Psychotherapy Reduces Self Esteem Scizophrenic Patients: Literature Review

Received 13 February 2021 Accepted 4 August 2021 Published 5 September 2021 Low self-esteemis all the thoughts, beliefs and beliefs that an individual knows about him self and affects his relationships without hers. This study aims to determine what interventions can be given to over come chronic low self-esteem problems. The method used in this research is descriptive review by conducting literature reviews both from with in and outside the country. Literature searches were carried out through several data bases, namely Google Scholar, Pubmed, and Science Direct. The strategy used to search the literature is to use the keyword "chronic low self-esteem, psychotherapy, schizophrenia/schizophrenia". Based on the search, we found 839. 112 articles, but after filtering the articles peryear, the complete articles and the suitability of keywords and article contents, it became 10 articles. Based on the result soft he study, it can be concluded that several interventions that can begiven to reduce chronic low self-esteem in patients with early psychotic symptoms and schizophrenia are CBT (Cognitive Behavior Therapy), EMDR (Eye Movement Desensitization and Reprocessing). GAT (Group Activity Therapy). Perceptual stimulation; told, therapyas usual (TAU) and Competitive Memory Training (COMET). Family involvement as care giver at home in the process of psychotic patient therapy can help the patient's recovery process. Keyword:


INTRODUCTION
According to Fajariyah (2012) low self-esteem is an assessment of self-achievement by analyzing how far behavior is in accordance with self-ideals. Prolonged feelings of worthlessness, insignificance and inferiority due to negative evaluation of oneself and one's abilities. Low selfesteem is all thoughts, beliefs and beliefs that constitute an individual's knowledge of himself and affect his relationships with others. Self-esteem is formed at birth but is learned as a result of a person's unique experiences in himself, with the closest people and with the reality of the world (Stuart, 2006).
Low self-esteem disorder is a negative self-evaluation and feelings of self or ability that can be expressed directly or indirectly (Townsend, 2001). Low self-esteem is a prolonged feeling of worthlessness, insignificance and inferiority as a result of a negative evaluation of oneself and one's abilities.
There is a feeling of losing self-confidence, feeling like a failure because he is unable to achieve his own ideal (Keliat, 2009). According to Sheila & Videbeck (2011), low selfesteem disorder is a person's negative assessment of self and ability, which is expressed either directly or indirectly. It can be concluded that low self-esteem is a lack of self-confidence which can lead to negative feelings for yourself, your abilities and others. Which results in a lack of communication with other people.
Every change in life situations, both positive and negative, can affect physical, mental and psychosocial balance such as conflicts experienced so that it has a huge impact on one's mental health, which means that it will increase the number of mental patients (Keliat, 2011) Mental disorders are a manifestation of a form of behavioral deviation due to emotional distortions so that irregularities and behavior are found. This happens because of the decline in all psychological functions (Muhith, 2011).
According to (Herman, 2011) mental disorders are disruption of a person's mental or psychological condition influenced by self and environmental factors. Matters that can affect human behavior are heredity and constitution, age and sex, physical condition, psychological conditions, family, customs, culture and beliefs, occupation, marriage and pregnancy, loss and death of loved ones, feelings of enmity between relationships. human.
Mental disorders cause the patient to be unable to properly assess the reality, unable to control himself to prevent disturbing others or self-destruct, so mental nursing care is needed. The phenomenon of mental disorders is currently experiencing a very significant increase, and every year in various parts of the world the number of people with mental disorders increases. Research by the World Health Organization (WHO) or the 2014 World Health Organization shows that no less than 450 million sufferers experience mental disorders, about 10% of adults have mental disorders at this time, 25% are estimated to have mental disorders at a certain age.
Mental disorders, which reach 13%, are likely to develop 25% by 2030. According to WHO, mental disorders are found as many as 450 million people in the world consisting of 150 million depression, 90 million substance and alcohol use disorders, 38 million epilepsy, 25 million schizophrenia, and nearly 1 million commit suicide at the Poltekkes Kemenkes Padang every year, and nearly ¾ of the global burden of neuropsychiatric disease is found in low and middle to low income. According to Riskesdas (2013), the number of mental patients in Indonesia is 236 million people with mild mental disorders, 6% of the population and 0.17% suffer from serious mental disorders, 14.3% of them experience pasung. It is recorded that 6% of the population aged 15.24 have mental disorders.
Mental disorder which is a major problem in developing countries is schizophrenia. Schizophrenia is a disease that affects the brain and causes strange and disturbed thoughts, perceptions, emotions, movements and behaviors. Schizophrenia develops gradually and the client does not realize that something is wrong in his brain for a long time. It is this gradual deterioration that eventually becomes acute schizophrenia. Schizophrenic period acute is a disorder that is brief and powerful, which includes distortion of the mind (delusions), and failure to think, and low self-esteem (Yosep, 2011).
Low self-esteem is a negative feeling towards oneself, loss of self-confidence, failure to achieve goals that are expressed directly or indirectly. Low self-esteem is all thoughts, beliefs, and beliefs about himself and influencing others. Self-esteem is not formed from birth, but is learned from a person's unique experiences in himself, with those closest to him, and with the environment (Stuart, 2013). According to (Keliat, 2011) the signs and symptoms of low self-esteem are self-criticism, feelings of inadequacy, a pessimistic view of life, decreased productivity, rejection of one's abilities.
In addition to the above signs and symptoms, one can also observe the appearance of a person with low selfesteem who seems less self-conscious, dressed untidy, decreased appetite, does not dare to look at the other person, looks down more and speaks slowly in a low tone of voice. Patients with low self-esteem are at risk of developing other mental problems if they are not immediately given proper therapy, because patients with low self-esteem tend to shut themselves up and be alone, this habit that triggers the problem of social isolation. Social isolation causes patients to be unable to focus their attention which causes voices or whispers to appear, causing hallucination problems, other problems that then occur are the risk of violent behavior, a feeling of disrespect for something because they feel humiliated by someone or a whisper that incites to take action to damage the environment and injuring others (Direja, 2011).
The role of the nurse to solve client problems with low self-esteem is to identify the abilities and positive aspects that the client still has, to help clients assess the abilities that can still be used, to help clients to select / determine the abilities to be trained and to train the abilities chosen by the clients and to help patients develop schedule for implementing the skills being trained (Prabowo, 2014). Family as the main support system also has an important role in helping patients increase their self-esteem (Dermawan, 2013).
Actions and family roles that can be taken to help solve client problems according to Yosep (2014) include encouraging patients to express their thoughts and feelings, provide activities according to the patient's abilities, set real goals, help clients reveal some plans to reveal problems, and help clients express efforts. that can be used in dealing with problems.
The results of research by Suerni, Titik et al (2013) in the Yudistira room Dr. H. Marzoeki Mahdi Bogor in 2013, of the 60 patients treated there were 35 patients (58.33%) with low self-esteem. Nursing actions that are given to clients are the professional nursing approach model (MPKP). Nursing measures taken were generalist therapy to 35 patients (100%), generalist therapy and cognitive therapy to 15 clients (42.48%) and a combination of generalist therapy, cognitive therapy and family psychoeducation to 20 clients (57.14%). Based on the annual report obtained from the medical record of the Nanggalo Puskesmas, the number of mental patients with schizophrenia who went to the Nanggalo Puskesmas from January to November 2017 was 106 people, with the number of each Kelurahan, namely Kelurahan Surau Gadang 65 people, in Kurao Pagang Village 36 people and 5 people in Gurun Laweh Village.
The number of Schizophrenia patients who experience low self-esteem at the Nanggalo Puskesmas is 13 people. 8 people from Surau Gadang Village, 4 people from Kurao Pagang Village, and 1 person from Gurun Laweh Village. The results of interviews conducted by the author to 2 chronic low self-esteem patients who went to the Nanggalo Public Health Center, the patient felt insecure because he did not have the ability, the patient felt that there was no one to help him because he felt that other people did not understand the problems he was facing. Patients feel isolated and uncomfortable with their families and the environment because there are many conflicts in the family. Patients also feel ashamed of their environment because they are often laughed at as crazy. The results of the author's interview with the holder of the mental program at the Nanggalo Community Health Center, the action given to patients who visit the Nanggalo Community Health Center is the provision of an Implementation Strategy and medical treatment, however, the provision of strategies implementation to chronic low self-esteem patients is not done optimally, the nurse does not provide Implementation Strategies to patients regularly when the patient visits. In West Java Province, patients with mild to severe mental disorders reached 465,975 people, up 63% from 2012 with 296,943 sufferers.
Therefore, based on several studies and phenomena found in patients with problems with low self-esteem disorders, nurses as health workers and nursing care providers can provide interventions that can be used by patients with low self-esteem problems. This study aims to determine what interventions can be given to overcome chronic low self-esteem problems.
The title of the article should reflect the essence of the content of a paper. The title should accentuate the phenomenon (object) studied, not the method and activities (projects). The title is informative, specific, useful and a maximum of 14 words. If the author of more than one person and work at the same institution, then the inclusion of one address has been considered sufficiently representative of other authors address.

METHOD
This study uses a literature study approach with a descriptive review type that aims to identify, assess and interpret all findings related to the research topic, in answering research questions, which have been predetermined. The data used in this research is secondary data from several national and international scientific articles. The data used is secondary data from several national and international scientific articles from 2010 -2020. The resource bases used are GoogleScholar, Pubmed, and Science Direct. The strategy used to search the literature is by using the keyword "chronic low self-esteem, psychotherapy / psychotherapy, schizophrenia / schizophrenia".
" while the keywords in English are "chronic low selfesteem, psychotherapy, schizophrenia". The results showed that CBT was effective in improving the cognitive abilities of low self-esteem clients who took CBT compared to low selfesteem clients who did not take CBT. This is because CBT is a form of psychotherapy that can increase self-esteem in schizophrenic clients.
In this study, cognitive behavior therapy was carried out in five sessions, namely, Session 1: Expressing feelings, negative automatic thoughts about oneself, other people and the environment experienced by the client (assessment) and recognizing negative thoughts and behaviors experienced. COMET for therapy in patients with low self-esteem appears to be an effective trans-diagnostic intervention. It is currently the most empirically supported specific intervention for improving self-esteem in the adult psychiatric population.
Competitive Memory Training (COMET) runs for 8 sessions of 2 hours each and consists of several steps, all of which aim to reinforce the patient's positive self-opinion and make him more competitive. All steps are repeated during therapy sessions and in homework. The following steps can be identified: First, identify a negative self-image. Next, a credible but inappropriate and more positive self-image is formulated, based on personal characteristics, actions, and experiences. This positive selfimage is reinforced by writing The results of the study proved that there were significant differences in anxiety, coping mechanisms and low self-esteem before and after CBT administration (p value <0.05), this proves a significant change in patients The assumption of researchers with CBT, patients doing exercises with a face-to-face approach in 5 sessions, or 5  symptoms. Effects were maintained at 3 months of follow-up. No differences between groups could be detected. Although the small sample needs caution in interpreting the findings, the results suggest that, when offered an adequate number of sessions, EMDR and CBT have the potential to be effective treatments for patients with low self-esteem and a wide range of outcomes. comorbid psychiatric conditions A randomized controlled trial with two parallel groups was used.
Participants were randomly allocated to 10 weekly sessions of EMDR (n = 15) or CBT (n = 15). They were assessed before treatment, after each session, post-treatment and at 3 months of follow-up selfesteem (Rosenberg's Self-Esteem Scale and Core Belief Credibility), psychological symptoms (Brief Symptom Inventory), social anxiety, and social anxiety.

DISCUSSION
A serious mental disorder that is often found in society is schizophrenia. Schizophrenia is a group of clinical syndromes characterized by changes in cognitive, emotional, perceptual and other aspects of behavior. One of the negative symptoms in schizophrenic clients is low self-esteem. Low self-esteem is a prolonged feeling of worthlessness, insignificance and low self-esteem as a result of negative evaluation of oneself and one's abilities, and is often accompanied by a lack of self-care, poorly dressed, decreased appetite, not having the courage to look at the other person, more bowing. , speaking slowly and in a weak tone of voice (Keliat,2010). To optimize the handling of clients with low self-esteem, cognitive therapy, interpersonal therapy, behavioral therapy, and family therapy can be applied.
Nursing actions in clients with low self-esteem can be individual, family therapy and community management, both generalists and specialists.
Research Suerni, Keliat and Helena (2013) on 35 clients with low self-esteem with predisposing factors the most on psychological factors, namely introverts and a history of failure as many as 35 clients (100%) and low socioeconomic factors as many as 30 clients (85.7%) and work problems as many as 22 clients (62.9%). Failure to carry out developmental tasks can result in individuals not confident, distrustful of others, doubtful, afraid of mistakes, pessimistic, unable to formulate and express desires and feel depressed. The most biological precipitation factor was drug withdrawal as many as 30 clients (85.7%). On psychological factors, most of the clients have unfulfilled desires as many as 25 people (71.4%). Signs and symptoms of clients with low self-esteem after being given generalist nursing actions and cognitive therapy, on the cognitive response of 100% of clients who thought it was useless fell to 20%, on the behavioral response of 100% of clients who were self-critical fell to 20%. Signs and symptoms of clients with low self-esteem after being given generalist nursing actions, cognitive therapy, and family psychoeducation therapy on the cognitive response of 100% of clients who think it is useless drops to 0%, the affective response of 100% of clients who feel sad and embarrassed falls to 0%, the behavioral response of 100% self-criticizing clients fell to 0%.
Cognitive therapy focuses on immediate thought processing, namely how the individual perceives or interprets his experiences and determines how he feels and behaves. Giving cognitive therapycan help clients to change their self-statement that affects their feelings into more positive thoughts. Family psychoeducation is used to provide information to families who experience distress, provide education to them to improve skills so they can understand and have coping due to mental disorders that cause problems in family relationships.
Low self-esteem problems in schizophrenic clients are often encountered with symptoms of decreased cognitive abilities. Cognitive behavior therapy significantly increased the behavioral abilities of clients with low self-esteem who received cognitive behavior therapy. This is because cognitive behavior therapy is a psychotherapy that can increase self-esteem in schizophrenic clients. In schizophrenic clients, cognitive behavior therapy also showed satisfactory results. Where the techniques used are problem and task-oriented in changing wrong or biased cognitive (using cognitive and views) by assessing situations and modifying assumptions (Turkington in Sasmita, Keliat, & Budiharto, 2010).
Research by Waite, McManus & Shafran (2012) states that cognitive therapy in clients with low self-esteem is widely used in routine clinical practice. Treatment based on the CBT (Cognitive Behavior Therapy) protocol for dealing with low self-esteem includes four phases namely (1) the individual formulation phase of goal setting and psychoeducation (sessions 1-2), (2) the phase of learning skills to re-evaluate anxious thoughts and critical of self and beliefs through cognitive techniques and experimental behavior (sessions 3-8), (3) a phase of increasing selfacceptance (phases 4-8), and (4) a phase of developing more adaptive beliefs and rules and planning for the future (session 7). -10). That 10 CBT sessions with a protocol and include a workbook as an adjunct to the session was more effective in reducing low self-esteem chronic.
Conflict that occurs in schizophrenia can be due to a maladaptive defense mechanism against changes that occur in life. One of the therapies that can be done in schizophrenic patients is cognitive behavioral therapy (CBT). Cognitive behavioral therapy helps patients with various problems and difficulties that a person experiences in various aspects of life. Various mental disorders also often take advantage of cognitive behavioral therapy either used singly or in combination with psychopharmaceuticals as well as other therapies. Cognitive behavioral therapy (CBT) helps individuals to develop by increasing skills in coping mechanisms to reduce anxiety and increase self-esteem (Wheeler, 2008). The results of the study proved that there were significant differences in anxiety, coping mechanisms and low self-esteem before and after giving CBT (p value <0.05), this proved that there were significant changes in patients who received CBT compared to those who did not (Caturini & Handayani, 2014).
Cognitive behavioral therapy (CBT) for psychosis is a proven psychotherapy intervention recommended by several international guidelines. More than 60 randomized controlled trials (RCTs) have examined the efficacy of CBT for patients with schizophrenia and other psychotic disorders. However, systematic reviews and meta-analyzes have reported a reduction effect in symptoms between the first meta-analysis published in 2001 [3] and the meta-analysis published in recent years. The mean effect sizes reported in the last study were small, and they were even smaller in the methodologically rigorous study. In addition, a recent Cochrane review concluded that there is no clear evidence to prefer CBT over other advanced therapies for psychosis patients. This systematic review and meta-analysis mostly included patients with a longstanding diagnosis of schizophrenia and other psychotic disorders.
The effects of CBT for patients in the early phase of psychosis have been less studied in RCTs. This is especially important because patients in the early phase of psychosis may have very different treatment needs compared to patients with multiple episodes and a longer history. In addition to experiencing psychotic symptoms such as hallucinations and delusions, patients in the early phases of psychosis often suffer from other conditions such as depression or low self-esteem, which can be as challenging for the patient as psychotic symptoms.
Approximately 50% of patients who experience first episode psychosis have a depressive disorder at the start of treatment, and about 80% of schizophrenic patients have a clinical disorder. Significant depressive episodes once or more than once during initial treatment. For these patients, depressive symptoms were associated with poorer clinical outcomes, lower functioning, and reduced subjective quality of life. In addition, psychotic sufferers often experience psychotic self-esteem disorders. This is associated with poorer development and duration of psychotic symptoms and clinical outcomes. The potential benefits of boosting selfconfidence were investigated in a study involving 30 patients who received six CBT sessions.
Significant increases in positive beliefs about self and self-esteem were reported. Depressive symptoms, low selfesteem, and negative schematic beliefs can all contribute to the development of psychosis symptoms. As a result, emotional processes may be important targets for treatment interventions in the early phases of psychotic disorders.
According to Griffioen, et.al (2017). EMDR (Eye Movement Desensitization and Reprocessing) and CBT can show a significant increase in self-esteem, raising two standard deviations on the main parameter (RSES). Furthermore, the results showed a significant reduction in general psychiatric symptoms. Effects were maintained at 3 months of follow-up. The results suggest that, when offering a sufficient number of sessions, EMDR and CBT can potentially be effective treatments for patients with low selfesteem and a wide range. comorbid psychiatric conditions. According to Daan Engel Jacob and Syamsu Yusuf (2013) in their research results show that the use of logotherapy counseling as an intervention program for the experimental group is more effective and has provided better results in the dynamics of behavior change among women victims of trafficking. Effectiveness is also proven by the results of observations and interviews. demonstrate positive values in the dynamics of victim behavior change. The logotherapy counseling model has strengths in self-exploration, selfacceptance, dissociation, self-transcendence, attitude values, and self-awareness, which are integrated with self-potential, self-activity and self-evaluation, so that this model can trigger positive changes among women victims of trafficking. . Therefore, there needs to be a logotherapy counseling model training guideline for social workers to improve the conceptual and empirical aspects of treatment, where the first focuses on understanding material, problems and skills development; counseling strategies and approaches.
Another study conducted by Hermawan et al., (2015) stated that there was a significant influence between the perceptual stimulation group activity therapy; tells about the positive experiences they have on increasing the level of selfesteem in patients with low self-esteem. The implementation of TAK stimulation of perception by telling stories about positive experiences that one has can increase one's self-esteem by exploring positive abilities and helping in dealing with other people, as well as changing destructive and maladaptive behaviors. Group strength lies in the contributions of each member, and within one's group can share experiences and find good interpersonal relationships and feel recognized and appreciated. This activity also trains respondents to perceive stimuli that have been experienced.
Competitive Memory Training (COMET) in patients with low self-esteem has also been shown to be effective in increasing self-esteem in the clinical population, at least when applied in combination with therapy as usual (TAU). Patients with depressive disorders increased significantly and with a large effect size after COMET + TAU when compared to TAU alone (Korrelboom, Maarsingh, & Huijbrechts, 2012).
Research conducted by Tanaya & Jayakrishnan (2018) on patients with schizophrenia begins by assessing their social and demographic conditions through a questionnaire. After that, the examination was carried out using a questionnaire to measure self-esteem, quality of life and symptoms in schizophrenic patients. The results showed that brain exercise had a positive impact in increasing self-esteem levels, quality of life and reducing symptoms in schizophrenia patients. Brain exercise can improve communication skills, help in the decision-making process, and help when dealing with rejection or feelings of disappointment. Brain exercise can also improve a person's mental condition such as improving concentration and memory.

CONCLUSIONS AND RECOMMENDATION
Based on the results of the discussion, there were several psychotherapy interventions to reduce chronic low selfesteem in patients with early psychotic symptoms and schizophrenic patients, namely CBT (Cognitive behavior therapy), EMDR (Eye Movement Desensitization and Reprocessing), TAK (Group Activity Therapy) stimulation of perception; told, therapy as usual (TAU) and Competitive Memory Training (COMET) / Competitive Memory Training. All of these psychotherapies have been proven by some researchers to reduce and overcome chronic low self-esteem, especially in psychotic or schizophrenic patients.

Recommendation
In general, in early psychotic patients using psychotherapy that has been mentioned in several studies, the results obtained may be significant but in schizophrenic patients where in these patients there has been more than one piscosa symptom, a decrease in chronic low self-esteem should be followed by therapy on symptoms others and must be done routinely and under the supervision of a psychiatrist by involving family caregivers in schizophrenic patients.