supportive Group therapy as a Prediction of Psychological Adaptation of Breast Cancer Patients undergoing Chemotherapy

Background. Breast cancer is the main cause of death for women. One of the therapies for breast cancer is chemotherapy. Chemotherapy has physical and psychological side effects. Patients need to adapt in order to be able to follow the process of chemotherapy treatment, and supportive group therapy is one of the ways to improve adaptation ability of patients. The aim of this study was to analyze supportive group therapies in improving the psychological adaptation of breast cancer patients undergoing chemotherapy. Method. This study uses pre-experimental one group pretest-posttest design. The sample consists of 35 respondents that were divided into 3 groups during the treatment. Pre-test and post-test were conducted to each group by using Likert scale. This study uses sampling technique of purposive sampling with inclusion criteria. Results. Before supportive group therapy is conducted, the average score of the respondents are 35,85 meanwhile after the supportive group therapy is conducted the average score increases to 43,82. The statistical analysis by using paired t-test shows that p-value .000 < 0,05 and this demonstrates that the supportive group therapy can improve psychology adaptation of breast cancer patient who undergone chemotherapy. Conclusions. Supportive group therapy can be an alternative to support the breast cancer patients to adapt and undergone chemotherapy.

continent with the highest percentage of breast cancer patients6,7.
Cancer patient should get a treatment to reduce metastasis of cancer cell in order to prevent the cancer spread to other body parts which may cause death 2,8,9.Chemotherapy is very important in cancer treatment besides radiation, surgery, as well as the injection of cytotoxic and anticancer.These are the main treatments which required to eliminate the cancer cells from the body10.However, the use of anti-cancers often have a side effect which harming the patients10.The use of chemotherapy has various impacts, including physical and psychological impacts.
Side effects of chemotherapy arise because the substances are very strong and such substances do not only kill cancer cells, but also attack healthy cells, especially cells that divide rapidly, such as hair cells, spinal cord, skin, mouth and bones and digestive tract9,11.In addition, the psychological impact that arises out from chemotherapy makes the majority of cancer patients worry, anxious, and fear of facing the threat of death and pain during the chemotherapy treatment5,11.This psychological response varies from person to person, it really depends on the stage of the cancer, the type of treatment being carried out and the characteristics of each patient7,12.The psychological impacts which often experienced by breast cancer patients undergoing chemotherapy are the feeling of helplessness, anxiety, shame, decreased self-esteem, stress, and anger13,14.Efforts should be made to improve coping mechanisms for cancer patients so that the result of the chemotherapy will be more optimum.The study conducted by Spahni, Bennett & Perrig, 2016 suggests that a person's adaptability is strongly influenced by the maturity and maturity of a person's age15-17.Psychological adaptation of patients with chemotherapy requires support from all parties, both from family, friends, and healthcare providers13,16,18.This is important so that during the chemotherapy the patient will be able to receive all the side effects of the treatment15, 19

Design
This study uses pre-experimental with pre-post test which designed to examine whether supportive group therapy can improve the psychological adaptation ability of patient who undergoing chemoterapy 23,24 .sample This study involves 35 breast cancer patients as the respondents who undergo chemotherapy at the chemotherapy center at Jember Hospital, Indonesia.The sample is divided into 3 groups, each group consists of 12 or 11 people.Such division is intended to make the interaction among the patients more effective 25,26 .The characteristic of sample in this study is a patient with breast cancer level II or III, who has undergone chemotherapy for more than 3 times, cooperative and able to communicate verbally, and agree to be a respondent.While exclusion criteria that used to eliminate confounding variable is the breast cancer patient level II and III who has complications due to cancer.This study used purposive sampling, which is a self-determined sampling technique which adjusted with the specified criteria 23,26 .

Measurement
The data collection procedures from 35 samples are divided into small groups with each group member as many as 11-12 people.Each group is accompanied by cancer therapists and volunteers.Interventions are carried out in 1 meeting by combining 4 sessions in one meeting.Data collection on psychological adaptation was conducted twice, namely before supportive group therapy and after intervention.The therapy is conducted in a quiet room, for 90 minutes.Assessment of the psychological adaptation of respondents includes cognitive, affective and psychomotor assessment using a Likert scale 26 .

Data analysis
In order to analyse the different group by using paired sample t-test, with value of alpha < 0,05 25,26 .Previously, data normality tests were conducted on the two groups 26 .Based on the analysis of respondents demographic data, most respondents (18 respondents) are >50 years old with the percentage of 51,4%.While the highest chemotherapy frequency is 5 times with the total of 9 respondents (25,7%).Most of the respondents are in level 3 of breast cancer, with the total of 20 respondents (57,1%) (Table 1).The results of the analysis using paired t-test suggest that P value is 0.000 <0.05 and thus, supportive group therapy can improve the adaptation of patients undergoing chemotherapy (Table 3).

DIsCussIon
Adaptation ability of a person is also depending on the age, the more mature, the more mature the meaning of life will be.So they will be wiser in responding to any stressors 28 .The results of this study indicate that most respondents are in middle adulthood.According to Hurlock (2009), middle adulthood is a transition period and a period of readjustment with behavioral patterns that have been carried out in early adulthood with physical and psychological changes occurring in middle age 17,29 .This result corresponds to a study conducted by Khariyatul (2017) which shows some factors that affecting adaptation ability, which is the age of the respondent who are more than 50 years old, and thus age greatly affects the adaptability of breast cancer patients undergoing chemotherapy 28,30 .
Another factor that affects the adaptation ability is marital status.According to Pamungkas (2011), the participation of families and those around the patient to provide life support for breast cancer patient will be very significant.The family must take care so that the patient does not experience stress and depression of the disease they are suffering from.The research conducted by Nurhidayati, T. & Rahayu, D. A. (2017)  shows that the support of partners are obtained in the form of instrumental, appreciation, emotional support and information 5 .
The results above show that average score of psychological adaptation of respondents after (post-test) supportive group therapy is conducted increase to 43.82, with the minimum score of 34 and the maximum score of 52 and thus, it can be qualified as 'adaptive' and the standard deviation is 4,768.This result demonstrates that the breast cancer patients undergoing chemotherapy are more adaptive in addressing the disease.This result corresponds to the study conducted by Nurcahyani, Dewi, & Randhianto (2016) which focuses on the effect of group supportive therapy on anxiety.Adaptability can also be influenced by one's religion and beliefs 5 .At the age of 50-60 years the level of religiosity is higher because good religiosity can affect a person's acceptance of his condition so that patients will be more adaptive.The higher the religiosity the lower the depression level, and vice versa 31 .
The result from the t-test analysis on 35 respondents shows that the p score is .000<0.05, thus H1 is accepted, which demonstrates that there is a correlation between supportive group therapy and the psychological adaptation of breast cancer patients undergoing chemotherapy.Supportive group therapy is a therapy that is carried out using peer groups who have relatively similar problems by sharing information about the problems experienced as well as solutions that need to be taken while the process of mutual learning and strengthening is very effective if done so that patients can adapt to their current situation 5,11,28,32 .According to the results of Yafuzsen's research, et al, (2015) supportive therapy groups has an influence on the changes in selfesteem between the intervention group and the control group 32 .

ConClusIon
Supportive group therapy can be an alternative for the healthcare providers to improve the psychology adaptation in order to support the healing process.This therapy can be conducted along with other therapies which performed by a professional healthcare provider.
ethical Clearance: This study has passed the institutional review board from Faculty of Health Sciences, Universitas Muhammadiyah Jember.
source of Funding: This study is self-funded research project.

table 2 Frequency Distribution of Respondents Based on the status of psychological adaptation of breast cancer patients before and after supportive group therapy Value Before Supportive Group Therapy After supportive Group therapy
26,27 on the table 2, to analyse paired t-test, normality data test is conducted by using Shapiro wilk test with significance of 0.0527and the result shows that the score for pre-test and post test are > 0.05, thus, it can be concluded that the variables are distributed normally26,27.