Reducing Intolerance of Uncertainty through Happy Spiritual Intervention Using FAMCY (Family Heart Connection)

Families of patients with violent behavior may experience mental health issues, such as stress due to the prolonged period of patient care and the heavy burden of caregiving, leading to feelings of uncertainty. Uncertainty about the disease becomes more pronounced as individuals confront it for extended period, making one’s life more unstable. The state of intolerance to uncertainty is closely related to the patient’s tendency for violent behavior which is difficult to predict. This study aims to investigate the effect of happy spiritual intervention on intolerance of uncertainty in families of patients with violent behavior. This study used a pre-posttest quasi-experimental design with a control group. Purposive sampling was utilized to recruit 50 respondents who were divided into two groups. The intervention group received six sessions of happy spiritual intervention using the family heart connection (FAMCY) application which included guidelines for implementing the therapy. The collected data were analyzed using a t-test to analyze the effect of the happy spiritual intervention on intolerance of uncertainty in the patient’s family. The results indicated a significant difference in intolerance of uncertainty between the two groups after the intervention was administered (p = 0.001). The intervention group exhibited a lower mean value (70.44) in comparison to the control group (80.44). The happy spiritual intervention has a significant effect on reducing intolerance of uncertainty in families dealing with violent behavior.


INTRODUCTION
Individuals with violent behavior often experience emotional disturbances and have social and financial issues for treatment that affect their families.Caring for patients with violent behavior can be an overwhelming responsibility.Families of patients with violent behavior often face multiple challenges such as caregiving burden, emotional strain, financial burden, uncertainty about the progression of the disease, and social stigma within society (Rosyanti & Hadi, 2021).
Uncertainty can manifest as feelings of anxiety and depression (Rettie & Daniels, 2021).Intolerance of uncertainty involves experiencing negative emotions, cognitions, and behaviors (Birrell, Meares, Wilkinson, & Freeston, 2011).This reaction suggests that worried individuals may find it challenging to deal with uncertain situations as they tend to interpret them negatively.Therefore, adopting an adaptive coping response is required to deal with uncertainty (Rettie & Daniels, 2021).
Increasing positive coping in families of patients with violent behavior can be achieved through various approaches, one of which is spiritual care.Additionally, families may benefit from interventions aimed at addressing uncertainty, such as mindfulness therapy (Epstein, 2021).Mindfulness therapy promotes open discussion between patients and healthcare providers to address uncertainties about illness, plan follow-up care, and make treatment decisions.However, this intervention does not directly address managing negative emotions in patients or families when dealing with uncertainty.On the other had, the happy spiritual intervention, as a spiritual-based therapy, aims to help families overcome intolerance of uncertainty through acceptance as a positive coping strategy; this intervention enables families who care for patients find happiness amidst the challenges they face (Dwidiyanti & Munif, Panduan Praktis Happy Spiritual, 2022).Therefore, it is necessary to implement a happy spiritual intervention as an alternative therapy.
Families dealing with violent behavior experience intolerance of uncertainty, leading to emotional distress.To address this challenge, implementing a spiritual-based therapy, such as happy spiritual intervention becomes crucial.Happy spiritual therapy can be independently performed by the family, and the Family Heart Connection Caring System (FAMCY) application can serve as a valuable companion in this spiritual healing.With this application, families can adequately access information about uncertainty, stress, depression, and self-efficacy.It also provides guidance for practicing the therapy.By utilizing the FAMCY application, it is expected that emotional bonds within families can be strengthened to foster forgiveness, support and prayers among family members (Dwidiyanti and Team, 2022).
This study aims to investigate the effect of the happy spiritual intervention using the FAMCY application on intolerance of uncertainty in families of patients with violent behavior at RSJD Dr. Amino Gondohutomo Semarang.

Overview of the happy spiritual intervention
The happy spiritual intervention is a therapeutic practice that focuses on clearing negative emotions stemming from unresolved past events.These emotions are cleared through the divine guidance and support of Allah or God Almighty.With this intervention, individuals or families of patients with violent behavior are expected to be able to regulate their emotions and feel happy and contented with what is happening in their lives.This therapy involves guiding participants through nine core stages, including setting intention, self-evaluation, repentance, acceptance, prayer, body scan, detoxification, relaxation, and cultivating trust (Dwidiyanti & Munif, Panduan Praktis Happy Spiritual, 2022).
The happy spiritual intervention is not limited to individuals with Islamic background; it is open to individuals with other religious or belief backgrounds.The ultimate goal of this intervention is to enable individuals to effectively regulate their emotions and feel happy with whatever happens in their life.Mindful individuals accept the conditions they experience gracefully; they will do things with full awareness and try to improve their ability to solve problems (Dwidiyanti, Fahmi, Ningsih, Wiguna, & Munif, 2019).
In families with patients exhibiting violent behavior, intolerance of uncertainty is commonly experienced, making nursing interventions crucial in managing uncertainty and mitigating negative outcomes for family caregivers (Assa & Umberger, 2022).Uncertainty can be managed by coping strategies, including assessing danger, seizing opportunity, coping, and adaptation.Addressing dangerous situations involves enganging activities that aim to reduce uncertainty and effectively manage emotions to create opportunities that generate positive outcomes, specifically in the form of adaptation (Smith & Liehr, 2018).living with patients for more than five months.The selection of respondents was done using a purposive sampling technique.This study included a total sample of 50 respondents, with 25 assigned to the intervention group and the remaining 25 to the control group.

Research Instruments
In this study, the Intolerance of Uncertainty Scale (IUS), consisting of 27 questions with a score of 1-5, was used to measure the respondent's intolerance of uncertainty.

Intervention
The intervention group was given the happy spiritual therapy for six sessions using the FAMCY application.This application could be used by the respondents as a guide in implementing the happy spiritual therapy independently.The researchers monitored the respondents in carrying out the therapy through Whatsapp (WA) chats and recapped their independent interventions.The post-test was conduucted after the respondents completed the intervention.
The FAMCY is a patient and family companion application that offers spiritual interventions to improve the ability to manage emotions in the face of uncertainty, reduce stress, alleviate depression, and increase self-efficacy.The main purpose of using the FAMCY application is to improve emotional bonds among family members, so that they can forgive, support and pray for one another.The following features are available in the FAMCY application: To access FAMCY, users require a login session first.If they do not have an account yet, they can "Register" by filling in their identity.On the other hand, if they already have an account, they can immediately "Log in" by entering the registered username and password.

Figure 2.
After successfully logging into the application, users can take advantage of available features, such as About FAMCY, Education, and Spiritual Practice.About FAMCY feature contains the description and purpose of the application.Meanwhile, the Education feature contains information about uncertainty, stress, depression, and self-efficacy.

Figure 3.
The Spiritual Practice feature contains a comprehensive guide for users to perform happy spiritual exercises independently.Each is accompanied by a backsound to enhance the user experience and background music to create a relaxed atmosphere (Dwidiyanti and Team, 2022).

Data collection
Respondents were asked to fill out a pre-test questionnaire prior to the intervention.Furthermore, the happy spiritual intervention was administered through the FAMCY.The post-test was carried out after the respondents completed the intervention.

Data analysis
Both univariate and bivariate analyzes were used in this study.Univariate analysis was conducted to analyze intolerance of uncertainty in families with patients at risk of violent behavior, including mean, mode, median and percentage.Meanwhile, bivariate analysis was used to find the effect of the intervention on intolerance of uncertainty using Mann-Whitney test.

Ethical Considerations
This research was approved by the Health Research Ethics Committee (KEPK) of RSJD Dr. Amino Gondohutomo, Central Java Province with reference number 420/09624 dated 15 June 2022.1 shows the results of the Mann-Whitney test, revealing a U value of 141 and a p-value of 0.001, which is less than the significance level of 0.05.This result indicated a significant effect of happy spiritual intervention on intolerance of uncertainty in families of patients with violent behavior.

DISCUSSION
The results of the study revealed a significant difference in intolerance of uncertainty among families of patients with violent behavior after implementing the therapy in the intervention group.In other words, the implementation of the happy spiritual intervention reduces intolerance of uncertainty in families of patients with violent behavior.Overall, the results of this study indicate that the happy spiritual intervention equips families of patients exhibiting violent behavior with improved emotional regulation, thereby reducing feelings of fear, shame, and worry about uncertainty concerning the course of the disease.
The decrease in intolerance of uncertainty can be influenced by several factors, namely antecedents of uncertainty.These anticedents consist of stimuli or events that determine and influence an individual's assessment of uncertainty.The stimuli come from symptom pattern (perceived disease symptoms), event familiarity (experiencing unfamiliar health services leading to discomfort), and event congruency (instability of the disease being suffered).In addition, cognitive capacity (an individual's ability to interpret an event) and structure providers, including education (health education which can influence the assessment of the level of uncertainty), also play a role in shaping the level of uncertainty experienced by individuals (Smith & Liehr, 2018).
The happy spiritual intervention guides individuals to attain a state of awareness, enabling them to express their intentions and desires of the heart, thus clearing negative emotions and feelings.Through these intervention exercises, individuals are expected to better manage their emotions, leading to an increase in cognitive capacity (the ability to interpret events) and a greater ability to accept and find happiness in whatever life events unfold (Dwidiyanti & Munif, Panduan Praktis Happy Spiritual, 2022).In families with patients exhibiting violent behavior, intolerance of uncertainty becomes a prominent challenge, necessitating nursing interventions to play a crucial role in managing this uncertainty and mitigating negative consequences for family caregivers (Assa & Umberger, 2022).Uncertainty can be managed using coping strategies, including assessing danger, seizing opportunity, coping, and adaptation.Overcoming dangerous situations involves engaging in activities that aim to diminish uncertainty and effectively manage emotions; by doing so, individuals can create opportunities that lead to positive outcomes, specifically in the form of adaptation (Smith & Liehr, 2018).
Previous research highlights that a spiritual approach can significantly impact the family health belief model in cases involving patients with violent behavior.Families experience changes in their perceptions about benefits, obstacles and self-efficacy.Families of patients with violent behavior remain confident and believe that all events that happen to them are parts of God's plan; they want patients to be more independent from their previous conditions, and hold the belief that mental disorders can be recovered, leading to improved patient conditions (Yusuf, 2013).
In this study, the underlying theory aligns with the core principles of the happy spiritual intervention, emphasizing the resolution of distressing emotions arising from individual experiences that evoke sadness or discomfort.This spiritualbased therapy seeks to empower families in overcoming intolerance of uncertainty through acceptance as a positive coping strategy, thereby enabling caregivers to find contentment in the face of their challenging circumstances facing (Dwidiyanti & Munif, Panduan Praktis Happy Spiritual, 2022).

RESEARCH LIMITATIONS
During the implementation of the study, certain limitations were encountered and acknowledged by the researchers.One significant limitation was the constraint of providing interventions to participants during patient visiting hours, which resulted in limited time availability for conducting the interventions.Due to the limited time available, the researcher was assisted by the facilitator to repeat time contracts with the respondents.

CONCLUSIONS AND SUGGESTIONS
The research findings demonstrate a significant effect of the happy spiritual intervention on intolerance of uncertainty in families of patients with violent behavior with a p-value of 0.001 (p<0.05).This study sheds light on the potential of the happy spiritual therapy to serve as an alternative intervention for families in providing care to patients with violent behavior.