The Effectiveness of Spiritual Psychotherapy on Patients with Mental Disorders: A Systematic Review

This article aimed to examine the effectiveness of handling mental-based mental disorders from various studies that have been conducted. The articles used in this systematic review were searched in the SCOPUS, PROQUEST, SPRINGERLINK, SAGE and SCIENCEDIRECT databases which is published between 2016-2020. The keyword used were "mental disorders" or "mental illness" and “spiritual” or “religious”, with the use of the phrase Boolean Operators. The articles selected according to the inclusion criteria include articles stating the effectiveness of spiritual healing for mental disorders, articles that analyzed mental illness patients in RCT, case-control studies and experiment. The articles obtained then were analyzed with the DSVIA conclusion table (design, sampling, variables, intervention and analysis). There were 15 articles that meet the criteria as a systematic review. The study result showed that there was a relationship between religious/spiritual involvement and mental disorders (positive). The findings from previous research indicated that religion play an important role in many situations because religious beliefs and rules affect people's lives. The majority of the previous literature stated a significant relationship between religious beliefs and practices and mental health.


INTRODUCTION
Currently, mental disorders are important problem in the world health sector. The high incidence of mental disorders and increase in each period makes it challenging for health workers to do many things in mental disorders and experiencing it 1 . Mental disorders are clinical signs of deviations in one's thinking, feelings and attitudes or behavior 2 . Mental disorders occur because of the unfulfilled needs of a person's soul. A person experiences dissatisfaction which then results in negative feelings such as disappointment, shame, and a special degree causing feelings of low self-esteem 3 .
The number of people with mental disorders in the world reaches 450 million, with an estimated 75% in countries with low income. However, individuals who expect the high level of social equality and could not meet the demands will experience stress, anxiety and depression until they finally experience real mental disorders 1 . There are about 35 million people affected by depression, 60 million people have bipolar disorder, 21 million have schizophrenia, and 47.5 million are affected by dementia. The various biological, psychological and social factors population diversity in Indonesia lead the number of cases of mental disorders continues to increase, increasing the burden on the state and decreasing human productivity for the long term 4 . A person who experiences mental disorders has unstable emotions and erratic mental status at any time and tends to experience a decline if not handled properly 5 .
The spiritual role is needed in improving one's mental condition because basically, someone who experiences mental disorders begins from the inability to think positively and give up on the situation 6 . The practice of spirituality in everyday life becomes the main asset for individuals to face life situations that have many demands 7 . This situation encouraging many hospitals, mental rehabilitation centers and mental health services apply spiritual concepts in overcoming mental disorders using spiritual motivation methods, spiritual practice and services based on religious principles 8 .
This study aimed to determine the application of spiritual healing to patients with mental disorders, and patients with depression. Previous studies have been discussed about the relationship of spiritual healing to the treatment of mental disorders, but this systematic review study discussed more specifically on how spiritual healing improves the condition of patients with mental disorders, and described the types of spiritual healing that have high authority in treating mental disorders.

METHOD
The literature search was carried out in several databases such as SCOPUS, SAGE, PROQUES, SCIENTDIRECT and SPRINKLINK. The search strategy for journals or articles is performed using theme terms with medical subject headings (MeSH) combined with Boolean operators. The keywords used in the search were "mental disorders" OR "mental illness" AND "spiritual" OR "religion" from 2016 to 2020.

Data Selection / Study
The data were assessed for feasibility using the PICOT framework (Population, Intervention, Comparation, Outcome, Time). The inclusion criteria were (1) patients with mental disorders (2) over 30 years of age, both male and female (3) patients in controlled conditions (4) type of research: randomized controlled trials (RCT), casecontrol studies, quasi-experimental and actual experimental (5) type of intervention: provision of spiritual healing and measurement of mental disorders (6) Main result: an article that discusses the effectiveness of spiritual therapy in the management of patients with mental , both as complementary and primary therapy.

Data Quality Assessment
A total of 2,712 journals were found. The search results were from five databases that Scopus as many as 721 articles, Sage as many as 83 articles, ProQuest as many as 825 articles, Science direct as many as 328 articles and Springer-link as many as 755 articles. Of the 2,712 articles found, 15 journals/articles were selected according to the inclusion criteria, both types of population, intervention, comparison, results and year of publication. As for details of the journal identification and selection process can be seen in Figure 1:a flow diagram adapted from preferred reporting terms for systematic reviews (PRISMA) at the design stage 9 .

RESULTS
The articles analyzed in this systematic review are 15 articles that fit the predetermined inclusion criteria. The articles derived from Israel, Japan, Poland, Australia, London, America, China and India. The number of respondents were varied between 15-7041. The research design used in the article was 3 articles with a qualitative design, 4 articles with a Randomized controlled trial (RCT) design, 3 articles with a cross sectional design and 3 articles with an observational/survey design, and 3 articles with an experimental design. From 15 articles found that there are many methods and forms of therapy used, namely strengthening spiritual motivation and therapy to implement spiritual practice (worship).
Various studies of 15 articles were obtained express opinions and findings of the same on the effectiveness of spiritual therapies against mental disorders. The average score of anxiety in group 2 after spiritual therapy intervention is significantly lower (P <0.05). which means that the combination spiritual and drug therapy is effective in reducing anxiety. The patients become more obedient to the officers direction ,think more positively and do not easily give up 5 . Another result also states that the correct spiritual practice makes patients feel comfort, sincerity, strength, happiness, and hope. The feeling of serenity make a positive value in reducing the symptoms of mental disorders 8 , as reinforcements of articles results similarity, found there is a significant decrease (p = 0.001 ) in the score of anxiety and muscle tension (p = 0.011), and the increase in well-being (p = 0.003). This means that treating depressed patients using a spiritual approach makes them stronger in facing illness and more positive in seeing lives 10 .
The following is a systematic explanation of the search results for the articles used in this study in table 1.  There was a significant change in the condition of the treated group with a decrease in anxiety and depression levels.

DISCUSSION
Religiosity and spirituality are broadly interpreted as patterns of thought, feelings, experiences, behaviors and attitudes that are believed to be the right things in accordance with the social order and group rules, whether human or the needs of the creator 20 . Spirituality is not always related to religious behavior such as praying and other worship activities. The spirit here is more inclined towards positive behavior such as confident, enthusiastic, realistic, honest and other good qualities that can positively impact the life process 21 . So that the spiritual position is believed to be able of providing psychological protection to individuals even in unfavorable circumstances 22 .

Impact Spiritual on Mental Health
This review found that spiritual participation in mental health is fundamental. Motivating with the spiritual approach of religious could reduce trauma and other negative turn into self-trusted, spirit and positive thinking 15 .
Other findings revealed the spiritual impact on mental health that a person who has spiritual solid beliefs will have low levels of suicidal thoughts, anxiety and depression. This means that spiritual beliefs being a foundation of one's thoughts, the bad things will be viewed positively 18 . In addition, individuals who have a spiritual solid level, such as thinking positively, honestly, accepting reality, will make a person feel motivated to socialize, try and be enthusiastic about recovering when he is sick. Because spirituality will make a person have a lighter burden in his feelings and thoughts 17 .
Needed spiritual role in the mental status improvement of a person with a mental disorder, in which the spiritual activities inserted in daily activities can be used as an important aspect in patient's health. The spiritual activities are thought to increase a person's confidence, especially patients with mental disorders. When the confidence arises, patients will be able to increase the immunity 23 .

Models of spiritual healing in mental health
Many forms of therapy are considered to have a positive impact in the management of mental disorders, as applied in this article: SQEFT (Spiritual Qur'anic and Emotional Freedom Technique) is a combination therapy of Al-Qur'an reading and EFT (Emotional Freedom Technique); initially this therapy was used to treat schizophrenic patients, which was later adopted as the scientific development of this therapy. The Islamic State is especially overcoming various mental disorders like depression, stress, anxiety, including violent behaviour. This therapy is effective in reducing mental disorders, but this can only be carried out by individuals who are Muslim and not for individuals of other religions 24 .
SCP (Spiritual Counseling Program) is a program of providing religious counselling. This therapy was aimed at the adolescent population, but it has recently been widely applied at all ages. This therapy is a counselling therapy provided by religious leaders affiliated with schools or counseling service providers that can provide life solutions to achieve a good quality of life, as for the content of the counselling, namely helping to establish a relationship with God. Specs and breathing techniques, concentration of mind, instill and balance of mind and calmness 19 .

CONCLUSION
Giving spiritual healing both systematically such as SQEFT and SCP therapy, and with a positive behavior reinforcement model will make individuals have calm in thinking and reduce the burden on them. The mental health of patients with mental disorder becomes good. It can be concluded that spiritual healing is effective given to patients with mental disorders as a single therapy or in combination with other therapies.