Article Title (Size 12; Bold; Times New Roman) www.jsser.org Journal of Social Studies Education Research Sosyal Bilgiler Eğitimi Araştırmaları Dergisi 2020:11 (4), 257-274 Life Review Therapy for Improving the Psychological Wellbeing of Elderly Retired Women in Indonesia Diah Karmiyati 1, Nixie Devina Rahmadiani2 & Nida Hasanati3 Abstract Retirement is considered an event that requires individual readjustment, so it can affect the psychological wellbeing of the elderly, especially for women. Better self-esteem can encourage individuals to respect themselves more, however, leading in turn to improvements in the dimension of psychological wellbeing. The aim of this study is to establish how self-esteem influences psychological wellbeing in elderly retired women. This study follows a randomized pretest and posttest, control group design. The research subjects were therefore divided into experimental and control groups, each comprising six people. The experimental group all received life review therapy, whereas the control group did not. All the subjects were elderly retired women with low- to-moderate levels of self-esteem and psychological wellbeing. The study used the Rosenberg self- esteem scale and the Ryff psychological wellbeing scale. Data analysis involved a non-parametric Wilcoxon analysis and the Mann–Whitney test. The results revealed that life review therapy improved self-esteem in the experimental group, and there were significant differences between the experimental group and the control group, with the experimental group showing a significant increase in its posttest scores. The results also showed an increase in psychological wellbeing along with self-esteem. It was therefore concluded that life review therapy can improve the psychological wellbeing of elderly retired women in Indonesia. Keywords: Life review therapy, self-esteem, psychological wellbeing, elderly retired women. Introduction Old age is the final developmental phase in the lifespan of a human being. Like during other stages of development, the elderly will experience changes in biological and motor function, vision and thinking, motives and affective life, social relationships, and community integration (Monks et al., 2006). The later years are seen as a source of considerable problems for human life, but in reality, many of these can be understood to some extent (Tandon, 2017). According to Erikson (Alwisol, 2009), if the elderly can develop optimally, then in their old age, they will have a strong ego identity and be able to achieve self-integrity, such that there is a feeling of being united and in touch with feelings according to the situation. Various kinds of changes are experienced by the elderly, both physically and psychologically, and some aspects will certainly impact their 1 Dr. Universitas Muhammadiyah Malang, Indonesia; Email: diah@umm.ac.id 2 MA. Universitas Muhammadiyah Malang, Indonesia; Email: nixie.nixie@yahoo.co.id 3 Dr. Universitas Muhammadiyah Malang, Indonesia; Email: nida@umm.ac.id mailto:diah@umm.ac.id mailto:nixie.nixie@yahoo.co.id mailto:nida@umm.ac.id Journal of Social Studies Education Research 2020: 11(4), 257-274 psychological wellbeing to some extent. Retirement can also cause issues in terms of experiencing a loss of physiological, psychological, and social involvement (Chiang et al., 2010). Most individuals assume that retirement from work is an event that leads to the next stage of adulthood, and this can affect physical and psychological wellbeing. However, the experience of retirement can differ for elderly men and women because they have different histories, work opportunities, and life experiences. Research shows that women are more negative about retirement than men are, so this can lead to a greater risk of depression and loneliness for women (Kim & Moen, 2002). This is also supported by the research of Hanayanthi (2003), which showed that attitudes toward retirement are more negative among women than men, because when women work, they tend to feel more capable and on an equal footing with men. This makes women more sensitive to the changes that occur when retiring from work. Over her life, an elderly woman will have carried out various types of activities and played several roles. Elderly women have various occupational backgrounds, ranging from someone who has worked full time for most of her working-age life before retiring for at least 5 years to someone who has been a homemaker, which can be regarded as someone working in the home all her life but never taking up a salaried position (Adelmann et al., 1993; Kato, 2018). The basic difference between a retiree and a homemaker is that a retiree receives a pension from her previous work, while a homemaker relies on income from her partner’s work. Homemakers do not experience huge work-related changes, so they do not experience significant work gaps (Silver, 2010). This is in line with research that showed that work status significantly influences the life satisfaction of elderly women. Elderly women who have been lifelong housewives have a greater level of life satisfaction and psychological wellbeing than elderly woman who have retired from work (Riddick, 1985). It therefore follows that elderly women who were previously active in the labor market will tend to have more psychological vulnerabilities than homemakers or other women who did not have regular jobs. Retirement from work is considered an important transition for individuals in old age, because it impacts how they spend their time and earn income, as well as whom they interact with (Palmore, Fillenbaum & George, 1984). In addition, the retirement process can also affect individual self- esteem. Research conducted by Bleidorn and Schwaba (2018) showed that individuals who worked start experiencing a decline in self-esteem five years before retirement, but they tend to stabilize five years after retirement. Research conducted by Reitzes and Mutran (2004), meanwhile, Karmiyati, et al. 259 revealed that individuals experience a decline in self-esteem after six or seven years, but they tend to stabilize afterwards because they have gone through the adjustment process. Toward the end of the 20th century, the focus of attention in mental health was to treat or prevent complaints and enhance the positive aspects of mental health. To improve the quality of life for individuals in the elderly population, it is necessary to provide opportunities for the elderly to fulfill themselves (i.e., self-fulfillment) through education, learning, and an active life, in addition to focusing purely on the problems that are naturally felt by the elderly (Singh & Kiran, 2013). Elderly people who are more oriented toward positive aspects—such as the potential for learning, wisdom, life satisfaction, and happiness—are more inclined toward positive integration and a more competent and successful aging process (Portero & Oliva, 2007). A healthy mental condition in turn improves their wellbeing (Weiss et al., 2016). Psychological wellbeing can in turn be a protective factor for health, such as by reducing the risk of severe physical illness and extending the life expectations of the elderly (Steptoe, et al., 2015). It also improves social and cognitive functions and reduces the risk of an early death (Beam, 2016). When the elderly have a high level of psychological wellbeing in aspects of environmental mastery and self-acceptance, it has been reported that they tend to have lower levels of HDL and triglycerides when compared to their peers with a lesser psychological wellbeing (Radler et al., 2018). The psychological wellbeing model focuses on development throughout the human lifespan. This relates to changes over age in the six dimensions of psychological wellbeing, because psychosocial tasks and environmental challenges change as a person ages. Studies conducted on young, middle- aged, and elderly people have shown that personal growth and purpose in life decreases with age, while environmental mastery and autonomy increase, and self-acceptance and positive relationships with others tend to be stable throughout adulthood (Homan, 2016). Beam (2016) explains that psychological wellbeing has a reciprocal relationship with social functions, cognitive functions, and health aspects. Factors that cause psychological wellbeing in the elderly include material conditions, family and social relationships, social roles and activities, and other factors related to changes with age (Steptoe et al., 2015). Research conducted by Almira, Hanum, and Menaldi (2019) showed that negative relationships between parents and children impact the psychological wellbeing of the elderly in Indonesia. Such relationships may manifest in a lack of sympathy, failure to receive help from children, and experiences of rejection, and these Journal of Social Studies Education Research 2020: 11(4), 257-274 can degrade the psychological wellbeing of the elderly. In addition, elderly people who participate in various social activities and roles reported having better psychological wellbeing than those who are relatively inactive (Lee et al., 2016). Another factor in achieving psychological wellbeing is self-esteem. Many studies have shown that personal and contextual factors strongly affect the achievement of psychological wellbeing in the elderly (Hassan et al., 2018). Hermida, Tartaglini, Feldberg, and Stefani (2017) found that individuals with low levels of psychophysiological disorder due to retirement tend to have better levels of psychological wellbeing. In addition, there is a relationship between self-esteem and life satisfaction, so this can reduce physical and psychological impairment. Russell, Nyame-Mensah, Wit, and Handy (2019) showed that a relationship exists between self- esteem and psychological wellbeing, and this is moderated by involvement in voluntary activities. Dewijayanti and Wahyudi (2018), meanwhile, found that self-esteem has a significant positive correlation with psychological wellbeing in Thalassemia patients. Psychological wellbeing can arise through self-esteem, because it affects a person’s self-assessment of his or her value. Some interventions can be made to improve psychological wellbeing in the elderly, such as gratitude interventions, which have been used to improve psychological wellbeing in individuals with a variety of different backgrounds (Bilbao et al., 2008; Ramírez et al., 2014; Renshaw & Rock, 2018). Research into gratitude interventions and psychological wellbeing has also been conducted in various areas. The research of Kuren and Macaskill (2015) showed that a gratitude intervention based on applying the concept of “three good things in life” enables significant progress to be made in improving psychological wellbeing. This happens because gratitude is associated with increasing positive individual emotions and decreasing the negative ones, leading the individual to a state of greater wellbeing (Armenta et al., 2017). Another intervention for improving psychological wellbeing is life review therapy, and this has been applied to improve psychological wellbeing for a variety of different subjects. Several studies have shown its positive results in reducing depressive symptoms and improving quality of life for the elderly (Damirchi et al, 2017; Korte et al., 2012; Sharif et al., 2017; Moghadam, 2018). However, other studies have shown life review therapy to have insignificant effects on improving psychological wellbeing (Preschl et al., 2012). This shows that there are still gaps in establishing the effectiveness of life review therapy at improving psychological wellbeing. Karmiyati, et al. 261 Life review therapy is a non-pharmacological therapy that focuses on human life experiences throughout the lifespan. The process of looking back at the life that has been experienced involves an evaluation of that individual’s life. On the one hand, it can help overcome previous conflicts and negative individual experiences. On the other hand, the process can also provide positive meaning for the subject’s life (Korte et al., 2012). Research conducted by Chiang et al. (2010) showed that life review therapy can positively affect the self-esteem of elderly 78-year-old men. Elderly people can review their life experiences and then evaluate and analyze them to enable a deeper self-concept through the process of life review (Sharif et al., 2018). Life review therefore involves a process of nostalgia, and it has three main functions in terms of protecting individual identity, increasing mastery over one’s life, and strengthening relational ties (Sedikides et al., 2008). In the life review process, there is a reframing process, so individuals can modify memories that are not self-acceptable and come to accept events that were previously perceived as negative (Haight & Burnside, 1993). Based on the above description, it is important to study the use of life review therapy to improve psychological wellbeing, because the results of previous studies have practical gaps in proving its effectiveness. Such research is also rarely pursued in Indonesia, especially when looking at positive individual aspects like psychological wellbeing. The uniqueness of this study comes in applying life review therapy for elderly retired women. Indeed, the purpose of this study is to determine the effect of life review therapy in improving self-esteem and consequently psychological wellbeing for elderly retired women. This research will likely benefit the study’s participants by enabling them to look back on their life experiences in way that will increase self- esteem and improve psychological wellbeing. The study’s results should also contribute to the body of knowledge in the field of clinical psychology, specifically for areas focusing on the psychological wellbeing of the elderly, and it may guide future researchers in developing further interventions to improve psychological wellbeing. Research Questions Drawing the above background, the research questions to be sought include: 1) How much does the life-review therapy improve self-esteem of the elderly retired women in Indonesia? 2) How much does the life therapy improve psychological well-being of the elderly retired women in Indonesia? Journal of Social Studies Education Research 2020: 11(4), 257-274 Methods Design This study uses a randomized pretest–posttest, control group design. This design involves measuring and comparing the pretest score and posttest score when a group is given treatment or not given treatment (Seniati, Yulianto & Setiadi, 2009). The research design is illustrated in Table 1. Table 1 Research design (KE) O1 → X → O2 (KK) O1 → → O2 Information: KE: Experiment Group; KK: Control Group; O1: Pretest self-esteem and psychological wellbeing before intervention; X: Life review therapy; O2: Posttest self- esteem and psychological wellbeing after the intervention. Participants The research subjects comprised 12 elderly people who were divided equally over two groups, namely the experimental group and the control group. Nonprobability sampling was used by determining purposive sampling, which is a sampling technique based on certain criteria (Sugiyono, 2011). In determining the division of subjects over the two group, random assignment was used in the form of entering subjects randomly into each group, so it can be assumed that there is a degree of homogeneity between the groups (Seniati et al., 2009). The criteria for participants were that they should be elderly women aged 56 years or older, show low-to-moderate psychological welfare scores, be no less than five years before retirement and no more than five years after retirement, not be following any other psychological intervention, be able to communicate, not be experiencing dementia or any tendency to depression or other severe psychological disorder, and be willing to follow life review therapy by signing an informed consent from the therapist. Instruments The variables in this study were self-esteem and psychological wellbeing. The operational definition of self-esteem relates to the individual’s self-assessment of his or her own value, while the operational definition of psychological wellbeing relates to a person’s ability to behave Karmiyati, et al. 263 independently (i.e., autonomy), have good social relationships (i.e., positive relations with others), master the environment (i.e., environmental mastery), grow personally (i.e., personal growth), have a purpose in life (i.e., life purpose), and be able to accept her current state (i.e., self- acceptance). The Rosenberg self-esteem scale (RSES) was used to measure self-esteem with a reliability of 0.696. The RSES has a total of eight items and features five answer choices (5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree). This is an example item statement: “I am able to do something like what other people can do.” The Ryff psychological well being scale was used to collect data about psychological wellbeing. This scale features 38 items and uses a six-point Likert scale (1 represents strongly disagree, while 6 represents strongly agree). Scores on this scale are grouped into three levels, with scores below 76 falling into the low category, scores in the 77–153 range falling into the medium category, and scores above 154 falling in the high category. This scale is based on six dimensions of psychological wellbeing, namely autonomy, environmental mastery, personal growth, positive relations, life purpose, and self-acceptance). The reliability of the Ryff psychological wellbeing scale is 0.927. This is an example item statement: “I feel in vain when I achieve a goal in life.” The following research procedures were conducted by the researchers: 1). Test the scale of measurement and the module. The data were then analyzed to learn the coefficient of validity and reliability of the scale. 2). Select a subject by looking for low-to-moderate self-esteem and psychological wellbeing scores. The researcher assigned qualifying subjects randomly to the experimental and control groups. 3). Subjects were asked to complete an informed consent sheet. 4). The intervention process was carried out individually for the six subjects in the experimental group. In the control group, self-esteem and psychological wellbeing scores were evaluated about four weeks after pretest. 5). After administering life review therapy, measurement is carried out again using the self-esteem and psychological wellbeing scales to determine any post-intervention changes. A further follow-up was also performed a month later for the experimental group. Journal of Social Studies Education Research 2020: 11(4), 257-274 Data Analysis Techniques Manipulation checks were calculated using the Wilcoxon test for the experimental group by looking at the pretest and posttest scores for self-esteem. Data analysis was performed by looking at differences between the pretest and posttest scores, which is called the gain score. The Mann– Whitney test is a procedure for nonparametric statistical tests to determine whether differences exist between two independent populations, whereas the Wilcoxon test is performed to test for differences in two paired populations (Suyanto & Gio, 2017). Results Self-esteem The first research question to seek the answer is the self-esteem. The results in Table 2 show that there are differences in the average pretest and posttest scores for the self-esteem and psychological wellbeing of the elderly retired women. Table 2 Descriptive data The variable being manipulated is that of self-esteem. Manipulation checks were calculated using the Wilcoxon test to establish whether there were differences in the pretest and posttest scores of the experimental group. The results of the Wilcoxon test for the experimental group are given in Table 3. Table 3 Manipulation check results Variable Mean Z Sig. Pretest Posttest Self-Esteem 25.50 32.83 -2.201 0.028 Self-esteem has a significance value of 0.028 (p<0.05). It was therefore concluded that there was a significant overall difference in self-esteem before and after intervention. This shows that life review therapy did successfully increase self-esteem scores in the experimental group. Indeed, Variable Group Pretest Posttest Mean Standard Deviation Mean Standard Deviation Self-esteem Experiment 25.50 2.07 32.83 4.26 Control 26.67 2.50 28.67 1.97 Psychological wellbeing Experiment 130.17 10.89 150.00 14.60 Control 130.33 8.07 134.17 6.44 Karmiyati, et al. 265 the goal of this therapy is to increase self-esteem in retired elderly women so that it will also improve their psychological wellbeing. Psychological Wellbeing Nonparametric analysis was applied here, namely in the form of the Mann–Whitney test. This test serves to identify differences between the control and experimental groups, while the Wilcoxon test is used to determine whether there is a difference between the pretest and posttest scores of the experimental and control groups. The differences in scores for psychological wellbeing in each group are shown in Table 4: Table 4 Differences in psychological wellbeing Group Pretest Posttest Sig. Information Mean SD Mean SD Experiment 130.17 10.89 150.00 14.60 .028 Pretest< Posttest Control 130.33 8.07 134.17 4.92 0.075 Pretest< Posttest The experimental group had an average pretest score for psychological wellbeing of 130.17, while at posttest, it increased to 150.0. The significance was 0.028 (p <0.05), so there was a significant difference in the average psychological wellbeing scores before and after treatment. The control group had an average pretest psychological wellbeing score of 130.33 and a posttest score of 134.17. The significance was 0.075 (p> 0.05), so the differences between pretest and posttest scores were not significant in the control group. The Mann–Whitney test was used to evaluate the differences in scores (i.e., the gain score) between the experimental group and the control group, and the results appear in Table 5. Table 5 Z score between the experiment and control groups Group N Mean Rank Z Sig. Experiment 6 9.08 -2.486 0.013 Control 6 3.92 The results showed a significance value of 0.013 (p<0.05), demonstrating that the difference in the level of psychological wellbeing between the two groups is significant, with the group that received life review therapy having higher psychological wellbeing scores than the group who did not. Journal of Social Studies Education Research 2020: 11(4), 257-274 Overall, life review therapy seems to increase self-esteem and consequently psychological wellbeing, because when the self-esteem of retired elderly women increases, psychological wellbeing also tends to increase. The influence of variables X and Y was then tested using the Kendall Tau-b test, with the posttest score for self-esteem and the posttest score for psychological wellbeing, both for the experimental group, being used as variables. Table 6 Effect of self-esteem on psychological wellbeing Variable N Correlation Sig. Self-esteem and psychological wellbeing 6 0.894 0.016 From Table 6, the correlation coefficient is 0.894, meaning that X and Y have a strong relationship. The value of the regression coefficient is positive, meaning that the relationship between the two variables follows the same direction, so if the variable X increases, the variable Y also increases. The significance value is 0.016 (p <0.05), meaning that the relationship between the X and Y variables is significant. It can therefore be concluded that self-esteem significantly influences the psychological wellbeing of elderly retired women. Follow-up was conducted a month after the intervention for the six subjects in the experimental group, and the scores from this were compared to the posttest scores. The mean score for psychological welfare in the experimental group is shown in Table 7. Table 7 Mean posttest and follow-up scores for the experiment group Variable N Mean SD Psychological wellbeing Posttest 6 150.00 14.60 Follow-up 154.00 10.62 Table 7 shows no loss of the posttest increase, implying that gains in psychological wellbeing from the intervention tend to be sustainable. We can therefore concluded that the subjects were able to maintain higher levels of psychological wellbeing after receiving life review therapy. Discussion The results of our experiment show that life review therapy can increase self-esteem, as evidenced by gains in the self-esteem score in the experimental group between pretest and posttest. These gains were significantly better than those seen in the control group. The influence of self-esteem Karmiyati, et al. 267 on psychological wellbeing was also found to be strong and unidirectional. Based on the results of the data analysis, it can be concluded that life review therapy can improve the self-esteem of retired elderly women, which in turn improves their psychological wellbeing. The intervention stage for the six subjects in the experimental group began by reviewing past events according to the stages of development, namely childhood, adolescence, young adulthood, old adulthood, the elderly, and now. When reviewing and recalling past events that had taken place, the subjects shared experiences that were both pleasant and unpleasant for them. Through life review therapy, individuals are likely to focus on both positive and negative events, so they can coherently balance their experiences (Preschl et al., 2012). A person’s self-esteem develops from childhood to adulthood according to various experiences. It can be sourced internally and externally. Internal sources, for example, include a sense of achieving something in life, while external sources generally come in the form of affirmations from other people or other positive events (Guindon, 2010). When an individual has an unpleasant experience, it will affect that person’s self-image, so that it will in turn affect his or her self-esteem. The intervention process increases the elderly’s self-esteem through the reframing process. When a person shows a sense of rejection, he or she is less able to accept events in life and tends to convey the less-pleasant experiences from life. The therapist’s role is then to reframe the event so the subject can see a positive side to it and become more receptive to it. In this study, the subjects showed changes in the reappraisal process when entering intervention sessions that focused on early adulthood and old adulthood. This related to unpleasant events in adulthood while beginning to feel the effects of a more complex life. In the reframing process, the subjects came to see events from the other perspective, thus changing the way the situation was viewed. Guindon (2010) revealed that self-esteem has a component that is related to evaluative elements, namely the extent to which individuals assess whether an experienced event has positive or negative attributes. A life review can fulfill individual existential functions and turn them into rich sources of emotions and positive experiences, which in turn can be traced so people are better able to deal with threats to their individual existence (Pyszczynski et al., 2010). A study of Moral, Terrero, Galan, and Rodriguez (2015) showed that a reminiscence intervention or life review resulted in a significant increase in the Rosenberg self-esteem scale (RSES) score in the experimental group when compared to the control group. Their research studied 34 elderly people who were asked to review life events over eight sessions. Through therapy based on a Journal of Social Studies Education Research 2020: 11(4), 257-274 review of individual events, the participants’ ability to understand increased, and this helped increase self-esteem, reduce levels of depression and helplessness, and improve self-integration or ego integrity (Chiang et al., 2010). In the concept of psychological wellbeing, one dimension that plays an important role is individual self-acceptance. In other words, individuals are better able to accept themselves when they can respect their current condition. This is related to self-esteem, which is a general feeling of self- acceptance, kindness, and respect for oneself (Herero & Extremera, 2010). Therefore, if individuals are able to accept themselves, they are more open rather than defensive and better able to improve their psychological wellbeing (Paradise & Kernis, 2002). Theories regarding psychological wellbeing emphasize the use of individuals’ potential to accept themselves and continue meaningful social relationships (Dogan et al., 2013). The higher cognitive, affective, and evaluative elements of self-esteem can therefore support the achievement of individual psychological wellbeing and happiness (Guindon, 2010). The purpose of a life review is to achieve integrity, while the therapist’s role is to accept, respect, show empathy, and reframe a single event. The process tends to be structured over a lifespan development approach, so it can lead individuals to achieve integrity and improve their wellbeing, wisdom, self-esteem, and life satisfaction (Haight & Burnside, 1993). An increase in self-esteem and psychological wellbeing of the experimental subjects of this study was accompanied by similarities in how they started participating in activities, both in the environment around their homes and elsewhere. This contributed to the process of finding positive things, thus influencing the evaluation process. Retirees with high or low levels of psychological wellbeing are significantly differently influenced by their self-esteem, how much remorse they feel, their life purpose, perceived social support, leisure activities, attitudes related to aging, and household decision-making (Neeta Sharma et al., 2015). One month after intervention, the researchers followed up on the members of the experimental group to determine if the intervention’s effects persisted. The mean score obtained revealed that the subjects were able to maintain the same level of psychological wellbeing some weeks after the intervention. The increase occurs because life review therapy comprises a nostalgic process that helps protect an individual’s identity, increases mastery over one’s life, and strengthens relational bonds, thus helping the individual to achieve psychological wellbeing (Sedikides et al., 2008). In addition, with the support of others, involvement in social activities also plays a role in ensuring Karmiyati, et al. 269 the psychological wellbeing of individuals. As stated by Steptoe et al. (2015), several factors can improve the psychological wellbeing of the elderly, such as social roles and activities and family and social relationships. There were some limitations in delivering interventions in that some subjects had time constraints, so several sessions were conducted with a time interval of approximately a week before proceeding to the next session. Conclusion and Suggestions The results demonstrate that life review therapy can increase the self-esteem of retired elderly women. Along with the increase in self-esteem, these women also experienced an improvement in their psychological wellbeing. One recommendation for further research is to apply this intervention among elderly subjects with different characteristics, such as those with a chronic illness or those who have lost their partners and live alone. Suggestions could be given to such research subjects, as well as the elderly in general, as to how to apply the reframing process or shift to a more positive attitude when dealing with unpleasant past incidents that can affect emotions. 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