The Effect of Assertive Acceptance Commitment Therapy on the

Ability to Control Violent Behavior of Schizophrenic Patients

Rustafariningsih, Ah Yusuf and Hanik Endang Nihayati

Faculty of Nursing, Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Assertive Acceptance Commitment Therapy (AACT), Violent behavior, Schizophrenia.

Abstract: Violent behavior is a behavior that uses physical force or power to threaten oneself, others, groups or

communities and environments that can result in injury, death, psychological harm and environmental

damage. Violent behavior is often recurrent even though the patient has had the ability to control his violent

behavior. So, it is required a more optimal handling. One therapy used is Assertive Acceptance

Commitment Therapy (AACT) which is integration between Assertive Therapy (AT) and Acceptance

Commitment Therapy (ACT). This study aims to analyze the effect of AACT on the violent behavior of

schizophrenic patients. The design of this study was quasi-experimental pretest-posttest with control group.

The population of the study was patients with violent behavior problems in inpatient wards of Menur

Mental Hospital Surabaya. Sample size of 32 respondents taken by simple random. The independent

variables were AT, ACT and AACT. Dependent variable was violent behavior. Data were collected by

filling in the observation sheet. Data processing was by using Manova statistical test. There were differences

in violent behavior of patients after given intervention AT, ACT, AACT, and implementation strategy with

p value = 0.04 (p <0.05). The AACT intervention group was better than AT (with mean diff = 0.75), ACT

(with mean = 1.25) and implementation strategy (with mean diff = 0.000). AACT can reduce the patient's

violent behavior by optimizing the personal and interpersonal system by mutually providing support through

a commitment to maintain adaptive behavior.

1 BACKGROUND

Violent behavior is one of the nursing problems that

arise in patients with schizophrenia. Schizophrenic

client disorders such as behavior derangement,

perceptive, cognitive disability will cause the client

can’t take care of himself adequately (Yusuf, 2017).

Violent behavior in schizophrenia is caused by the

previous experience of a stressful stressor that

threatens the ego, the threat is perceived to interfere

with the self-concept or self-integrity, while the

patient's actualization has not been reached, resulting

in the patient experiencing low self-esteem. If this

condition is going over time, the patient will be

depressed and continue to be schizophrenic. In a

maladaptive condition, schizophrenic patients

experience violent behavior and hallucinations

(Stuart & Laraia, 2012).

Mental disorder is the problem with cognitive

and mal-adaptive behavior (Yusuf, 2015b). Violent

behavior is often recurrent even though the patient

has had the ability to control his violent behavior.

Violent Behavior is a condition in which a person

performs actions that can be physically harmful to

oneself, others and environment verbally and non-

verbally (Keliat BA, 2006, Isaacs, 2005).

The impact of violent behavior on self is in the

form of attempted suicide or allowing self in the

form of self abandonment. The extreme impact of

violent behavior is death for patients themselves.

Violent behavior in others is aggressive action aimed

at injuring or killing others. Violent behavior in the

environment is such as environmental destructive

behavior (As’ad & Sucipto, 2010). Annually more

than 1.6 million people die from violent behavior,

especially males aged 15-44, while survivors

experience physical, sexual, reproductive and mental

health disorders (Hawari, 2012).

There are about 236 millions people in Indonesia

with a mild mental disorder of 6% (14,160,000

people) while those with severe mental disorder is

0.17% (401,200 people) (RISKESDAS, 2013). 68%

of patients with severe psychiatric disorder (or about

272,816 people) experienced re-hospitalization due

to violent behavior (Wiyati, 2010).

508

Rustafariningsih, ., Yusuf, A. and Nihayati, H.

The Effect of Assertive Acceptance Commitment Therapy on the Ability to Control Violent Behavior of Schizophrenic Patients.

DOI: 10.5220/0008327605080512

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 508-512

ISBN: 978-989-758-336-0

The prevalence of severe mental disorder

(schizophrenia) in East Java is 1.4% from

38,318,791 residents or about 536,464 people, while

in Surabaya 0.2% of 1,602,875 people or about

3,206 people (RISKESDAS, 2013). The results of

the assessment at Menur Mental Hospital on

February 1

, 2017, the top five diagnoses during the

last month were Violent Behavior (32%), Sensory

Perception Disorder: Hallucinations (29%), Self-

Care Deficit (24%), Self-Withdraw (10 %) and Low

Self-Esteem (5%).

Violent behavior is influenced by two factors:

predisposing and precipitation factors. Predisposing

factors that cause violent behavior include

psychological, socio-cultural and biological factors

(Wahyuningsih, 2009). Psychological factors

include loss, failure that can lead to frustration,

strengthening and support for violent behavior.

Socio-cultural factors are related to the norms about

which angry expression is acceptable or

unacceptable, so it will determine how individuals

express their anger. Biological factors are caused by

disorders of the limbic system, the frontal lobes,

hypothalamus and neurotransmitters. Changes in the

limbic system will lead to an increase or decrease in

the risk of violent behavior. Frontal lobe damage

results in impaired decision making, impairment of

judgment, inappropriate behavior and aggression.

The hypothalamus produces dopamine, where

excessive dopamine will result in anxious and

aggressive behavior. Neurotransmitters can facilitate

or inhibit aggressive impulses (Stuart & Laraia,

2012).

Precipitation factor that causes violent behavior

is divided into two namely internal factors and

external factors. Internal factors include physical

weakness, despair, helplessness and lack of

confidence. While being included in external factors

is the commotion, loss of valuable people or objects

and social interaction conflicts (Yosep, 2011).

Several therapies that have been used to establish

schizophrenia patients in controlling violent

behavior include Behavior Therapy (BT), Cognitive

Behavior Therapy (CBT), Logo Therapy, Reality

Therapy, Family Psycho Education, Rational

Emotive Behavior Therapy (REBT), Assertive

Training Therapy (AT), Music Therapy and

Acceptance Commitment Therapy (ACT) both done

personally and interpersonally in groups

(Sudiatmika, 2011, Hidayati, 2012, Aini, 2011).

Assertive exercise is a therapy in which the patient

learns to express feelings of anger appropriately and

assertively so that the patient is able to state what he

wants (Corey, 2009). Violent behavior patients can

also be taught to create acceptance, attention and

more openness in developing their capabilities. One

of the therapies that can be given to create

acceptance and commitment is Acceptance

Commitment Therapy (ACT). Handling of violent

behavior patients needs support from various parties

from both the patient's family and the patient's

environment. The family has an important role to

participate in the healing process as it is a major

supporter in caring for mental patients (Suhita,

2017). A family situation that provides emotional

support will help the patient to achieve optimum

healing (Yusuf, 2015a). Group support is also

needed to help patients behave adaptively in dealing

with the problem (Varcarolis, 2010, Stuart & Laraia,

2012).

In this study the authors integrate Assertive

Therapy (AT) and Acceptance Commitment

Therapy (ACT) into Assertive Acceptance

Commitment Therapy (AACT). Assertive therapy is

not enough because assertive behavior without any

commitment to maintain adaptive behavior, the

patient can perform repeated acts of violent

behavior. This is because patients are not taught how

to accept situations that cause anger and are

committed to maintaining their adaptive behavior.

Patients given Acceptance and Commitment

Therapy (ACT) will have acceptance and

commitment to maintain adaptive behavior, but they

have no knowledge of how to act assertively to vent

their anger. This study aims to analyze the effect of

AACT on the violent behavior of schizophrenic

patients.

2 METHODS

This study was designed with experimental research

(pre-post test control group design), with the aim to

prove the effect of AACT on the violent behavior of

schizophrenic patients. The population of this study

was patients with violent behavior problems at

Inpatient Menur Mental Hospital Surabaya. Sample

criteria: male patient, age 25 - 55 years old, medical

diagnosis schizophrenia, non-destructive aggressive

action with score RUFA III with score 21 - 30 and

patients have received minimal 1

implementation

strategy of generalist therapy (establishing

relationship of trust, identification causes of feelings

of anger, signs and symptoms perceived, violent

behavior, consequences and 1

physical control), no

severe physical illness that accompanies, the patient

can communicate verbally, can write and read.

The Effect of Assertive Acceptance Commitment Therapy on the Ability to Control Violent Behavior of Schizophrenic Patients

509

The calculation of the minimum sample size

based on the calculation results using the test

difference between two averages with 5% degree of

significance, 95% test strength and two-sided

hypothesis test was calculated based on the sample

formula from Lemeshow (1997). In anticipation of

drop outs, loss follow ups or subjects who are not

observant in the quasi-experimental research

process, the estimated sample size was enlarged with

an estimated proportion of estimated drop out of

10% (f = 0.1). The number of final sample required

in this study were 32 respondents divided into four

groups (groups of AT, ACT, AACT and

implementation strategy), each group consisted of 8

respondents.

Independent variables in this research were AT,

ACT and AACT. Dependent variable in this

research was violent behavior. The research

instruments used in the independent variables of AT

and ACT used the evaluation guidance of the

implementation of AT and ACT adopted from the

FIK UI Mental Health Module (2016). Assertive

Acceptance Commitment Therapy (AACT) research

instrument used implementation evaluation guidance

modified by the researcher by considering the data

requirement in this research. Research instrument of

violent behavior, conducted by observation using the

scale of measurement of violent behavior from

Keliat (2003) which was adoption from Morison

(1994) with validity test of pearson product moment

with value r = 0.75 (greater than 0.30) which means

valid used. Reliability was tested using Alfa

Cronbach technique with the results 0.90 (Keliat,

2003).

The stages of collecting and retrieving the data

by the researcher were coordinated with Menur

Mental Hospital to make the form of observer team,

then socialized the research implementation. The

nurse is supposed to have the ability to direct the

patient to follow the treatment program as planned

with other health teams (Yusuf, 2016) and research

instrument, Selected the respondents who meet the

inclusion criteria. Divided the respondent to in three

treatment groups and one control group. Each group

consisted of 8 respondents, Selected respondents got

pre tested with 3 days hardness (3 x 24 hours or 3

shift), Three treatment groups were given AT

intervention, ACT and (AACT) AACT. While the

control group given intervention of implementation

strategy according to hospital standard, Intervention

was given in the inpatient room where the

respondent was treated, every day in a row at 09.00-

12.00 hours (each intervention for 45 minutes - 1

hour), Researchers recapped the results of the

evaluation of the ability of the respondents on the

evaluation documentation sheet. Conducted a post

test to see the ability of respondents in controlling

violent behavior, by observation using the scale of

measuring violent behavior for 3 days (3 x 24 hours

or 3 shifts).

3 RESULTS

Before the intervention, it was obtained that p =

0,045 (p <0,05). It can be concluded that there are

differences before intervention is done to patients

who are given the intervention of AT, ACT, AACT

and implementation strategy. After intervention, it

was obtained that p = 0,013 (p <0,05). It can be

concluded that there is a difference after the patient

is given the intervention of AT, ACT, AACT and

implementation strategy.

Statistical test of Multivariate Tests table got the

value p = 0.04 (p <0.05) means there are differences

of violent behavior of patient after given

intervention AT, ACT, AACT and implementation

strategy (Table 1).

From the Multiple Comparisons table shows the

difference of AACT and ACT group obtained mean

value difference = 0.75. This shows that AACT

intervention is better than ACT. Differences of

groups AACT and AT obtained mean value

difference = 1.25. This shows that AACT

intervention is better than AT. Differences group

AACT and SP obtained value mean difference =

0.00. This shows that AACT intervention is better

than implementation strategy (Tabel 2).

4 DISCUSSION

The results showed that there were differences in

violent behavior of patients after the intervention

given AT, ACT, AACT and implementation strategy

with p value = 0.04 (p <0.05). The AACT

intervention group was better than AT (with mean

diff = 0.75), ACT (with mean = 1.25) and

implementation strategy (with mean diff = 0.000).

AACT is a combination of AT and ACT. AACT

is provided to patients of violent behavior jointly

with their group to learn to communicate needs,

reject requests and express positive and negative

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

510

feelings openly, honestly, directly in accordance

with understanding, creating acceptance, attention

and more openness in developing their capabilities.

Group support is also needed to help patients behave

adaptively in dealing with the problem. Support

from family is able to prevent relapses (Tristiana

RD., 2017).

In this study, the authors integrated AT and

ACT. AT is not enough because by assertive

behavior without any commitment to maintain

adaptive behavior, the patient can perform repeated

acts of violent behavior. This is because patients are

not taught how to accept situations that cause anger

and are committed to maintaining their adaptive

behavior. Patients given ACT will have acceptance

and commitment to maintain adaptive behavior, but

they have no knowledge of how to act assertively to

vent their anger. Assertive Acceptance Commitment

Therapy (AACT) conducted on a group of violent

behavior patients and provided skills to the patient to

assertive behavior then they would accept the

problems they experienced with adaptive behavior

and finally have a commitment to maintain adaptive

behavior. Commitments gained in the group would

be individual commitments. The study about

assertive community stated that implementation of

assertive community treatment in overcoming the

self-image, that is with the client's self-management

(Fitriasari, 2017).

Assertive Acceptance Commitment Therapy

(AACT) was implemented in seven sessions, one

session identified the events, thoughts, feelings,

needs and desires, behavior impact and

consequences, session two identified value based on

experience, a four-session trained to express anger

by saying "no" to irrational requests and conveying

the reason, a five-session trained patient to received

events using selected values, a six-session trained

patient committed to preventing recurrence and

session seven maintained assertive behavior in

various situations. Assertive Acceptance

Commitment Therapy (AACT) interventions in

schizophrenic patients who experience violent

behavior taught patients to have the ability to control

their violent behavior personally and committed to

maintaining adaptive behavior with support within

Table 1: Multivariate Tests.

Value F Hypo-

thesis df

Error df Sig.

Intercept

Pillai's Trace 1.00 6,603.39 2.00 27.00 0.00

Wilks' Lambda 0.00 6,603.39 2.00 27.00 0.00

Hotelling's Trace 489.14 6,603.39 2.00 27.00 0.00

Roy's Largest Root 489.14 6,603.39 2.00 27.00 0.00

Method

Pillai's Trace 0.41 2.43 6.00 56.00 0.04

Wilks' Lambda 0.59 2.73 6.00 54.00 0.02

Hotelling's Trace 0.69 3.00 6.00 52.00 0.01

's Lar

est Root 0.69 6.40 3.00 28.00 0.00

Table 2: Multiple Comparisons.

Scheffe

Dependent

variable

(I) Method (J) Method Mean

Difference

(

I-J

)

Std.

Error

Sig. 95%

Confidence

Interval

Lower Bound

After ACT AT 0.50 1.38 0.009 - 3.60

AACT - 0.75 1.38 0.009 - 4.85

Implementation Strategy - 0.75 1.38 0.009 - 4.85

AT ACT - 0.50 1.38 0.009 - 4.60

AACT - 1.25 1.38 0.008 - 5.35

Implementation Strategy - 1.25 1.38 0.008 - 5.35

AACT ACT 0.75 1.38 0.009 - 3.35

AT 1.25 1.38 0.008 - 2.85

lementation Strate

0.000 1.38 0,001 - 4.10

Implementation Strategy ACT 0.75 1.38 0.009 - 3.35

AT 1.25 1.38 0.008 - 2.85

AACT 0.000 1.38 0,001 - 4.10

The Effect of Assertive Acceptance Commitment Therapy on the Ability to Control Violent Behavior of Schizophrenic Patients

511

groups built between group members, so that

patients could optimize their positive abilities.

5 CONCLUSIONS

Schizophrenic patients with violent behavior in the

three treatment groups are able to control their

violent behavior.

A given AT is able to control the patient's violent

behavior by exercising expressing verbal and

nonverbal attitudes, feelings, opinions and rights,

enhancing interpersonal skills for assertive behavior,

understanding that aggressive behavior should be

controlled and expressing anger appropriately. ACT

teaches acceptance of unwanted thoughts and

feelings that cannot be controlled, lead a more

meaningful life without having to eliminate

unpleasant thoughts that occur and practice

commitment based on positive values chosen by the

patient himself. AACT provides the patient with the

skills to assertive behavior, then he/she will accept

the problem with adaptive behavior and finally have

a commitment to maintain its adaptive behavior.

Assertive Acceptance Commitment Therapy AACT

is more effective for controlling the violent behavior

of schizophrenic patients.

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