RELIGIOUS AND SPIRITUAL THERAPY IN REHABILITATION OF PEOPLE WITH MENTAL ILLNESS IN ISLAMIC BOARDING SCHOOL

Rehabilitation for people with mental disorders (PMD) plays an important role in helping the healing process. Given the limited number of mental institutions, Islamic boarding schools participate in assisting in the handling of PMD. This study aims to: (i) Identify the religious activities conducted by Islamic boarding schools in the rehabilitation of PMD, (ii) Identify the benefits of spiritual therapy and religious activities in assisting the recovery of PMD. This is a mixed-method research conducted in three boarding schools that provide rehabilitation of the PMD in Yogyakarta, namely Nurul Haromain, Al Islamy and Tetirah Dzikir in February-March 2017. Data from 84 randomly selected respondents with mental disorders were collected using Daily Spiritual Experience Scale (DSES) and PSP (Personal and Social Performance) questionnaires to see the relationship between the spiritual level with changes in personal and social functions in PMD and analyzed using spearman rank correlation test. Qualitative data is conducted by Focus Group Discussion. Results show that there was a relationship between the spiritual level and changes in the personal and social functions of the PMD (p = 0.008; r = 0.286). In addition, most of the religious activities obtained by PMD were praying, reciting the Quran and dhikr. The perceived benefits of religious activities for the PMD were feeling healed from mental illness and the heart becomes more calm. Spiritual therapy in the form of religious activities has an important role for PMD in assisting healing and providing hopes. Activities and living in Islamic boarding schools may enhance PMD’s confidence and social function.


INTRODUCTION
According to national health survey (Riskesdas) in 2013, the prevalence of emotional mental disorder in Indonesia was 6%, while the prevalence of severe mental disorder were 1%. Since 2007-2011, Central Java Province experienced an increase in the prevalence of mental illness from 0.49% to 17.18% . Yogyakarta as one of the cities in Central Java ranks highest in the prevalence of severe mental disorder (Riskesdas, 2013). Data of Regional Mental Hospital (RSJD) Dr. Amino Gondohutomo Semarang showed that the number of inpatients was 3,914 people with 99% suffering from schizophrenia and emotional mental disorder (Lukitasari and Hidayati, 2013).
People with mental disorders (PMD) have various symptoms as a form of mental disorders ranging from disorders, such as psychosis (hallucinations and delutions), speech and behavioral disorders, loss of motivation and cognitive impairment (Moller, 2009;Townsend 2008). Stigma facing PMD in Indonesia is still very strong. The impact of stigmatization will lead to PMD experiencing social isolation, lack of life opportunities such as employment and social discrimination (Horrison and Gill, 2010).
Rehabilitation for PMD plays an important role in assisting the healing process. However, Mental Hospital (RSJ) as one of the rehabilitation institution for PMD has limited capacity, unable to match the increasing number of PMD every year (Kompas, 11 February 2012). Various rehabilitation institutions appear to overcome the problems of people with mental disorders. Islamic boarding school (Pondok Pesantren) which is established to forge Islamic religious knowledge also participate in providing service facilities for PMD through religious and spiritual coaching efforts.
Previous research has shown that rehabilitation at Islamic Boarding School is beneficial in assisting healing through worship activities conducted within the boarding schools (Rachman, 2013;Sari & Wijayanti, 2014). Activities include praying congregation, reading qur'an together, dzikr and individual coaching (Dahliyani, 2012). Research by Sari and Wijayanti (2014) through a qualitative approach with observations and interviews explores the experience of PMD spirituality and benefits while living in boarding school. The results show that the patient is spiritually closer to God by conducting routine religious activities and the patient gets healing from mental illness, symptoms management, behavior change, emotional change and attention to the future.
This study aims to identify religious activities conducted by boarding schools in Yogyakarta as a city that has the most prevalence of mental disorders in Central Java province in the process of PMD rehabilitation and to identify benefits felt by PMD patients so that it can be further developed by family, community, even hospital.

MATERIALS AND METHODS
This is a mixed-method research using quantitative and qualitative approach. This research was conducted in 3 Islamic boarding schools that provide rehabilitation to PMD in Yogyakarta, namely boarding school Nurul Haromain, Al Islamy and Tetirah Dzikir in Yogyakarta. The study was conducted in February-March 2017. This study was obtained ethical clearance from Faculty of Medicine, Gadjah Mada University.

Sampling
Respondents in the study included caregivers who were fully in charge of caring for PMD, boarding school board members, and PMD in the three boarding schools of Yogyakarta amounted to a total of 200 respondents. The PMD and caregivers were randomly selected from all PMD within the boarding schools from the list of PMD diagnosis obtained from caregivers. with inclusion criterias of age ≥18 years, in stable condition, and able to communicate. Based on this criteria, the sample of this study was 84 respondents. Based on the questionnaire, respondent were recruited for FGD yielded 5 respondents.

Data Collection
Data collection was performed by trained enumerators who were selected based on experience in nursing practice. Enumerators were trained by researchers for 3 days. Respondents received Informed Consent as a form of approval in the study which contains the intent and purpose of the study.
Data was collected using Demographic Data Questionnaire (KDD), Daily Spiritual Experience Scale (DSES), and Personal and Social Performance Scale (PSP). In addition, the study also used Focus Group Discussion (FGD).

Data Analysis
Data analysis was done by 2 processes, ie univariate analysis for frequency distribution of respondent characteristics (demographic data and clinical data), spirituality level of DSES and PSP. Bivariate analysis was performed to assess the correlation of DSES spirituality level with PSP by using spearman test. The result of FGD were analyzed by using thematic analysis.

RESULTS
There were 84 respondents with PMD who responded to the questionnaires. Table 1 shows that the average age of the PMD respondents were 38 years old. The majority of them were men (71.4%), and high school graduates (48.8%). Around a third (33.3%) of them did not work. Almost all respondents were Muslim (96.4%) and of Javanese culture (90.5%). Table 2 shows that the average PMD had been living in boarding school for 25.64 (2.76) months, the average admission to boarding school was 1.38 (0.92) times, the length of suffering from mental disorders was 25.90 (8.99) years on average, with the age of onsetat aged 27.76 (9.37) years old. They had been admitted to any mental institutions on average for 3.43 (4.37) times. The majority of the respondents had severe mental disorders (54.8%). Table 3 shows the 5 major spiritual therapies that were given to PMD during the stay at the boarding school. Most respondents claimed to have received praying therapy (24.2%) mostly for the reason to recover from the disease (36.3%). Most respondents felt healed from the symptoms of the illness (28.6%) after therapy. The most preferred treatment respondents were physical exercise (21%) and half of the respondents stated that they welcome all types of therapy (59.5%). Table 4 shows that the majority of respondents felt close to God (92.9%). Table  5 personal and social performance (PSP) scores the respondents had an average of 66.55 and most respondents fell on the category of having a clear disability (73.8%). Table 6 shows it was an association between the level of spirituality and PSP. The relationship between the level of spirituality with PSP in PMD were positively significant although not particularly a strongly associated (r=0.29, p = 0.01). The higher the spirituality of PMD the higher the score of Personal and Social Performance.

Qualitative Outcome Overview
Queries Results The importance of spirituality The closeness to God is important Prayer / therapy or worship activities Dzikir, tausiah, tarekat, ngaji / read Quran, dhuha prayer, night prayer Supported by family Get family support Bath Therapy Never had a bath therapy Interviews with PMD informants defined that spirituality or close to God was important. Close to Allah was described by the informant by feeling more calm and serene. "... close to God is very important because it all depends on God ..." (Respondent 1, male) ... proximity to God makes us feel at ease ...
(Respondent 2, male) The therapy obtained by informants during the boarding school dzikir, sermon, tarekat, ngaji / read Quran, morning prayer, and night prayer. Here's a statement from one of the informants: ... [I've been] taught to read Quran, taught about religion, tarekat, dhuha prayer, night prayer ...
(Respondent 1, male) During the stay in the boarding school some informants did not feel supported by their family because nobody paid them a visit. Others felt the support of their family and felt comfortable living in the boarding school. This is like the results of interviews conducted with informants obtained as follows: ... [I was] visited by relatives, they want to take me back home but I am not ready ...
(Respondent 1, male) The results of interviews conducted with all informants found that those in Al Islamy boarding school had never received bath therapy. The relationship between Spirituality with the PSP

DISCUSSION
Our study found that 76.2% PMD had closer proximity to God. This is in line with research conducted by Rohmatullah and Sari (2014) on the description of the level of spirituality in people with schizophrenia (PWS) in the Outpatient of Dr. Amino Gondohutomo Hospital, Semarang, which states that 52% of ODS had a high level of spirituality. In addition, the results of this study are similar to Swiss studies of 115 patients with schizophrenia that found that 45% of patients consider religion to be the most important element in their lives (Huguelet et al., 2011). This is also in accordance with previous research conducted by Rosmarin et al (2013), showing that of the 47 respondents surveyed, the majority (29 respondents) stated that religion was important to them.
This study also shows that the types of spiritual therapy obtained by PMD such as dhikr, prayer, and reading Qur'an were similiar to those reported by previous research such as Dahliyani (2012), Rachman (2013), Nusrotuddiniyah (2013) and Sarjana, Fitrikasari dan Sari (2015).
The activities at the boarding school and the closeness to God made PMD feel more calm and peaceful. This is in accordance with research from Sari and Wijayanti (2014) who explored the experience of PMD's spirituality and the benefits of living in boarding school for PMD which indicates that the benefits of spiritual healing of mental illness were on the management symptoms, behavior changes, changes in emotions and attention to the future.
In addition, the results of this study indicate that the spiritual and activities in Islamic boarding schools were perceived to make PMD recover from symptoms of mental illness. The results of the study were in accordance with previous research on psychiatric patients in boarding schools such as Dahliyani (2012), Rachman (2013), Nusrotuddiniyah (2013) and Sarjana, Fitrikasari dan Sari (2015) that spiritual therapy in boarding schools such as prayer and dhikr can help healing PMD. Spirituality has an important role for schizophrenic patients in assisting healing. This is in line with the research of Manami, Tuchman and Duarte (2010) that the positive form of the spiritual can be beneficial for individuals with mental illness including schizophrenia in particular can reduce symptoms and