PENGARUH PSIKOTERAPI SPIRITUAL TERHADAP PENINGKATAN HITUNG SEL T-CD4+ PADA PENDERITA HIV/AIDS SPIRITUAL PSYCHOTHERAPY EFFECT TO INCREASE CD4+ COUNT IN HIV /AIDS PATIENTS.
M. Faisal Idrus,1 Jayalangkara T, 1 Syamsu, 2 Ilham,3
1
2
Department of Psychiatry, Medical Faculty of Hasanuddin University Departement of Internal Medicine, Medical Faculty of Hasanuddin University 3 Departement of Physiology, Medical Faculty of Hasanuddin University
Alamat Korespondensi : M. Faisal Idrus Bagian Psikiatri Fakultas Kedokteran Universitas Hasanuddin Makassar, HP : 081524966494 Email :
[email protected]
Abstrak HIV/AIDS adalah penyakit infeksi virus yang menyebabkan penurunan imunitas tubuh ditandai dengan penurunan hitung sel CD4+. Penurunan hitung sel T-CD4 ini disebabkan oleh karena proses penghancuran sel limfosit T oleh human immunodificiencies virus Sedangkan psikoterapi spiritual adalah bentuk pengobatan kejiwaan yang memberikan ketenteraman, kedamaian, dan kebahagiaan jiwa. Ketenangan jiwa diharapkan akan membangkitkan respons imunitas tubuh individu. Penelitian bertujuan untuk mengetahui pengaruh psikoterapi spiritual terhadap hitung sel T-CD4. Ini adalah penelitian quasi experimental pretest-post-test control group design dengan jumlah sampel 40 orang penderita HIV/AIDS yang dipilih secara purposive sampling. Penelitian ini dilaksanakan di Pokja HIV/AIDS dan bangsal rawat inap RS BLU. Dr. Wahidin Sudirohusodo. Makassar. Sampel dibagi menjadi dua kelompok, yaitu 10 orang kelompok rawat inap yang mendapat psikoterapi spiritual secara intensif, 10 orang dari Lapas Bolangi yang mendapat psikoterapi spiritual yang kurang intensif dan 20 orang kelompok kontrol yang tidak mendapat psikoterapi spiritual. Analisa statistik dengan menggunakan uji Wilcoxon test. Hasil analisis CD4+ serum berbeda secara bermakna (p < 0,05) antara kelompok perlakuan dan kelompok kontrol. Setelah perlakuan pada kelompok rawat inap hitung sel T-CD4 serum meningkat dari 15 menjadi 160, tetapi kelompok lainnya (kelompok bolangi dari 446,50 menjadi 365,50 dan kelompok kontrol dari 424,5 menjadi 201,0) mengalami penurunan, terutama pada kelompok kontrol (tabel 2 dan 3). Tabel 4 menunjukkan bahwa dari 10 orang kelompok rawat inap, semuanya mengalami peningkatan kadar CD4+ serum, sedangkan pada kelompok Bolangi hanya 3 orang (30%) diantara 10 orang kelompok kontrol, dari 20 orang hanya 1 orang (5%) mengalami peningkatan kadar CD4+ serum, 19 orang (95%) lainnya mengalami penurunan. Kata kunci : Psikoterapi spiritual – relaksasi – hitung sel T- CD4
ABSTRACT HIV / AIDS is a viral infection that causes decrease of immunity system characterized by decrease CD4+ T lymphocyte counts. Low CD4 T-cell counts are considered due to destruction of lymphocytes T by human immunodeficiency virus. The spiritual psychotherapy is a form of psychiatric treatment that provides peace, and happiness of the soul. Peace of mind is expected to generate individual immune response. Objective to determine the effect of spiritual psychotherapy to CD4 T-cell count. This is a quasi experimental study pretestposttest control group design of 40 sample with HIV / AIDS who were selected by purposive sampling. This research was conducted in the HIV / AIDS Working Group and hospital inpatient BLU. Dr. Wahidin Sudirohusodo. Makassar. The samples were divided into two groups, the treatment group of 10 inpatient who received intensive spiritual psychotherapy, 10 sample from Lapas Bolangi and 20 control group who did not receive supportive psychotherapy. Statistical analysis using the Wilcoxon test. The results of the analysis of CD4 + serum between the treatment and control groups was significantly different (p <0.05). After treatment, the CD4 T-cell count in the inpatient group increased serum from 15 to 160, but in the other groups (group bolangi from 446.50 to 365.50 and the control group from 424.5 to 201.0) was decreased, especially in the control group (Tables 2 and 3). Table 4 shows that of the 10 inpatient samples group, all had increased levels of CD4 + serum, whereas in the group Bolangi only 3 samples (30%) among the 10 sample of the control group , of 20 sample only 1 person (5%) had increase of CD4 + serum , and 19 sample (95%) had decrease Keywords: Spiritual Psychotherapy – relaxation - CD4 count
2
INTRODUCTION HIV / AIDS is now a priority public health problem in the world and gets a very serious attention. Disease caused by HIV (Human Immunodeficiency Virus) causes decreased level of immunity. (Adler MW, 1996; Irwin M., (2001). Decreased immunity level will facilitate the entry of other germs into the body whether pathogenic or non-pathogenic. These other infections is known as. "Opportunistic - infection ". Virus is transmitted through infected body fluids, especially blood and semen. (Barlett JG, 2007). Standardized tests assessing prognosis of AIDS progression was determined by measuring the increase in viral load or" viral load "and a decrease in CD4 cell count. Disadvantaged areas with limited examination of CD4 + cell count can be replaced by a count of total lymphocytes or total lymphocyte count (TLC) (Barlett JG, 2007; Irwin, 2001). At the end of 2010, it is estimated that there are about 34 million people living with HIV, 30.8 million are adults, 3.4 million are children. New infections in adults are 2.7 million,
390,000
are
children
and
1.8
million
deaths
from
AIDS.
(Http://www.avert.org/worldstats.htm. UNAIDS (2010). Statistics data of the HIV / AIDS cases in Indonesia were reported cumulatively from April 1, 1987 s / d December 31, 2011 are derived from Direktorat Jenderal PP & PL Departemen Kesehatan RI (2003). Cumulative cases of HIV was 76,879 people and AIDS was 29 879 people and the number who died (mortality rate) was 5430 people . Sulawesi Selatan number of HIV / AIDS was ranked 8th of 33 provinces in Indonesia, that is 2448 HIV cases and 874 AIDS cases. (Direktorat Jenderal PP & PL RI Departemen Kesehatan RI February 29, 2012). One of the interventions that needed to be considered to cope with the rate of progression of the disease is through religious activities (meditation, devotions and prayer) that triggers the relaxation response and helps the body to relax and to calm the mind (Ayad A, (2008). Relaxation response, spearheaded by Herbert Benson. Dr. Benson explained as a response to the body's relaxation response, which produces physiological changes, while individuals involved in mental activity repeatedly and consciously ignore negative thoughts intrude. Dr. Benson has shown scientific evidence of the physiological changes that occur during the relaxation response, such as a decrease in heart rate, blood lactate and rapid decline associated with low levels of anxiety and lower blood pressure in people with hypertension. Relaxation response gives individuals the ability to control the activity of physiological, self-control and peace (Pasiak T, 2012. Benson H, 2000). 3
According Hawari, D (2005) psikoreligius therapy or psikospiritual will raise the confidence (self-confident) and a sense of optimism. Two of these (self-confidence and a sense of optimism) is important for the healing of a disease in addition to drug therapy and other medical treatment (Hawari, D., 2002). From the results of research in this area that was done by Snyderman (1996), produced a conclusion, states that "medical therapy alone without prayer and dhikir is incomplete; otherwise prayer and dhikr without medical therapy is not effective". Similarly opinions of Christy (1998) which states that "prayer and remembrance as well as a drug (prayer as medicine)" (Hawari, D. 2010). Woods (1999) from the University of Miami found that HIV-positive patients who were actively running religious services showed that the number of CD4 + and percentage CD4 + (T-helper inducer cells) was increase, which means that the function of the immune system were running well. Ironson (2000) conducted a study on the influence of religion / spirituality in the immune system of HIV / AIDS concluded that religion plays an important role in extending the age of a person suffering from HIV / AIDS. (D Hawari, 2002). Harold G. Koenig on the first study of 87 patients with depressive state who were -religious recover faster than those without religion (Koenig, HG, et al, 1992). In the second study of 1700 elderly showed immunity factor of the pious people who were significantly better (Koenig, HG 1996) .. This issue is an interesting thing for me. So I decide to pay attention and to see whether the spiritual psychotherapy by religion activity (dzikir, praying, meditation, etc) can affect the increasing of health recovering in patients with HIV/AIDS. This study is aimed to determine the effect of spiritual psychotherapy for CD4 + cell count
MATERIALS AND METHODS Location and design This study was conducted at the hospital of Dr. Wahidin Sudirohusodo with quasi experimental design with pretest-posttest control group design to examine the influence of spiritual psychotherapy to CD4 + T-cells Population and Sample. The study population was HIV inpatient and outpatient in the working group of HIV / AIDS (Infection Center) at BLU RS. Dr. Wahidin Sudirohusodo and in Lapas Narkoba Bolangi. Samples were patients with HIV (+) as evidenced by the results of a reactive rapid test methadone treatment clinic and inpatients in RS.Dr. Wahidin Sudirohusodo and Drug 4
Bolangi prison. Sampling was done by purposive sampling, ie sampling conducted on the basis that the subject can provide sufficient information to answer the research question (Sastroasmoro & Ismael, 2002). Data Collection and Analysis Data from subjects were collected from outpatient status in the clinic and inpatient HIV / AIDS patients who were treated dibangsal and of Prison Drug Bolangi. to assess the patient's level of immunity by the measurement of CD4 T-cell count. The statistical analysis used in this study is the analysis of the Wilcoxon test for small sample amounts. Presentation of the results in tables and described descriptively linearly with the percentage.
RESULTS. The study collected 40 people with HIV who meet the criteria of the sample. Group consisted of 10 inpatients, 10 people were treated at Bolangi and 20 ambulatory care (control). The distribution of age groups, gender, education, occupation and marital status in all three groups can be seen in table 1.Table 1 shows that all three groups can be considered homogeneous by gender, age group, education level, occupation, marital status (p> 0.05). After treatment, in the inpatient group, the CD4 T-cell serum count was increased from 15 to 160, but in the other groups (group bolangi from 446.50 to 365.50 and the control group from 424.5 to 201.0) was decreased, especially in the controls (Tables 2 and 3). Table 4 shows that of the 10 sample group hospitalization, all had increased levels of CD4 + serum, whereas in the group Bolangi only 3 sample (30%) among the 10 sample and in the control group of 20 sample only 1 person (5%) had elevated levels of CD4 + serum , 19 sample CD4’s (95%) was declined. Graphic 1 shows the changes in CD4 T-cell count in the group received spiritual psychotherapy (inpatient group) and the group that did not receive spiritual psychotherapy (Bolangi group and the control group) after three months. In the group receiving intensive treatment (inpatient) , the number of CD4 T-cells increased. Whereas the other two groups had decreased CD4 T-cell count, especially in the control group.
DISCUSSION In the last two decades a number of studies have demonstrated the success of spiritual care. The study comes from a wide number of areas and is associated with religious and 5
spiritual practices. (Fenwick P, (2003) Most studies on spiritual care is associated with meditation. (Mohandas E. 2008. Newberg AB, Iversen J., 2003). Meditation will evoke the relaxation
response
which
will
work
through
psychoneuroimmunology.
Psychoneuroimmunology is a science system that connects medical psycho (emotions, thoughts), neuro (reflexes, neuroendocrine), Immunology (cellular immune system and humoral immune system) (http://www.drpaulose.com/spirituality/psycho-neuro-immunologypni. (Madeline M., Lorentz RN, 2006. Pasiak T, 2012). The relationship between these three systems is aime to maintain body homeostasis. This relationship through the two subsystems, namely, hypothalamic-pituitary-adrenal (HPA axis) and the autonomic nervous system (SSO). ( Pasiak T, 2012. Madeline M., Lorentz RN, 2006) The results of this study indicate that the group who received spiritual psychotherapy adjuvant had increased CD4 T-cell count, especially those with CD4 T-cell count was initially low, while at the group did not getting the adjuvant spiritual psychotherapy had decreased CD4 T-cell count despite of the high initial CD4 T-cell count . This suggests that the increased levels of CD4 in spiritual psychotherapy adjuvant group is believed to be the effects of adjuvant spiritual psychotherapy. According Pasiak (2012) psychotherapy works to increase the development of cognition, emotion, and behavior skills. Psychotherapy is also enhance the development of neurons and neuronal networks integration. Changes that occur at the brain is in line with the changes in glucose metabolism, neurotransmitter concentrations and blood flow, which in turn will boost the immune system (CD4 +). Behavior spiritual (meditation, prayer and dhikr). freeing our minds from the superstitions, doubts and thoughts that lead to sin, and filled with love, affection, and reflect on God's creation gives us a feeling of tranquility and peace. (Ayad A, 2008). This spiritual healing mechanism psychotherapy through two pathways, namely the hypothalamic-pituitary-adrenal (HPA axis) and the autonomic nervous system (SSO). (Pasiak T, 2012. Madeline M., RN Lorentz, 2006). HPA axis is the stress management system which aims to maintain a homeostatic state of the body through the control of the hormone cortisol, HPA axis and cytokines that affect each other. (Pasiak T, 2012) The results are consistent with the results of research carried out by "Natural Pharmacist" to 40 first-stage cancer patients. They were divided into two groups, then they are asked to implement the religious teachings, especially prayers and prayer. Six days in a week for ten weeks. The patients undergoing therapy and treatment for six months. And the 6
changes are clearly visible in the group of patients who were devout prayer. The researchers believe that sample are obedient worship such as prayer and prayer less likely to develop the disease, either mental illness or physical diseases. They also have greater strength to bear the pain and endure the pain. They also have a stronger and more stable soul that they can avoid the stress, anxiety, and despair. Not only that, they also have a healthier body and if they get pain, the recovery process goes faster. (Elzaky J, 2011) This is also in line with what was reported by the Magazine "Psychosomatic Medicine" , conducted a study involving two groups of respondents, namely 78 patients were black and 77 white men, whose ages varied between 25 and 45 years. The two groups were separated in the study because African Americans tend to be more religious and more obedient to run prayer groups and prayer than whites. The patients were then asked to carry out the commands of religion more obedient and reverent, especially prayer and prayer. The results showed that a lot of prayer and prayer they do can reduce high blood pressure, especially in black patients. Disease that affects the white patients did not experience any significant change because they are more lazy followers pray and prayer. (Elzaky J, 2011) Snyder states that "medical therapy alone without prayer and dhikr is incomplete; otherwise prayer and dhikr without medical therapy is not effective". (Hawari D, 2002). While Einsein stated that "Science without religion is blind, while science without religion is lame (D Hawari, 2002). In a hadith the Prophet said:" "Every disease is curable. If proper medication is given, by Allah's disease cured ". (Narrated by Ahmad and Hakim Bukhari Saheeh Muslim). So in treating a patient , we should not just focus on medical therapy alone, but we should also pay attention to the spiritual aspect of the patient.
CONCLUSIONS AND RECOMMENDATIONS This study gives us an understanding of the linkages between health and religion / spiritual . From this study can be concluded that spiritual psychotherapy can influence the increasing of the CD4 cell count through HPA axis activity and Autonomic Nervous System (SSO). This spiritual power is the power that is not limited because it comes from God the Creator that can be used to help the healing process. Therefore, in providing treatment to patients, we need to pay attention to the spiritual aspects of the patient to help achieve a cure
7
REFERENCES. Ayad A, (2008). Meditation and Dhikr-Allah. Healing Body & Soul. International Islamic Publishig House. Riyadh Saudi Arabia. 409-418. Adler MW, (1996). Perkembangan Epidemiologi, dalam Petunjuk Penting AIDS, edisi ketiga. Alih Bahasa : Ken Ariata Tengadi. EGC, Jakarta,.hlm 1-4 Bartlett JG, Gallant JE, (2007). Medical Management of HIV Infection. John Hopkins University Medicine: Johns Hopkins Medicine Health Publishing Business Group, Baltimore. Benson H, Proctor W, (2000). “Keimanan Yang Menyembuhkan dasar-dasar respon relaksasi” Alih bahasa : dr. Nurhasan. Penyunting : Ary Nilandari. Cetakan 1. Penerbit Kaifa.. Bandung. Januari. hal. 34. Christy M, (1998). “Prayer as Medicine”. Forbes. 136-137. Direktorat Jenderal Pemberantasan Penyakit Menular & Penyehatan Lingkungan Departemen Kesehatan RI (2003). Pedoman Nasional Perawatan, Dukungan dan Pengobatan Bagi ODHA, Departemen Kesehatan RI., Jakarta, Elzaky J, (2011). "Fushul fi Thibb al-Rasul (Buku Induk Mukjizat Kesehatan Ibadah)", Alih Bahasa : Dedi Slamet Riyadi MA, Cet 1. Penerbit Zaman, Jakarta Fenwick P, (2003). The Neuroscience of Spirituality. www.rcpsych.ac.uk/.../... Hawari D, (2002). Manajemen Stres, Cemas dan Depresi. Gaya Baru, Jakarta. Hawari D, (2005). Dimensi Religi dalam Praktek Psikiatri dan Psikologi. Cetakan ke-2. Balai Penerbit FKUI. Jakarta. Hawari D, (2010). Panduan Psikoterapi Agama (Islam). Fakultas Kedokteran Universitas Indonesia. Jakarta Ironson G, Stuetzle R, Fletcher M A, et all (2006). An Increase in Religiousness / Spirituality Occurs After HIV Diagnosis and Predicts Slower Disease Progression over 4 Years in People with HIV, Gen Intern Med, 21(S5): S62–S68 Irwin
M, (2001). Low Cd4+ http://www.virusmyth.com/aids/hiv/milowcd4.
T
Lymphocyte
counts
Kaplan HI, Sadock BJ, (2000). Acquired Immune Deficiency Syndrome (AIDS), Pocket Handbook of Clinical Psychiatry , 6 th ed, William & Wilkins, Baltimore USA, , p297 – 303 Koenig HG, Cohen HJ, Bazer DG, et al, (1992). Religious coping and depression in elderly hospitalized medically ill men, American Journal of Psychiatry, 149: 1693-1700 8
Koenig HG, (1996). Depressive disorder in hospitalised medically ill elders, Funded by National Institutes of Mental Health, grant # MH01138. Madeline M, Lorentz RN, (2006). Stress and Psychoneuroimmunology. Alternative Journal of Nursing. Issue 11.p1-11 Mohandas E. (2008). Neurobiology of Spirituaity. Mental Health, Spirituality, Mind Volume : 6 page : 63-80 Newberg A.B, Iversen J, (2003). The neural basis of the complex mental task of meditation: neurotransmitter and neurochemical considerations, Med Hypotheses , 61 : 2, p 282291. Pasiak T, (2012). Pikiran Yang Mengubah Otak. Tuhan Dalam Otak Manusia Mewujudkan Kesehatan Spiritual Berdasarkan Neurosains. Cetakan 1. Mizan Media Utama, Bandung. hal 51-76. Sastroasmoro S, Ismael S, 2002. Dasar-Dasar Metodologi Penelitian Klinis. Sagung Seto, Jakarta Sayyid AB, 2008. Terapi Spiritual dan Psikologi. Kekuatan Ruhiyah (The Spiritual Power). Alih Bahasa : Sibawea Lc. Ziyad Visi Media. Surakarta. 12- 32 Snyderman, 1996. Religious Approach in the Medical Treatment. Faculty of Medicine. Duke University. Woods TE, Antoni MH, Ironson GH, Kling DW., (1999). Religiosity is associated with affective immune status in symptomatic HIV-infected gay men. Journal of Psychosomatic Research.;46(2):165–176.
9
LAMPIRAN Tabel 1. The Three Groups Demography Group Charateristic
Age (year)
Gender
School
Job
Marital status
In patient Bolangi (n=10) (n=10)
control (n=10)
20 – 29
4
6
10
30 – 30
5
4
10
40 – 49
1
0
0
Male
7
10
15
Female
3
0
5
SD
0
0
2
SMP
4
0
3
SMA
6
8
11
D3
0
0
1
S1
0
2
3
No
4
6
15
Yes
6
4
5
Not yet
5
5
6
Marriage
4
5
13
Widow
0
0
1
Widower
1
0
0
p=0,469
p=0,179
p=0,201
p=0,172
p=0,589
Tabel 2. Difference CD4 serum before perlakuan three groups 10
Group Variable
In patient
Bolangi
Control
Kruskal
(n=10)
(n=10)
(n=20)
Wallis Test
CD4 before
87,10 (148,14)a
531,30 (286,82)b 438,80 (325,41)b
p=0,001
CD4 after
253,70 (250,91)
484,70 (341,40)
p=0,120
275,30 (234,98)
Tabel 3. The changes of CD4 after spiritual psychotherapy on three groups
Variable
CD4+
group
Before
After
Changes
Min-Maks
Median
Min-Maks
Median
Median
In Patient
2 – 399
15,0
7 – 720
160,0
73,0
Bolangi
198 -1033
446,50
229 -1280
365,50
- 66,5
Control
6 – 1240
424,5
3 – 751
201,0
-126,0
Tabel 4. The difference of CD4 on three groups Changes Variable
CD4 Count
Group
Increase
Decrease/stabil
In patient
10
0
Bolangi
3
7
Control
1
19
P value
p=0,000
11
Graphic 1. The Amount of CD4+ count Before and after the therapy.
12
