of the symptoms that commonly occur in patients with paraplegia (Pentland et al., 2002).At the study participants, since having paraplegia, the intensity of the anger that they feel has increased dramatically, so the impact of the lack of harmony in the relationship with her husband.Spouse as the closest person to the paraplegia patient, also will experience a variety of stresses such as the economic, psychological disorders, stress from family friends, and other social problems (Chan et al., 2000).Supportive therapy reassurance to participants Y5 and Y6 aims to reconstruct the attitude of those who have been the trigger for the emergence of problems in the household (Wolberg, 1967).

Conclusions
Based on the results of data analysis, concluded that giving reassurance supportive therapy may reduce levels of depression in patients with paraplegia Bantul earthquake survivors.The pattern of decline seen from the decrease of the intensity of symptoms of depression by participants are sadness, pessimism, sense of failure, dissatisfaction, guilt, expectation of punishment, dislike of self, self-accusation, tend to suicide, crying, anger, withdrawal from the environment, difficult decisions, the impression of the body, slow work, loss of appetite, the body's response, less libido, depend to other people, and headaches.However, this therapy is less able to reduce the Some suggestions are proposed to overcome the limitations of this study include: 1.For researchers who will use the reassurance supportive therapy as a method of intervention, it's good to pay attention to the following matters: a. Looking for information on the subject of psychological research on the characteristics of interventional what ever obtained.This will determine the type of treatment to be used, including in this case supportive therapy.
b.In practice, the application of supportive therapy reassurance growing niche to be difficult to do strict control, so it would appear the influence of external factors that can influence research results.
2. For researchers who will use the Beck Depression Inventory as a measure of depression in people with paraplegia: a.At paraplegia, Beck Depression Inventory usage often leads to bias.This is due to there are some symptoms on a scale that is a natural disturbance in paraplegia and not caused by the symptoms of depression such as fatigue, sleep disturbances, bowel and bladder.It is expected that the researchers will examine depression in people with paraplegia can use a certain scale can be arranged themselves according to the research context to uncover the aspects of depression as a whole, so that the bias can be minimized.
b. Measurement of symptoms in this study is only based on one aspect of the intensity measurements alone.
Though it can be used other aspects of measurement to determine comprehensively symptoms experienced due to paraplegia.
c. Limitations of the study period only last for 23 days to make these results less than the maximum.Future studies that have relevance to the theme of this research was to utilize time study for approximately two months, in order to obtain optimal results.
intensity of pain attacks symptoms, fatigue and sleep disturbances.Pain attacks have caused nerve damage caused by spinal cord injury.The pain attacks affect the participants' sleep quality of patients with paraplegia, because the pain attacks occur almost any time, including during sleep.Fatigue symptoms in patients with paraplegia, paralysis of lower body make them have to work to maximize the upper limbs, especially the arms.This has resulted in easy fatigue occurs.