Forgiveness Therapy to Improve Subjective Well-Being Among Families of Patients with Chronic Illness

Families (caregivers) of patients with chronic illness should ideally have high subjective well-being to care for chronic illness patients well. In reality, they cry frequently, look pensive


INTRODUCTION
Chronic diseases are non-communicable diseases of relatively long duration that are rare (Revenson & Hoyt, 2018).Chronic conditions and lifestyle behaviors harm the quality of life because of physical disability and emotional concerns (Somrongthong et al., 2016).The impact of this chronic illness on mental health includes some short-term depressive symptoms, negative affect, and grief at particular points in the illness trajectory, for example, when someone is first diagnosed with a certain chronic illness (Revenson & Hoyt, 2018).Living with a person with a chronic illness requires individuals and their families to adjust to a new normal.These patients with chronic illnesses will experience dependence on others because of their decreased mental and physical functions (Kristaningrum et al., 2021).It should be noted that chronic illness affects not only the patients but also their families (Martire & Helgeson, 2017).
The illness disturbs the whole family system because of its unpredictability and treatment (Pate, 2016).Chronic illness represents a major event that constitutes a major challenge for the family, with physical, socioeconomic, psychological, and behavioral effects on patients and their caregivers translating into vulnerability and decreased quality of life and family functioning (Toledano-Toledano & Luna, 2020).The family has a role in helping to carry out various kinds of tasks related to activities of daily life, ranging from maintaining cleanliness, preparing food, doing household chores, giving attention, providing comfort and treatment, socializing, administering medicine, and following up on medical care (Siregar et al., 2021).Chronic illness also emotionally impacts the patient's family, such as through worry, frustration, anger, and guilt.Worry was reported when family members were thinking about the future or the patient's death.The degree of stress experienced by caregivers is 49-63% by measuring the frequency of stress and psychosocial variables, and the responses given include anxiety, depression, and stress (Kartika et al., 2017).
Based on interviews with families who do routine care for patients with chronic illness, the responses to the pressure are expressed by crying, often being pensive, and thus having their daily activities distracted.Chronic illness affects every aspect of an individual's life and the quality of life in their family (Hagedoorn et al., 2017).Adaptation is required for family members to overcome the difficulty while caring for the patient and cope with the event (Martire & Helgeson, 2017).When the caregiver knows their family member got seriously sick for the first time, it must be unexpected.Rejection, fear, shock, and confusion are some of the responses that occur to deal with the crisis (Fields et al., 2020).
An ideal thing that family members should do is have positive emotions.Family members who take care of the patients develop more happiness (Hizbullah & Mulyati, 2022).These traits indicate that family members caring for patients with chronic illness have individual characteristics of good subjective well-being (SWB).Subjective well-being is the cognitive and affective evaluation of individuals lives.Cognitive evaluation of the well-being of individuals showed high life satisfaction.At the same time, effective evaluation results were much more positive and less negative (Diener et al., 1999).Subjective well-being evaluates a person's effects and cognition related to his life, including satisfaction with important things (life satisfaction) and high positive and low negative emotions (Akhyar et al., 2019).The individual with good subjective well-being is also creative, optimistic, hardworking, not easily disheartened, and smiles more than those who consider themselves unhappy (Widhigdo & Erawan, 2020).Bintamur (2020), in his research, found that there was a significant positive relationship between forgiveness and life satisfaction, where self-forgiveness and situation forgiveness are very significant with life satisfaction, while other forgiveness is quite significant with life satisfaction.Forgiveness also correlates significantly with positive and negative emotions.Swickert, Robertson, and Baird (2015) explained that forgiveness eliminates hurt feelings and hatred when responding to transgression.Forgiveness has a positive impact because of the process of forgiveness.Cognition, physiological responses, behavioral intentions, emotions, motivation, and possibly behavior toward the offender become more positive over time (Fernández-Capo et al., 2017).Furthermore, Kaleta and Morz (2020) found that apology was positively related to emotional and decisional forgiveness.The study also explained that forgiveness correlated negatively and significantly with stress (Rahmandani, 2015), desire for revenge (Scull, 2015), and depression symptoms (Dezutter et al., 2016).As the only personality dimension, agreeableness moderated the link between apology and decisional forgiveness.
The novelty of this study compared to previous studies is that the study participants are unique.This study involved the families of patients with chronic illnesses.In contrast, previous studies involved young adulthood (Bintamur, 2020), university students (Rahmandani, 2015), elderly adults (Dezutter et al., 2016), community and college campus persons (Swickert et al., 2015), and survivors of invasion (Scull, 2015).
This study explores the effect of forgiving therapy on increasing subjective wellbeing (life satisfaction and happiness) among the families (caregivers) of patients with chronic illnesses.This research is expected to be a reference or to give additional information for psychological science related to forgiveness therapy, subjective well-being, and family members of patients with chronic illness.
The data were analyzed using the assumption test before the hypothesis test (Sugiyono, 2019).The assumption tests include normality and hypothesis tests.A 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 is normal.
On the contrary, the data is abnormal if the significance level is less than 0.05.A homogeneity test determines whether some variants of the data population are the same.The data group has the same variant if the significance value exceeds 0.05.The results showed that the distribution of data was normal but not homogeneous.The non-homogeneous data was then analyzed using a noparametric test on the hypothetic test.The hypothetic tests used the T-test and Mann-Whitney Analysis (Azwar, 2019).

METHODS
This research used a quasi-experimental design.The quasi-experimental design is an experimental design in which subjects cannot be randomly selected for different treatments (Latipun, 2017).The nonrandomized study design model was a pretest-posttest control group design, which was an experimental method that attempted to compare the effect of a treatment on the treatment group that was given the therapy and the control group that had not been given the therapy of forgiveness (Latipun, 2017).
The participants were family members actively caring for the patient with a chronic illness.All of them were Muslims, aged 30 to 75 years old.Eleven subjects were involved in the study.They were then divided into two groups, i.e., six people in the treatment group and five others in the control group.
Life satisfaction variables were measured by adapting the subjective well-being scale by Takwin et al. (2012), from the Satisfaction with Life Scale (SWLS) from Diener and Pavot, which consists of 5 items.Based on previous experiments by Takwin et al. (2012), useful items amounted to 5, with an alpha reliability coefficient of 0.87.The happiness scales in this study were adapted from the Positive Affect Negative Affect Schedule (PANAS) scale, which consists of 20 items to measure happiness (10 negative and 10 positive emotions).Previous research yielded an alpha coefficient of 0.73 for positive and 0.83 for negative emotions (Takwin et al., 2012).
The intervention provided is forgiveness therapy.It is a therapy used to help a person reconcile feelings of resentment within himself, understand what is meant by a violation, see from the point of view of the offending person, and foster selfawareness of the need to forgive.The theory of forgiveness refers to the theory of Nashori (2016), which states that forgiveness consists of dimensions of emotion, cognition, and interpersonal interaction.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 offices, primary health care, and selecting participants, facilitators, and observers.Before the data collection, this research module had also been evaluated by two psychologists as a professional judgment.At this stage, the researcher provided advice as a module correction.In the next stage, the researchers conducted a module test on three caregivers for patients with chronic illnesses to further prepare this research.The next phase is forgiveness therapy.It lasted four meetings based on a mutually agreed schedule between the researchers and the research subject.Each meeting lasts for approximately 120 minutes.
The stages involved in the therapy of forgiveness consist of four stages (Enright, 2001).First, the uncovering stage aims to identify the negative state that the participants experience.Second is the decision stage, in which the subject forgives the offender.Third, the stage of work aims to cultivate empathy and compassion for the offender and do good things for the offender.Finally, the deepening stage is when the individual understands forgiveness and can find a new life goal after forgiving the offender.Islamic values, such as the importance of forgiving others as God's commandment, praying for the harmed, and attempting to maintain a friendship or the quality of relationships with offenders, are incorporated into this therapy.The stages of forgiveness therapy can be seen in Table 1.The data were analyzed using the assumption test before the hypothesis test (Sugiyono, 2019).The assumption tests include normality and hypothesis tests.A 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 is normal.
On the contrary, the data is abnormal if the significance level is less than 0.05.A homogeneity test determines whether some variants of the data population are the same.The data group has the same variant if the significance value exceeds 0.05.The results showed that the distribution of data was normal but not homogeneous.The non-homogeneous data was then analyzed using a noparametric test on the hypothetic test.The hypothetic tests used the T-test and Mann-Whitney Analysis (Azwar, 2019).

Result
Table 2 shows that in the treatment group, the average value of life satisfaction at the pre-test was 27.83, and the post-test mean score was 28.83.Meanwhile, the average pre-test score in the control group was 23.30, and the average post-test score was 22.40.Hypothesis 1 (life satisfaction) testing should be done by the non-parametric method, that is, by using the Mann-Whitney different test.Table 3 showed a significant difference between the groups given forgiveness therapy and those who were not given the therapy (p = 0.000).The subject's forgiveness after the forgiveness therapy showed a significance value of p = 0.006 (p <0.01).In the second post-test, the significant result was 0.006 (p <0.01).This finding suggests a difference between excuses in the treatment and control groups after being given apology therapy.The forgiveness in the treatment group tends to improve compared to the control group, which is not given forgiveness therapy.Table 4 shows that in the treatment group, the average value of the positivenegative effect at the pre-test was 75.17, and the post-test mean score was 77.67.
In the control group, the average pre-test score was 64.00, and the average posttest score was 62.00.Hypothesis 2 (happiness/positive-negative affect) testing should be done by the parametric method, using a mixed ANOVA test.The results showed a significant difference between the groups given forgiveness therapy and those not given it (p = 0.000).The result of the subject's forgiveness after the forgiveness therapy showed a significance value of p = 0.001 (p <0.01).In the second post-test, the significant result was 0.001 (p <0.01).This finding suggests a difference between excuses in the treatment and control groups after being given apology therapy.
The forgiveness in the treatment group tends to improve compared to the control group, which was not given forgiveness therapy.

Discussion
This study aims to determine the effect of forgiveness therapy on improving subjective well-being in families with chronic illnesses.Based on the research and data analysis, the researcher found that there was a difference in the subjective level of well-being between the treatment group that received the therapy of forgiveness and the control group that did not receive the therapy of forgiveness.This was seen in the quantitative data that showed changes in execution, measurements from the first post-test, and measurements from the second posttest.In contrast, the subjective well-being scores in the control group tend to remain the same.Hence, forgiveness therapy can improve subjective well-being.
This study supports research by Bintamur (2020), who used forgiveness therapy to increase life satisfaction.Research has been conducted on the subject of university students.This research also aligns with the correlational research Scull (2015) conducted about the relationship between forgiveness and the desire for revenge.The study subjects were the survivors of the 1990 Iraqi invasion of Kuwait.Dezutter et al. (2016) revealed a correlation between forgiveness and depression symptoms.Their research was conducted on elderly adults.Some of the above studies showed that forgiveness could improve subjective well-being for various subjects.Furthermore, the importance of forgiveness on subjective well-being for individuals-that is, individuals with a mindset related to views for a better future-rate high forgiveness, which is related to a higher level of subjective well-being (Septarianda et al., 2020).
These results found that forgiveness not only played a role in improving subjective well-being in the subject groups of young adulthood, university students, survivors of invasion, and community and college campus persons but also confirmed that in study participants who had a heavy burden, such as families or caregivers of patients with chronic illness, forgiveness theory could increase subjective well-being.
In their research, Nashori et al. (2020) found that this increased forgiveness.Neuroticism must be minimized, which aligns with the steps taken in forgiveness therapy in this study.Among the steps taken in this forgiveness therapy is expressing discomfort.This phase helps reduce the level of neuroticism experienced by a person.In this forgiveness therapy, there was a family (caregiver) intervention with chronic illness in which there was 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 can make someone share experiences, learn from the events faced by others, understand the way to more effective problem solving, cultivate empathy, and have goals and expectations in this life.
As stated in the introduction, the novelty of this study is the research participants.The research participants were families or caregivers of patients with chronic illnesses.The content of forgiveness therapy was tailored to the research participants.Implementing this therapy allows each individual to share stories and exchange experiences, especially unpleasant experiences in treating patients with chronic diseases.The disclosure phase makes the individual realize that the unpleasant conditions experienced are not only felt by themselves.It opens up the view that many people serve as family caregivers for sick family members.The therapy of forgiveness allows members who care for sufferers to adapt by enhancing existing social support (Elliott, 2011).
Similarly, Warsah (2020) found that in the discourse on positive psychology, forgiveness is important to instill in humans and must continue to be built because it positively impacts mental health, good relationships, physical health, and positive well-being.In Islamic teachings, forgiveness is also taught so that it is continuously implanted properly.Prophet Muhammad SAW has given an example that humans must always forgive and even pray for others for the pleasure of Allah SWT.Therefore, both positive psychology and Islam encourage humans to become forgiving individuals.
At the time of disclosure, participants recognize a variety of emotions.Each described the various emotions felt while caring for people with chronic diseases.They understand the negative effects caused when feelings of resentment, blame, and resentment are expressed.The effect is felt uncomfortable by each individual.This inconvenience makes them understand the less effective method.The ineffectiveness is shown by avoiding, silencing, and even getting lost in negative emotions.Individuals were given the option to forgive.Forgiving therapy builds mental and emotional well-being and promotes healthy relationships (Akhtar & Barlow, 2018).Wijaya and Widiyastuti (2019) stated that forgiveness would reduce negative emotions, characterized by a reduced desire to take revenge on or avoid the offender.To forgive means to accept the bitter reality that has ever happened and to make peace with it.On the other hand, Azra (2017) showed supporting results, namely that forgiveness and subjective well-being indicate life satisfaction and dominant positive emotions.
Family members must understand the treatment of chronically ill patients correctly because family members must manage to deal with this stressful condition.The therapy of forgiveness for building family members has a more positive perspective, as corroborated by psychoeducation related to the effects of chronic disease.Subjects look at the patient from a subjective point of view and understand the patient's condition.In this case, understanding includes what causes a person to behave in a way that makes the caregiver uncomfortable, such as anger, disappointment, yelling, and performing behaviors considered harmful.A new perspective can foster empathy in people with chronic diseases.This forgiveness process also impacts strong ties to subjective well-being, including a reduction in negative affect, positive emotions, positive relationships with others, spiritual growth, a greater sense of meaning and purpose in life, and an improved sense of empowerment (Akhtar et al., 2017;Prihantini et al., 2022).This condition will make chronic pain treatment feel a lot lighter (Pausig, 2015).
Researchers observed that participants could explore and realize the benefits of the therapy.

CONCLUSION
In this study, it was found that forgiveness therapy can improve subjective wellbeing in the families of patients with chronic illnesses.This is supported by the fact that the group that received the remission intervention therapy had higher subjective well-being scores compared to the group that did not receive the therapy.
The Based on the implementation and evaluation results, the researchers made some suggestions.First, forgiveness therapy improved subjective well-being in families with chronic diseases.It 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 family to establish rapport with them.In this phase of the approach, it takes time until it finally The subject is open to wanting to follow the therapy process.The approach should be initiated by introducing yourself or showing an ID if the researcher has never met the patient.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 communicate with the officers or deliver patients during routine health control.Third, a suggestion is for Chronic Disease Management program managers.
Research has shown that forgiveness therapy can improve subjective well-being in families of patients with chronic illness, so it can provide psychological interventions for caregivers and families of patients with chronic illness.Caregivers and families still need support to optimize their roles and stabilize the patient's health condition.

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Building a sense of comfort and trust between the facilitator and the participants.-Knowing the level of resilience scores and the participants' forgiveness.Understanding the situation from the point of view of the patients Diana, Nashori, Pihasniwati, Indranata, & Fitri | Forgiveness Therapy to Improve Subjective Well-Being Among Families of Patients with Chronic Illness a series of therapeutic processes are done -Convincing the participants that they can solve their problems with the techniques learned during the therapy independently -Post-test

Table 1 .
Stages of Forgiveness Therapy

Table 2 .
Descriptive statistics of life satisfaction of the treatment and control groups

Table 3 .
Mann Whitney Test Statistics (non-parametric) Life Satisfaction

Table 4 .
Descriptive statistics of the positive-negative effect of the treatment and control groups study has several limitations.The first limitation is the number of study participants.The number of participants (families or caregivers of patients with chronic illness) is limited, with only 11 participants.Standard quantitative research should involve a minimum of 30 research subjects.The next limitation is generalization.Subject limitations have implications for the limited generalization of research results.The quasi-experiments in research are also another limitation.In this study, a quasi-experiment uses certain limitations, especially the common control of extraneous variables.