FORGIVENESS THERAPY ON IMPROVING RESILIENCE ON FAMILY

(CAREGIVER) FOR PATIENT WITH CHRONIC ILLNESS

Asiska Danim Indranata, H Fuad Nashori, Yulianti Dwi Astuti

Magister Psikologi Profesi Fakultas Psikologi dan Ilmu Sosial Budaya
Universitas Islam Indonesia
asiska180@gmail.com

Abstract
The objective of this study is to explore the effect of forgiveness therapy on
increasing resilience in a family (caregiver) for the patient with chronic illness.
Resilience is an ability to adapt while facing stressful situations. Forgiveness
therapy is a method for client and therapist to judge the situation where someone
is treated unfairly and later he/she is able to express the feelings so the person
could have other another new perception and slowly let the anger go and showing
the better attitude towards the offender. There are 11 participants (3 male and 9
female) who were divided into 6 (1 male and 5 female) persons for experiment
group and 5 others (2 male and 3 female) for the control group who caring patient
with chronic illness for 2 until 8 years. The resilience was measured by Modified
Connor-Davidson Resilience Scale (CD-RISC) where the study was analyzed
through Mix Anava and Mann Whitney’s compare means. The results showed that
there were differences between the resilience in experimental and control group.
The results show that forgiveness therapy is effective to improve resilience in a
family (caregiver) for patients with chronic illness.

Keywords: Resilience, Forgiveness Therapy, and Family (Caregiver) For Patient

With Chronic Illness

Chronic illness is a disease that persists over a long period of time, cannot
be disappeared by itself, rarely can be cured and often leads to the inability of the
patients to do their daily habits (Mc Kenna & Kollin, 2009). Chronic illness
affects every aspect of the patient's life and leaves a deep impression of life on
everyone who suffers (Thompson, 2009). Severe conditions not only experienced
by patients but families who took care of them (Newby, 1996). Research
conducted by Theofanidis (2007) in the Health Science Journal said that when a
member of a family, especially children diagnosed a chronic pain, it could affect
the family to be shocked, stressed, angry, and experienced profound grief.
According to Murray (Thompson, 2009), many aspects of family life could be
affected by chronic illness such as daily activities, financial problems, career,
friendship, academic achievement, strategies in care and the involvement of other
family members could be the trigger to make the problem become bigger as well.
Based on the results of interviews with families who do a routine caring
for patients with chronic illness, the response to the pressure is expressed by
crying, often pensive, and interfere with daily activities. This situation showing
that individuals are less able to manage stress and decide to lost in grief rather
than resolving and move on. Chronic illness has an impact on relationships among
family members (Thompson, 2009). Adaptation is required to any family
members to pass through the difficulty while caring for the patient and be able to
interpret the event (Newby, 1996). When the caregiver know that her/his family
member got seriously sick for the first time, it must be an unexpected thing.
Anger, rejection, self-blame, fear, shocked, confusion and feeling helpless are
some of the responses that occur to deal with the crisis (Thompson, 2009).
Ideal conditions that family members should do caring is having an
optimistic attitude, courage to face the challenges of life, and take a lesson from
every occurrence (Southwick & Carney, 2012). family members who take care the
patients develop more adaptability rather than self-blame or blame others (Scott,
2013). The family decides to do positive coping stress process as a form of
togetherness in the family (Walsh, 2016). These traits indicate that family
members caring for patients with chronic illness have individual characteristics
with good resilience.
Resilience is the ability of individuals to be able to adapt to stress and
adversity (Gupta & Kumar, 2015). Resilience also directs a person's ability to
achieve balance and stable health in both psychological and physical conditions
despite the conditions of high stress and traumatic events (Meichenbaum, 2009).
Resilient individuals are individuals with characteristics that have a good method
of dealing with stress, can still run with good results despite being under pressure,
can arise from trauma and use challenges as a trigger to get better (Chaudhary &
Chaudhary, 2014).
Forgiveness as one of the factors that can develop resilience is one of a
method to have a positive coping (Meadows, Miller, & Robson, 2015).
Forgiveness can also help the process of adaptation and rise while facing
problems (Kumar & Dixit, 2014). A resilient person could be a tough person by
learning from painful experiences, seeking healing and relieving pain with
forgiveness (Broyles, 2005).
Resilience also correlates significantly with self-forgiveness, forgiveness
of others and forgiveness of the situation (Gayatrivadivu, Poonguzhali, Ofelia &
Vijayabanu, 2014). The previous study by Sheffield and Wolin explained that
forgiveness is the path to resilience (Broyles, 2005). Forgiveness can improve
resilience because forgiveness leads a person to solve problems in his life while
resilience regularly as a process of adaptation and the ability to handle stressful
conditions. Forgiveness is able to make a person adapt to the unpleasant
conditions of his life (Mary, 2015). Nashori explained that forgiveness therapy is
closely related to the conditions of being able to accept unpleasant facts under
controlled conditions (Khoiryasdien & Soeparno, 2015).
This study aims to explore the effect of forgiving therapy on increasing resilience
in family (caregivers) for the patient with chronic illness. This research is
expected would be a reference or additional information for the development of
psychological science that related to the forgiveness therapy, resilience and family
member of patients with chronic illness.
 RESEARCH METHODS
Participants
Participants are family members who are actively caring for the patient with
chronic illness, aged 30 to 75 years. There were 11 subjects who involved in the
study. Subjects were then divided into two groups, ie 6 persons in the
experimental group and 5 others in control group.

Research design
This research uses the design of quasi-experimental design. The quasi-
experimental design is an experimental design used when subjects cannot be
randomly selected to receive different treatments (Latipun, 2004). The
nonrandomized study design model was pretest-posttest control groups design,
which was an experimental method that attempted to compare the effect of a
treatment on the experimental group given therapy and the control group that had
not been given the therapy of forgiveness (Latipun, 2004).

Method of collecting data

This study is done through interview method, observation, and some related-
scales. Interviews are used to deepen the results of the qualitative analysis.
Observations are used for general observation (participants 'understanding of the
material, the participants' self-involvement during the therapy, the seriousness of
the participants during the task, how many trainers are considered by the
participants, and overall, how effectively participants perform the task),
observations during the therapy phase (therapeutic facilities , the quality of the
trainer, the therapeutic process, and the circumstances of the participant), and the
observation of the subject's performance during the therapy (suggesting an
opinion or idea or idea, giving examples, asking questions, volunteering,
interrupting, listening, chatting with friends, recording material, something that
has nothing to do with therapy).
 Resilience variables were measured by adapting resilience scale by
Kurniawan (2015) from Connor-Davidson Resilience Scale by Dong et al (2013)
consisting of 25 items. Based on the results of previous experiments conducted by
Kurniawan (2015) valid items amounted to 25, with the moving validity
coefficient of 0,560-0,905. The alpha coefficient of reliability is 0.975. This study
was conducted on thalassemia’s caregiver. The forgiveness scales in this study
adapted the forgiveness scale (Nashori, 2012) consisting of 14 items to measure
forgiveness as a benchmark of the intervention of forgiveness therapy provided.
Previous research yielded the total item coefficient moving from 0.304 to 0.742
with an alpha coefficient of 0.935 (Kusprayogi, 2016).

Intervention Procedures
The intervention provided is forgiveness therapy. It is a therapy used to help a
person reconcile with feelings of resentment within himself, helping to understand
what is meant by a violation, to see from the point of view of the offending person
and to foster self-awareness of the need to forgive. The theory of forgiveness
refers to the theory of Nashori (2012) that is forgiveness consists of dimensions of
emotion, cognition, and interpersonal. Forgiveness therapy conducted in this study
refers to the above view.
The intervention procedure consists of preparation and implementation.
The preparation stage includes module testing, licensing of offices and primary
health care, selection of participants, facilitators, and observers. Prior to the data
collection, this research module has also been evaluated by two psychologists as
professional judgment. At this stage, the researcher adds advice as a module
correction. The next stage, to further prepare this research, the researchers
conducted a module test conducted to three caregiver for patients with chronic
illness. In the next phase is the implementation of the forgiveness therapy. The
implementation of forgiveness therapy lasted for four meetings based on a
mutually agreed schedule between the researcher and the research subject. Each
meeting lasts for approximately 120 minutes.
The stages involved in the therapy of forgiveness consists of four stages (Enright,
2001). First, the uncovering stage that aims to identify the negative state that is
experienced by the participants. Second, the decision stage, the stage in which the
subject decides to forgive the offender. Third, the stage of work that aims to
cultivate empathy and compassion to the perpetrator, and do good things to the
perpetrator. Finally, the deepening stage, which is the stage in which the
individual understands forgiveness and can find a new life goal after forgiving the
perpetrator.

Table 1.
Stages of Forgiveness Therapy
Meetings Stages Activities Objective
- Building a sense of comfort and
trust between the facilitator and the
Opening,
participants.
Introduction, and
- Knowing the level of resilience
Pre-test
scores and the participants'
forgiveness.
- Providing an understanding of the
Introduction of series of therapies performed.

I Uncovering Pardon & - Clarifying the purpose and

120’ Informed Consent contract of intervention to the

participants
- Turning on the participants'
emotion related to problem/conflict
- Knowing the problems that occur
Self Report
- Providing information about the
impact of emotions, thoughts and
interpersonal relationships
 Closing Ending the first meeting
Understanding the impact of
Evaluation
negative feelings in the chamber
- Assessing the effectiveness of
the current settlement
- Offering forgiveness
- Providing psychoeducation of
"I forgive" the importance of forgiveness
II Decision
- Knowing the reconciliation
120’
efforts that have been done
- Deciding and commit to
forgive
Stabilizes the mind, emotions,
Relaxation
and physicality of the client
Homework Relaxing
Changing that occur after
Evaluation
relaxation
- Understanding the situation
from the point of view of the
Understanding
patients
III and compassion
- Accepting the perceived
120’ Work
suffering and bringing empathy
Improving interpersonal
Moral gift relationships by praying for the
health of the patient
Strengthen the process of
Closing
forgiveness that has been done
IV Taking lesson from forgiveness
120’ Deepening Evaluation that proved to benefit the self
and others
 Determining the purpose of
River life
"New Life"
Anticipating the obstacles that
Coping imagery
will occur to achieve the goal
Maintaining quality
Reflection relationships with people who
have hurt
- Explaining that a series of
therapeutic processes is done
- Convincing the participants
Evaluation & that he/she can solve his/her
Termination problems with the techniques
learned during the therapy
independently
- Post test

Data Analysis Technique

Data analysis in this study uses assumption test first before analyzing data to
do hypothesis test (Sugiyono, 2014). Assumption test conducted include
normality test and hypothesis test. Normality test is performed to determine
whether the population data is distributed normally or not. The normality test was
performed using the Kolmogorov-Smirnov Test technique. Data is normally
distributed if the significance is greater than 0.05. If the level of significance is
greater than 0.05 then the data in normal circumstances, on the contrary, if the
level of significance is less than 0.05 then the data in the abnormal state.
Homogeneity test is used to find out whether some variants of the data population
are the same or not. The data group having the same variant if the value of
significance is greater than 0.05. The results show that the distribution of data is
normal and not homogeneous. The existence of nonhomogeneous data will be
analyzed using nonparametric test on the hypothetic test. Hypothetic test using
Anava Mix and Mann Whitney Analysis (Azwar, 2003).

RESEARCH RESULT

The result of normality showed that resilience data on pretest value of

kolmogorov-smirnov = 0,164, p = 0,200 (p> 0,05), this indicated that pre-test data
distribution was normal. At post 1 test the value of columnogorov-smirnov =
0,260, p = 0,037 (p <0,05), this indicates abnormal data distribution. In the second
post test the value of columnogorov-smirnov = 0.247, p = 0.247 (p> 0.05), this
indicates the distribution of normal data. The result of normality test of
forgiveness variable on pre test shows the value of kolmogorov-smirnov = 0,175,
p value = 0,200 (p> 0,05). In the first post-test data the value of kolmogorov-
smirnov = 0.216, value p = 0.16 (p> 0.05). The data retrieval after the second test
of kolmogorov-smirnov = 0,216 and p value = 0,158.
Normality test results show pre-test, after the first test and the second post
has a normal data distribution. The result of homogeneity resilience test on a pre-
test of Levene statistic test showed 0,558 with p = 0,476 (p> 0,05) this showed the
data of two experimental groups and pre-test control group is no different. In the
first post-test the Levene statistic number showed 1,800 with p = 0.21 (p> 0.05)
this indicates that the first two experimental and control groups of post-test were
no different. In the second post, second test results showed the Levene statistic
0.468 with p = 0,513 (p> 0,05), indicating that both experimental and control
group has any different.
The homogeneity test of forgiveness at pre-test shows levene statistic 0,522,
p = 0,488 (p> 0,05). In the first post test levene statistic 1.262 and p = 0.29 (p>
0.05). On the second homogeneity test post-test levene statistic numbers showed
3.165 and p = 0.109 (p> 0.05). In the homogeneity test of pretax forgiveness, the
first and post test post between the experimental and control groups was no
different.
 Hypothesis testing should be done by the nonparametric method, that is by
using mixed anava test and Mann Whitney different test. Estimate effect shows as
0.993 or 99.3%. This means that the forgiveness therapy given to the experimental
group has an effective contribution of 99.3% (Dancey & Ready, 2011). While the
observed power has a value of 1000 or 100%. The results showed that there was a
significant difference between the groups given forgiving therapy and those not
given (p = 0,000). The result of the subject's forgiveness after the forgiveness
therapy showed a significance value of p = 0.006 (p <0.05), in the second post-test
the significant result was 0.006 (p <0.05). This suggests that there is a difference
between excuses in the experimental group and the control group after being
given an apology therapy. The forgiveness in the experimental group tends to
improved comparing to the control group who are not given forgiveness therapy.

DISCUSSION

The purpose of this study was to determine the effect of forgiving therapy to
improve resilience in families with chronic illness. Based on the result of research
and data analysis, the researcher got the result that there is the difference of
resilience level between the experimental group given the therapy of forgiveness
and the control group which is not given the therapy of forgiveness. This is
evident from the quantitative data showing changes in execution, first post-test
measurements, and measurements on the second post-test whereas in the control
group the resilience scores tend to remain. This suggests that forgiveness therapy
can improve resilience.
This study supports the results of previous research conducted by Lee and
Kim (2014) who did the therapy of forgiveness to improve resilience, self-esteem,
and spirituality. This research was conducted on the subject of liquor addicts. This
research is also in line with correlational research conducted by Gayatrivadivu, et
al (2015) about the relationship of forgiveness, resilience and marital satisfaction.
The subjects of this study were conducted on married individuals. Other studies
conducted by Kumar and Dixit (2014) show a correlation between forgiveness,
resilience, and gratitude. Research conducted on 50 youths at several universities
in India. Some of the above studies show that forgiveness is able to improve
resilience with various subject characters.
It is a form of family intervention (caregiver) with chronic illness in which
there is a phase of disclosure of the condition and the discomfort felt, the deciding
phase to forgive, the phase of forgiveness, and the deepening phase of the
meaning of forgiveness itself (Enright, 2001). This therapy is able to make
someone share experiences, learn from the events faced by others, understand the
way of more effective problem solving, cultivate empathy, have goals and
expectations in this life.
In the implementation of this therapy allows each individual to share stories,
exchange experiences especially unpleasant experience in treating patients with
chronic diseases. In the phase of disclosure makes the individual realize that the
unpleasant conditions experienced not only felt themselves. This opens up the
view that there are many people who serve the role of a family caring for sick
family members. The therapy of forgiveness allows members who care for
sufferers to have the ability to adapt by enhancing existing social support (Elliott,
2011).
At the time of disclosure, participants recognize a variety of emotions. Each
individual tells the various emotions that are felt at the time of caring for people
with chronic diseases. Individuals understand the negative effects caused when
feelings of resentment, blame, and resentment is done. The effect is felt
uncomfortable in each individual. This inconvenience makes the individual
understand the way what has been less effective. The ineffectiveness is shown by
avoiding, silencing, and even getting lost in negative emotions. Individuals are
actually given the option to forgive. At the time the individual decides to forgive
the individual feel relieved, calm and comfortable emotionally. It is also explained
that forgiving therapy builds emotional well-being and promotes healthy
relationships (Fincham, & Beach, 2007).
Family members need to understand the treatment of chronically ill patients
needs the right way. This is because family members need to manage to deal with
this stressful condition. The therapy of forgiveness of building family members
has a more positive perspective. This is corroborated by psychoeducation related
to the effects of chronic disease. Subjects not only look from a subjective point of
view but also understand the condition of the patient. Understanding, in this case,
includes what causes a person to behave that makes the caregiver uncomfortable
such as anger, disappointment, yelling and performing behaviors that are
considered harmful. A new perspective is able to present empathy in people with
chronic diseases. This condition will make chronic pain treatment change feeling
that has a lot of loads becomes lighter (Pausig, 2015). Researchers observed that
participants were able to explore and realize the benefits of the therapy.
Qualitative results indicate that an experience sharing session can change
the mindset. This mindset is related to the idea that there are others who
experience more severe but able to live it. Unpleasant events become part of life
that must always be faced with a process of adaptation. This is confirmed by
research conducted by Lee and Kim (2015) that resilience is a process of
adjustment to conditions that are considered less profitable.

CONCLUSIONS AND SUGGESTIONS

Conclusion
The results showed that therapy of forgiveness can improve resilience in
families with chronic diseases. This is evidenced by the results of the study that
the group who received the intervention therapy of forgiveness has a higher
resilience score than the group that did not get the therapy of forgiveness.

Suggestion
This research has been carried out with as much and as possible, but of
course, there are weaknesses. Therefore, based on the results of implementation
and evaluation, the researcher conveyed some suggestions that, firstly, forgiveness
therapy proved able to improve resilience in families with chronic diseases. This
allows for further research to develop research with therapy on different subjects.
If the next researcher is interested in continuing research on a family of chronic
illnesses, you should meet directly with the home to rapport the family. In this
phase of the approach, it takes time until finally, the subject would be open to
wanting to follow the process of therapy. The approach should be initiated by
introducing yourself or showing an ID if the researcher has never met the patient
before. In subsequent studies, it is better to use variable controls such as stress
levels, the severity of chronic illness and family support.
Second, suggestions for research subjects are expected to develop
knowledge of chronic pain suffered by family members. Research subjects are
also active to communicate to the officers or participate in delivering patients
during routine health control.
Third, suggestions for prolanis program managers. Research has shown that
apologetic therapy can improve resilience in families with chronic diseases, so
forgiveness therapy can be used to provide psychological interventions in
caregiver for patients with chronic illness. Caregiver still needs to get support to
be able to optimize its role so that the patient's health condition becomes more
stable.

DAFTAR PUSTAKA

Azwar, S. (2003). Reliabilitas dan Validitas. Yogyakarta: Pustaka Pelajar.

Broyles, L. C. (2005). Resilience : Its relationship to forgiveness in older adults.
Disertasi (tidak diterbitkan). Tennessee: University of Tennessee
Chaudhary, H., & Chaudhary, S. (2014). Positive emotions , resilience , gratitude
and forgiveness : Role of positive psychology in 21st century, 5(4), 528–530.
Connor, K. M., & Davidson, J. R. T. (2003). Development of a new resilience
scale: The Connor-Davidson Resilience scale (CD-RISC). Depression and
Anxiety, 18(2), 76–82. https://doi.org/10.1002/da.10113

Dancey, C., & Reidy, J. (2011). Statistics without maths for psychology.
Italy:Pearson

Elliott, B. A. (2011). Forgiveness therapy : A clinical intervention for chronic

disease, 240–247. https://doi.org/10.1007/s10943-010-9336-9
Enright, R. (2001). Forgiveness is a Choice. Washington: APA
Fincham, F. D., & Beach, S. R. H. (2007). Forgiveness and marital quality:
Precursor or consequence in well-established relationships. Journal of
Positive Psychology, 2, 260-268.
Gayatrivadivu, Poonguzhali, Ofelia & Vijayabanu. (2014). A study on
relathionship between forgiveness, resilience and marital satisfaction among
married individuals. Indian Journal of Positive Psychology, 5(4), 382-387
Gupta, N., & Kumar, S. (2015). Significant predictors for resilience among a
sample of undergraduate students : Acceptance , forgiveness and gratitude,
6(2), 188–191.
Khoiryasdien, A.D. & Soeparno, K. (2015). Pengaruh terapi pemaafan la tahzan
dalam meningkatkan penerimaan diri istri yang mengalami kekerasan dalam
rumah tangga. Jurnal Intervensi Psikologi, 7, 1, 15-39.
Kumar, A., & Dixit, V. (2014). Forgiveness , gratitude and resilience among
Indian youth, 5(12), 1414–1419.
Kurniawan, Y. (2015). Terapi kelompok pendukung untuk meningkatkan
resiliensi pada orangtua penderita thalasemia. Tesis (tidak dipublikasikan).
Yogyakarta : Universitas Islam Indonesia.
Kusprayogi, Y., & Nashori, F. (2016). Kerendahatian dan pemaafan pada
mahasiswa. Psikohumaniora, 1, 1, 12-29.
Latipun. (2004). Psikologi eksperimen. Malang:Universitas Muhammadiyah
Malang
Lee, E., Enright, R., & Kim, J. (2015). Forgiveness Postvention with a Survivor of
Suicide Following a Loved One Suicide: A Case Study. Social Sciences,
4(3), 688–699. https://doi.org/http://dx.doi.org/10.3390/socsci4030688
Mary, E. M. (2015). Relationship between forgiveness , gratitude and resilience
among the adolescents, Indian Journal of Positive Psychology, 6(1), 63–68.
Mc Kenna, M. & Collins, J. (2010). Current issues and challeges in chronic
disease. Washington DC: American public health asociation
Meadows, S. O., Miller, L. L., & Robson, S. (2015). Airman and Family
Resilience Lessons from the Scientific Literature. California: RAND
Corporation.
Meichenbaum, D. (2009). Bolstering resilience: Benefiting from lessons learned.
In D. Brom, R. Pat-Horenczyk & J.D. Ford. (Eds.), Treating traumatized
children: Risk, resilience and recovery. (pp. 183-192). New York:
Routledge.
Nashori, F. (2012). Pemaafan pada etnis Jawa. Disertasi. Bandung: Program
Pascasarjana Universitas Padjajaran
Newby, N. M. (1996). Chronic illness and the family life-cycle. Journal of
Advanced Nursing, 23(4), 786–791. https://doi.org/10.1111/j.1365-
2648.1996.tb00052.x
Pausig, D. (2015). Caregiver Burden Track Six Essentials.Texas:Huntington's
Disease of America
Scott, C. B. (2013). Alzheimer’s disease caregiver burden: Does resilience matter?
Journal of Human Behavior in the Social Environment, 23(8), 879–892.
https://doi.org/10.1080/10911359.2013.803451
Southwick,S. Carney, D. (2012). Resilience as related to definition, theory, and
challeges. International Society for Traumatic Stress Studies, 12-14
Theofanidis, D. (2007). Chronic illness in childhood: Psychosocial adaptation and
nursing support for the child and family. Health Science Jornal, 1(2), 1–9.
Retrieved from http://www.hsj.gr/index.files/volume1_2.htm
Thompson, J. J. (2009). How chronic illness a ects family relationships and the
individual,30.Retrieved from
http://www2.uwstout.edu/content/lib/thesis/2009/2009thompsonj.pdf
Sugiyono. (2014). Metode penelitian pendidikan pendekatan kuantitatif &
kualitatif. Bandung: Alfabeta.
Walsh, F. (2016). A family resilience framework : Innovative practice
applications, (March 2002). https://doi.org/10.1111/j.1741-3729.2002.00130.x