Cognitive Behavioral Therapy as an Effort to Improve Self Acceptance of Adolescents in Orphanage

Received: February 22, 2017 Revised: March 29, 2017 Accepted: August 04, 2017 Abstract: Background: The Ministry of Social Affairs found several relevant facts about the condition of child care in orphanages across five cities in Indonesia, among others is the lack of attention to the fulfillment of emotional needs and psychosocial development. This problem persists despite the knowledge that major changes in maturity and psychosocial development, particularly associated with the social function, progressed greatly during adolescence, increasing the need for intensive psychological assistance during self-discovery. The process of self-discovery always begins with self-acceptance.


INTRODUCTION
Every period of human life from birth to adulthood is filled with growth and development.One part of our developmental stage is adolescence.Adolescence is a period of strife (storm and stress) which is a time for them to seek their identity and look for ways to be accepted by their environment.Gunarsa [1] suggested that many changes in maturity and psychosocial development, particularly regarding social function, is evident during adolescence.The adolescent's social environment also influences their developmental stage.
In Indonesia, a research publication by Save The Children in collaboration with the Ministry of Social Affairs in 2008, revealed several important facts about the condition of child care in orphanages across five cities in Indonesia [2]: Lack of care in institutions/child care institutions.1.
Emphasis on providing access to education as the primary goal.2.
Focuses on the fulfillment of education and material needs (food, shelter, and tuition fees).

3.
Lack of attention on the fulfillment of emotional needs and psychosocial development.4.
Length of placement is similar to the length of formal education, sometimes with minimal frequency of 5.
returning home.Individual treatment, especially when the child has a special condition or problem.6.
Lack of full-time caregiver.7.
Children take care of themselves, and adults care for the institution.8.
Observation, discipline and use of violence were ways to manage children.10.
The focus of the work staff is not on the child's growth but instead on the institution's operationalization.11.
Stigmatized as neglected/abandoned child or children from a damaged family.12.
Since the 1950s, studies have shown that orphanage upbringing has long-term negative consequences on a child's cognitive, emotional and social development [3 -6].Several studies on adolescents' behavioral problem found that teen orphans have more behavioral problems compared to those living outside of the system [7,8].Adolescents living in an orphanage also experience confusion, anxiousness, guilt and rejection [9].Simms, Dubowitz, and Szilagyi [10] stated that youth in the foster care system experience an excessive risk of mental and behavioral health problems as well as developmental disorders compared to peers.Forkey and Szilagyi [11] also suggested that nearly two-thirds of the orphanage children had mental problems and behavior.According to Hurlock [12], orphanage has an adverse effect on the orphans' personality development because the environment of a substitute family fails to replace the function of a real family.This lack of function results in the formation of a passive, apathetic, withdrawn, easily despaired, fearful and anxious personality that makes it difficult for individuals to establish social relations with others.They also showed negative behavior, fear of contacting others, a sense of hostility and selfishness, as well as a preference to be alone.Research conducted by Shulga, Savchenko, and Filinkova [13] stated that children living in orphanages suffer disruption in their emotional intelligence and regulation.
The inability to accept things that are different from themselves makes them prone to psychological and behavioral problems.Self-acceptance is a psychological mechanism which enables individuals to endure and comfort themselves by recognizing and accepting both their positive and negative traits during negative situations [14].People who can accept their condition, can respect and reflect on themselves as well as discover ways to make peace with their flaws.Further, individuals who can accept themselves will have a healthy and vigorous personality.By contrast, people with trouble in self-acceptance often dislike their characteristics, feels useless and under confident [12].Self-acceptance according to Hurlock [12] is the ability and willingness of an individual to live with all his/ her characteristics.People who can accept themselves are defined as those with no trouble nor burden towards themselves, increasing their chance to adapt to their surroundings.According to Ellis [15], self-acceptance is defined as holding a positive regard for or attitude toward oneself, including one's past life experiences.Self-acceptance does not rely on the approval of others or personal achievements.Corsini [16] defined self-acceptance as getting acquainted with your abilities and accomplishments together with accepting your limitations.Ryff [17] revealed that self-acceptance is seen in individuals with a positive outlook about him/ herself, acknowledging and accepting the different facets of their self.Germer [18] defined self-acceptance as the ability to have positive views about his/ her real self which are developed individually.Hayes [19] has defined psychological acceptance of as one of the most significant contextual change strategies.Acceptance refers to the conscious abandonment of a direct change agenda in the key domains of private events, self, and history, and an openness to experience thoughts and emotions as they are, not as they say they are [20].This research aims to provide cognitive behavioral therapy on teenage orphans, in the hope that the subjects will receive the lessons given by the therapists more easily.Orphanage youth are more able to introspect on the capacity that exists within themselves and to accept the response from others whether regarding thought, expectation, character, or values that are presented both positively and negatively.Self-acceptance has positive impacts on social interaction such as having more frequency in thinking positively about both, self and the environment, as well as the views of others about themselves and inculcating feeling that they have the same rights as others, particularly the right to succeed in the same sense as other teenagers.Cognitive behavioral therapy according to Beck [21], is a treatment based on cognitive formulation, belief and behavior.Treatment is also based on the client's conceptualization and understanding of the targeted belief and behavior that need to be changed.CBT encourages and teaches clients to provide alternative ways of thinking or other reasons when solving problems, modify thoughts and change their belief which will be followed by changes in emotions and behavior.Meichenbaum [22], stated that modification of cognitive behavior is a self-statement that will affect one's behavior by developing cognitive, emotional and behavioral skills.
McKay [23] stated that CBT refers to a collection of techniques that are applied to treat a broad range of psychological conditions.It is based on a framework that assumes that thoughts, emotions and behaviors are all connected, and more specifically, drives emotion and behavior.Thus, an underlying assumption in CBT is that in identifying and changing one's dysfunctional thoughts, one's maladaptive emotions and behaviors will consequentially be modified as well.Froggatt [24], stated that all the cognitive therapies that developed so far are an opinion that human feelings and attitudes are strongly influenced by their cognitive thinking.By influencing the mindset (cognitive) through cognitive and behavior, it is possible to change disturbance in human's emotion and behavior.

Subject
Research subjects were chosen using purposive sampling which is selecting participants based on a certain purpose.The inclusion criteria used to achieve research objectives and maintain the validity of the content in this study are as follows: Lives in an orphanage 2. Adolescent 3.

Respondent
Subjects used in this study amounted to 24 people, with 12 people in the experimental group and 12 people within the control group.

Research Procedure
This is a quasi-experimental research.The design used in this study is the untreated control group design with multiple dependent pretest and posttest [25], which is part of a two-group experimental design (between subject design), designed by dividing without randomly assigning subjects into the experimental and control group.The experimental group receives experimental manipulation, whereas the control group is under controlled conditions to determine the value of the dependent variable without experimental manipulation of the independent variable [26].
The study design is the untreated control group design with multiple dependent pre-test and post-test [25].The intervention conducted a pretest on both the experimental and control groups.The procedure of this study includes: Constructing research instrument, creating CBT module, choosing support team, determining the experiment and control groups, conducting pre-test, giving the treatment, and conducting post-test.

Construction of Research Instrument
The construction of self-acceptance measurement instruments for adolescents.

Preparation of CBT Intervention Module
The preparation of CBT module is done to support the flow of the research implementation.This module consists of a CBT module.The module is organized to be done in 7 meetings with topics on the values of self-acceptance.Each material takes 120 minutes, so the whole training takes 23 hours.The presented material consists of self-acceptance values.These values are contained in each theme presented.

Therapist
This study uses CBT module to determine its influence in increasing empathy, conscience, and self-control.Therefore, it requires an experimenter who has professionality in doing CBT.The experimenters are taken from psychologists who have considerable experience therapist in doing CBT.The therapist is responsible for delivering material that has been arranged in the module and directs the experiment process to run smoothly.The therapist is a graduate of the psychology profession and has been doing therapy, particularly cognitive and cognitive behavioral therapy.The practice of CBT was initiated in 2005 to deal with cases of people with a phobia on chicken and social barriers.In 2006, behavioral treatment therapy was used against cigarette addiction.In 2007, trauma from being bullied was addressed using the same method.In the same year, CBT also tackled problems of underachievers.Further, in 2008 cases of homophobia and self-esteem were done using cognitive counseling.In 2009, Rational Emotive Behavioral Therapy handled cases of victims of domestic violence.The year 2010 handles depression cases with REBT and logo therapy.In 2011, cases of the quality of life in patients with diabetes mellitus were tried out.In 2012 victims of domestic violence were treated with Cognitive Religious Therapy.In 2013, junior high school students' aggressiveness was dealt.In 2014, three cases of sexual harassment were handled, followed by another three cases in the following year.In the year 2016, cases of victims of domestic violence were addressed.The year 2017 handles cases of porn video addiction

Provision of Treatment
Observations and interviews were conducted before, during and after therapy.Observations and interviews concerns was on adolescent's behavior during the treatment process and the constraints and special events that occurred during the treatment process.The requirement to be an observer and interviewer is that they have experience interacting with adolescents and are accustomed to performing psychological tests to adolescents individually.
The research group received CBT treatment.The material given contains self-acceptance values by Sheerer [27] namely: The belief in their ability to face their life, consider themselves equal to others, do not regard themselves as an abnormal person and do not expect other people to ostracize them, are not shy nor fearful of being reproached by others, accounts for their actions, do not conform easily to others' lifestyle, receive praise or criticism objectively, and does not hurt themselves.These aspects of self-acceptance which are used to construct the study's self-acceptance scale are the self-acceptance scale from Berger [28] which has been modified.The self-acceptance scale consists of 36 items with a score ranging from four to one.

Method of Analysis
To test the proposed hypothesis, the collected pre-test and post-test data will be analyzed statistically with ANOVA mixed design combining two sub-analyzes i.e.Within Subject Test and Between Subject Test.

RESULTS
The results of the statistical analysis were obtained from 24 subjects who were divided into two groups.As many as 12 subjects were categorized into the experimental group and 12 subjects in the control group.Pre-test, post-test, follow-up, and the analysis of parametric ANOVA mixture were used to determine whether a difference of selfacceptance between the experimental group and the control group exist.
In Table 1 the analysis result using mix ANOVA obtained F = 4.11 (p <0.05).This result indicates that there is a significant difference in the self-acceptance score from pre-test to post-test between both the experimental and control design.In Table 2, an average change of self-acceptance from pre-test to post-test is seen in both the experimental group (Mean Difference (MD) = -6.25,p <0.05) and the follow up experimental group (MD = -7.25,p <0.05).This shows a significant increase in self-acceptance score in the experimental group after being given Cognitive Behavior Therapy.In the control group, a noticeable improvement was found with MD = -0.67.However, this increase was not significant, as indicated by the value of p = 0.47 (p> 0.01).The results of observations and interviews found that many things inhibited the development of self-acceptance.Feeling depressed, receiving unfavorable treatment, lack of support, verbal aggression or words that discourage selfconfidence to make children feel different and less valuable, physical assault, bullying, tendency to withdraw and shy away from the public were obtained at the orphanage.The absence of motivation to learn and loss of passion for school.Anger and aggressive behavior are often expressed by unsympathetic behaviors of caregivers, friends, parents, and others.
The subjects suffer from a tremendous lack of social support that could motivate them to keep trying.The judgments people often make on orphans made them feel worthless, different from others, incapable, and less confident, causing them to have difficulty to adapt and think.That condition also causes them to feel awkward socializing and feels unwelcome in a social environment.
They find it very difficult to accept the circumstances that exist within themselves.This is because they feel different from other friends with parents who are always there to support, advise and cherish them.Parents who would provide loving support and attention and fulfillment of material needs.They feel unwanted because his or her parents are gone, their hope for building a career seems hopeless, and their dream for success also falters.

DISCUSSION
Self-acceptance is formed through a process that involves several supporting factors.These supporting factors include the environment, peers, and parents [29].This implies that caregivers and peers play a critical role in the formation of self-acceptance.
This study reveals that caregivers/adults have an enormous role in the development of self-acceptance of adolescents in the orphanage.A few positive or negative affirmations could greatly affect the thinking of the orphaned teenagers relating to themselves as well as the thoughts of others regarding themselves.Hurlock [29] suggested several conditions play a role in the acceptance of one's self, which are: Self-understanding a.
Realistic expectations b.
Free from social barriers c.
A pleasant social behavior d.
A stable self-concept e.
A pleasant emotional state f.
Cognitive behavioral therapy aims to reconstruct false beliefs and replace it with a positive mindset that affects the emergence of positive emotion and self-confidence, resulting in a more adaptive behavior.According to Maslow [30] individuals with a positive attitude towards themselves will be able to accept their condition calmly with all their strengths and weaknesses.Positive reinforcement is associated with a positive view of themselves from their environment (i.e., orphanage, school, or neighborhood).
Cognitive behavioral therapy has been extensively tested, with the first study being published in 1977 [21].More than 500 studies have shown positive results of cognitive behavioral therapy for a variety of psychiatric disorders, psychological problems, and medical conditions with psychological components [31,32].Studies have shown the effectiveness of cognitive behavioral therapy in the community [33,34].Some researchers have pointed out that there are neurobiological changes associated with cognitive behavioral therapy for the treatment of various disorders [35].Hundreds of research studies have also validated the cognitive therapy model for depression and anxiety (Clark and Beck, 2010).Cognitive behavioral therapy suggests that dysfunctional thinking (which affects mood and behavior) is common to all psychological disorders.Cognitive processes associated with dysfunctional thinking is what gives rise to negative feelings and maladaptive behavior that can cause psychological disorders.As individuals continue to learn to be more realistic and adaptive, they will experience a much-improved feeling and behavior [21].

CONCLUSION
Kuntari [36,37] stated that there were many negative incidences in the orphanage, unhealthy treatment will cause trauma that affects individuals' pathological personality formation.Parenting style is very influential in a child's psychological development.There is a general agreement among researchers that children placed in an orphanage since an early age and for an extended period are greatly at an increased risk of developing serious pathological conditions later in life [38].The parenting style of the caregivers will influence the psychological development of the child if they continue to stay at the orphanage.Good and accurate parenting style coupled with excellent social support is needed for the psychological development of orphanage children.
The rules applied at the orphanage should not hinder the task of child development but instead, be adapted to the conditions.The rules are used to harmonize life at the orphanage so that it can be harmonious.However, when the effect of the given rules gives adverse effects, for example, inhibits the activity associated with the development of a child's talent or social relationships with the environment, it may cause harm to the development of the child.
CBT is instrumental in improving self-acceptance of adolescents in the orphanage.The level of self-acceptance after receiving CBT was greater than the standard of self-acceptance before getting CBT.Based on the partial eta squared, it is known that the magnitude of CBT's contribution in improving self-acceptance in adolescents is 68.6%.This number suggests that CBT can increase self-acceptance.CBT emphasizes on the core beliefs that an individual has about themselves, their world, and others.Modification of their dysfunctional beliefs will result in a change for the better.For example, looking at them in a more realistic view.Everyone has strengths and weaknesses.This fact can modify the individual's perception of his/herself.Thus, it is expected that there will no longer be words such as, "I cannot do it," "I cannot succeed," "I am different," "I am not wanted," "I am not useful," "nobody needs me."Conversely, if they made a mistake they will think, "I can if I have the will", "I'll be successful because everyone has a right to if we just make an effort", "everyone has the same rights", "All living people will definitely be something, have hope, and capabilities", "I have my unique purpose in life, as do everything else on earth "," I was created because someone needed me", and "I have the ability, and I will prove it".Good parenting will provide positive affirmation to the orphans' condition, support everything they do so long as it does not break any norms or rules, praise their success, and educate them to always think positively about themselves regardless of their condition.They will also provide positive words to help the orphans to accept their condition, feel confident, and able to develop their potentials to reach optimal growth.Caregivers are expected to provide additional lessons on life, social support, and positive thinking that could sustainably support the stimulation that CBT has given to increase adolescents' self-acceptance.Future research is expected to provide intervention over a longer period, on an ongoing basis and across all ages.Also, further research may consider other factors that may affect self-acceptance such as emotional states, stress coping, peer social support and others.

Table 3 ,
the effective contribution of Cognitive Behavior Therapy in improving self-acceptance, can be seen from Wilks' Lambda table column of 0.686, which means that Cognitive Behavior Therapy gives an effect of as large as 68.6% in adolescent's self-acceptance.