Empathic Love Therapy to Reduce Depression among Female Victims of Domestic Violence

Female victims of domestic violence often experience depression. This research used Empathic Love Therapy (ELT) to reduce depressive symptoms, by enabling individual to understand one-self deeper by realizing, understanding, accepting, and loving all aspects of the self, which is the early process of healing. This research is quasi-experiment research using a single group simple interrupted time series design. Five women aged 30-60 years old who experience depression, based on BDI (Beck Depression Inventory) score, participated in an eight-session therapy. Participants were recruited purposively based on theory-based or operational construct sampling. Data analysis combined quantitative and qualitative methods, of which Wilcoxon Signed Ranks Test was used for quantitative analysis, whereas qualitative analysis adopted a descriptive analysis. Quantitative findings significant difference in BDI score between before and after treatment (Z = -2.023 with p= 0.043<0.05). Qualitative findings showed that participants were able to find survival personality that emerged from past painful experiences and plays a role in the depression symptoms they are currently experiencing. With the power of love they find from God, they are able to accept themselves, and focus their lives on their potential and positive future plans. Therefore, it can be concluded that Empathic Love Therapy is effective to be used to reduce depressive symptoms.

SARAGIH & YUNIARTI || EMPATHIC LOVE THERAPY 204 were reported to experience more than one kind of wound on their bodies. Similarly, Nelson (2006) found that victims of domestic violence usually experience hitting, getting thrown with objects, physical dragging, verbal abuse, and many more. In addition, victims of domestic violence also often experience worsening mental health conditions and are diagnosed with various disorders, such as depression and anxiety (Aldridge, 2013;Chhabra, 2018;Sarabu, 2016;Mapayi et al., 013).
Female victims of domestic violence live in a non-empathic environment (physical, verbal, emotional, or sexual abuse) and this experience led to primal wounding. Firman and Gila (2010) explained that individuals under this condition tend to develop a personality that does not represent his/her authentic expression (authentic personality) but to help them survive from the wound as part of a defense mechanism. The Individual will start to think and act to avoid non-being and experiences that relate to non-being. The emergence of this survival personality might affect the individual to lose his/herself and live without having empathic love.
This research aimed to measure the effectiveness of Emphatic Love Therapy (ELT) in reducing depressive symptoms in women of domestic violence victims. The hypothesis of this research was Empathic Love Therapy (ELT) could effectively be used to reduce depressive symptoms in female victims of domestic violence. It is expected that this study will provide an alternative treatment for depression.

Literature review
Depression can be caused by psychological factors. Scholars such as Barlow and Durand (2012) explained that only about 20-40 percent of depression cases are caused by genetic factors, while other major factors are life experiences. Based on several studies, victims of domestic violence tend to experience depression (Ferrari et al., 2014;Haritonova et al., 2019;Haqqi & Faizi, 2010;Hsieh & Shu, 2019;Yuan & Hesketh, 2019). Depression is indicated by a depressed mood most of the day, diminished interest or pleasure, significant weight loss, fatigue or loss of energy, worthlessness, diminished ability to think or concrete (American Psychiatric Association, 2013). Depression is estimated to be a commonly occurring disorder across countries (Kessler & Bromet, 2013). An individual with depression can have several specific characteristics like negative and unrealistic selfimage about oneself, present, and future. They also develop hatred toward one-self, fear, unhappiness, loss of concentration, forgetfulness, hopelessness, and indecisiveness (Lestari, 2014). Depression is a serious mental illness and without proper and serious treatment, it can endanger the lives of people who experience it (Appiah & Mohammed, 2013). Barlow and Durand (2012) further argued that depressive symptom contributes to damaging individuals' relationship with his/her social environment such as work-life and friendship.
This study focused on the Psychosynthesis approach from Firman and Gila (2002).
Psychosynthesis, a transpersonal psychology and therapeutic approach, points to primal wounding being the foundation of negative experiences such as depression. Primal wounding occurs if individual experiences non-being like self-rejection, loose one-self, isolation, and emptiness because of a non-empathic environment (Firman & Gila, 2007).
Psychosynthesis sees depression as the internalization of the oppressor and the lingering essence of early non-empathic unifying centers (Firman & Gila, 2002). Transcending the self will help the individual to have transformational growth and a healthy ego that lead to a healing process (Clements, 2016). Transcending the self starts when the individual can accept and love all aspects of themself. The individuals can be aware of the pain and tragic events, find ways to face the emptiness inside, and rejuvenate self-aspects that have been long gone. Moreover, individuals could find ways to face threats in life and find each of its potentials (Firman & Gila 2010).
This research uses seven primary concepts of Assagioli Psychosynthesis (Firman & Gila, 2007) to help the individuals working through their depression symptoms. The Empathic Love Therapy (ELT) module was designed based on seven primary concepts of Assagioli psychosynthesis. In this study, Emphatic Love Therapy (ELT) is defined as a technique to assist individuals to realize, be aware, understand, accept, and develop love to all aspects of their personality, and use self-potential to control individuals' behavior.
The growth of empathic love in individuals can contribute to healing wounds resulting from past experiences towards recovery. This is done by applying by applicating the seven main concepts (Firman & Gila, 2007) in ELT, these are, Disidentification, Personal Self or I, Will-Good, Strong, and Skillful, The Ideal Model, Synthesis, The Superconscious or Higher Unconscious, dan Transpersonal Self or Self. The purpose of disidentification is to help the client consciously experience and control their self-identity. Will is a core function to assist in self-exploration and motivation; synthesis is an integrating subpersonality including recognizing the wound and the manifestation of it in survival personality. Exploring superconscious or Higher Unconscious will help an individual to connect to the world and find a deeper meaning in life (Firman & Gila, 2002).

Participants
The participants of this research were 5 women purposively recruited according to the following criteria: 1) adult within the age of 30-60 years old; 2) having experience abuse in their household; 3) experiencing depression based on Beck Depression Inventory (BDI); 4) not diagnosed with other psychological disorder; and 5) not in the middle of a SARAGIH & YUNIARTI || EMPATHIC LOVE THERAPY 206 psychological treatment process. The participants were obtained based on the operational construct (theory-based/operational construct sampling). Samples were chosen using certain criteria, based on theories or operational constructs that correspond with previous studies, or with the purpose of the research. This was done so that the samples really represent the phenomenon being studied.
These participants were recruited from 5 health centers in Yogyakarta through direct references of the health centers' psychologists. Participants were provided with informed consent to indicate their willingness to participate in the study. Table 1

Study design
The study adopted a quasi-experiment with a single group simple interrupted time series design. Empathic Love therapy (ELT) module was designed based on seven primary concepts of Assagioli psychosynthesis (Firman & Gila, 2007): Disidentification, Personal Self or I, Will-Good, Strong, and Skilful, The Ideal Model, Synthesis, The Superconscious or Higher Unconscious, dan Transpersonal Self or Self. As such, the ELT module consists of 7 sessions: 1) My Exploration; 2) Wound Exploration; 3) Player Interactions; 4) I Love My Self; 5) Will; 6) Aspiration and Action Plan; and 7) Love and Gratitude.
The final draft of the module was first simulated through role-playing among the researchers to adjust language, time, instruction, and phases in each session. The final module has been tested piloted with 9 participants. At the end of the pilot session, a debriefing was conducted using General Overall Assessment (GOA) and Specific Assessment and Reactions (SAR) to provide feedback for module adjustment.
This module was then validated using expert judgment methods, inviting a panel of experts in Transpersonal Psychology. The experts were asked to give an evaluation of the designed module. The result of the rating from these experts was analyzed with Aiken's V to determine the validity of the content. The result of Aiken's V is as follows: 1). The therapy was conducted from 23rd October to 7th November 2014. The participants followed an 8-session ELT therapy in one group led by a psychologist who has previously trained on the module to ensure their capability in conducting the therapy.

Pre-session, Preparation
Only five of the eight participants were able to remain and complete the entire session in this therapy. Some participants could not attend the entire session due to personal reasons.

Data collection
BDI measurement was done several times before and after treatment to investigate the comparison between pre and post treatment. Before the intervention, baseline measurement was conducted twice, two weeks before therapy and right before the therapy began. Similarly, after the intervention, measurement was conducted twice, promptly after therapy, and within a two-week span.

Data analysis
The study used quantitative and qualitative analysis of the data. The researcher used Wilcoxon Signed Ranks Test to analyze research data by comparing BDI score before treatment was given (BDI I dan BDI II) and after treatment was given (BDI III and BDI IV). This hypothesis testing was assisted by SPSS 18.0. Meanwhile, descriptive analysis was conducted to provide qualitative data about the condition of each participant in every session of the therapy.

Result
The primary quantitative data in the study was the depressive symptoms score resulted from several BDI measurements. The researcher compared participants' scores from each measurement before and after the therapies. Table 2 outlines comparison on score results in each measurement. We can see from Table 2, that there was significant difference in participants' depression score before and after treatment with decreasing score trend across measurement between 17 and 30.

Research Participants' Depression Score
Statistical result from data analysis could be seen in Table 3. On the table 3 we could see that subjects' average BDI score before treatment was given is 44.80 while BDI score after treatment was given is 16.60. It can be concluded that there is a reduction of BDI average score before and after treatment was given, where the BDI score after treatment was given is lower than the BDI score before treatment was given. Furthermore, we can see from Table 4 that all 5 participants experienced a reduction in BDI score after treatment was given. We can also see that no participants experiencing an increase in BDI score after treatment was given.   Analysis result of Wilcoxon signed ranks test on Depression Score resulting in Z=2.023 with significancy of 0.043. This indicated that there is significant difference (p = 0.043; p<0.05) between BDI score after and before treatment was given. Where BDI score before treatment was higher (M pre= 44.80) than BDI score after treatment (Mpost = 16.60).

Discussion
Results confirmed that this research hypothesis is accepted, of which Empathic Love Therapy (ETL) was effective to reduce depressive symptoms among female victims of domestic violence. The therapeutic process of Empathic Love Therapy to reduce depressive symptoms is as follows. Disidentification helps female victims of domestic violence to recognize and realized that each feeling they have whether it is happy, sad, unworthiness, desperation, not liking themselves, disappointed, disgusted, even hating themselves. Through the identification and disidentification process, individuals learn to love with full empathy and finally accept traumatic experiences (Firman & Gila, 2007) and move towards recovery (Rueffler, 1995).
The experience of disidentification enables individuals to see their whole life experience so they can identify each event that is hurtful to them. Individuals can also see parts of themselves that were wounded, the player inside who is hurt, and how the manifestations of that player towards the depression they are experiencing. With identification, individuals can realize the part of them or one of the players which have all this time dominates, conflicts, and detains the growth and development of their personality (Firman & Gila, 2007). Align with Shapiro and Soidla (2004)

These individuals' responses and reactions confirmed depression symptoms correspond
with what has been presented by Davison et al. (2006) and Beck (1985).
According to Rueffler (1995), the ability to do disidentification on various subpersonality and experience that has happened will make individuals able to find a new understanding of what is happening to themselves and to change something that is identified as themselves. In this instance's female victims of domestic violence can realize Personal Self or "I" that is more clearly able to see and realize more deeply that they are free from restrictions and experiences so that they could also freely lead themselves towards better life purposes.
The nature of "I" is basically a will that is good, strong, skillful, and following the transpersonal will (Firman & Gila, 2007). In individuals with depression, we can see that there is impairment on the will, indicated by the loss of positive motivation, which leads to individuals encountering difficulties to direct themselves to do basic tasks like eating, taking a bath, and others. Individuals are usually aware of what they need to do but they do not have the internal stimulus or the desire to do it. The desire to run, evade, or even death (Beck, 1985). When the aspect of positive "will" does not show up, it might happen because the "I" is still identified as a part of the personality that does not give them the chance to express their will freely. One of those aspects of personality might contain wounds from traumatic experiences resulting from powerlessness and an unemphatic environment.
Acceptance of weakness and various deeper traumatic experiences will lead individuals to find their true strength. This is what Firman and Gila (2007) argued as the emergence of power and freedom from the will of "I" that is to accept with full love inadequacy of humans and various traumatic experiences. This will help individuals to choose and make the best decision for themselves. Individuals develop themselves to reach self-recovery, learn to love empathically, and finally accept traumatic experiences.
Love energy full of empathy is used to harmonize perpetrators that had conflicted all this time. This process is called synthesis where two or more subpersonalities are ready to make a new unit, finding ways to make peace to accept one another so the authentic self of the individual will emerge (Rueffler, 1995;Firman & Gila, 2007).
Similarly, as explained by Cooper (2003), self-acceptance is individual awareness towards the whole part of themselves and want to live with that condition, which includes acceptance of the individual as a whole, including the strength and weaknesses.
Moreover, Cooper (2003) suggested that when an individual understands the motive of the behavior was so then he will love himself more. The individual will feel valued, satisfied with themselves suggest that when an individual understands what is the basis of their own behavior then they will love themselves. Individuals will feel worthy, satisfied with their own self, and accept themselves accurately.
Through the Superconscious or Higher Unconscious individuals were trained to recognize the crucial potential other than only wounds. Importantly, individuals are encouraged to recognize the potential to love, bravery, creativity, wonder, humor, joy, happiness, light, love, patience, righteousness, faith, and wisdom (Firman & Gila, 2007).
Individuals then were led to find their "Ideal Model" or self-realization where individuals use all their conscious and self-potential to find an image of their life until it builds a feeling of identity and direction/purpose in life. This exploration is done by using all of the consciousness and self-potential they have. When individuals find that, "Ah, I want to be this, not like that" then they are starting a change of direction in a healthy personal growth (Firman & Gila, 2007).
Life purpose based on intrinsic motivation is a positive foundation in personal development. Intrinsic motivation helps individuals experience a sense of belonging on their path and their own life development and a part of self-actualization. Purpose in life is a very important thing because it determines the meaning of life, the drive for selfactualization, and the continuation of life (Burn, 2009). Life purposes also help individuals to dare hope or to have them. Hope is a type of thinking which contains faith that someone could produce a way to reach a wanted goal and faith that individuals could maintain the motivation and energy to reach that goal (Synder, 2002). This hope will help individuals to overcome the problem that they face in reaching their goals.
Individuals were also led to recognize their Transpersonal Self or Self which is a pinnacle condition when someone has reached a whole-self and show a self-actualization nature. The dynamics of self-realization is done with how someone looks or sees the truth deeper than their life, and responds through practical decisions in everyday life (Firman & Gila, 2007). Female victims of domestic violence are trained to be sensitive to hear their self a source of consciousness, and each face and in every development phase. In other words, the women can find guidance for life inside of themselves through contact with "self" without considering the disturbance, pain, or wound, so that the sound of Self can guide them.
Research results showed that depressive symptoms experienced by an individual were reduced after receiving ELT. This is in accordance with theories that Welwood can also facilitate the drive that is carried since we were born which is to actualize self, synthesis, and unity.
Empathic love supports humans to go through journeys in their life span and helps to grow the soul and spirit of the human itself. After individuals experience empathic love, they can understand and develop love in each aspect of their personality, accept and love, and be responsible for their own health and personal growth in each life experience (Firman & Gila, 2007). Furthermore, individuals can find ways to face threats in their life and find each potential. The same thing was stated by Welwood (2006) that a direct connection with the perfect love will heal every wound and influence how individuals show their existence on the face of the earth. Corresponding with findings from Llabres (2003), achieving health for people with depression starts from a relationship that is full of love towards oneself and realization of unity with God who is the true love.
Align with Shapiro and Soidla (2004) who stated that one of the key aspects to individual life-changing process corresponding with the transpersonal line is by developing attention that is unfavored and witnessing life experiences unfold.

Conclusion
It can be concluded that Empathic Love Therapy is effective to reduce depressive symptoms among female victims of domestic violence. Quantitative analysis showed that there is a significant difference on BDI score participants before and after the treatment.
The reduction of depressive symptoms happens because individuals develop love and accept their aspects of personality. The growth of this love started when individuals wish to understand their own life experiences especially hurtful moments, wanted to accept parts of the self that were hurt because of that experience, identifying each of this big potential that they did not realize all this time, shifting their focus from the past towards aspirations or the final purpose of their life. Realistically individual started to actualize dreams with love and gratitude.

Suggestion
This study had also equipped health center psychologist with Empathic Love Therapy technique and are expected to implement this therapy for individual treatments poststudy in health center settings according to the discussed modules. Furthermore, this study can also be used by other stakeholders, such as non-government organizations concerned with vulnerable women and domestic violence, to design therapy and intervention for victims of domestic violence in the household. This study focused on the application of ELT therapy for female victims of domestic violence. Future research can also attempt to apply this technique to other at-risk community groups, such as people with other psychological disorders (e.g., neurotic or psychotic).

Funding
This study had been funded by UGM research grant.