Effect of Cognitive Therapy and Family Psychoeducation in Stroke Clients with Depression and Disability

Stroke patients who were take care in the hospital 30-40% in depression condition. This research aim was to determine the effect of cognitive therapy and psycho Education for depression, helplessness, and ability to change negative thoughts for stroke patients. This research design was quasi experimental pre and post test with control group with a total of sample 87 person with 29 persons are given cognitive therapy and family psychoeducation therapy, 29 persons are given only cognitive therapy and 29 persons are not given therapy. Analysis by anova test and Pair t-test. The result of research show a decrease in depression and helplessness condition and increase the ability to change negative thoughts of stroke clients whom received cognitive therapy and family psychoeducation group larger than whom just only receive cognitive therapy and the group without therapy (p value <0,05). There was factor that contribute depression condition of stroke client is age. Cognitive therapy and Family Psychoeducation are recommended for stroke klien who got depression and helpless to increases the ability to change negative thinking.


INTRODUCTION
Stroke is a description of neurological changes as a result of pathological processes in the blood vessel system by thrombosis or embolism, rupture of brain blood vessel walls, changes in blood vessel wall permeability and changes in viscosity and blood quality itself (1). Stroke ranks as the third leading cause of death after heart disease and cancer in the United States (1). Based on data from the Indonesian Stroke Foundation, the highest number of stroke sufferers is in the first position in Asia. the number of deaths caused by stroke ranks second at the age of 60 years and fifth at the age of 15-59 years (2). Based on the 2013 Riskesdas data, the national prevalence of stroke was 12.1 per mile, while in the 2018 Riskesdas the prevalence of stroke was 10.9 per mile.
In stroke patients, depression occurs 10-25% for women and 5-12% in men. The results showed that about 30-40% of stroke clients who were hospitalized experienced depression (3). Depression experienced by individuals with chronic illnesses can increase the burden of physical illness and somatic symptoms, increase functional impairment and increase medical costs. The results showed that around 30-40% of stroke clients who were hospitalized experienced depression (3).
Depression is a prolonged or abnormal sadness and grief (4). Depression is characterized by a decreased mood, loss of interest or pleasure. The client feels sad, hopeless, sad or worthless. Symptoms of depression include fatigue, inability to concentrate / create decisions, feeling sad, worthless / guilty (5). According to WHO, depression is a mental disorder that is usually followed by feelings of sadness, loss of interest or pleasure, decreased energy, feelings of guilt or inferiority, disturbances in sleep patterns or appetite and lack of concentration.
Nursing problems that can arise in stroke are anxiety, low self-esteem, helplessness, hopelessness, social isolation, ineffective individual coping. Common psychological disorders that arise in stroke clients include ineffective individual coping, anxiety, social isolation, changes in self-concept and helplessness. (1). Dependence on other people can lead to irritability, anger, guilt and dissatisfaction with the inability to carry out previous activities (6).
Therapies that can be given to stroke clients who experience depression and helplessness are cognitive therapy and family psychoeducation. Cognitive therapy can help stop negative thought patterns and help sufferers fight depression because this therapy aims to change negative thoughts into positive ones, find out the causes that are felt, help self-control and prevention and personal growth (7).
According to NANDA (2012) helplessness is the client's perception or response that the behavior or actions he has done will not bring the expected results or will not bring about changes in the results as expected, so it is difficult for clients to control the situation that occurs or to control the situation that will occur. Powerlessness is the biggest impact of chronic disease as a result of self-acceptance and changes in the lifestyle of clients with chronic diseases. In dealing with chronic disease, an adaptive coping mechanism is needed as an effort to prevent the development of stressors into maladaptive conditions that can cause chronic disease sufferers to experience helplessness against the disease they are experiencing (8).
Therapies that can be given to stroke clients who experience depression and helplessness are cognitive therapy and family psychoeducation. Cognitive therapy can help stop negative thought patterns and help sufferers fight depression because this therapy aims to change negative thoughts into positive ones, find out the causes that are felt, help self-control and prevention and personal growth (7). Research related to cognitive therapy conducted by (9) showed that the level of self-esteem increased more significantly and depressive conditions decreased more significantly in the group of chronic kidney failure clients who received cognitive therapy compared to the group of chronic kidney failure clients who did not receive cognitive therapy.
Sarfika's (10) states that cognitive therapy can significantly increase the ability to change negative thoughts, cognitive therapy and logotherapy can increase the ability to interpret life more than cognitive therapy. Family Psychoeducation therapy is one element of the family mental health care program by providing information and education through therapeutic communication involving families. Family Psychoeducation is a specialist therapy that is appropriate to be given to families with family members who experience health problems, both physical and mental illnesses.
Based on research conducted by (11), the recurrence rate in clients with disorders without family therapy was 25-50%, while the recurrence rate in clients who were given family therapy was 5-15%. This means that family support is important in reducing psychosocial problems that arise in stroke clients through psychotherapy. So that cognitive therapy and family psychoeducation are given here with the aim of being able to reduce depression, helplessness and increase the ability to change negative thoughts in stroke clients.

METHODS
The design of this research is a "quasi experimental pre and post test with control group" with the intervention of cognitive therapy and family psychoeducation therapy. The sampling technique is Consecutive Sampling with inclusion criteria: clients with a stroke diagnosis with a productive age of 30-69 years, able to communicate well, experiencing depression (with a score> 10 on the measurement using BDI), experiencing helplessness, willing to be respondents, accompanied by family who continuously take care of clients. The sample in this study consisted of 29 people who received cognitive therapy and family psychoeducation, 29 people who only received cognitive therapy and 29 people who did not get therapy. The study was done in four week to get the data. The sample was given a pretest before getting cognitive therapy and family psychoeducation. Furthermore, the sample was given cognitive therapy and psychoeducation for four days after which the post test was carried out.
The variables in this study consisted of respondent characteristics, depression, helplessness and the ability to change negative thoughts. The instrument used in this study consisted of a questionnaire containing data on the characteristics of the respondents. Questionnaire two contains the measurement of depression using the Beck Depression Inventory scale, questionnaire three contains the measurement of helplessness where validity and reliability tests are carried out before the research is carried out with a value of r count> r table (0.361) and a cronbach alpha coefficient value is obtained, namely 0.735 and questionnaire four is about measurement. the ability to change negative thoughts where researchers use instruments that have been tested for validity and reliability by previous researchers, namely (10).
Univariate analysis was carried out on the characteristics of stroke clients (age, gender, occupation, education and duration of stroke, depressive conditions, conditions of helplessness and ability to change negative thoughts). Analysis of changes in depression, helplessness and the ability to change negative thoughts using a paired ttest. The analysis used to see changes in depression, helplessness and the ability to change negative thoughts between the three groups used the ANOVA test. To see differences in conditions of depression, helplessness and ability to change negative thoughts using Bonferroni.
This research was conducted with due observance of the ethical principles of research (12), which started from providing an explanation of the research (Informed consent sheet) to stroke clients who were respondents in this study. The explanation given is in the form of research objectives, research benefits (beneficience), research procedures and consequences of being research respondents as well as a guarantee of research confidentiality (Confidentiality) by keeping all forms of information and the name of the respondent confidential where the respondent's name is changed in code form (Anonymous) which is only known by the researcher. (attachment 2). After the respondent agrees to be involved in this research, the respondent signs the consent form to become the respondent. Respondents' rights are considered in this study where each respondent is given full rights to approve or refuse to be a respondent without any sanctions (autonomy). Researchers provide justice to all respondents both before, during and after the research takes place (justice) by explaining all research procedures and providing booklets to respondents who were not given therapy after a post test.

Changes in the Depression Condition of the Client Stroke Before and After the Family Psychoeducation and Cognitive Therapy Intervention
Characteristics of stroke clients who were hospitalized in this study with an average age of 54.58 years, the most sexes who suffered from stroke were male 55.2%, 52.9% did not work, 54% were highly educated and had an average length of time. suffered a stroke 15.49 days.

B. The Effect of Cognitive Therapy and Family Psychoeducation on Depression
Conditions.
Depressive conditions in general before treatment in 87 stroke clients with an average of 19.14 who were in a moderate depression condition. There was a significant decrease in depressive conditions in stroke clients who were given cognitive therapy and family psychoeducation where the depressive conditions were in mild depression. The following can be seen a graph of changes in depressive conditions before and after being given therapy.
The average depression condition in the group that was given cognitive therapy and family psychoeducation before the intervention was 17.59 which was in a moderate depression condition after being given the intervention the average depression condition was 13.76 where it was in a mild condition. The results of statistical tests showed that there was a significant decrease in the average depression condition before and after being given the intervention of cognitive therapy and family psychoeducation (Pvalue <0.05). In the group that was given cognitive therapy and family psychoeducation, the decrease in depression condition was 3.83.
The average depression condition in the group that only received cognitive therapy before being given the intervention was 19.24 after being given the intervention, the average depression condition was 16.76 in the moderate depression range. The results of statistical tests showed that there was a significant decrease in the average depression condition before and after being given cognitive therapy intervention (Pvalue <0.05). In the group that only received cognitive therapy decreased depression condition decreased 2.48.
The average depression condition in the group that did not get therapy (control) before 20.59 after giving therapy to the cognitive therapy and family psychoeducation groups and the cognitive therapy group averaged 19.34. There was a change in the mean depression condition before and after therapy in the cognitive therapy & family psychoeducation group and those who only received cognitive therapy in the group who did not receive therapy but it was not significant (Pv> 0.05).
In the group that was given cognitive therapy and family psychoeducation, the decrease in depression condition was 3.83. In the group that only received cognitive therapy, the decrease in depressive conditions decreased by 2.48 and in the group that did not receive the difference in reduction in depression conditions by 1.24. The condition of helplessness in stroke clients before the intervention was at a score of 31.08 and showed equivalence with a value of> 0.05. Based on the research instrument, the score of helplessness ranged from 13 to 52 for the condition of helplessness. The following can be seen a graph of changes in helplessness before and after being given therapy.
The average condition of helplessness in the group that was given cognitive therapy and family psychoeducation before the intervention was 31.83 with a standard deviation of 4.622 after being given the intervention the average of helplessness was 35.41 with a standard deviation of 4.171. The results of statistical tests showed that there was a significant increase in the mean of helplessness before and after being given the intervention of cognitive therapy and family psychoeducation (Pvalue <0.05). In the group that was given cognitive therapy and family psychoeducation, the difference in the helplessness score increased by 3.586 The average group that only received cognitive therapy before being given the intervention was 31.07 with a standard deviation of 3.817 after being given the intervention the average condition of helplessness was 33.21 with a standard deviation of 3.178. The results of statistical tests showed that there was a significant increase in the average condition of helplessness before and after being given cognitive therapy intervention (Pv <0.05). In the group that only received cognitive therapy, the difference in the increase in the score of helplessness was 2.138 The mean score of helplessness in the group that did not get therapy (control) before was 30.34 with a standard deviation of 4.328, the mean score of helplessness after giving therapy to the group that received cognitive therapy and family psychoeducation and who only received cognitive therapy in the group that did not get therapy to be 31.72 with a standard deviation of 4.697. There was an increase in the mean score of helplessness before and after being given therapy in the group receiving cognitive therapy and family psychoeducation and the group receiving cognitive therapy only in the control group (Pv <0.05).

D. The Effect of Cognitive Therapy and Family Psychoeducation on the Ability to Change Negativse Thoughts
The average ability to change negative thoughts in stroke clients before being given cognitive therapy and family psychoeducation is at a score of 62.60 and shows equivalence with a value of> 0.05.
The average ability to change negative thoughts in the group given cognitive therapy and family psychoeducation before the intervention was 61.07 with a standard deviation of 9.067 after being given the intervention, the average depression condition was 72.76 with a standard deviation of 12.557. The results of statistical tests showed that there was a significant increase in the average ability to change negative thoughts before and after being given the intervention of cognitive therapy and family psychoeducation (Pvalue <0.05). In the group that was given cognitive therapy and family psychoeducation, the difference in the increase in the ability to change negative thoughts was 11.69.
The average group that only received cognitive therapy before being given the intervention was 64.03 with a standard deviation of 10.972 after being given the intervention the average depression condition was 72.74 with a standard deviation of 9.884. The average ability to change negative thoughts in the group that did not receive therapy before was 62.69 with a standard deviation of 10.404. The results of statistical tests showed that there was a significant increase in the average ability to change negative thoughts before and after being given cognitive therapy intervention (Pv <0.05). In the group that only received cognitive therapy increased ability to change negative thoughts 8,207.
The average condition of the ability to change negative thoughts before giving therapy in the CT & FPE group and CT in the control group was 62.38 with a standard deviation of 10.404 to 66.62 with a standard deviation of 11.037. There was a significant increase in the average ability to change negative thoughts before and after therapy (Pv <0.05).
In the group that was given cognitive therapy and family psychoeducation, the increased ability to change negative thoughts was 11.69. In the group that only

Changes in Ability to Change Client's Negative Thought of Stroke Before and After CT & FPE Intervention
CT & FPE CT Kontrol received cognitive therapy an increase in the ability to change negative thoughts was 8,207 and in the group that did not receive the therapy, an increase in the ability to change negative thoughts was 3,931.

DISCUSSION a. The Effect of Cognitive Therapy and Family Psychoeducation on Depression Conditions.
Depressive conditions in the group that received cognitive therapy and family psychoeducation decreased significantly and significantly. The average depression condition in stroke clients before the intervention was 30.38%. The results of this study are supported by research conducted by (10) which shows that 79% of DM clients who are hospitalized experience depression. After being given cognitive therapy intervention and logotherapy, his depression condition decreased significantly. The decrease in depressive conditions after being given cognitive therapy and family psychoeducation was 6.08%. Depressive conditions arise due to psychological factors in the form of failures experienced due to physical weakness in the form of an inability to do work as usual.
Family therapy aims to provide information about illnesses suffered by family members who are sick. Family psychoeducation is an important element in a family mental health program, namely providing information and education through therapeutic communication (4). Families need to know what are the impacts that arise from a stroke experienced by clients in addition to its physical impacts. So that by knowing the psychological impact experienced by clients, the family is able to help and remind clients how to deal with the psychological effects that arise due to physical illnesses such as depression. In addition, psychological support is needed to support the healing process of stroke clients. According to (13), giving FPE increases the family's ability to provide social psychological support to family members who have suffered a stroke.
The results showed that the depression condition before being given the intervention of cognitive therapy and family psychoeducation was 17.92 (27.92%), which was in moderate depression to 13.76 (21.84%), namely in mild depression. The results of research by (10) showed that there was a decrease in depression after being given cognitive therapy and logotherapy by 79.4%. The results of another study conducted by Pasaribu where the depression condition after giving cognitive therapy and stopping thoughts decreased by (50.21%). This is different from the results conducted by researchers where the results of a decrease in depressive conditions by 6.08% were not too significant for changes in depressive conditions. Here the depressive condition decreases from moderate to mild.
Depressive conditions are characterized by clients feeling sad, hopeless, troubled or worthless. In stroke clients 73-80% of clients suffer from hemiparesis or hemiplegi. The impact of this disability causes limitations to stroke clients in carrying out activities. Clients tend to depend on other people. The client feels helpless due to the physical condition he is experiencing. The recovery process from this disability condition takes a long time.
The results showed that cognitive therapy alone could reduce depression in stroke clients, namely 19.24 (30.53%) to 16.76 (26.55%), namely 3.98%. The results of research conducted by (10) where the provision of cognitive therapy alone can reduce depression by 71.97%. The results of another study conducted by (14) showed that depression after being given cognitive therapy decreased by (35%). Cognitive therapy given to clients with depressed conditions can reduce depressive conditions. Psychological factors that play a role in depression are feelings of helplessness, hopelessness, role conflict, anger, shame about changes in body image and denial of disease. This condition is a response that arises due to negative perceptions in clients with stroke. Negative perceptions are generated by distortions of thought. Distortion is produced by situations that are unpleasant, uncomfortable or threatening. Someone who tends to process information with a negative mindset will produce a pathological scheme so that they tend to remember negative information (13). Stroke clients tend to bring up negative thoughts due to the impact of the stroke they are experiencing. Therefore it is necessary to be given training to help change negative thoughts into positive thinking patterns.
In the group that was not given the intervention, the depression condition before the intervention was 20.59 (32.68%) to 19.34 (30.69%), there was a decrease in the depressive state but it was still in the moderate depression range. Depression decreased by 1.99%. This insignificant decrease occurred due to emotional responses that appeared in stroke clients due to their physical conditions. The client has not accepted the physical condition he is experiencing. The client has not received a loss of physical function from disabilities that arise due to the impact of stroke. The client has not been able to accept his physical condition after having a stroke.
There was a decrease in depressive conditions in clients who received cognitive therapy and family psychoeducation but not 100%. Family psychoeducation therapy here focuses more on solving problems faced by families when caring for stroke clients. Most of the families caring for stroke clients disclosed the emergence of problems in caring for clients such as time burdens, financial burdens and difficulty resting because they were anxious about the client's condition.
The success of giving cognitive therapy to reduce depressive conditions is not very significant, this can be caused by other factors such as the number of meetings that are still insufficient to help clients identify as many negative thoughts as possible so that these negative thoughts no longer exist in the client. Depressive symptoms with 20 sessions are estimated to be able to reduce 75% of signs and symptoms of depression in clients combined with behavioral therapy (16). Cognitive therapy stops when there are no negative thoughts in the client.
Cognitive therapy is a method that can be used to increase the ability to change negative thoughts. Meanwhile, family psychoeducation is a therapy that can provide information and education through therapeutic communication that supports treatment and rehabilitation. Cognitive therapy was originally used to treat depressive conditions, and is now being used to treat emotional disorders and other clinical conditions such as panic disorder, general anxiety disorder, social phobia, obsessive compulsive disorder, PTSD, eating disorders, drug addiction, personality disorders, schizophrenia, partner problems, bipolar disorder, hypochondriasis, and somatoform disorders (17). In clients with a stroke, emotional changes such as anger, fear, anxiety, depression, emotional paralying, hopelessness and helplessness can appear. If this condition is not resolved, it can aggravate the client's psychological condition. The events experienced by clients make it important to increase the client's ability to control negative thoughts so that the impact of psychosocial problems that arise can be overcome. Another goal of cognitive therapy is to help clients think about their disease objectively in an adaptive way.
The purpose of providing cognitive therapy and family psychoeducation is to help clients overcome depression and helplessness by increasing the ability to change the client's negative thoughts. In the group that received cognitive therapy and family psychoeducation, the increased ability to change negative thoughts was not too different from the group that only received cognitive therapy. This is because stroke clients who have a disability condition suddenly need a long process to return to their original state. This is what causes changes in emotions and feelings to stroke clients.
The success of giving cognitive therapy and family psychoeducation is due to the fact that at each session the client is trained to fight negative thoughts that arise. Besides that, in session 4, the existence of family support that helps remind clients to do exercises against negative thoughts also has an impact on the success of therapy. The provision of cognitive therapy and family psychoeducation was able to increase the ability to change negative thoughts in stroke clients more significantly than in clients who only received cognitive therapy. Family support is very important for stroke clients.

b. The Effect of Cognitive Therapy and Family Psychoeducation on helplessness Conditions.
The results showed that there was a significant decrease in helplessness after intervention after cognitive therapy and family psychoeducation was seen from the increase in the score of helplessness. The score of helplessness before being given the intervention was 61.21%, increasing to 68%. There was an increase in the score of 6.79%. The expected score increase is 100%, which means that the higher the score for the client's condition, the more empowered the stroke is. The responses that arise from helplessness consist of verbal, emotional responses, participation in daily activities and responsibility for self-care (Miller, 1991). NANDA (2012) defines that helplessness is the perception that a person's actions will not significantly affect the results, perceptions of the current situation or situations that will occur soon. It can be said that helplessness is a deficit of internal and external control over the individual or client's perceptions of helplessness which is verbalized explicitly in the form of emotional and behavioral changes.
By providing cognitive therapy and family psychoeducation, it is hoped that it can reduce the helplessness experienced by stroke clients. In this study, the score of helplessness after giving cognitive therapy and family psychoeducation increased only by 6.79%. Stroke is a disease caused by neurological changes due to disruption of blood flow to the brain. The impact of stroke in general is disability that makes stroke clients experience limitations in their daily activities.
The client feels lost due to his previously good physical condition being unable to carry out daily activities. Clients tend to depend on other people, causing a feeling of helplessness. In the first session of cognitive therapy, there is an expression that the client cannot do anything with his physical condition, the client is ashamed of disability and cannot do anything, the client repeatedly, the client is annoyed that his hands and feet cannot be moved, the client feels guilty to bother others. It can be seen that the client has not accepted his physical condition, which used to be healthy, has become limited in carrying out activities and there is a sense of guilt from the client's condition.Thoughts affect the mood, feelings and behavior of stroke clients. Cognitive therapy aims to change negative thoughts into positive ones and focus on the current situation.
Family is the client's source of coping in dealing with the client's illness. With family support, it can help depression in stroke clients in accepting their physical condition. Lack of family knowledge about the client's illness can adversely affect the psychological response experienced by the client and the family itself.
Another study conducted by (18) where acceptance and commitment therapy (ACT) reduced the condition of helplessness in clients with CRF. The results of another study conducted by (19) on chronic disease in the intervention group after Ability to Change Negative Thought before the intervention in Client Stroke given ACT therapy with a follow-up for 3 months showed a decrease in the level of depression, anxiety, the intensity of chronic pain experienced, increased physical abilities and became more psychologically flexible in dealing with stressors related to their condition.

c. The Effect of Cognitive Therapy and Family Psychoeducation on the Ability to Change Negative Thoughts
The results showed that the ability to change negative thoughts in stroke clients who received cognitive therapy and family psychoeducation before receiving intervention was 61.07 (43.62%), increasing to 72.76 (51.97%). Cognitive therapy is a basic therapy and is very influential in increasing the client's ability to change negative thoughts, while family psychoeducation therapy is a complementary therapy to help individuals practice the ability to change negative thoughts.
Beck, et al (1987) in Townsand (2015) explain that the goal of cognitive therapy is to monitor negative automatic thoughts experienced by clients by recognizing and correcting wrong thoughts, affective and behavior and changing interpretations towards more reality and learning to identify and change beliefs. wrong as a result of a bad experience or situation. (7) explains that negative thoughts come from unpleasant or threatening events such as decreased physical conditions, the impact of treatment, causing fear, loss, disability, dependence.
The results of the research by (10) that there was an increase in the ability to change negative thoughts in DM clients who received cognitive therapy and logotherapy by 42.06%. Increased ability to change negative thoughts occurs because clients are trained to fight negative thoughts that arise due to negative perceptions of the client's illness.
Cognitive therapy can help clients improve their ability to change negative thoughts so that they can minimize distress due to disturbing, anxious and threatening thoughts. Clients can replace negative thoughts with more realistic thoughts that are in accordance with the client's current condition. Renfrow (2006) explains that cognitive therapy is effective in overcoming depression which focuses on modifying cognitive distortions and correcting maldaptive thoughts and changing negative thoughts. (20) states that clients with emotional disorders such as depression tend to experience negative automatic thoughts, where the client has an emotional response that generates many negative thoughts which are automatically stored in their memory without being analyzed rationally and logically. This is also found in stroke clients.

CONCLUSION
Clients in this study were more men, with an average age of 54.85 years, highly educated, most of whom did not work and on average suffered a stroke of 15.49 days. Depression conditions before intervention in stroke clients amounted to 30.38% and the condition of helplessness was 59.76% and the ability to change negative thoughts was 52.67%. Depressive conditions after being given therapy to clients who received cognitive therapy and family psychoeducation experienced a decrease and were in a state of mild depression, a decrease of 6.08%. The provision of cognitive therapy and family psychoeducation reduced the condition of helplessness by increasing the score of helplessness by 6.79%. The provision of Cognitive Therapy and Family Psychoeducation increased the ability to think positively from 43.65% to 51.97%. Cognitive therapy increased the ability to change negative thoughts in stroke clients by 3.93. The ability to change negative thoughts is associated with depression. The ability to change negative thoughts has nothing to do with a state of helplessness.
It is necessary to have a mental specialist in a public hospital and collaborate with other specialists such as medical surgical nursing so that clients with stroke who experience depression get holistic nursing care and can help the healing process to be better. The results of the study prove that the combination of cognitive therapy and family psychoeducation can be used to help reduce psychosocial problems, especially depression and helplessness and increase the ability to change negative thoughts. The results of this study can be used as evidence based in comparing the effectiveness of various therapies that can be given to stroke clients with depression and helplessness. There is a need for research that combines specialist cognitive therapy and family psychoeducation with logotherapy to achieve changes in conditions of anxiety and helplessness in stroke clients.