The Effect of Acceptance and Commitment Therapy Islamic Approach on Self-Acceptance of Patients with Mental Disorder

: Mental disorders have different manifestations and symptoms but are generally characterized by some combination of disturbances of thought, perception, emotion, behavior, and impaired relationships with other people. Severe mental disorders, including schizophrenia, are prone to stigma. Good self-acceptance has a robust negative correlation with stigma. This study examines the effect of Islamic acceptance and commitment therapy (ACT) on self-acceptance in patients with mental disorders. The research method is quantitative with a semi-experimental pre-post-test. Respondents in this study were Thirty-one mental illness patients diagnosed with schizophrenia who were selected using a purposive sampling technique that met the criteria of being Muslim, having awareness and understanding of patients with mental disorders experienced in the good category, namely being aware of the disease experienced. The measuring instrument used in this study consisted of a demographic questionnaire and an Unconditional Self-Acceptance Questionnaire (USAQ). The study was conducted over a period of three months, with intervention times varying between one and three weeks for each patient. Results showed that ACT with an Islamic approach significantly increased self-acceptance in patients with mental disorders (P<0.001). ACT can be used as an effective intervention to increase self-acceptance in a patient with mental disorders.


INTRODUCTION
Mental disorder is a disease that affects thoughts, feelings, and behavior.Mental disorders have different manifestations and symptoms but are generally characterized by disturbances of thought, perception, emotion, behavior, and impaired relationships with others (WHO, 2019).The recovery process from this disease also varies depending on the type of mental disorder experienced.Some mental disorders that are classified as severe mental disorders that become common problems include depression, bipolar disorder, schizophrenia, and other psychotic disorders.Globally, it is estimated that 264 million people suffer from depression, 20 million people have schizophrenia, and about 45 million people have bipolar disorder worldwide.
Severe mental disorders, including schizophrenia, are prone to stigma.In one study, it was found that the prevalence of perceived stigma was high in people with schizophrenia, as much as 62.6%, and was significantly associated with female gender, age, the onset of schizophrenia, length of hospitalization, and duration of illness (Tesfaw et al., 2020).The stigma of mental disorders seen from the patient's point of view can lead to delays in patients gaining access to care and poor adherence to treatment and follow-up care (Sayed et al., 2021).
Good self-acceptance has a strong negative correlation with stigma (Maharjan & Panthee, 2019), so the thing that mental patients can do is accept conditions that they have mental disorders and commit to therapy to achieve healing.The illness you suffer can be a trial; if you succeed in accepting it can increase the degree of your faith.One therapy that can increase self-acceptance is the Acceptance and Commitment Therapy Islamic Approach.The principle of this therapy is to accept the current condition of a mental disorder and commit to achieving healing.In the teachings of Islam, endeavor and surrender are one of the efforts to achieve healing.

METHOD
The study employed a quantitative research approach, utilizing a quasi-experimental pre-post test design without a control group to assess changes in patient self-acceptance following therapy.The research was conducted during the period of April to June 2022.A purposive sampling technique was employed to select 31 participants diagnosed with schizophrenia who met specific criteria, including being Muslim, having insight into their condition, and possessing a good understanding of mental disorders.Exclusion criteria encompassed individuals who didn't attend therapy sessions or failed to complete the provided questionnaire.
Patients who fulfilled the established inclusion criteria received a comprehensive explanation of the research procedures.They were subsequently invited to participate as respondents by providing their consent through the signing of a consent form, a process overseen by a nurse.The ACT Islamic approach was individually administered to each eligible patient.The ACT therapy encompassed four distinct sessions, structured according to a therapy module/workbook: 1. Session I: Delved into exploring distressing events or encounters experienced by the patient.2. Session II: Focused on examining the patient's reactions to these distressing experiences.3. Session III: Collaboratively identified the repercussions of the patient's responses to distressing events.This stage involved practicing acceptance through an Islamic lens, involving surrender to Allah about the experienced incidents.4. Session IV: Centered on recognizing the patient's inherent values and discussing strategies for committing to and striving for therapy, thereby working towards healing and achieving acceptance objectives grounded in Islamic values.
Each patient received a series of four therapy sessions, with the interval between sessions varying between one to three weeks.For ethical considerations, the researcher provides complete information about the objectives and benefits of the study, gives freedom to the patient to decide whether or not to participate, and maintains the confidentiality of the data of the respondents who participated in this study.In addition to applying ethical principles, this research has also received ethical approval from the Health Research Ethics Committee of UIN Alauddin Makassar with the number C.75/KEPK/FKIK/II/2022 Health Research Ethics Committee UIN Alauddin Makassar.
Researchers at Dadi Hospital in South Sulawesi Province conducted the therapy sessions.Before and after therapy, patients were given a questionnaire to assess the patient's self-acceptance.The Unconditional Self-Acceptance Questionnaire (USAQ) (Chamberlain & Haaga, 2001).USAQ is a questionnaire used to assess the self-acceptance of patients with mental disorders.The USAQ consists of 20 questions with seven answer options: Strongly Not Appropriate, Not Appropriate, Slightly Not Appropriate, Neutral, Somewhat Appropriate, Appropriate, and Very Appropriate.USAQ has 9 positive/favorable statements and 11 negative/unfavorable statements.On a positive statement, a score of 1 is given if the answer is almost always untrue, a score of 2 is Usually untrue, a score of 3 is More often untrue, a score of 4 is Neutral, a score of 5 is more often true, a score of 6 is Usually true, a score of 7 is Almost always true.In negative statements, if the patient answers Almost always true, then a score of 1 to 7 is given if the answer is almost always untrue.The score of the assessment results varies with a range of 20-140, with a higher total score indicating high self-acceptance (Davies, 2008).
The USAQ instrument has been widely used to measure self-acceptance.Cronbach's alpha value (α) is in a good category with acceptable internal consistency, so the instrument is feasible.Research that uses the USAQ instrument includes the research of (Chamberlain & Haaga, 2001), obtaining a value of = 0.72 with 107 participants, and the results of the instrument reliability test obtained a value of = 0.84 with 300 participants (Rahayu, 2017).
Subsequently, the collected data underwent analysis, encompassing univariate examination through the frequency distribution of patient demographic information.Bivariate analysis was conducted utilizing paired t-test analysis to ascertain disparities in patient self-acceptance pre-and post-therapy.

Characteristics of respondents
Distribution of characteristics of patients with mental disorders at Dadi Hospital in South Sulawesi province (n=31) are shown in Table 1.  1 presents the mean age of participants as 37 years, ranging from a minimum age of 22 to a maximum of 49 years.A significant portion, specifically 12 respondents, possess a high school education.The predominant gender among the participants is male, and a notable proportion of them are unmarried.On average, respondents have undergone treatment within the hospital setting approximately four times, with the minimum number of admissions being one and the maximum being 19 instances of hospitalization in mental health facilities.Table 2 illustrates the assessment of patient self-acceptance both before and following the administration of ACT therapy using an Islamic approach.The evaluation encompasses 20 distinct elements of self-acceptance, derived from the USAQ standard instrument, employing a seven-point scoring scale.Specifically, a score of 1 corresponds to responses indicating "almost always untrue."In contrast, a score of 2 represents "usually untrue," a score of 3 corresponds to "more often untrue," 4 signifies a neutral response, 5 denotes "more often true," 6 corresponds to "usually true," and finally, 7 indicates "almost always true.".The cumulative score falls within the range of 20 to 140, reflecting the extent of self-acceptance.A higher total score signifies a heightened level of self-acceptance in respondents before implementing ACT therapy.The respondents' average responses vary between 2.42 and 5.61, signifying instances where their perspectives either do not align with the given statements or agree with them.Statement number 8 emerges as a component indicating discordant views, wherein respondents do not establish personal goals as a source of happiness.Conversely, statement number 15 is an illustrative case where respondents exhibit alignment with the statement, as they perceive successful individuals in their endeavors as highly esteemed.

The level of self-acceptance of patients with mental disorders before and after giving ACT using an Islamic approach
Upon examining the aggregate responses of the respondents, the calculated mean score amounts to 3.91, which can be approximated to 4. This score reflects a neutral stance adopted by the average respondent concerning their self-acceptance level before applying ACT therapy through an Islamic approach.The overall cumulative score averages at 78.23, leading to the inference that the self-acceptance level before undergoing ACT therapy remains comparatively modest.
The level of self-acceptance of patients with mental disorders after giving ACT therapy using an Islamic approach, the mean value of respondents' answers ranges from 3.00 to 6.84, which indicates the meaning of the respondent's condition, which is somewhat inconsistent with the statement.A respondent's condition is also very in accordance with the statement.The component that indicates the condition is somewhat inappropriate is statement number 8; the respondent does not set goals for himself in the hope that it makes him happy.The component that shows the appropriate condition is statement number 11; the respondent believes himself to be useful because the respondent is a human.
Upon holistic examination of the collective responses from the participants, the calculated mean score equates to 4.81, approximating to 5.This score signifies a partial alignment exhibited by the average respondent concerning their self-acceptance level after receiving ACT therapy through an Islamic approach.The comprehensive cumulative score averages 96.23, indicating that the selfacceptance level after the administration of ACT therapy is relatively elevated.
2. The effect of ACT using an Islamic approach on the level of self-acceptance of patients with mental disorders 3 The effect of ACT therapy using an Islamic approach on self-acceptance of mental patients (n=31)

*paired sample t-test
Table 3 showcases the impact of employing ACT therapy with an Islamic approach on the selfacceptance levels of individuals dealing with mental disorders.The results derived from statistical analyses exhibit ACT therapy's significant and positive influence on enhancing self-acceptance among mental health patients (p<0.05).This conclusion supports the observed rise in the mean self-acceptance score, which increases from the pre-test to the post-test phase, displaying a notable difference of 18 points.Consequently, it can be deduced that the application of ACT therapy, rooted in an Islamic framework, has the capacity to amplify the self-acceptance quotient in patients grappling with mental disorders by an increment of 18 points.For instance, if we consider individuals who initially held a selfacceptance score of 78.23 before undergoing therapy, their score would elevate to 96.23 following the implementation of ACT therapy, indicating a transformation from low to high self-acceptance levels.

DISCUSSION
Characteristics of patients with mental disorders in this study included age, gender, education, marital status, and the number of hospitalizations.The average age of the respondents in this study is 22-49 years old, included in the category of young and middle adults.Globally, the onset of the first mental disorder occurs in individuals before the age of 25 years, as much as 62.5% (Solmi et al., 2022).Conditions that include symptoms of psychosis most often appear in late adolescence or early adulthood, with symptoms in the form of hallucinations or delusions (WHO, 2021).
The investigation findings depict that, before undergoing ACT therapy, the collective average score of respondents' responses indicated a score of 3.91, signifying a neutral stance taken by the average respondent.The aggregated total score reflected an average of 78.23, indicative of a relatively limited degree of patient self-acceptance.Subsequently, following the application of ACT therapy employing an Islamic approach, the comprehensive average score of respondents' answers revealed a score of 4.81, denoting a partial alignment with the self-acceptance level.The overall cumulative score exhibited an average value of 96.23, underscoring a heightened level of self-acceptance after receiving ACT therapy with an Islamic approach.
The results showed a significant difference in the patient's self-acceptance before and after giving ACT with an Islamic approach.Based on the findings, it can be concluded that ACT leads to increased self-acceptance of patients with mental disorders.The implementation of ACT in this study is intended to help patients with mental disorders use psychological acceptance as a coping strategy in dealing with stressful situations experienced both internally and externally that are not easy to overcome.This aligns with the findings (Daneshvar et al., 2019) that using the ACT approach to strengthen the patient's abilities, beliefs, emotions, and emphasis on patient values can increase the sense of worthiness and self-efficacy in coping behaviors against cancer.Constructive coping used by the patient can also increase this acceptance, which can affect general health.In one study, it was found that ACT also significantly improved general health and decreased aggressiveness in psychotic patients (Ghouchani et al., 2018).
According to Hayes et al., more than half of the changes in depressive symptoms result from a lack of acceptance and willingness.An essential ACT process is dealing with clarifying one's values.Values are intrinsic reinforcement, which provides a chosen direction for a person's behavior and actions despite facing obstacles.Patients may be unaware of their values when faced with a stigmatized mental illness.Therefore, helping individuals clarify their values and valuable life domains motivates them to go beyond and actively deal with adversity, including stigma and discrimination.By clarifying values and goals, patients will understand that accepting people's thoughts and feelings about their illness helps them engage in behaviors that comprise their values rather than struggling with these thoughts and feelings.So, even though their activities are limited due to mental disorders, they can still carry out activities that are considered valuable, such as communicating with others, helping each other during hospitalization, and carrying out religious and spiritual activities.This is in line with research conducted by (Gul & Aqeel, 2021); ACT interventions are efficacious in reducing stigma and shame in the substance use disorder group.
Active involvement in valuable life domains leads to increased self-acceptance.The application of the ACT to psychotic patients with a history of trauma showed that the severity of psychosis and anxiety symptoms decreased during treatment.The participant's ability to regulate emotional reactions to receive trauma increased.This study also found that treatment involvement increased in seeking help for those in the ACT group compared to controls (Spidel et al., 2018).ACT can also be used by Educators of Children with Special Needs to increase educator self-acceptance, although not significantly (Barida & Widyastuti, 2019), and was found to increase self-efficacy in stroke patients (Ismoyowati & Adiyasa, 2021).In the perspective of Islam, self-acceptance is part of the study of qona'ah.Qona'ah is a feeling of pleasure and satisfaction with the distribution of sustenance that Allah Ta ala has given.The nature of qona'ah is one of the characteristics that indicate the perfection of faith because this trait shows the pleasure of the person who has it towards all the provisions and destiny of Allah, including in terms of the distribution of sustenance (Permatasari & Gamayanti, 2016)

CONCLUSION
ACT using an Islamic approach has a significant effect on the level of self-acceptance of patients with mental disorders.Nurses need to apply ACT using an Islamic approach as a modality of therapy for patients with mental disorders

Table 2 .
Level of self-acceptance of patients with mental disorders before and afterACT (n=31)