Applying Art Therapy in Improving Resilience in Child Victims of Domestic Violence

Domestic violence experienced by children make them more prone to emotional, behavior, adaptation and mental health problems. Some researches show that children with high resiliency are able to develop a positive attitude, perspective and adaptability despite a history of violence. The purpose of this study was to determine the effect of CBT Art Therapy intervention to increase the resiliency of children expose to domestic violence. The method used in this research is single case single-subject experiment ABA design. Resilience measurement instruments used in this research are Quotient Test (RQT) and resilience behavior observation sheet. Data were analyzed through visual analysis and descriptive data analysis. The results showed an increasing score in RQT (27 points) as well as the intensity of resilience behavior and positive changes in the use of color, quality and theme of the artwork. A child should ideally grow in a conducive family situation but there are some children expose to domestic violence. Such forms of abuse of domestic violence include physical, sexual, psychological and / or abuses that occur within the household (Law of the Republic of Indonesia Number 23 on Elimination of Domestic Violence [Undang-Undang Republik Indonesia Nomor 23 tentang Penghapusan Kekerasan dalam Rumah Tangga], 2004: World Health Organization, 2012). The incidence of domestic violence in Indonesia is increased by year. In 2015 there are 11,207 cases of domestic violence both on the wife and children (Komisi Nasional Anti Kekerasan Terhadap Perempuan, 2016), increased compare to the number of cases in 2014 those are 8,626 (Komisi Nasional Anti Kekerasan Terhadap Perempuan, 2015). In addition to that, incomprehensive treatment for the victims of domestic violence may ca119use cycle of violence (Afandi et al., 2012). The victims of domestic violence may experience psychological problems such as depression, posttraumatic stress disorder (PTSD) anxiety, insomnia, and suicidal ideation (Alejo, 2014; Job et al., 2013; Holt et al., 2008; Hegarty, 2011; World Health Organization, 2012). Psychological problems are also experienced by children who are exposed to domestic violence such as experiencing trauma (Kaur & Garg, 2008, Lamers-Winkelman et al., 2012), developing distorted thinking patterns such as catastrophizing (Bloom, 2010), self-blame (Cunningham & Baker, 2007) due to the egocentric mind-set of children (Holt et al., 2008; Vernon, 2009); children may blame themselves for the conflict of their parent (Edleson et al., 2007). These children are Submitted: 7 January 2020 Accepted: 8 June 2020 Published: 30 November 2020

According to physiological examination, the stress of violence exposure may affect the neuropsychological condition of the children such as a fluctuation in cortisol levels and functional change on pituitary gland activity (Stirling et al., 2008;Lokhmatkina et al., 2013). High levels of cortisol and catecholamines as the body's response to stress damaged brain tissue and disrupt brain function then may lead to decreased of memory and concentration (Black & Hawks, 2009), as well as problems in children's behavior development (Al Odhayani et al., 2013). Violent exposure also changes the cortex structure of the child correlate with social function, empathy ability and susceptible to psychopathology (Kelly et al., 2013).
Increased resilience can also be done through art therapy. Art therapy helps to release stress in children because it can help children to express emotions that are difficult to express verbally (Cristina & Aneta, 2012) as well as providing a safe distance between children with emotions (Abdallah, 2009). (Folostina et al., 2015) uses drama and drama art therapy to improve the resilience of vulnerable children (due to poverty, poor supervision, abuse and abuse, children with chronic illness), the study also uses the image media to check the level of child resilience.
Art therapy approach essentially aids the healing process because the creative process has a healing effect, improves the quality of life and facilitates the communication of thoughts and feelings non-verbally (Malchiodi, 2003). The Art Therapy in this research uses Cognitive Behavior Therapy (CBT) approach as the approach is considered to be able to support measurable behavior changes (Hanson, 2013). The process of expression in art therapy with CBT approach can reduce negative emotions and cognitive distortions because it can access the child's memory and emotions in a non-scary way (Hanson, 2013) with the steps that are based on 4 core problems: self-image,  (Smeijsters et al., 2011).
Research of Art therapy with CBT approach for child victims of domestic violence ever done by Puspitasari (2015) for the child victims of domestic violence who experienced PTSD. The results showed the child's ability to excite negative emotions, decreased avoidance behavior toward sources of stressors or figures that resemble and descend anxiety and explosive emotions. In Septiani's research (2015) it is showed that CBT Art Therapy intervention can significantly decrease aggressiveness intention and reduced the frequency of aggressive behavior.
The CBT Art Therapy Intervention used in this research is the development of Art Therapy Intervention Module for Children Victims of Domestic Violence compiled by Erawan et al. (2015). The research begins with a preliminary session of building rapport and emotional recognition. The activity continued with a number of sessions referring to three basic aspects of CBT: make an image of a stressor, restructuring the negative and cognitive reframing. The therapist plays an important role in giving feedback to the discussion session with the subject through "the miracle questions" which in the CBT approach known as the challenging mind technique (Longmore & Worrell, 2007;Cully & Teten, 2008) so the subject can practice an alternative thinking skill. Modifications to the previous module are done by simplifying the instruction and applying multimodal art medium those are drawing and sculpting.
The art therapy intervention in this study aimed to increase the resiliency of child victims of domestic violence. Stages of intervention which are believed to support the formation of resiliency such as the stage of "Make an Image of A Stressor" that aims to improve causal analysis to help children recognize themselves and make preparations for unpleasant situations so as to form efficacy and self-esteem that by Rizo et al. (2011) is considered to support the fostering of child resiliency; the "Negative Restructuring" stage children are encouraged to be sensitive to their thoughts, emotions and their influence on maladaptive behavior. This stage prepares the children for the cognitive reframing stage so the children are able to find problem solving strategies, improve the ability to empathize and reaching out with regard to the ability to self-regulation, pro-social and optimistic thinking.
The art therapy intervention in this study is presented individually to have an intensive interaction with the subject and to make sure that the therapy is provided in accordance with the readiness and needs of the subject. The hypothesis that will be proven in this research is that The CBT Art Therapy can effectively improve the resilience of child victims of domestic violence.

METHOD Subject
A 9 year old boy. Who experienced (KDRT) in the form of punches, pinches and sabetan from his mother for ± 2 years, previously had witnessed verbal violence and emotions father against his mother. Aggressive behavior increased after watching the police arrest his father at home 2 years ago. Subject Has behavioral problems that lead to moderate resilience levels.

Instruments
Effects of The Art Therapy module is measured by Resilience Quotient Test that refers to the theory of Reivich & Shatté. According to Reivich & Shatté (2002) resilience has seven aspects: emotional regulation, impulse control, optimism, causal analysis, empathy, self efficacy, and reaching out. The RQT scale in this study is a modification of the Indonesian adaptation RQT scale compiled by Suwarjo (2008).

Research Design
This research uses single-case ABA design single-subject experiments beginning with initial baseline condition (A) that is normal behavior without treatment, then giving manipulation or treatment (B) as independent variable and then observing behavior change by eliminating independent variable Then returns to baseline condition (A) to determine the effect of treatment given (Myers & Hansen, 2011;Wilmhurst, 2012 A 1-5 = initial baseline (subject's level of resiliency); B= treatment (10 sessions CBT Art Therapy); A 1-5 =baseline subject's resiliency level after treatment.

Research Procedures
Research begins by modifying and selecting a scale of RQT. The scale contains 56 items with correlation correlation correlation coefficient (corrected item-total correlation) moving from 0.277 to 0.687 and Alpha Cronbach coefficient of 0.933 which means having good validity and reliability. The results of the research intervention were also analyzed qualitatively with the artwork analysis of observing changes in the subject image results during the intervention.
Adjustment of instrument language is done to meet the age range characteristics of the research subjects. The process of language adjustment includes the assessment of the difficulty level of sentences by 3 children aged 8-11 years and input 14 people with educational background S2 psychology who understand the concept of psychology scale. The modified scales were tested in 159 children aged 9-12 years from the vulnerable environment of domestic violence. The aitem selection uses the standard corrected item-total correlation> 0.25. There are 28 remaining RQT items and the Alpha Cronbach coefficient of 0.811 is obtained. Administration RQT done in a way read given the condition of subjects who have not been able to read smoothly, the subject answered using visual stimulation assistance in the form of smiley.
Modification of modules is done by adding sculpturing techniques using plastisin media to ease emotional tension at sessions that address the subject stressor source. The addition of techniques and media art done without changing the aspects of the module that is Make An Image of A Stressor, Restructuring The Negative, and Cognitive Reframing. The modified module has been assessed by 4 rater as a clinical psychologist and 1 rater is a counselor of the Women's Empowerment, Child Protection & Family Planning Board and has conducted research on art therapy. Assessment of the rater is then processed statistically resulting in an interclass correlation coefficient of 0.980.
Research subjects were children aged 9-12 years who had a tendency of low-moderate resilience behavior due to experiencing domestic violence and had never received psychological treatment. Initial screening results at NGO S indicated there were 3 children who met the criteria but only 1 child got consent approval to get immediate psychological intervention art therapy.

RESULTS AND DISCUSSION
The results of this research can be seen from the subject's artwork which are analyzed qualitatively by the visual analyzis while subject's cognitive and behaviour changes are analyzed by the descriptive data analyzis and the changes in subject's resiliency level is measured by the RQT.

Drawings Transformation
Subject initially draw in black color only, images with colors other than black are made on separate side. Furth (2002) mentions that black color symbolizes ignorance, the use of excessive black color indicates a negative connotation. Physical violence from the mother coupled with the emptiness of separation from the father and the rejection of the environment can make the subject overwhelmed with emotions or negative thoughts. In the next picture the black color is no longer dominant and the color giving according to the real object color.
The subject's drawing is difficult to understand because it has different character from the original object. Subject draws in scribbling and basic form quality without any details. Malchiodi (1998) mentions that children who are exposed to violence solve the picture quickly but pay less attention to detail, image integration and composition in other words the expression of the art is shallow, stereotyped or scribble.
Subject shows excessive shading strokes in session 3, 5 and 7. Furth (2002) defines black shading as negative, symbolizing the dark side of the mind, a threat or fear. Epperson in Malchiodi (1998) explains that children who are exposed to violence often make shading because it makes them feel good. Excessive shading making is often used as a means of self-soothing (Malchiodi, 1997). The quality of the subject's drawing develops in the session 7 shows the face detail on the person's figure. Significant changes that can be observed in the subject's drawings are the use of color, themes and image quality seen in the image 1.
Subject image themes often contain elements of violence. Malchiodi (1998) mentions that violence-themed images often reveal certain issues and feelings that children experience. Drawings in sessions 6 and 7 show more positive activity than previous drawings. Children who experience domestic violence but show a positive aspect on the image that he made indicates the characteristics of resilience (Malchiodi, 1998).

Changes in behaviour: Pre-intervention behavior
Subject has lack impulse control and often showing aggressive behavior. He also has less consideration of the consequences of their actions. Subject do not want to admit mistakes, reluctant to make up and show hostility toward people he hates. Greenspan & Woods (2014) states that children with intellectual disabilities have limited reasoning abilities to deal with everyday situations. The cause of intellectual disability is caused by environmental conditions such as problematic birth (Maerlender, 2004) as experienced by the subject.

Behavior During Intervention
Subject with intellectual obstacles did not experience significant problems during followup interventions of CBT. Greenspan & Woods (2014) explains that children with intellectual disabilities experience obstacles in reasoning ability and thinking rather than learning ability so that they can be equipped with concrete skills through behavior modification method. The application of CBT to intellectual disability children focuses on emotion recognition and cognitive restructuring (Wood et al., 2009) to modify cognitive distortions that affect presenting problems (Taylor et al., 2008). It's just that the subject has a high physical activity needs and easily bored so that variations of techniques and media art done in order to overcome the blocking conditions.

Post-Intervention Behavior
Subject exhibit behavioral developments such as increased ability of emotional regulation and impulse control even though the development of causal analysis capabilities or reasoning is less than optimal. The reasoning ability involves the frontal lobe area in the cerebral part of the brain (Damasio et al., 2004). Subject have a history of hypoxia because the airway is closed amniotic fluid at birth and seizures when aged 4 years are likely to result in brain injury. Brain injury in the neonatal occurs due to a lack of blood supply containing oxygen to the brain, one of the causes is hypoxia (Huang & Castillo, 2008).

Changes in Resilience Behavior
Measurements using resilience scale showed a change in RQT score of 27 points from a score of 75 (medium resilience) to 102 (medium resilience). From the results mentioned above, subject's RQT scale measurement shows 27 points increase as well as the visual graph which shows resilience behavior increasing after the intervention phase. The descriptive data also shows the increase of emotional regulation and impulse control skill. The artwork analysis also indicate an increase in resilience behavior from the colorful artworks and positive story theme in the last 3 sessions.
Results of this research show that the CBT Art Therapy can effectively be applied to help raise resiliency level in children victim of domestic violence. This research had modify the RQT scale and CBT Art Therapy Intervention module so it has more simple instruction and use multimodal technique to help the double handicapped subject (victims of domestic violence and classified as intellectually defective). Things that need to be considered in the establishment of CBT Art Therapy intervention for double handicapped children is the focus on the process of emotion recognition, cognitive restructuring and the role of the therapist in helping the subjects to find their core belief or automatic thoughts since the subjects' condition may impede them to do it independently.
Further research are expected to be able to develop art therapy module that can be presented by non-psychologist such as teacher, social worker or related parties that are handling child problems. For psychologists, it is necessary to establish cooperation and make programs to improve the skills of handling problems in children such as art therapy for the facing parties directly dealing with children such as parents, teachers and social workers. Psychologists can also work with artists to enrich the techniques used in art therapy interventions. For Non-Psychologist Professionals, the basics of image and color meanings need to be known by teachers and parents so that they can see children's work with a broader perspective. The CBT Art Therapy module for double handicapped children is expected to help improve the capacity of non-psychologist professionals such as inclusive school teachers, special education teachers and social workers in understanding and handling double handicapped children especially those experiencing domestic violence.