Reduce Stigmatization towards Schizophrenic Patients using

Acceptance and Commitment Therapy

Astri Haryanti and Nurul Hartini

Faculty of Psychology, Universitas Airlangga, Surabaya, Indonesia

Keywords: Acceptance and Commitment Therapy, Family, Schizophrenia, Stigma.

Abstract: People with mental disorders are more vulnerable to stigmas in society. Schizophrenia is a stigmatized

mental disorder. Stigmas can cause people with mental disorders, such as schizophrenia, to not receive the

right treatment. Families can associate with the stigmatization of the patient. Stigmatization from their

family can worsen the prognosis. Acceptance and Commitment Therapy (ACT) is an intervention that has

been proven to reduce stigmatization. This therapy encourages individuals to receive the internal experience

that occurs without trying to judge and simultaneously establish the behaviors that serve as the objectives to

be achieved. This research used quasi-experimental design using a single-subject design on four participants

(caregivers). Data collection techniques using the Attribution Questionnaire-27 (AQ-27). Data analysis was

conducted by using visual analysis to observe changes in each subject. The results of data analysis show that

Acceptance and Commitment Therapy can reduce stigmatization in each caregiver to schizophrenic patients.

The findings of this study can serve as a basis in supporting and improving families’ acceptance of patients’

conditions, to provide a better view of schizophrenic patients.

1 INTRODUCTION

Mental health problems in Indonesia need to receive

more attention because the number of mental

disorders continues to increase, creating a burden on

the state and a decline in human productivity over

the long term (Minister of Health Republic of

Indonesia, 2016). Based on the World Health

Organization (WHO) data (2017), mental health

problems such as depression are suffered by more

than 300 million people of all ages around the world,

and the number of people with schizophrenia

problems based on WHO data (2018) is more than

21 million people worldwide. In Indonesia, based

on data from Indonesia Health Research (Riskesdas)

2013 (Minister of Health Republic of Indonesia,

2016) revealed the prevalence of severe mental

disorders, such as schizophrenia reached about

400,000 people or as many as 1.7 per 1,000 people.

People with psychiatric problems are more

vulnerable to stigmas in society. Stigmas occur when

people give different labels to humans and mix

beliefs in with the culture of unwanted people or

negative stereotypes (Link and Phelan, 2001).

Stigmatization as described by the Goffman concept

(1963 as cited in Overton and Medina, 2008) was

related to social identity. He discussed that people

are stigmatized when they become disfavored or

rejected in society and then they become outcasts.

According to WHO (2016), stigma, discrimination,

and human rights violations are common in people

with schizophrenia. People with psychotic disorders

also have a high risk of human right violations, such

as long-term confinement in a shelter institution.

Stigma, discrimination, and the inability to

recognize mental disorders are still a major obstacle

to treatment. In Indonesia, the incorrect assumption

is made that mental disorders are related to the

supernatural (Minister of Health Republic of

Indonesia, 2015). Schizophrenic patients are also

often regarded as strange and dangerous people so

they do not immediately receive medical treatment

but are hidden or taken to “orang pintar” (Hawari,

2012). The conditions of schizophrenic patients

require attention regarding various aspects. Gerety

and Edwards (2014) revealed that schizophrenia can

affect someone’s well-being, shorten their life, and

can be one of the main causes of global disability.

This condition is often ignored and misunderstood

and is a heavy burden on the individual, family

members, and caregivers.

Haryanti, A. and Hartini, N.

Reduce Stigmatization towards Schizophrenic Patients using Acceptance and Commitment Therapy.

DOI: 10.5220/0008588002610266

In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in

Global Community, pages 261-266

ISBN: 978-989-758-435-0

261

There has been no single treatment for

schizophrenia until now, but patients may have to

undergo lifelong treatment. Effective treatment for

patient with schizophrenia is medication and

psychosocial support (WHO, 2016). Families, as

part of providing support to schizophrenic patients,

have an important role in their treatment. Care and

the presence of a patient’s family members are

considered necessary because their involvement will

support the patient recovery process (Setyanto,

Hartini and Alfian, 2017).

Families, who are an important part of handling

people with mental disorders, certainly do not all

accept the fact that their family members are

suffering from a disorder (Community Care for

People with Schizophrenia in India, 2012). Families

can become agents of stigmatization due to a lack of

adequate information and resources and the burden

of daily care that leads to strong social exclusion

behavior and the family’s distrust during recovery

(Sousa, Marques, Curral and Queiros, 2012). Living

with a patient with a mental disorder in a family

context can lead to a variety of negative emotions,

including fear of the patient’s reactions and

behavior, especially when the patient becomes

aggressive, which is often unpredictable. A family

may feel threatened by the patient, thus reject

acceptance and trigger the patient’s withdrawal

(Vicente, Mariano, Paiano, Waidman, and Marcon,

2013). Therefore, if a family is not ready when the

patient leaves hospital and returns to the family and

community, their attitude will tend to lead to

possible stigma and prejudice, even aggression

towards the patient.

Stigma is one of the factors that inhibits

intervention treatment; however, specific action to

reduce stigma in various mental illnesses has proved

beneficial and achieved better results. Reducing

stigma can be a way to reduce the risk of recurrence

and worse outcomes caused by the a stigmatized

environment (Shrivastava, Johnson, and Bureau,

2010).

Masuda et al. (2009) reveal that a high stigma of

mental health is associated with high psychological

distress. This condition is due to reducing

psychological flexibility. Psychological flexibility is

the ability to be open and full of any experience,

which drives value that leads to a worthwhile goal

(Hayes, Luoma, Bond, Masuda and Lilis, 2006, in

Masuda and Latzman, 2011). Acceptance and

commitment therapy (ACT) is proven to provide

positive clinical outcomes to improve psychological

flexibility (Hayes et al., 2006).

Several studies have shown that acceptance and

commitment therapy (ACT) can reduce stigma.

Masuda et al., (2007) differentiate the provision of

ACT and stigma-related education to people with

psychological disorders. The results showed that

both interventions could reduce the stigma attached

to psychological disorders. Participants with

emotions avoid, blend in with their thinking, and

unable to take value from difficult thoughts and

feelings, and when given educational interventions,

they are unable to benefit from such interventions.

This is in contrast to participants who received ACT

intervention, suggesting that interventions can

reduce their stigmatization.

Based on the above, it is necessary to provide

treatment in the form of acceptance and commitment

therapy to families to reduce their stigmatization

towards schizophrenia patients. The treatment is

expected to develop new understanding in increasing

the acceptance of family members who are affected

by schizophrenia. Finally, this is an effort to reduce

stigma and discrimination for people with mental

disorders, which result in the threat of human rights

on the deprivation experienced by mental health

patients.

2 METHOD

The research was conducted using a quasi-

experimental design, using single-subject design

with a reversal A-B design category. The aim of this

research is to know understand acceptance and

commitment therapy to reduce the stigmatization of

a family towards a schizophrenic patient in the

family. Inclusion criteria of the subjects in this study

were one family member who treated the

schizophrenia patient and still had a negative

judgment on the patient, which was measured using

the attribution questionnaire (AQ)-27 resulting in the

medium to high range. Exclusion criteria is domicile

outside the city of Surabaya. Based on the

measurement results there were four research

subjects.

This research used the attribution questionnaire

(AQ)-27 and the acceptance and action

questionnaire-stigma (AAQ-S). AQ-27 was

developed by Corrigan (2012) and consisted of nine

stereotypes of people with mental disorders,

including blame, anger, pity, help, dangerous, fear,

avoidance, separation, and coercion. Questionnaires

from each stereotype consisted of three items so

altogether there are 27 items. Data collection using

AAQ to measure the psychological flexibility that is

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

262

associated with stigmatization. AAQ-S consists of

21 items with a reliability of 0.84.

Intervention using acceptance and commitment

therapy developed from the research of Masuda et

al. (2007) based on the manual acceptance and

commitment therapy (ACT) by Hayes et al. (1999).

Interventions were conducted based on six basic

principles of ACT compiled into five sessions,

including the discussion of problems and practice of

acceptance, diffusion, being present, self as context,

values, and committed action.

Data analysis of the single-subject design

research using visual analysis is presented in the line

graph. The graph shows a change in condition from

the baseline phase to the treatment phase. Visual

analysis provides a visualization of the changing

conditions of each research subject.

3 RESULT

The results of the visual analysis from each subject

is seen from the measurement with AQ-27. Data

collection were made twice during the baseline

phase (A) and five times during the treatment phase

(B). The condition of each can be explained as

follows:

3.1 Subject 1

Figure 1: Subject 1.

Subject 1 shows that there is a positive trend towards

the change in levels from the baseline phase to the

treatment phase, and that there is a two-point

reduction. The average values of the baseline phase

and the treatment phase decreases. This proves that

the subject’s condition has improved since the

treatment was given.

The analysis in subject 1 shows a 20% overlap of

data, which indicates that the treatment can influence

80% to reduce stigmatization.

3.2 Subject 2

Figure 2: Subject 2.

Subjects have decreased from the baseline phase to

treatment phase; this is shown by a downward trend

and positive change in level. The level change is

indicated by a score of 15 and an overlap of 0%,

which means there is a large influence on the

intervention.

3.3 Subject 3

Figure 3: Subject 3.

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The result of the stability effect decreased, and

the level changed positively from the baseline to 24

after the intervention. It is also supported by overlap

percentages of 0%. This overlap condition indicates

that the intervention has a 100% effect, which is

positive in reducing stigmatization.

3.4 Subject 4

Figure 4: Subject 4

Subject 4 shows a decrease in stigmatization. This

can be seen from the stability effect with a

downward positive level change with a change in the

score of 46. Data shows an overlap of 0%, which

means that the intervention has a 100% effect. This

is substantial in reducing stigmatization.

3.5 Analysis AAQ-S

The result of the AAQ-S questionnaire analysis,

related to the psychological flexibility of each

subject is between 63 and 71. The entire subject

showed a high degree of psychological flexibility.

The results were not comparable to participants who

had low levels of psychological flexibility, so there

was only one group of participants with high

psychological flexibility.

4 DISCUSSION

Mental health problems are often associated with

stigma. Families often contribute to stigmatization.

Families may raise doubts over medical treatment

due to minimal changes in patients, which prompts

them to complain that the condition does not

demonstrate significant change. Also, there is an

emergence of the view that the patient is less

competent, which ultimately leads to the family’s

dissatisfaction with the patient’s condition. This

condition was also shown by some families of

relapsing study subjects; a lack of change in patients

causes the family to be disappointed with the

condition of the patients.

The results showed that acceptance and

commitment therapy can reduce the stigmatization

of schizophrenia patients for a family. Acceptance

and commitment therapy (ACT) in reducing

stigmatization is in line with previous studies.

Masuda et al. (2007 shows that acceptance and

commitment therapy can reduce stigmatization in

subjects with either low or high levels of

psychological flexibility. In this study, the overall

subjects had high psychological flexibility. This will

ultimately make the subject’s condition to readily

improve over the course of the intervention process

since act itself attributes the role of psychological

flexibility in providing intervention.

Psychological flexibility is the process of

engagement with personal psychological events such

as thoughts, feelings without judgement, evaluations,

alterations, corrections or regulations. Psychological

flexibility enables a person to accept all events

without judgment, even if they are seemingly

negative thoughts and feelings, which ultimately

becomes a possibility for a person to have those

thoughts and feelings without making the impact of

those thoughts and feelings a truth or reality

(Masuda et al., 2009).

Psychological flexibility is associated with

mental health stigma. Mental health stigma is closely

related to negative psychological outcomes for

people who are stigmatized, including those with

psychological health disorders. Psychological

flexibility is found to be inversely related to mental

health stigma and negative psychological outcomes.

Further analysis revealed that the relationship

between mental health stigma and poor

psychological outcomes was partially considered by

such psychological flexibility (Masuda et al., 2009).

These conditions illustrate from the research subjects

that when they have high psychological flexibility, it

is easier for them to lower the stigma they have,

including the behavior they bring, and the burden

they feel to experience a positive change. This is in

line with research conducted by Hayes et al (2004)

to reduce the stigmatization of drug addict

counselors to their clients through ACT. The results

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

264

indicate that the stigmatization attitudes of the

counselor decreases after the intervention is

delivered. The intervention can reduce the burnout

of the counselor so that the intervention, in addition

to lowering stigma, also has the influence to promote

the welfare and effectiveness of their

professionalism.

In the family, acceptance is also an important

part of reducing stigmatization of schizophrenic

patients. Acceptance is an important part of

behavioral interventions, including ACT (Cordova et

al., 2001). Acceptance as an important part of the

ACT intervention process and is related to

psychological flexibility. ACT can increase

psychological flexibility to gain a more meaningful

life by directing the values of life (Butler, 2015).

Acceptance is part of creating a warm relationship,

fixing emotional issues, coping with mismatches,

and irreconcilable differences and problems that

cannot be resolved. Paul and Nadkarni (2014) state

that family support is an important part of stigma for

schizophrenic patients. Some families play a strong

role in supporting people recovering from

schizophrenia by expanding family acceptance to

reduce stigma and discrimination in schizophrenic

patients.

5 CONCLUSION

Based on the results of data analysis and the

discussion of research, it can be concluded that

acceptance and commitment therapy can reduce

stigmatization towards schizophrenic patients in

families. Reducing the stigmatization of each subject

is indicated by changes in the different

psychological dynamics between subjects. The

findings of this study can serve as a basis in helping

to increase family acceptance of the patient’s

condition to provide a better view of schizophrenic

patients. These conditions can improve the quality of

the relationship between the family and the patient to

improve their welfare and provide a better quality of

life.

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