http://e-journal.unair.ac.id/JNERS | 207 Jurnal Ners Vol. 13, No. 2, October 2018 http://dx.doi.org/10.20473/jn.v13i1.4686 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Original Research Life Writing Therapy Decreases Depression in Late Adolescence Zulaikah Nur Istiqomah, Erna Erawati and Suyanta Suyanta Nursing Department of Health Polytechnic Kemenkes, Semarang, Indonesia ABSTRACT Introduction: Late adolescence (16-18 years old) usually experiences a crucial period in life which makes teenagers vulnerable to mood disorders such as depression. One of the interventions that can decrease depression is writing a memoir, biography, diary, and life writing. Writing can disclose the feeling and help mind care. The objective of this study was to investigate the influence of life writing therapy to decrease depression in late adolescence. Methods: This study used pretest-post-test control group design with 40 people as samples, divided into intervention and control groups. Before and after the treatment, both groups were measured using the scale of the PHQ-9A to see the depression in late adolescence of high school students. Results: Life writing therapy shows differences in mean between intervention group and control group with a p-value of 0.000 (α <0.05). Conclusion: The life writing therapy has an effect in reducing depression in students. It facilitates subjects to evaluate, analyze, and reassess past, current and future events so that subjects can get an understanding, develop a solution and self-motivation, accept the existing situation, learn from what is experienced, focus thoughts on positive things, and assess positive things from an event. ARTICLE HISTORY Received: June 16, 2017 Accepted: January 04, 2019 KEYWORDS depression, adolescence; life writing therapy CONTACT Zulaikah Nur Istiqomah  zulaikahnuristiqomah@gmail.com  Nursing Department of Health Polytechnic Kemenkes, Semarang , Indonesia Cite this as: Istiqomah, Z, N., Erawati, E., & Suyanta, S. (2018). Life Writing Therapy Decreases Depression in Late Adolescence. Jurnal Ners, 13(2), 207-212. doi:http://dx.doi.org/10.20473/jn.v13i2.4686 INTRODUCTION The term adolescence comes from Latin word adolescere (noun, adolescentia which means teenager) which means “to grow” or “to grow into adulthood”. The term adolescence, as used nowadays, has a broader meaning including mental, emotional, social and physical maturity (Hurlock, 2002). The term adolescence, once a synonym for puberty, is now more emphasized stating the psychosocial changes that accompany puberty. However, the acceleration of somatic growth which is part of physical changes at puberty is called adolescent growth spurt (Soetjiningsih, 2010). Adolescence is a transition period between childhood and adulthood followed by biological, cognitive, and socioemotional changes (Santrock, 2014). Adolescence has a broad meaning including mental, emotional, social, and physical maturations (signs of secondary sex, maturation of reproduction, a way of thinking is more abstract, logical, and idealistic, emotionally more labile, and the relationship with peers become more intimate). Adolescence is divided into two stages, early and late adolescences. Early adolescence usually lasts roughly from 13-16 years old, while late adolescence starts from 16 or 17 years old to 18-years-old. During the late adolescence, teenagers commonly spend their times studying at high school. In addition, they experience a crucial time in life because they live in transition period between adolescence and adulthood. When teenagers are in the last year of high school, their parents usually consider that they are almost an adult and about to enter higher education or receive specific job training. Being student also makes them aware of the responsibilities they had never thought before (Hurlock, 2002). Awareness of new formal status, either at home or at school, has encouraged most of teenagers to behave in a more mature way. However, looking at the juvenile psychological mental status, it is not stable yet. In addition, some of them assume that this responsibility is a huge burden. Pressure from parents, schools, and environment can make https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Z. N. ISTIQOMAH ET AL. 208 | pISSN: 1858-3598  eISSN: 2502-5791 teenagers feel frustrated or stressed because of the lack of gain in self-fulfillment (Soetjiningsih, 2010). Inability to deal with stressors or pressures has led teenagers to the risk of disorders moods such as depression to behave detrimental both for themselves and others. Most of the depressions in adolescents are undiagnosed. Psychological developments commonly found in adolescence include emotional disorder, excessive introspection, and high sensitivity. As a result, the symptoms of depression are considered as part of the change in adolescent development. In fact, depression is a normal response phenomenon to negative life experiences, such as loss of family, valuables or social status. Depression can be seen as a continuum that moves from normal depression to clinical depression (Murti, 2012). Caron in Aditomo (2004) mentions the normal symptoms of depression such as feelings of not getting excited, feeling of hopeless, etc. that usually do not last long or minor depression. Coping with these symptoms, a new perspective that is more mature will appear; thus, normal depression could be seen as an adaptive experience. Depression becomes maladaptive and abnormal when appear in high intensity and settle or major depressive disorder. Depression in teenagers is basically a disorder that affects affective regulation. In particular, this disorder appears to cause problems by initiating, maintaining, or modifying the quality, intensity, or affective response time. The key aspects of this disorder, especially the sedentary low mood and anhedonia typical of depressive episodes, can be conceptualized as changes in affective regulation. Both the intensity and duration of the affective stage appear abnormal in depression as showing changes in the regulatory affective process (Forbes, Silk, & Dahl, 2009). BPS Kota Magelang (2015) states that the population of adolescents at the age of 15-19 are 10.759 teenagers and the numbers of student who study at high school in Magelang are about 4,716 students. Lentera Jiwa (2015) in one of their articles mention the results of a survey conducted in 50% of schools in Magelang ranging from early childhood through high school in June 2014. The survey shows a comparison of the number of children and adolescents who had problems in Magelang, i.e. mental-emotional disorders. Longitudinal research conducted by Sihvola et al. (2016) on 1854 respondents indicates that minor depression is more common in adolescents than major depression with a ratio of 12%: 2.5%. This percentage indicates the importance of research to assess effective method in reducing depression in adolescents. Some types of interventions have been studied for its effectiveness in reducing depression. One of the therapies that can be done is Cognitive Behavior Therapy that drives to think of realistic and positive about themselves, environment and future whether in dialogues or writing. Life Writing is one of cognitive therapies by writing the stories, memoirs, biographies, diaries (Progoff in Pranoto, 2015). Research conducted by Pennebaker about emotional writing has also proven that writing can help heal the effects of trauma (Pranoto, 2015). In addition, writing will stimulate the brain to organize his thoughts, pour emotions and feelings, and help solve problems. Writing a diary or life writing therapy is the treatment to write the easiest thing to do. Domar in Rais & Hidayati (2009) states that writing is a step to express emotions and feelings and help care for the mind. The effect of writing in alleviating depression has also been investigated by Qonitatin (2011). In these studies, there is a significant influence on students who have mild depression. Through expressive writing therapy, emotional experiences as catharsis or emotional release their lower levels of mild depression. The objective of this study is to examine the effect of life writing therapy in decreasing depression in late adolescence. MATERIALS AND METHODS This study was a quasi-experiment research with the pretest-posttest control group design method. The research was conducted in a high school in Magelang from January to February 2017. The population of this study was 146 students of the 12th grade who experienced depression based on the preliminary study conducted by researchers. The samples were selected using the purposive sampling technique based on inclusion criteria, i.e. the subjects were the 12th grade student at the age of 16-18 with depression scores between 10-27 (mild depression to severe depression using PHQ-9A), able to write, and had never been exposed to depression-related therapy. There were 40 samples who were divided into two groups, intervention and control groups consisting of 20 students for each. The groups were divided using simple random sampling with statistic application where samples have the same opportunity. The data collection tool uses a modified PHQ-9A scale measuring tool for teens (Patient Health Questionnaire-9 Adolescence), i.e. a tool to measure the scale of depression in adolescents with Likert scale 0-3 consisting of 9 questions, each of which represents an indicator of depression for approximately 2 weeks last. This questionnaire has been tested for validity and reliability. The validity test showed that the question items were valid with a correlation value between 0.434 - 0.826 at the 95% significance level. The value of reliability in this questionnaire was 0.822; thus, the questionnaire was reliable or trusted. The ethical considerations were met, as the participants signed an informed consent form. After obtaining approval from all respondents, it was subjected to an initial reassessment or pretest as a baseline to strengthen screening data in both the intervention and control groups. The intervention JURNAL NERS http://e-journal.unair.ac.id/JNERS | 209 was carried out for 4 weeks with a total of 8 meetings containing 3 sessions of writing with a different topic for approximately 45-60 minutes simultaneously at each meeting. Respondents were given workbooks related to interventions consisting of several commands for life writing therapy that could be written every day and done at home. Post- test was conducted after the follow-up during the last week of intervention. The media used in this study were workbook, observation sheet, and evaluation sheet. This research study received ethical clearance approval from the ethics committee of the research and community service units of the Health Polytechnic Kemenkes Semarang No. 1475 in 6th February 2017. RESULTS The respondents were 40 students of the 12th grade divided into two groups: the intervention and the control groups. During the research, there were no respondents who dropped out and all of them were included in the analysis. Most respondents were at age of 17, 60% in the intervention group and 75% in the control group. Based on the sex, most respondents were female, 50% in the intervention group and 65% in the control group. 77.5% respondents were Science Class and 22.5% respondents were Social Class (Table 1). Table 2 shows that the average pre-test score in the intervention group is 8,9 and post-test score is 4.8,and the difference between pre-test and post-test score are 4.10 (Table 2). Meanwhile, the control group shows the average pre-test score of 8.55 and average post-test score of 8.40; thus, the difference between pre-test and post-test is 0.15 (Table 2). Table 2 shows the comparison between the average, decrease in depression pre-test and post- test scores in the intervention group and the control group of 0.000 (p-value <0.05). It means that there is a very significant influence of life writing therapy to decrease depression in adolescents (Table 2). DISCUSSION The research results show that most respondents from a total of 40 students were at age of 17, or 67.5%. Another study which had the same thing was a study conducted by Harijanto, Handayani, & Asmika (2008). It reported that the prevalence of the depression among the high school students based on the age was found at the age of 17. There are a lot of factors that can influence it as revealed by EL Kelly in Bahiyatun (2011). At the age of 16 to 18, teenagers are commonly spend their times studying at high school. In addition, they will experience a crucial transition period between adolescence and adulthood. During this period, the status of the individual is not clear and there are doubts about the roles that must be performed. They are not expected to be childish anymore, but also not expected to behave like adults. The results also show that that the number of female students was higher than male students, 57.5% women and 42.5% males. What makes it different is because girls tend to keep their depressed moods and strengthen them, female self- image, especially in a more negative body image than males, females find more discrimination than males, and puberty occurs earlier in females (Santrock, 2014). Darmayanti (2008) concludes that there were differences in depression between adolescent girls and boys. Adolescent girls have depressive tendencies compared to adolescent boys. The research results also show that the mean pre-test score in depression of the intervention group was 8.90, and the control group was 8.55. The ranges of depression levels based on the set score are 0-4 not depressed/normal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 severe depression, 20-27 very severe depression. Seeing these results, it can be said that both groups experienced an average level of mild depression. The results of this study are consistent with the results of research conducted by Safitri (2013) and Harijanto (2008) who reported that the level of depression experienced by adolescents at most was mild depression. Ardjana (2010) suggests that a person can be said to experience mild depression if he/she shows at least two of the main symptoms. In addition, there should be no severe symptoms, and the duration of the entire episode is about two weeks. The main symptoms felt are the atmospheres of feeling depressed throughout the day and losing interest and passion in almost all activities, fatigue and decreased activity. The research results show that there is the influence of life writing therapy to decrease depression in adolescents. This hypothesis is proven by statistical tests using independent t-test results showing p-value of 0.000 (p-value <0.05). It means that the average decrease in depression pre-test and post-test scores in the intervention group is larger than in the control group. Therefore, it can be concluded that there is a very significant effect on the depression score between the group with life Table 1. Characteristics of respondents (n=40) Variable Intervention Control Total f % f % f % Age 16 0 0 1 5 1 2.5 17 12 60 15 75 27 67.5 18 8 40 4 20 12 30.0 Sex Boys 10 50 7 35 17 42.5 Girls 10 50 13 65 23 57.5 Class Science 19 95 12 60 31 77.5 Social 1 5 8 40 9 22.5 Z. N. ISTIQOMAH ET AL. 210 | pISSN: 1858-3598  eISSN: 2502-5791 writing therapy than the group without this treatment. The measurements before taking the life writing therapy show that a mean decrease in depression score of the pre-test in the intervention group is 8.90 and the control group is 8.55. It means that both groups had a quite similar mean of depression score. The intervention of life writing therapy is not performed immediately after the measurements pre- test are limited due to the time of respondents. The intervention of life writing therapy took 4 weeks and 8 meetings. Post-test was conducted on the last day of therapy and showed that a mean of depression score in the intervention group was 4.8 or at the level of the normal depression; while in the control group was 8.40 or at the level of mild depression. Therefore, both groups showed equally decreased mean of depression score. Since this study was included in the social studies, it is very difficult for researchers to control the daily activities of the subject and other variables that could affect the decrease in depression score either the intervention group or the control group, and it is one of the weaknesses in this study. In addition, the research results show that the mean of depression score in the pre-test of the intervention group decreased by 4.10; while, in the control group, it decreased by 0.15. It suggests that the decrease in the intervention group was higher than in the control group. Furthermore, the results show that there was a change in the level of depression for the intervention group in which the mild depression in the pre-test changed into normal depression in the post-test. Whereas, there was no difference in the control group between the depression levels in the pre-test and post-test scores. The results also show that the respondents stated that writing was fairly effective means to vent feelings, understand the situation of themselves and were able to identify a problem that was happening. The results of this research are consistent with the results of research conducted by Susilowati and Hasanat (2011) which reported that there is a significant decrease in emotional experience after implementing life writing therapy for depression in the first year students. Furthermore, a study by Indah, Afiatin, & Astuti (2011) shows that there is significant emotional experience to reduce depression among women of violence victims. However, these results are against the results of research suggested by Murti and Hamidah (2012) finding that there is no significant effect of expressive writing on decreasing depression in adolescents in Vocational High Schools. They found that the control group also experienced a decrease in depression scores caused by giving treatment of writing daily activities. Seligman in Maulida (2012) states that depression is an emotion that comes amid helplessness and failure of individuals, and when an individual attempting to gain unrealized power. One thing that can be done to let the emotions go is by writing. Qonitatin (2011) reports that expressive writing therapy of emotional experience has a significant impact as a catharsis or emotional release in lowering the level of mild depression. Hawkins in Indah (2011) also mentions that the model of therapy-oriented catharsis, as is done in the intervention group with life writing or writing life, has the power to dramatically and automatically change the personality or alter the regulatory process accompanying personality changes. This model holds that a cathartic experience is achieved, and then there is an automatic process that transforms a person becomes better. Writing can integrate thoughts and feelings about experiences that are experienced so that they can see or analyze what really happened to themselves. Therefore, one can understand the existing problems and develop problem-solving strategies (Firdaus, 2015). The process of writing therapy conducted in this research is to tell about their past, current, and future lives which are not only painful but also fun. Pennebaker in Hernowo (2016) suggests that the thoughts and feelings associated with the trauma force individuals to unite the many facets of the complex events that a person can digest complex thoughts into a unity that is more easily understood. Writing unpleasant emotional experience may also increase positive emotions temporarily. Some topics that can be written in life writing therapy are about themselves, like who I am, the body, personal or family problems and their relationship with themselves, relationships with friends, loss of someone, change management, and mind building (Bolton, 2011). Besides, the topic is not only related to past experience but also the situations faced in the future and dreams (Susanti, 2013). Murti (2012) states that the use positive words will lead positive cognitive at the end of the therapy; while the use of negative words in moderation (no more or less) storyline is clear and well-organized. Furthermore, the emerging outlook and positive expectations after writing therapy can help reduce depression. Therefore, life writing therapy can be Table 2. Differences in depression scores of pre and post life writing therapy Groups Mean SD P-value CI 95% Pre-test Post-test Intervention (n=20) 8.9 4.8 4.10 (3.46) 0.000 3.95 (2.0-5.9) Control (n=20) 8.55 8.40 0.15 (2.50) JURNAL NERS http://e-journal.unair.ac.id/JNERS | 211 used as one of the interventions to help decrease depression. Researchers realized that there are still a lot of shortcomings of this study that make this research is far from perfect. There are some limitations in this analysis. First, it is a social experiment research so that there are internal and external factors that cannot be controlled during the study. Second, the distance between pretest and intervention as well as the distance in each meeting to write the course made the respondents experienced a different atmosphere at each meeting and influenced the internal validity of the study. Since there was no expert assistance in conducting the therapy, there was bias or manipulation during the research. During the meeting, therapy was conducted by taking over a counselling guidance class (60 minutes) and the time spent to write was 45 minutes. It was insufficient to devote about their lives, feelings and thoughts completely, although their writing in the second session could be continued at home. The writing therapy performed on a scheduled basis at certain times had the respondent should write about their lives on the condition whether they were interested or not. This study can be one of effective therapies applied to the risk groups so that it can prevent depression in adolescents. This therapy can be done by anyone and anywhere since it is easy to apply. Besides, it can also be a learning material for nursing care especially in adolescent mental health and can be used as evidence for further research related to adolescent mental health by developing writing therapy both for individual or group of individuals. CONCLUSION Life writing therapy is proved to influence on decreasing depression in adolescents. It occurs because life writing therapy facilitates the subject to evaluate, analyze and reassess past, current, and future events so that the subjects get an understanding, develop a solution, have self- motivated, accept the existing situation, learn from what is experienced, focus thoughts on positive things, and assess the positive things of an event. It is recommended that the next researchers who wants to conduct similar research should examine the internal and external factors that can influence depression in adolescents. Furthermore, the intervention was suggested to be carried out on the same day as the pre-test and intervention was not carried out by the researchers themselves to increase the accuracy of the results of the study. In addition, there is a need for additional time in writing therapy so that respondents can devote more about their feelings. 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