Improving Adolescent Mental Health Development through Therapeutic Group Therapy in Saint Beatrix Orphanage, Sidoarjo

Adolescents who live at an orphanage may be at risk of mental disorders among adolescents. As adolescent orphans usually have bad memories, therapeutic groups are alternatives to overcome this issue. A civic engagement program was conducted to tackle development issues in adolescents as it performed a therapeutic approach with their peers. This program involved twenty-one female adolescents in Saint Beatrix orphanage Sidoarjo. They took a pre-test, which indicated a low level of knowledge about adolescent development. Group therapy was conducted in seven sessions, each of which took an hour. In the evaluation stage, questionnaires were distributed to test the adolescents’ knowledge about adolescent development. After conducting the therapeutic group therapy, it showed that adolescents’ knowledge about the development stages and their challenges improved. Based on the result of the Wilcoxon Sign Rank Test, it's known that p-value = 0,000


INTRODUCTION
The preliminary survey showed that there were 21 orphan adolescents at Saint Beatrix orphanage. The population of the orphan adolescents was 33 people with four caregivers. A psychological portrayal showed that these adolescents feel inferior, unconfident, isolated, and shy. The caregivers stated that older adolescents consider themselves superior to the younger ones. Such seniority had caused abuses among the younger adolescents. Six of the 21 adolescents, who had undergone therapeutic group therapy, were victims of verbal and psychological bullying at schools. Bullying might have made them feel inferior, frustrated, and depressed (Hapsari & Purwoko, 2016).
Moreover, adolescence is when individuals experience unstable emotions and stress (Mukhtar & Mahmood, 2018). During this period, they may feel unstable emotionally and anxious, so that they are getting influenced by their environment easily (Illahi et al., 2018). Prolonged stress may become aggressive, and thus adolescents have negative coping strategies and behave unassertively (Winiarski et al., 2018).
Female children and adolescents in the orphanage have different family backgrounds, such as economic constraints and negligence records. They come from other islands, such as Papua, East Nusa Tenggara, and Kalimantan. They went to Sidoarjo to access better education for their future.
As they have bad memories, they have difficulties in building social relationships with others. In response to this issue, health workers need to contribute strategically to promote preventive health measures and a healthy lifestyle to achieve positive life quality. After the consultation with the caregivers, it was agreed that they would conduct a therapeutic group therapy that could facilitate the orphan adolescents to have a more positive life quality.
Adolescents are considered healthy-age groups, but mental disorders increase in this adolescence (Sampasa-Kanyinga et al., 2020). Orphanages may be the place where adolescents are more at risk of mental disorders. Bad memories of the past, such as violations, negligence, abuses, parental conflicts, or bullying at schools would scratch them emotionally resulting in www.jurnal.ugm.ac.id/jpkm Vol. 7, No. 3, depression, anxiety, and stress (Mohammadzadeh et al., 2018). It turns out that it is in contrast with the fact that emotional development occurs in healthy adolescence (Adhvaryu et al., 2019). Adolescents are vulnerable to emotional problems as they experience emotional tensions due to significant physical and psychological changes (Butzer et al., 2017). Not fully optimal adolescent development will cause mental disorders, which will continue until adulthood (Evensen et al., 2017).
The task of adolescent psychosocial development is identity versus role confusion. Adolescents try out many different roles regarding their relationships with peers, family, and society. In every phase of development, including adolescence, individuals have developmental tasks that must be fulfilled. If individuals can complete developmental tasks well, satisfaction will be achieved, and happiness will also determine the success of individuals in fulfilling developmental tasks in the next phase. The developmental tasks of adolescence accompanied by stress and new expectations make them easy to experience disturbances in the form of thoughts, feelings, and behavior disorders. Stress, sadness, anxiety, loneliness, self-doubt in teenagers make them take risks by doing delinquency (Daulay et al., 2021). If adolescents are not successful in carrying out their developmental tasks, they will experience confusion or role diffusion (Kylie & Susan, 2015). The stage of adolescence cannot be separated from deviant behavior. Violent behavior carried out by adolescents is not only physical but also verbal. Verbally aggressive behavior is more often done by adolescents (Yosep, 2013).
Mental health is affected by cognitive factors and knowledge as well as other factors, such as autonomy and independence, the capability to develop oneself, the capability to tolerate uncertainty, having good selfesteem and proper reality orientation, and being able to manage stress (Videbeck, 2008). Adolescents with good mental health may have problem-solving skills, social skills, and good sedulousness. These skills could help them relieve hard times, avoid maladaptive behavior, and have a productive life (Lawrence et al., 2015).
Group therapy is commonly useful in clinical practice for adolescents both with mental health and mental health issues. Group therapy typically consists of young people of similar ages but with different personalities (Arias-Pujol & Anguera, 2017). With such a group therapy, adolescents become able to learn from each other according to their development (Wood, 2009). Adolescents can meet their needs in a positive, meaningful way for peer groups and the formation of self-identity (Stuart, 2009). Therapeutic group therapy is therapy whose main focus is on preventing disorders by teaching effective ways to deal with emotional stress in a situation or developmental crisis (Townsend & Mary, 2014). Therapeutic Group Therapy enables adolescents to learn from each other according to their development (Wong, 2004). It can help adolescents in meeting their needs in a positive, meaningful way for peer groups and the formation of self-identity (Stuart & Laraia, 2011)

METHOD
Therapeutic group therapy was conducted through several methods, such as sharing experiences, questions and answers, lectures, and playing games in groups. This activity can be done using leaflets and flipcharts. Each session is designed according to the aspects of adolescent development as discovered by Hockenberry et al. (2013). During this community service program, the therapeutic group therapy consisted of 7 sessions, sharing, and discussing adolescent development, biological or physical and psychosexual development stimulation, and cognitive and language development stimulation. The rest were about moral and spiritual development stimulation, emotional and psychosocial development stimulation, talent and creativity development stimulation, and evaluation of the benefits of the stimulations.
The program evaluation was done to identify the level of knowledge before and after the group therapy implementation. The evaluation could provide information on the effectiveness of the program. The statistical test was used to evaluate the effectiveness of the therapeutic group therapy was the Wilcoxon signedrank test.

Materials and tools
The materials and tools used during the group therapy comprised (a) laptop, (b) audio player, (c) wireless microphone, (d) flipchart, and (e) leaflets.

Preparation stage
The preparation stage started with a discussion and program promotion to the caregivers. The discussion aimed to analyze and inform a type of activity that would be conducted. Subsequently, the community service team visited the orphanage and identified the number of adolescents that could participate in the therapeutic group therapy. Finally, all facilities and infrastructures were prepared.

Activity Implementation Stage
The therapeutic group therapy was conducted from the 1st to the 8 th of February 2020.

Evaluation Stage
In this stage, the team evaluated the program to identify adolescents' levels of knowledge about the stages of adolescent development.

Location
The program was implemented in Saint Beatrix Orphanage, Sidoarjo.

Schedule
The program was conducted from the 1st to the 8th of February 2020.

Duration of the program
The therapeutic group therapy was conducted once a week and divided into seven sessions. Each of the sessions was conducted for an hour.

Evaluation
The evaluation of the program implementation reviewed the results of the pre-test and post-test. Questionnaires about adolescent development stages were distributed to the participants to identify their knowledge, indicating the program's success.

RESULT AND DISCUSSION
The therapeutic group therapy was executed by Anindya Arum Cempaka and Putu Indraswari Aryanti.
In the very first beginning, the team screened the results of questionnaires distributed in the pre-test. Topics covered in the first therapy activity were the characteristics of healthy adolescent development and some deviances. Meanwhile, the second meeting delivered topics on physical and psychosexual development stimulation. In the third meeting, the participants were presented with topics on cognitive and language development stimulation. Subsequently, they learned about moral and spiritual development stimulation the following day. Topics on emotional and psychosocial development stimulation were delivered in the fifth meeting. Additionally, a topic on bullying issues was presented since some participants had bullying experiences at schools.
In the sixth meeting, the participants discussed talent and creativity development stimulation. Finally, in the seventh meeting, the participants discussed the benefits of the stimulations given. In addition to distributing questionnaires for the evaluation, the team also conducted interviews to collect information about the participants' feelings towards the therapeutic group therapy.
The participants said that the therapeutic group therapy was helpful because they received new knowledge, felt better, and improved teamwork with their peers, especially the younger ones. The team also interviewed the caregivers regarding the participants' development after the program implementation. The caregivers stated that the program was useful as it provided new information and assistance in adolescent health development.
During the therapy activities shown in Figure 1, the participants were attentive and active in asking about any unclear subject matter, their conditions, and ways to tackle problems that they might face. The posttest result showed there was an increase in knowledge about the stages of adolescent development. The change in the knowledge level is presented in Table 1 The statistical test used, which was Wilcoxon, signed-rank test with a significance level α=0.05. The results in Table 2 showed that there was an effect of the therapeutic group therapy on the level of knowledge (p=0.000) in the group. It can be concluded that the therapeutic group therapy may have caused the improvement of their knowledge.
Adolescent therapeutic group therapy has been conducted by Hasanah (2017). It showed that the activity could improve knowledge on the aspects of developmental tasks facing adolescence and help develop their psychological strength and boost their life quality. Insufficient information, creativity, and readiness in facing the suppressing transition period make adolescents vulnerable to stress, anxiety, and even depression (Farid et al., 2019). Therapeutic group therapy is one mental health promotion to avoid mental health and psychosocial problems.
An adolescent is an individual developing their social skills to interact and adapt to their surrounding society (Hardiansyah, 2020). Therapeutic activities in groups may allow adolescents to learn together about solving problems and conflicts (Venter & Uys, 2019). Group therapies may overcome developmental www.jurnal.ugm.ac.id/jpkm Vol. 7, No. 3, problems since they apply a peer-group approach that is expected to positively affect adolescents (Hasanah, 2017).

CONCLUSIONS
During the therapeutic group therapy activities, the participants paid attention and actively asked questions about unclear aspects of the presentations, their conditions, and how to manage their problems. They could also answer questions correctly. The questionnaires' recapitulation indicated that the respondents' knowledge level increased by 29% after participating in the activities. In summary, the participants' knowledge level about the stages of adolescent development also improved.
This community engagement could provide new information, happiness, and improved teamwork among the participants, especially the younger ones. After the program implementation, the participants could optimally carry out developmental tasks as they had had good knowledge about adolescent development stages and a more productive life. In addition, they had become able to avoid maladaptive behavior in their adolescence.