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Adjustment Disorders

The adjustment disorders are a diagnostic category characterized by an emotional response to a stressful event. Typically, the stressor involves financial issues, a medical illness, or a relationship problem. The symptom complex that develops may involve anxious or depressive affect or may present with a disturbance of conduct. By definition, the symptoms must begin within 3 months of the stressor and must remit within 6 months of removal of the stressor. A variety of subtypes of adjustment disorder are identified in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), varying on the particular predominant affective presentation. These include adjustment disorder with depressed mood, anxious mood, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified type.

Epidemiology

According to DSM-IV-TR, the prevalence of the disorder is estimated to be from 2 to 8 percent of the general population. Women are diagnosed with the disorder twice as often as men, and single women are generally overly represented as most at risk. In children and adolescents, boys and girls are equally diagnosed with adjustment disorders. The disorders can occur at any age, but are most frequently diagnosed in adolescents. Among adolescents of either sex, common precipitating stresses are school problems, parental rejection and divorce, and substance abuse. Among adults, common precipitating stresses are marital problems, divorce, moving to a new environment, and financial problems.

Adjustment disorders are one of the most common psychiatric diagnoses for disorders of patients hospitalized for medical and surgical problems. In one study, 5 percent of persons admitted to a hospital over a 3-year period were classified as having an adjustment disorder. Up to 50 percent of persons with specific medical problems or stressors have been diagnosed with adjustment disorders. Furthermore, 10 to 30 percent of mental health outpatients and up to 12 percent of general hospital inpatients referred for mental health consultations have been diagnosed with adjustment disorders.

Etiology

By definition, an adjustment disorder is precipitated by one or more stressors. The severity of the stressor or stressors does not always predict the severity of the disorder; the stressor severity is a complex function of degree, quantity, duration, reversibility, environment, and personal context. For example, the loss of a parent is different for a child 10 years of age than for a person 40 years of age. Personality organization and cultural or group norms and values also contribute to the disproportionate responses to stressors.

Stressors may be single, such as a divorce or the loss of a job, or multiple, such as the death of a person important to a patient, which coincides with the patient's own physical illness and loss of a job. Stressors may be recurrent, such as seasonal business difficulties, or continuous, such as chronic illness or poverty. A discordant intrafamilial relationship can produce an adjustment disorder that affects the entire family system, or the disorder may be limited to a patient who was perhaps the victim of a crime or who has a physical illness. Sometimes, adjustment disorders occur in a group or community setting, and the stressors affect several persons, as in a natural disaster or in racial, social, or religious persecution. Specific developmental stages, such as beginning school, leaving home, getting married, becoming a parent, failing to achieve occupational goals, having the last child leave home, and retiring, are often associated with adjustment disorders.

Psychodynamic Factors

Pivotal to understanding adjustment disorders is an understanding of three factors: the nature of the stressor, the conscious and unconscious meanings of the stressor, and the patient's preexisting vulnerability. A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment disorders. Vulnerability is also associated with the loss of a parent during infancy or being reared in a dysfunctional family. Actual or perceived support from key relationships can affect behavioral and emotional responses to stressors.

Several psychoanalytic researchers have pointed out that the same stress can produce a range of responses in various persons. Throughout his life, Sigmund Freud remained interested in why the stresses of ordinary life produce illness in some and not in others, why an illness takes a particular form, and why some experiences and not others predispose a person to psychopathology. He gave considerable weight to constitutional factors and viewed them as interacting with a person's life experiences to produce fixation.

Psychoanalytic research has emphasized the role of the mother and the rearing environment in a person's later capacity to respond to stress. Particularly important was Donald Winnicott's concept of the good-enough mother, a person who adapts

P.787

to the infant's needs and provides sufficient support to enable the growing child to tolerate the frustrations in life.

Clinicians must undertake a detailed exploration of a patient's experience of the stressor. Certain patients commonly place all the blame on a particular event when a less obvious event may have had more significant psychological meaning for the patient. Current events may reawaken past traumas or disappointments from childhood, so patients should be encouraged to think about how the current situation relates to similar past events.

Throughout early development, each child develops a unique set of defense mechanisms to deal with stressful events. Because of greater amounts of trauma or greater constitutional vulnerability, some children have less mature defensive constellations than other children. This disadvantage may cause them as adults to react with substantially impaired functioning when they are faced with a loss, a divorce, or a financial setback; those who have developed mature defense mechanisms are less vulnerable and bounce back more quickly from the stressor. Resilience is also crucially determined by the nature of children's early relationships with their parents. Studies of trauma repeatedly indicate that supportive, nurturant relationships prevent traumatic incidents from causing permanent psychological damage.

Psychodynamic clinicians must consider the relation between a stressor and the human developmental life cycle. When adolescents leave home for college, for example, they are at high developmental risk for reacting with a temporary symptomatic picture. Similarly, if the young person who leaves home is the last child in the family, the parents may be particularly vulnerable to a reaction of adjustment disorder. Moreover, middle-aged persons who are confronting their own mortality may be especially sensitive to the effects of loss or death.

Family and Genetic Factors

Some studies suggest that certain persons appear to be at increased risk both for the occurrence of these adverse life events and for the development of pathology once they occur. Findings from a study of more than 2,000 twin pairs indicate that life events and stressors are modestly correlated in twin pairs, with monozygotic twins showing greater concordance than dizygotic twins. Family environmental and genetic factors each accounted for approximately 20 percent of the variance in that study. Another twin study that examined genetic contributions to the development of posttraumatic stress disorder (PTSD) symptoms (not necessarily at the level of full disorder and, therefore, relevant to adjustment disorders) also concluded that the likelihood of developing symptoms in response to traumatic life events is partially under genetic control.

Table 26-1 DSM-IV-TR Diagnostic Criteria for Adjustment Disorders

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant as evidenced by either of the following: marked distress that is in excess of what would be expected from exposure to the stressor significant impairment in social or occupational (academic) functioning The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. The symptoms do not represent bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify if: Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months or longer Adjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV. With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Unspecified (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000.)

Diagnosis and Clinical Features

Although by definition adjustment disorders follow a stressor, the symptoms do not necessarily begin immediately. Up to 3 months may elapse between a stressor and the development of symptoms. Symptoms do not always subside as soon as the stressor ceases; if the stressor continues, the disorder may be chronic. The disorder can occur at any age, and its symptoms vary considerably, with depressive, anxious, and mixed features most common in adults. Physical symptoms, which are most common in children and the elderly, can occur in any age group. Manifestations may also include assaultive behavior and reckless driving, excessive drinking, defaulting on legal responsibilities, withdrawal, vegetative signs, insomnia, and suicidal behavior.

The clinical presentations of adjustment disorder can vary widely. DSM-IV-TR lists six adjustment disorders, including an unspecified category (Table 26-1).

Adjustment Disorder with Depressed Mood

In adjustment disorder with depressed mood, the predominant manifestations are depressed mood, tearfulness, and hopelessness. This type must be distinguished from major depressive

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disorder and uncomplicated bereavement. Adolescents with this type of adjustment disorder are at increased risk for major depressive disorder in young adulthood.

Adjustment Disorder with Anxiety

Symptoms of anxiety, such as palpitations, jitteriness, and agitation, are present in adjustment disorder with anxiety, which must be differentiated from anxiety disorders.

Adjustment Disorder with Mixed Anxiety and Depressed Mood

In adjustment disorder with mixed anxiety and depressed mood, patients exhibit features of both anxiety and depression that do not meet the criteria for an already established anxiety disorder or depressive disorder.

A 48-year-old married woman, in good health, with no previous psychiatric difficulties, presented to the emergency room reporting that she had overdosed on a handful of antihistamines shortly before she arrived. She described her problems as having started 2 months earlier, soon after her husband unexpectedly requested a divorce. She felt betrayed after having devoted much of her 20-year marriage to being a wife, mother, and homemaker. She was sad and tearful at times, and she occasionally had difficulty sleeping. Otherwise, she had no vegetative symptoms and enjoyed time with family and friends. She felt desperate and suicidal after she realized that “he no longer loved me.” After crisis intervention in the emergency setting, she responded well to individual psychotherapy over a 3-month period. She occasionally required benzodiazepines for anxiety during the period of treatment. By the time of discharge, she had returned to her baseline function. She came to terms with the possibility of life after divorce and was exploring her best options under the circumstances. (Courtesy of Jeffrey William Katz, M.D., and Oladapo Tomori, M.D.)

Adjustment Disorder with Disturbance of Conduct

In adjustment disorder with disturbance of conduct, the predominant manifestation involves conduct in which the rights of others are violated or age-appropriate societal norms and rules are disregarded. Examples of behavior in this category are truancy, vandalism, reckless driving, and fighting. The category must be differentiated from conduct disorder and antisocial personality disorder.

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

A combination of disturbances of emotions and of conduct sometimes occurs. Clinicians are encouraged to try to make one or the other diagnosis in the interest of clarity.

Adjustment Disorder Unspecified

Adjustment disorder unspecified is a residual category for atypical maladaptive reactions to stress. Examples include inappropriate responses to the diagnosis of physical illness, such as massive denial, severe noncompliance with treatment, and social withdrawal, without significant depressed or anxious mood.

Differential Diagnosis

Although uncomplicated bereavement often produces temporarily impaired social and occupational functioning, the person's dysfunction remains within the expectable bounds of a reaction to the loss of a loved one and, thus, is not considered adjustment disorder. Other disorders from which adjustment disorder must be differentiated include major depressive disorder, brief psychotic disorder, generalized anxiety disorder, somatization disorder, substance-related disorder, conduct disorder, academic problem, occupational problem, identity problem, and PTSD. These diagnoses should be given precedence in all cases that meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant. Patients with an adjustment disorder are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another condition, clinical judgment is necessary. Some patients may meet the criteria for both an adjustment disorder and a personality disorder. If the adjustment disorder follows a physical illness, the clinician must make sure that the symptoms are not a continuation or another manifestation of the illness or its treatment.

Acute and Posttraumatic Stress Disorders

The presence of a stressor is a requirement in the diagnosis of adjustment disorder, PTSD, and acute stress disorder. PTSD and acute stress disorder have the nature of the stressor better characterized and are accompanied by a defined constellation of affective and autonomic symptoms. In contrast, the stressor in adjustment disorder can be of any severity, with a wide range of possible symptoms. When the response to an extreme stressor does not meet the acute stress or posttraumatic disorder threshold, the adjustment disorder diagnosis would be appropriate. PTSD is discussed fully in Chapter 16.5.

Course and Prognosis

With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later have mood disorders or substance-related disorders. Adolescents usually require a longer time to recover than adults.

Treatment

Psychotherapy

Psychotherapy remains the treatment of choice for adjustment disorders. Group therapy can be particularly useful for patients who have had similar stresses—for example, a group of retired persons or patients having renal dialysis. Individual psychotherapy offers the opportunity to explore the meaning of the stressor

P.789

to the patient so that earlier traumas can be worked through. After successful therapy, patients sometimes emerge from an adjustment disorder stronger than in the premorbid period, although no pathology was evident during that period. Because a stressor can be clearly delineated in adjustment disorders, it is often believed that psychotherapy is not indicated and that the disorder will remit spontaneously. This viewpoint, however, ignores the fact that many persons exposed to the same stressor experience different symptoms, and in adjustment disorders, the response is pathological. Psychotherapy can help persons adapt to stressors that are not reversible or time limited and can serve as a preventive intervention if the stressor does remit. Psychiatrists treating adjustment disorders must be particularly aware of problems of secondary gain. The illness role may be rewarding to some normally healthy persons who have had little experience with illness's capacity to free them from responsibility. Thus, patients can find therapists' attention, empathy, and understanding, which are necessary for success, rewarding in their own right, and therapists may thereby reinforce patients' symptoms. Such considerations must be weighed before intensive psychotherapy is begun; when a secondary gain has already been established, therapy is difficult. Patients with an adjustment disorder that includes a conduct disturbance may have difficulties with the law, authorities, or school. Psychiatrists should not attempt to rescue such patients from the consequences of their actions. Too often, such kindness only reinforces socially unacceptable means of tension reduction and hinders the acquisition of insight and subsequent emotional growth. In these cases, family therapy can help.

Table 26-2 ICD-10 Diagnostic Criteria for Adjustment Disorders

Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type. The individual manifests symptoms or behavior disturbance of the types found in any of the affective disorders (except for delusions and hallucinations), any disorder in neurotic, stress-related, and somatoform disorders, and conduct disorders, but the criteria for an individual disorder are not fulfilled. Symptoms may be variable in both form and severity. The predominant feature of the symptoms may be further specified. Brief depressive reaction A transient mild depressive state of a duration not exceeding 1 month. [3pt] Prolonged depressive reaction A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years. Mixed anxiety and depressive reaction Both anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders. With predominant disturbance of other emotions The symptoms are usually of several types of emotions, such as anxiety, depression, worry, tensions, and anger. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder or for other mixed anxiety disorders, but they are not so predominant that other more specific depressive or anxiety disorders can be diagnosed. This category should also be used for reactions in children in whom regressive behavior such as bed-wetting or thumb-sucking is also present. With predominant disturbance of conduct The main disturbance is one involving conduct, e.g., an adolescent grief reaction resulting in aggressive or dissocial behavior. With mixed disturbance of emotions and conduct Both emotional symptoms and disturbances of conduct are prominent features. With other specified predominant symptoms Except in prolonged depressive reaction, the symptoms do not persist for more than 6 months after the cessation of the stress or its consequences. However, this should not prevent a provisional diagnosis being made if this criterion is not yet fulfilled. (Reprinted with permission from World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Copyright, World Health Organization, Geneva, 1993.)

Crisis Intervention

Crisis intervention and case management are short-term treatments aimed at helping persons with adjustment disorders resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. The frequency and length of visits for crisis support vary according to patients' needs; daily sessions may be necessary, sometimes two or three times each day. Flexibility is essential in this approach.

Pharmacotherapy

No studies have assessed the efficacy of pharmacological interventions in individuals with adjustment disorder, but it may be reasonable to use medication to treat specific symptoms for a brief time. The judicious use of medications can help patients with adjustment disorders, but they should be prescribed for brief periods. Depending on the type of adjustment disorder, a patient may respond to an antianxiety agent or to an antidepressant. Patients with severe anxiety bordering on panic can benefit from anxiolytics such as diazepam (Valium), and those in withdrawn or inhibited states may be helped by a short course of psychostimulant medication. Antipsychotic drugs may be used if there are signs of decompensation or impending psychosis. Selective serotonin reuptake inhibitors have been found useful in treating symptoms of traumatic grief. Recently, there has been an increase in antidepressant use to augment psychotherapy in patients with adjustment disorders. Pharmacological intervention in this population is most often used, however, to augment psychosocial strategies rather than serving as the primary modality.

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ICD-10

The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) also contains a category of adjustment disorders. The diagnosis is similar to the DSM-IV-TR entity in outlining the development of psychological symptoms following a stressor. In ICD-10, however, the symptoms must appear within 1 month of the stressor, instead of the 3-month temporal course of DSM-IV-TR (Table 26-2). The ICD-10 criteria share with DSM-IV-TR the requirement that symptoms must not persist for longer than 6 months after the removal of the stressor. The ICD-10 and DSM-IV-TR differ in their consideration of chronicity. Whereas the DSM-IV-TR requires the specification of acute or chronic for all subtypes of adjustment disorder, the ICD-10 only refers to chronicity if the primary experience involved is a depressed state. In this case, the diagnosis of prolonged depressive reaction is used to describe symptoms lasting for as long as 2 years.

References

Akizuki N, Akechi T, Nakanishi T, Yoshikawa E, Okamura M, Nakano T, Murakami Y, Uchitomi Y. Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer. 2003;97:2605.

Gonzalez-Jaimes EI, Turbull-Plaza B. Selection of psychotherapeutic treatment for adjustment disorder with depressive mood due to acute myocardial infarction. Arch Med Res. 2003;34:298.

Judy DH. Seasons change: Adjustment disorder as summons to new life structure. In: Mijares SG, Khalsa GS, eds. The Psychospiritual Clinician's Handbook: Alternative Methods for Understanding and Treating Mental Disorders. New York: Haworth Press, Inc.; 2005:33–50.

Katz JW, Tomori O. Adjustment disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2005:2055.

Kim KJ, Conger RD, Elder GH Jr, Lorenz FO. Reciprocal influences between stressful life events and adolescent internalizing and externalizing problems. Child Dev. 2003;74:127.

Levitas AS, Hurley AD. Diagnosis and treatment of adjustment disorders in people with intellectual disability. Mental Health Aspects of Developmental Disabilities. 2005;8:52–60.

Linden M. Posttraumatic embitterment disorder. Psychother Psychosom. 2003;72:195.

Newcorn JH, Strain JJ, Mezzich JE. Adjustment disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2000:1714.

Portzky G, Audenaert K, van Heeringen K. Adjustment disorder and the course of the suicidal process in adolescents. J Affect Disord. 2005;87:265–270.

Powell S, McCone D. Treatment of adjustment disorder with anxiety: A September 11, 2001, case study with a 1-year follow-up. Cognitive and Behavioral Practice. 2004;11:331–336.

Van der Klink JJ, van Dijk FJ. Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. Scand J Work Environ Health. 2003;29:478.

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Adjustment Disorders

The adjustment disorders are a diagnostic category characterized by an emotional response to a stressful event. Typically, the stressor involves financial issues, a medical illness, or a relationship problem. The symptom complex that develops may involve anxious or depressive affect or may present with a disturbance of conduct. By definition, the symptoms must begin within 3 months of the stressor and must remit within 6 months of removal of the stressor. A variety of subtypes of adjustment disorder are identified in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), varying on the particular predominant affective presentation. These include adjustment disorder with depressed mood, anxious mood, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified type.

Epidemiology

According to DSM-IV-TR, the prevalence of the disorder is estimated to be from 2 to 8 percent of the general population. Women are diagnosed with the disorder twice as often as men, and single women are generally overly represented as most at risk. In children and adolescents, boys and girls are equally diagnosed with adjustment disorders. The disorders can occur at any age, but are most frequently diagnosed in adolescents. Among adolescents of either sex, common precipitating stresses are school problems, parental rejection and divorce, and substance abuse. Among adults, common precipitating stresses are marital problems, divorce, moving to a new environment, and financial problems.

Adjustment disorders are one of the most common psychiatric diagnoses for disorders of patients hospitalized for medical and surgical problems. In one study, 5 percent of persons admitted to a hospital over a 3-year period were classified as having an adjustment disorder. Up to 50 percent of persons with specific medical problems or stressors have been diagnosed with adjustment disorders. Furthermore, 10 to 30 percent of mental health outpatients and up to 12 percent of general hospital inpatients referred for mental health consultations have been diagnosed with adjustment disorders.

Etiology

By definition, an adjustment disorder is precipitated by one or more stressors. The severity of the stressor or stressors does not always predict the severity of the disorder; the stressor severity is a complex function of degree, quantity, duration, reversibility, environment, and personal context. For example, the loss of a parent is different for a child 10 years of age than for a person 40 years of age. Personality organization and cultural or group norms and values also contribute to the disproportionate responses to stressors.

Stressors may be single, such as a divorce or the loss of a job, or multiple, such as the death of a person important to a patient, which coincides with the patient's own physical illness and loss of a job. Stressors may be recurrent, such as seasonal business difficulties, or continuous, such as chronic illness or poverty. A discordant intrafamilial relationship can produce an adjustment disorder that affects the entire family system, or the disorder may be limited to a patient who was perhaps the victim of a crime or who has a physical illness. Sometimes, adjustment disorders occur in a group or community setting, and the stressors affect several persons, as in a natural disaster or in racial, social, or religious persecution. Specific developmental stages, such as beginning school, leaving home, getting married, becoming a parent, failing to achieve occupational goals, having the last child leave home, and retiring, are often associated with adjustment disorders.

Psychodynamic Factors

Pivotal to understanding adjustment disorders is an understanding of three factors: the nature of the stressor, the conscious and unconscious meanings of the stressor, and the patient's preexisting vulnerability. A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment disorders. Vulnerability is also associated with the loss of a parent during infancy or being reared in a dysfunctional family. Actual or perceived support from key relationships can affect behavioral and emotional responses to stressors.

Several psychoanalytic researchers have pointed out that the same stress can produce a range of responses in various persons. Throughout his life, Sigmund Freud remained interested in why the stresses of ordinary life produce illness in some and not in others, why an illness takes a particular form, and why some experiences and not others predispose a person to psychopathology. He gave considerable weight to constitutional factors and viewed them as interacting with a person's life experiences to produce fixation.

Psychoanalytic research has emphasized the role of the mother and the rearing environment in a person's later capacity to respond to stress. Particularly important was Donald Winnicott's concept of the good-enough mother, a person who adapts

P.787

to the infant's needs and provides sufficient support to enable the growing child to tolerate the frustrations in life.

Clinicians must undertake a detailed exploration of a patient's experience of the stressor. Certain patients commonly place all the blame on a particular event when a less obvious event may have had more significant psychological meaning for the patient. Current events may reawaken past traumas or disappointments from childhood, so patients should be encouraged to think about how the current situation relates to similar past events.

Throughout early development, each child develops a unique set of defense mechanisms to deal with stressful events. Because of greater amounts of trauma or greater constitutional vulnerability, some children have less mature defensive constellations than other children. This disadvantage may cause them as adults to react with substantially impaired functioning when they are faced with a loss, a divorce, or a financial setback; those who have developed mature defense mechanisms are less vulnerable and bounce back more quickly from the stressor. Resilience is also crucially determined by the nature of children's early relationships with their parents. Studies of trauma repeatedly indicate that supportive, nurturant relationships prevent traumatic incidents from causing permanent psychological damage.

Psychodynamic clinicians must consider the relation between a stressor and the human developmental life cycle. When adolescents leave home for college, for example, they are at high developmental risk for reacting with a temporary symptomatic picture. Similarly, if the young person who leaves home is the last child in the family, the parents may be particularly vulnerable to a reaction of adjustment disorder. Moreover, middle-aged persons who are confronting their own mortality may be especially sensitive to the effects of loss or death.

Family and Genetic Factors

Some studies suggest that certain persons appear to be at increased risk both for the occurrence of these adverse life events and for the development of pathology once they occur. Findings from a study of more than 2,000 twin pairs indicate that life events and stressors are modestly correlated in twin pairs, with monozygotic twins showing greater concordance than dizygotic twins. Family environmental and genetic factors each accounted for approximately 20 percent of the variance in that study. Another twin study that examined genetic contributions to the development of posttraumatic stress disorder (PTSD) symptoms (not necessarily at the level of full disorder and, therefore, relevant to adjustment disorders) also concluded that the likelihood of developing symptoms in response to traumatic life events is partially under genetic control.

Table 26-1 DSM-IV-TR Diagnostic Criteria for Adjustment Disorders

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant as evidenced by either of the following: marked distress that is in excess of what would be expected from exposure to the stressor significant impairment in social or occupational (academic) functioning The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. The symptoms do not represent bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify if: Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months or longer Adjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IV. With depressed mood With anxiety With mixed anxiety and depressed mood With disturbance of conduct With mixed disturbance of emotions and conduct Unspecified (From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000.)

Diagnosis and Clinical Features

Although by definition adjustment disorders follow a stressor, the symptoms do not necessarily begin immediately. Up to 3 months may elapse between a stressor and the development of symptoms. Symptoms do not always subside as soon as the stressor ceases; if the stressor continues, the disorder may be chronic. The disorder can occur at any age, and its symptoms vary considerably, with depressive, anxious, and mixed features most common in adults. Physical symptoms, which are most common in children and the elderly, can occur in any age group. Manifestations may also include assaultive behavior and reckless driving, excessive drinking, defaulting on legal responsibilities, withdrawal, vegetative signs, insomnia, and suicidal behavior.

The clinical presentations of adjustment disorder can vary widely. DSM-IV-TR lists six adjustment disorders, including an unspecified category (Table 26-1).

Adjustment Disorder with Depressed Mood

In adjustment disorder with depressed mood, the predominant manifestations are depressed mood, tearfulness, and hopelessness. This type must be distinguished from major depressive

P.788

disorder and uncomplicated bereavement. Adolescents with this type of adjustment disorder are at increased risk for major depressive disorder in young adulthood.

Adjustment Disorder with Anxiety

Symptoms of anxiety, such as palpitations, jitteriness, and agitation, are present in adjustment disorder with anxiety, which must be differentiated from anxiety disorders.

Adjustment Disorder with Mixed Anxiety and Depressed Mood

In adjustment disorder with mixed anxiety and depressed mood, patients exhibit features of both anxiety and depression that do not meet the criteria for an already established anxiety disorder or depressive disorder.

A 48-year-old married woman, in good health, with no previous psychiatric difficulties, presented to the emergency room reporting that she had overdosed on a handful of antihistamines shortly before she arrived. She described her problems as having started 2 months earlier, soon after her husband unexpectedly requested a divorce. She felt betrayed after having devoted much of her 20-year marriage to being a wife, mother, and homemaker. She was sad and tearful at times, and she occasionally had difficulty sleeping. Otherwise, she had no vegetative symptoms and enjoyed time with family and friends. She felt desperate and suicidal after she realized that “he no longer loved me.” After crisis intervention in the emergency setting, she responded well to individual psychotherapy over a 3-month period. She occasionally required benzodiazepines for anxiety during the period of treatment. By the time of discharge, she had returned to her baseline function. She came to terms with the possibility of life after divorce and was exploring her best options under the circumstances. (Courtesy of Jeffrey William Katz, M.D., and Oladapo Tomori, M.D.)

Adjustment Disorder with Disturbance of Conduct

In adjustment disorder with disturbance of conduct, the predominant manifestation involves conduct in which the rights of others are violated or age-appropriate societal norms and rules are disregarded. Examples of behavior in this category are truancy, vandalism, reckless driving, and fighting. The category must be differentiated from conduct disorder and antisocial personality disorder.

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

A combination of disturbances of emotions and of conduct sometimes occurs. Clinicians are encouraged to try to make one or the other diagnosis in the interest of clarity.

Adjustment Disorder Unspecified

Adjustment disorder unspecified is a residual category for atypical maladaptive reactions to stress. Examples include inappropriate responses to the diagnosis of physical illness, such as massive denial, severe noncompliance with treatment, and social withdrawal, without significant depressed or anxious mood.

Differential Diagnosis

Although uncomplicated bereavement often produces temporarily impaired social and occupational functioning, the person's dysfunction remains within the expectable bounds of a reaction to the loss of a loved one and, thus, is not considered adjustment disorder. Other disorders from which adjustment disorder must be differentiated include major depressive disorder, brief psychotic disorder, generalized anxiety disorder, somatization disorder, substance-related disorder, conduct disorder, academic problem, occupational problem, identity problem, and PTSD. These diagnoses should be given precedence in all cases that meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant. Patients with an adjustment disorder are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another condition, clinical judgment is necessary. Some patients may meet the criteria for both an adjustment disorder and a personality disorder. If the adjustment disorder follows a physical illness, the clinician must make sure that the symptoms are not a continuation or another manifestation of the illness or its treatment.

Acute and Posttraumatic Stress Disorders

The presence of a stressor is a requirement in the diagnosis of adjustment disorder, PTSD, and acute stress disorder. PTSD and acute stress disorder have the nature of the stressor better characterized and are accompanied by a defined constellation of affective and autonomic symptoms. In contrast, the stressor in adjustment disorder can be of any severity, with a wide range of possible symptoms. When the response to an extreme stressor does not meet the acute stress or posttraumatic disorder threshold, the adjustment disorder diagnosis would be appropriate. PTSD is discussed fully in Chapter 16.5.

Course and Prognosis

With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later have mood disorders or substance-related disorders. Adolescents usually require a longer time to recover than adults.

Treatment

Psychotherapy

Psychotherapy remains the treatment of choice for adjustment disorders. Group therapy can be particularly useful for patients who have had similar stresses—for example, a group of retired persons or patients having renal dialysis. Individual psychotherapy offers the opportunity to explore the meaning of the stressor

P.789

to the patient so that earlier traumas can be worked through. After successful therapy, patients sometimes emerge from an adjustment disorder stronger than in the premorbid period, although no pathology was evident during that period. Because a stressor can be clearly delineated in adjustment disorders, it is often believed that psychotherapy is not indicated and that the disorder will remit spontaneously. This viewpoint, however, ignores the fact that many persons exposed to the same stressor experience different symptoms, and in adjustment disorders, the response is pathological. Psychotherapy can help persons adapt to stressors that are not reversible or time limited and can serve as a preventive intervention if the stressor does remit. Psychiatrists treating adjustment disorders must be particularly aware of problems of secondary gain. The illness role may be rewarding to some normally healthy persons who have had little experience with illness's capacity to free them from responsibility. Thus, patients can find therapists' attention, empathy, and understanding, which are necessary for success, rewarding in their own right, and therapists may thereby reinforce patients' symptoms. Such considerations must be weighed before intensive psychotherapy is begun; when a secondary gain has already been established, therapy is difficult. Patients with an adjustment disorder that includes a conduct disturbance may have difficulties with the law, authorities, or school. Psychiatrists should not attempt to rescue such patients from the consequences of their actions. Too often, such kindness only reinforces socially unacceptable means of tension reduction and hinders the acquisition of insight and subsequent emotional growth. In these cases, family therapy can help.

Table 26-2 ICD-10 Diagnostic Criteria for Adjustment Disorders

Onset of symptoms must occur within 1 month of exposure to an identifiable psychosocial stressor, not of an unusual or catastrophic type. The individual manifests symptoms or behavior disturbance of the types found in any of the affective disorders (except for delusions and hallucinations), any disorder in neurotic, stress-related, and somatoform disorders, and conduct disorders, but the criteria for an individual disorder are not fulfilled. Symptoms may be variable in both form and severity. The predominant feature of the symptoms may be further specified. Brief depressive reaction A transient mild depressive state of a duration not exceeding 1 month. [3pt] Prolonged depressive reaction A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of a duration not exceeding 2 years. Mixed anxiety and depressive reaction Both anxiety and depressive symptoms are prominent, but at levels no greater than those specified for mixed anxiety and depressive disorder or other mixed anxiety disorders. With predominant disturbance of other emotions The symptoms are usually of several types of emotions, such as anxiety, depression, worry, tensions, and anger. Symptoms of anxiety and depression may meet the criteria for mixed anxiety and depressive disorder or for other mixed anxiety disorders, but they are not so predominant that other more specific depressive or anxiety disorders can be diagnosed. This category should also be used for reactions in children in whom regressive behavior such as bed-wetting or thumb-sucking is also present. With predominant disturbance of conduct The main disturbance is one involving conduct, e.g., an adolescent grief reaction resulting in aggressive or dissocial behavior. With mixed disturbance of emotions and conduct Both emotional symptoms and disturbances of conduct are prominent features. With other specified predominant symptoms Except in prolonged depressive reaction, the symptoms do not persist for more than 6 months after the cessation of the stress or its consequences. However, this should not prevent a provisional diagnosis being made if this criterion is not yet fulfilled. (Reprinted with permission from World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Copyright, World Health Organization, Geneva, 1993.)

Crisis Intervention

Crisis intervention and case management are short-term treatments aimed at helping persons with adjustment disorders resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. The frequency and length of visits for crisis support vary according to patients' needs; daily sessions may be necessary, sometimes two or three times each day. Flexibility is essential in this approach.

Pharmacotherapy

No studies have assessed the efficacy of pharmacological interventions in individuals with adjustment disorder, but it may be reasonable to use medication to treat specific symptoms for a brief time. The judicious use of medications can help patients with adjustment disorders, but they should be prescribed for brief periods. Depending on the type of adjustment disorder, a patient may respond to an antianxiety agent or to an antidepressant. Patients with severe anxiety bordering on panic can benefit from anxiolytics such as diazepam (Valium), and those in withdrawn or inhibited states may be helped by a short course of psychostimulant medication. Antipsychotic drugs may be used if there are signs of decompensation or impending psychosis. Selective serotonin reuptake inhibitors have been found useful in treating symptoms of traumatic grief. Recently, there has been an increase in antidepressant use to augment psychotherapy in patients with adjustment disorders. Pharmacological intervention in this population is most often used, however, to augment psychosocial strategies rather than serving as the primary modality.

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ICD-10

The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) also contains a category of adjustment disorders. The diagnosis is similar to the DSM-IV-TR entity in outlining the development of psychological symptoms following a stressor. In ICD-10, however, the symptoms must appear within 1 month of the stressor, instead of the 3-month temporal course of DSM-IV-TR (Table 26-2). The ICD-10 criteria share with DSM-IV-TR the requirement that symptoms must not persist for longer than 6 months after the removal of the stressor. The ICD-10 and DSM-IV-TR differ in their consideration of chronicity. Whereas the DSM-IV-TR requires the specification of acute or chronic for all subtypes of adjustment disorder, the ICD-10 only refers to chronicity if the primary experience involved is a depressed state. In this case, the diagnosis of prolonged depressive reaction is used to describe symptoms lasting for as long as 2 years.

References

Akizuki N, Akechi T, Nakanishi T, Yoshikawa E, Okamura M, Nakano T, Murakami Y, Uchitomi Y. Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer. 2003;97:2605.

Gonzalez-Jaimes EI, Turbull-Plaza B. Selection of psychotherapeutic treatment for adjustment disorder with depressive mood due to acute myocardial infarction. Arch Med Res. 2003;34:298.

Judy DH. Seasons change: Adjustment disorder as summons to new life structure. In: Mijares SG, Khalsa GS, eds. The Psychospiritual Clinician's Handbook: Alternative Methods for Understanding and Treating Mental Disorders. New York: Haworth Press, Inc.; 2005:33–50.

Katz JW, Tomori O. Adjustment disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 8th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2005:2055.

Kim KJ, Conger RD, Elder GH Jr, Lorenz FO. Reciprocal influences between stressful life events and adolescent internalizing and externalizing problems. Child Dev. 2003;74:127.

Levitas AS, Hurley AD. Diagnosis and treatment of adjustment disorders in people with intellectual disability. Mental Health Aspects of Developmental Disabilities. 2005;8:52–60.

Linden M. Posttraumatic embitterment disorder. Psychother Psychosom. 2003;72:195.

Newcorn JH, Strain JJ, Mezzich JE. Adjustment disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Vol. 2. Baltimore: Lippincott Williams & Wilkins; 2000:1714.

Portzky G, Audenaert K, van Heeringen K. Adjustment disorder and the course of the suicidal process in adolescents. J Affect Disord. 2005;87:265–270.

Powell S, McCone D. Treatment of adjustment disorder with anxiety: A September 11, 2001, case study with a 1-year follow-up. Cognitive and Behavioral Practice. 2004;11:331–336.

Van der Klink JJ, van Dijk FJ. Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. Scand J Work Environ Health. 2003;29:478.

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Butuh Jurnal Pelatihan Berpikir Positif? Kontak Aja

Pengaruh Pelatihan Berpikir Positif Terhadap Efikasi Diri Akademik Mahasiswa

(Studi Eksperimental di Fakultas Psikologi Universitas Diponegoro Semarang)

Aswendo Dwitantyanov, Farida Hidayati, dan Dian Ratna Sawitri

Fakultas Psikologi Universitas Diponegoro

ABSTRAK

Pendahuluan: Efikasi diri akademik merupakan keyakinan individu untuk menghadapi tugas-tugas akademik sesuai yang diharapkan. Efikasi diri akademik mendorong mahasiswa untuk ulet dan gigih dalam menyelesaikan tugas-tugas kuliah, mencapai tujuan, dan mengatasi hambatan yang muncul (Bandura, 1997, h. 117). Berpikir positif membantu mahasiswa menghadapi situasi yang menimbulkan stres dalam studi dan membuat mahasiswa fokus pada hal-hal positif. Untuk itu, berpikir positif sering dijadikan tolak ukur efikasi diri akademik yang tinggi, karena membuat mahasiswa fokus pada kemungkinan berhasil dalam akademik saat situasi rawan stres (Kivimaki, dkk, 2005, h. 413).

Metodologi: Penelitian ini bertujuan untuk menguji pengaruh pelatihan berpikir positif untuk meningkatkan efikasi diri akademik mahasiswa. Penelitian ini dilakukan pada 21 mahasiswa tahun pertama tingkat S1, belum pernah mengikuti pelatihan berpikir positif sebelumnya, dan memiliki tingkat efikasi diri akademik yang rendah. Mahasiswa dikelompokkan dalam dua kelompok, yaitu kelompok eksperimen dan kontrol. Hipotesis yang diajukan Ada perbedaan perbedaan efikasi diri akademik pada kelompok eksperimen dan kontrol. Penelitian ini menggunakan desain Randomized Pretest-Posttest Control Group Design. Pelatihan berpikir positif diberikan selalam tiga pertemuan. Pengumpulan data dilakukan dengan menggunakan metode observasi, wawancara, dan skala efikasi diri akademik mahasiswa.

Hasil: Hasil pengujian hipotesis dengan Independent Sample t-test menghasilkan nilai p (0,000) < 0,05. Hal ini menunjukkan bahwa ada perbedaan skor efikasi diri akademik yang signifikan antara kelompok eksperimen dan kelompok kontrol setelah perlakuan. Dengan demikian, berpikir positif dapat menjadi salah satu cara untuk meningkatkan efikasi diri akademik pada mahasiswa.

Simpulan: Ada pengaruh pelatihan berpikir positif terhadap efikasi diri akademik mahasiswa tahun pertama fakultas psikologi Universitas Diponegoro Semarang.

Kata Kunci: Pelatihan berpikir positif, efikasi diri akademik, mahasiswa.

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COURTS AND THE LEGAL SYSTEM CIVIL FORENSICS

Mendefinisikan Sakit Mental

Meskipun komunitas kesehatan mental sering menggunakan istilah mental illness untuk tujuan diagnosis dan treatment, tetapi hal ini diasumsikan lebih luas dimata hukum dalam konteks yang lebih luas. Yang penting adalah hal ini bisa menjadi syarat commitmen sipil dan jika mental illness itu berdampak pada hukum hal ini berimplikasi pada insanity dan kompetensi seseorang. Mental illness juga bisa berdampak untuk menentukan kompetensi seperti kompetensi untuk menghadapi pengadilan, untuk melaksanakan keinginan, atau untuk mengatur diri sendiri. Definisi mental illness juga masih tidak cukup. Evaluator forensic harus memiliki definisi yang spesifik, mengenai mental illness atau kondisi lain (mental retardasi atau kondisi medis). Misalnya kasus Andrew Goldstein, permohonan insanity ditolak (seorang schizophrenia yang melempar seorang perempuan ke rel kereta api di New York).

Mental illness itu menjadi isu setelah alasan insanity bisa membebaskan seseorang dari hukuman. Individu diijinkan untuk dirumah sakitkan di psikiater ketika tidak bisa mengikuti persidangan, kurang rasional, dan tidak mampu untuk mempertahankan diri dikarenakan mental illness.

Karena memang penting, maka psikolog dan pengadilan kriminal perlu memikirkan hal ini. mental illness menjadi kontroversi di hukum. Mental illness memiliki definisi berbeda dengan mental illness yang biasa dipahami oleh kesehatan mental. Maka perlu definisi mental illness yang lebih detail dengan konteks komitmen sipil dan insanity defence.

Kasus Gina

Gina berumur 27 tahun. Gina memiliki sejarah kesehatan ketidakstabilan mental dengan diagnosis gangguan kepribadian narsistik dan antisocial, sebagaimana depresi yang parah dan kadang-kadang memiliki ide bunuh diri. Akhir-akhir ini Gina menunjukkan adanya beberapa peristiwa penuh tekanan termasuk kematian teman dekatnya dan putusnya hubungan hubungan yang telah lama dibina. Teman-teman dan orang tua memperingatkan Gina tentang kondisi psikisnya yang tidak baik, dan takut jika nanti dia akan melukai dirinya sendiri maupun orang-orang yang ada disekitarnya. Beberapa menyarankan bahwa Gina ke psikiater. Meskipun begitu Gina mengatakan bahwa dirinya ‘baik’ dan menolak usaha-usaha intervensi psikologi. Teman dan keluarganya merumahsakitkan Gina meskipun Gina tidak menginginkannya, karena menurut mereka hal itu yang terbaik untuk Gina. Mempertimbangkan bahwa Gina dimungkinkan dapat melakukan tindakan yang berbahaya, maka dimata hukum dia termasuk sakit mental.

Civil komitmen

Criteria Substansive untuk komitmen sipil adalah kehadiran mental illness. Sebagian besar hukum, mendefinisikan eksistensi mental illness pada individu menunjukkan bahwa dia mengalami mental disorder. Karena mental illnes menjadi prasyarat untuk komitmen sipil.

Hukum lebih melihat dari sudut pandang “bahaya” melukai orang lain, berbeda dengan psikiater yang melihat dari segi melukai diri sendiri.

Penyakit mental adalah istilah yang mudah dimanipulasi. Definisi operasional yang dibuat itu masih samar dan tidak jelas. Melton mengutip salah satu upaya legislasi yang paling spesifik untuk mendefinisikan penyakit mental yaitu sebagai berikut:

Gangguan substansial pemikiran, suasana hati, orientasi persepsi, atau memory yang merusak keputusan, perilaku, kapasitas untuk mengenali kenyataan atau kemampuan untuk mengenali tuntutan kehidupan yang biasa tetapi tidak termasuk keterbelakangan mental.

Banyak ketetapan, tetapi kondisi yg dimaksud adalah kecuali kondisi keterbelakangan mental, penyalahgunaan zat, dan epilepsy. Alkohol dan penyalahgunaan obat tidak termasuk dalam penyakit mental di koridor hukum. Hukum memiliki batasan tertentu dalam menentukan ruang lingkup gangguan kejiwaan.

Ketidakakuratan dalam mendefinisikan mental illness membuat hukum, membuat isu mengenai definisi kata ‘mental ill’. Tanggung jawab menilai potensi penyakit mental, oleh pengadilan diserahkan pada saksi ahli (psikiater dan psikolog). Kekuatan yang diberikan tergantung pada ahli kesehatan mental tadi. Penelitian membuktikan bahwa ternyata psikolog dan psikiater memiliki persetujuan yang sama tentang mental illness. Hal ini akhirnya sering mengharuskan hukum untuk bertindak.

Sebagai contoh, standar M’Naugten untuk pembelaan insanity yang digunakan di banyak pengadilan sering tidak mengklarifikasi pemahaman atau apresiasi terhadap kejahatan dari perbuatannya, apakah itu kejahatan hukum atau kejahatan moral. Misal kasus Andrea Yates, dia paham bahwa aksinya adalah kejahatan hukum, tetapi delusinya tidak bisa dikatakan sebagai kejahatan moral. Tingkat keparahan depresi post partumnya, ditambah dengan psikosis menyebabkan delusi bahwa ia menyelamatkan anak-anaknya dari kutukan kekal, namun dalam kasusnya pembelaan bahwa dia adalah seorang insanity tidak berhasil.

Pembelaan insanity

Insanity bisa digunakan untuk bebas dari tindak perilaku criminal di mata hukum. Perilaku kriminal individu tidak hanya mental illness, tetapi mental illness-nya itu secara langsung menyebabkan disfungsi yang relevan ketika kejahatan dilakukan. Ketika itu pertanyaan psikolegal: diagnosis spesifik bukan menjadi isu sentral, namun dampak pada kapasitas fungsional atau kemampuan seseorang untuk mengetahui perbedaan antara benar dan salah adalah yg terpenting dalam hukum, dengan demikian dampak fungsional dari penyakit mental menjadi isu yang utama. Namun secara historis orang-orang yang sukses melakukan pembelaan 60-90 persen adalah mereka yang sudah psikotik.

Definisi yang ditawarkan APA dianggap merupakan kondisi yang terlalu abnormal. Dengan demikian definisi dari Negara satu dengan Negara lain berbeda.

Foucha v. Louisiana

Mahkamah Agung menjelaskan tentang arti penyakit mental di kasus Foucha dan Lousiana. Pengadilan menyatakan, bukan tindakan konstitusi ketika menahan individu yang memiliki sakit mental atau gangguan kepribadian antisosial. Masalah utamanya adalah apakah konstitusi akan menahan individu yang telah dibebaskan tapi sudah sembuh dari penyakitnya? Jawab pengadilan “tidak”. Untuk tujuan secara paksa seseorang harus berpenyakit mental (mental illness) dan berbahaya. Implikasinya bahwa gangguan kepribadian antisosial bukan merupakan penyakit mental yang memenuhi syarat untuk tujuan kurungan. Tetapi di mata pengadilan temuan ini tidak dibenarkan, dan ini masih menjadi perdebatan.

Psikologi Forensik dan Implikasi Kebijakan

Kegagalan pengadilan dalam menyelesaikan kasus mental illness meninggalkan sejumlah masalah analisis dan praktis di kalangan psikolog forensik. Sistem hukum menemukan cara yang tepat dengan memberikan kasus ini pada tim kesehatan mental untuk membedakan “sakit jiwa” dan “tidak sakit jiwa”. Sayangnya pengadilan terlalu menggantungkan pada ahli-ahli tersebut, sehingga orang-orang seperti Gina mungkin dipaksa untuk dirawat di satu kelompok treatment dan tidak dengan kelompok yang lain. Ada resiko orang-orang yang tidak sakit mental tanpa sengaja dirumah sakitkan.

Implikasi psikologi forensik untuk individu seperti Gina (berpotensi untuk diinterfensi secara hukum). Sementara kebebasan individu dalam menentukan nasib sendiri harus diakui, psikolog forensik harus memperhatikan masalah yang lebih umum, seperti keselamatan publik dan kesehatan.

Hak Untuk Menolak

Hak kebebasan merupakan hak yang paling berharga, individu harus memutuskan apa yg terjadi pada tubuh dan pikirannya. Orang yang sakit bisa memilih untuk menerima atau tidak menerima pengobatan medis. Namun pada kenyataannya kebebasan tidak dinikmati oleh individu dengan gangguan mental. Pada situasi tertentu, individu menjadi subjek treatment psikologis yang tidak diinginkannya, hal ini menjadi kontroversi “hak untuk menolak pengobatan”.

Dalam kasus komitmen Re commitment of denis H, pengadilan Wisconsin menegakkan lima standard untuk komitmen sipil berdasarkan ketidakmampuan membuat pilihan dalam pengobatan dan treatment. individu diberi kebebasan karena tidak mampu memutuskan (tidak mampu membuat pilihan obat dan treatment yg diperlukannya) :akibat kasus ini, maka hukum ‘tidak mampu membuat keputusan’ diperluas.

Kasus Alysa: 34 tahun, menderita gangguan pikiran, Alysa menderita halusinasi dan delusi, akhir-akhir ini memburuk. Dia tidak menunjukkan bahaya bagi diri sendiri maupun orang lain, gaya hidup cukup aman dan bukan merupakan calon orang yg akan dipaksa dalam pengobatan. Di Psikiater dia disarankan untuk melakukan pengobatan dengan antipsikotik: Thorazine. Alisa menolak karena dia tahu efek sampingnya yang mungkin permanen, dan ingin mencoba mencari alternative lain. Nah psikiater ini bertanya, bagaimana bisa seorang ‘sakit’ memutuskan? Dan apakah si psikiater memiliki hak untuk memperlakukan demikian? Bagaimana?

Literature review

Hak untuk menolak pengobatan adalah isu paling controversial di dunia psikiatri.

Alternatif membatasi dan Hak menolak pengobatan

Doktrin LRA (Least Restrictive Alternatif) menempatkan individu pada dikondisi yang sedikit membatasi ketika mereka diharuskan berada pada kondisi intervensi. Tujuannya adalah untuk memperlakukan individu dengan cara yang meminimalisir kebosanan pada kebebasan individu.

Kemudian Beberapa peneliti memberikan saran: alternative paling membatasi juga harus di tafsirkan, dengan memperhitungkan pertimbangan dari pasien, dokter dan hukum. Disini ahli kesehatan itu didorong untuk melibatkan pasien dalam proses pengobatan. Namun tetap saja peneliti-peneliti ini menemukan bahwa beberapa dokter itu ingin “berkuasa” dan pasien “ragu-ragu berbagi preferensi”. Meskipun dalam system pengobatan manapun sebenarnya pasien berhak menolak pengobatan ketika dia memang tidak ingin.

Doktrin Informed consent

Mengharuskan pasien mendapat informasi yang cukup tentang pengobatan yg akan dijalaninya umumnya yg akhirnya membuat pasien mampu memutuskan. Informasi dapat berupa efek samping, risiko, manfaat, potensi sembuh tanpa obat, pengobatan lain yang mungkin tersedia.

Peraturan ini berlaku untuk orang dewasa umum dan sakit jiwa. Hak ini hilang ketika secara legislasi ternyata dia tidak mampu (incompeten).

Kompetensi

Berdasar pada informasi yang diberikan maka titik beratnya bukan pada keputusan akhir tetapi pada bagaimana individu menyimpulkan. Maka dilihat dari kasus alisa tadi dia boleh menolak, karena dia bisa menyimpulkan. Keputusan dibuat sesuai dengan konteksnya, individu mampu atau tidak.

Dalam keputusan Harper V Harper: hak menolak itu tidak dipertimbangkan, karena jika orang tersebut dinilai berbahaya bagi diri sendiri dan orang lain maka demi kepentingan umum hak untuk menolak itu tidak diberikan.

Psikologi Forensic Dan Implikasi Kebijakan

Praktek dan teori memang berbeda pada kenyatannya. Dalam prakteknya pasien itu berhak menolak pengobatan ketika ada psikiater , keputusan itu kemudian ditinjau kembali oleh dokter, jadi sebenarnya kebebasan individu tetap ditangan dokter.

Tapi dokter itu menghadapi dilemma yaitu menyeimbangkan perawatan pasien dan kebebasan sipil, terkadang pasien ternyata tidak mampu untuk membuat keputusan, ex: kasus sizophren yang mati kepanasan di Texas saat musim panas, dimana jika dia dirawat maka mungkin dia memiliki nasib yang berbeda.

Sebagai seorang psikolog forensic itu harus mempertimbangkan efek negative dan efek positif dengan tujuan untuk melindungi kebebasan individu dari pengobatan yang tidak diperlukan

Doktrin LRA (Least Restrictive Alternatif)

Doktrin LRA meminta agar pasien ditempatkan di kondisi yang tidak begitu membatasi pada keadaan treatment. Kondisi ini melibatkan pasien yang membahayakan diri sendiri maupaun orang lain, kemudian pasien yang dimasukkan secara paksa harus dipertimbangkan sejauh mana pembatasannya. Tujuannya adalah melindungi kebebasan individu dari treatment yang berbahaya atau tidak berguna.

Pemberian pembatasan dan treatmen menjadi hal yang perlu diperhatikan. Pertama, konsep pembatasan (mental illness dan tingkat bahaya) harus didefinisikan dengan jelas. Konsep pembatasan sepeerti apa? Apakah pengaturan dan perencanaan pengobatan itu bukan merupakan bentuk pembatasan?

John, pustakawan 42 tahun, riwayat penyakit mental dan hidup sendiri. Rentan terhadap serangan mental tetapi fungsiny bagus dalam akhir2 minggu ini. John, beberapa minggu ini fungsinya terganggu dan tidak bisa merawat diri. Dia membutuhkan perawatan. Dia dirujukkan oleh teman2nya. Setelah diperiksa oleh beberapa professional. John diputuskan untuk mengikuti program pengobatan.

Pertanyaannya adalah apakah ini jalan terbaik? Mengingat John tidak berbahaya? Apakah rumah sakit memang benar kebutuhan yang diperlukan John?

Literature review

Kasus pertama yg menerapkan LRA: seorang nenek yang tidak mau berkomitmen melakukan treatmen, meskipun dia bingung untuk dan rentan mengembara tetapi dia tidak cukup berbahaya sampai memerlukan ‘penguncian’ di psikiatri. Meskipun perawatan itu diperlukan tetapi pengurungan paksa rumah sakit jelas tidak perlu.

“perampasan kebebasan semata-mata karena bahaya untuk orang sakit
sendiri tidak harus melampaui apa yang diperlukan untuk perlindungan mereka” . perlu dipertimbangkan mana yang benar-benar butuh dirawat inap dan yang bisa mandiri.

Hal yang perlu diperhatikan diantaranya: lokasi, program, pengobatan yang diberikan, campuran pasien, otonomi yang diberikan pada pasien, lama tinggal dkk. LRA bukanlah pemahaman yang tanpa debat dari pihak lain. Permasalahan LRA hampir sama rumitnya dengan pendefinisian mental illness. Batasan-batasan yang dimaksud dalam LRA harus didefinisikan dengan jelas.

Doktrin LRA meminta adanya keefektifan intervensi yang diberikan pada pasien yang melibatkan bidang kesehatan. Dengan demikian akan memberikan keefektifan analisis kebijakan dan implementasi dimana inisiasi baru membutuhkan wawasan psikologis. Psikologi forensic bisa jadi menjadi pemecahan untuk mengatasi baik masalah kesehatan mental maupun hukum dalam satu kerangka sudut pandang.

Evaluasi Disabilitas Kerja Psikiatrik (Psychiatric Work-Related Disability)

Pada saat seorang individu mengalami gangguan mental, simptom-simptom yang muncul pada dirinya memberikan efek yang melemahkan. Yang dimaksud dengan melemahkan adalah menurunnya kemampuan individu baik dalam hal kognitif, sosial, maupun pekerjaan. Onset gangguan mental menghambat individu untuk belajar ketrampilan vokasional. Sementara gangguan mental yang kronis dapat berdampak negatif pada kemampuan kognitif dan sosial, emosi, dan perilaku dalam sejumlah hal sehingga individu yang mengalaminya tidak memiliki cukup dukungan dari dalam dirinya untuk bekerja.

Salah satu peran psikolog forensik dalam isu ini adalah memberikan penilaian mengenai disabilitas berdasarkan gangguan mental. Gangguan mental yang berat dan persisten merupakan dasar yang paling banyak digunakan untuk memberikan klaim disabilitas. Lebih jauh lagi, psikolog forensik diminta mengevaluasi apakah simptom-simptom yang dimiliki seseorang menghambatnya untuk bekerja atau tidak. Di Amerika sendiri, terdapat suatu Undang-Undang (American with Disability Act) yang mengatur mengenai Disabilitas. Salah satu isinya menyebutkan tidak diperbolehkannya diskriminasi terhadap individu dengan disabilitas fisik maupun mental dalam hal pekerjaan sehingga yang dapat membatasi secara substansial aktivitas utama dalam hidup individu tersebut.

Sebuah studi yang meneliti mengenai pengalaman kerja dari 20 orang dewasa dengan oset awal skizofrenia yang dirujuk ke California Department of Vocational Rehabilitation (DVR) menunjukkan sebagian dapat mempertahankan pekerjaan dan sebagian lagi tidak. Sayangnya, kondisi di lapangan menunjukkan jarangnya pihak pemberi kerja yang mau mengakomodasi pekerja dengan gangguan mental. Hal ini mempersulit proses rehabilitasi dan pemberian hak sipil kepada individu dengan gangguan mental.

Review Literatur

Tingkat pengangguran nasional (Amerika) individu dengan gangguan mental mencapai 80-90%. Sejumlah studi empiris menunjukkan bahwa stigma dan kepercayaan bahwa orang dengan gangguan mental selalau ber berbahaya, tidak dapat diandalkan, tidak dapat diprediksikan, dan irasional merupakan salah satu faktor yang menyebabkan terjadinya kondisi ini. Pemberi kerja umumnya skeptis dalam mengangkat individu dengan gangguan mental sebagai pegawai dibandingkan dengan individu dengan disabilitas lainnya. Melihat kondisi ini, sejak tahun 1935 Social Security Administration (SSA) melalui Undang-Undang Social Security Act  di Amerika, disediakan dana pendapatan bagi pensiunan, individu dengan disabilitas, dan keluarga dari pekerja yang meninggal.

Program disabilitas SSA berupa Social Security Disability Insurance (SSDI) dan Supplemental Security Income (SSI) diberikan kepada warga yang memenuhi kriteria disabilitas. Sementara dana dari kedua asuransi atau pendapatan tersebut diperoleh dari potongan gaji selama bekerja sebelumnya atau pajak. Kebijakan ini berdampak lanjutan mengenai banyaknya klaim yang diajukan kepada pemerintah. Pemerintah pun harus melakukan evaluasi apakah individu yang bersangkutan memang benar-benar layak memperoleh bantuan tersebut.

Salah satu kriteria yang harus dipenuhi berdasarkan SSA adalah adanya ketidakmampuan untuk melakukan kerja sederhana dan repetitif. Kriteria lain adalah adanya gangguan pada fungsi-fungsi esensial yang diperlukan dalam bekerja, seperti konsentrasi dan atensi. Sumber data penilaian dapat diperoleh melalui observasi, wawancara, dan tes psikologi. Dan yang perlu dipahami mengenai program ini adalah bahwa, kemampuan yang dimiliki individu tersebut tidak harus sama dengan kemampuannya sebelum mengalami gangguan mental. Sebagai contoh, ketika individu yang sebelumnya bekerja sebagai manajer mengalami gangguan mental dan kini hanya mampu melakukan tugas sederhama seperti membungkus barang, maka dana bantuan gugur untuk diberkan. Hal ini dikarenakan individu masih dapat bekerja pada pekerjaan sederhana.

Selanjutnya mulai tanggal 1 Januari 2001, aturan yang ada ditambah dengan mempertimbangkan pendapatan individu per bulan. Individu yang masih memiliki pendapatan di atas 740$ tidak dapat mengakses dana bantuan SSI. Terkait gangguan mental seperti apa yang dapat dimintakan klain asuransi/ dana bantuan, SSA telah menyusun daftar gangguan mental berdasarkan DSM-IV yang berfungsi memprediksi disabilitas yang dimiliki. Ketika ganggaun mental yang dialami tidak terdapat dalam daftar tersebut, maka individu terpaksa harus ditolak klaimnya. Seluruh proses evaluasi terhadap disabilitas dalam makna hukum ini dilakukan oleh disability reviewer.

Psikologi Forensik dan Implikasi Kebijakan

Meski telah cukup memiliki panduan dalam kebijakan yang ada, pada penerapannya ternyata masih banyak yang belum seideal yang diharapkan. Sebagai contoh, dari keseluruhan individu yang diajukan untuk memperoleh dana pemerintah sebagai kompensasi dari gangguan mental yang dimiliki, hanya 33% yang diterima. Selanjutnya pada review pengajuan yang kedua, sekitar 15% diterima, sisanya baru diterima setelah proses ketiga atau setelah diuji di hadapan persidangan.

Kondisi ini ketika dievaluasi ternyata disebabkan oleh kurang sesuainya laporan pemeriksaan psikologis yang dilampirkan dengan standar kualifikasi pemberian dana bagi individu dengan gangguan mental. Gambaran yang diberikan kurang mampu menjelaskan hambatan atau inkompetensi individu yang bersangkutan untuk bekerja.

Persoalan lain yang terjadi di lapangan adalah terkait supervisi kerja bagi individu dengan gangguan mental. Individu dengan gangguan mental yang telah melalui proses terapi dan dimungkinkan dapat kembali bekerja perlu mendapatkan program pelatihan atau asistensi kerja. Hal tersebut dikarenakan pekerjaan yang dapat dilakukan bisa jadi berbeda dengan apa yang telah dikuasai sebelum sakit. Sehingga diperlukan pendampingan dan pelatihan terlebih dahulu agar individu tersebut dapat menyesuaikan diri dengan baik dengan pekerjaan barunya.

Saran Penelitian Selajutnya

Sejumlah saran untuk penelitian selanjutnya yang perlu dilakukan agar dapat mengoptimalkan implementasi civil forensic dalam lingkungan kerja antara lain:

1.      Perlunya pengembangan metode maupun alat asesmen yang reliabel untuk tingkat keberfungsian kerja individu oleh para ahli kesehatan mental. Semakin objektif metode dan alat ukur yang dikembangkan akan semakin baik karena sesuai dengan tuntutan aturan legal yang berlaku.

2.      Perlunya penelitian yang mengevaluasi interagreement antar reviewer yang mengevaluasi layak tidaknya seorang individu menerima dana dari pemerintah.

3.      Perlunya penelitian yang mengeksplorasi tingkat efikasi dari bermacam strategi yang sukses mempekerjakan individu dengan gangguan mental.

Kewajiban untuk Memberi Informasi VS Konfidensialitas Klien

Kewajiban untuk memberikan informasi dan konfidensialitas klien merupaka satu isu yang juga kontroversial. Kontroversi muncul terutama terkait dengan kewajiban psikolog/psikiater secara etik dan legal untuk menjaga kerahasiaan informasi yang diberikan oleh klien dan kewajiban untuk memperingatkan pihak yang terancam bahaya oleh tindakan yang mungkin dilakukan klien. Meski prinsip konfidensialitas klien berakar dari psikologi, aturan hukum yang ada memicu pertanyaan kritis, yaitu “Kapan sesungguhnya konfidensialitas klien dapat dilanggar?”

Di Amerika sendiri isu ini mulai diperbincangkan sejak tahun 1976 dengan adanya keputusan pengadilan tinggi negara bagian California terkait kasus Trasoff vs Regents of the University of California.  Pada kasus tersebut, keluarga Tarasoff menuntut psikolog yang bertanggungjawab pada pembunuh Tarasoff karena tidak memberikan peringatan agar berhati-hati dikarenakan kliennya memiliki rencana untuk menyakitinya. Berdasarkan hasil pengadilan tersebut, disebutkan bahwa seorang psikolog harus mempertimbangkan sejumlah isu, yaitu: konfidensialitas, informed consent, kode etik, ada tidaknya korban yang teridentifikasi, tingkat berbahaya, dan ancaman yang telah dikomunikasikan.

Pasca keputusan tersebut, muncul isu kontemporer yang masih mengundang kontroversi, yaitu kewajiban memberikan informasi mengenai klien yang terinfeksi HIV AIDS.  Kerentanan penularan virus tersebut telah jelas diketahui dan tingkat keberbahayaaan virus tersebut juga telah dipahami. Ketika klien meminta psikolog untuk merahasiakan kondisi tersebut kepada orang-orang di sekitar klien yang rentan tertular, lantas apakah konfidensialitas harus dilanggar? Pada isu ini, masih belum diperoleh kesamaan pendapat.

Review Literatur

Prinsip etik APA menyebutkan bahwa seorang psikolog profesional harus menjaga konfidensialitas kliennya. Konfidensialitas ini dimaksudkan agar klien dapat merasa lebih bebas dalam mengungkapkan pikiran maupun perasaanya. Di samping itu, konfidensialitas juga dimaksudkan untuk meminimalkan stigmatisasi. Oleh karena itu, prinsip etik konfidensialitas sebenarnya sangat erat kaitannya dan berperan dalam proses hubungan psikolog dan klien yang efektif.

Konfidensialitas sebagian besar berkaitan dengan informasi yang disampaikan oleh klien selama proses konseling atau terapi. Pengungkapan informasi tersebut kepada orang lain hanya diijinkan atas persetujuan klien atau persetujuan dari representasi legal klien. Oleh karena hal ini sangat menentukan kepercayaan yang sulit terbangun di awal relasi, maka pelanggaran konfidensialitas berkorelasi dengan terminasi dini dan kegagalan proses terapi atau konseling.

Meski demikian, sekarang ini telah muncul banyak isu yang meningkatkan resiko pelanggaran konfidensialitas tersebut, seperti isu yang berkaitan dengan hukum maupun keputusan profesional. Dengan demikian, konfidensialitas klien kini memiliki keterbatasan dan klien seyogyanya paham mengenai keterbatasan tersebut. Isu ini mungkin lebih nyata ketika terdapat korban potensial (resiko munculnya korban) yang terlibat.

Kewajiban untuk memperingatkan yang kini lebih banyak dibincang memiliki akar historis dari kasus yang ditangani oleh Pengadilan Tinggi California, yaitu Tarasoff v. Regents of the University of California. Pada kasus tersebut, seorang klien bernama Poddar menyatakan kepada psikolognya, Dr. Moore, dalam proses konsultasi psikologi bahwa dia memiliki niat untuk membunuh seorang perempuan setelah dia pulang dari liburan. Dr. Moore merespon ancaman tersebut secara serius dan segera berkonsultasi dengan supervisornya dan polisi kampus. Pada kasus ini, Poddar tidak memenuhi kriteria involuntary civil commitment sehingga tidak dimasukkan ke dalam rumah sakit. Polisi kampuspun menangkap Poddar, akan tetapi setelah itu melepaskannya setelah diputuskan Poddar tidak memiliki rencana maupun usaha untuk melukai. Dua bulan setelahnya, saat Tatiana Tarasoff pulang dari berlibur, Poddar membunuhnya. Orang tua Tarasoff pun mengajukan tuntutan hukum terhadap Dr. Moore, polisi kampus, supervisornya, polisi kampus, dan pemerintah daerah atas tidak dilakukannya peringatan tentang bahaya Poddar yang ada di bawah tanggung jawab mereka.

Sebagai respon terhadap tuntutan tersebut, pihak tersangka membela diri bahwa memperingatkan Tarasoff merupakan bentuk pelanggaran kode etik yang tidak dapat mereka lakukan karena melanggar konfidensialitas klien. Pengadilan tinggi pun merespon pembelaan diri tersebut dengan menyatakan bahwa ketika terapis menilai bahwa pasien memiliki resiko untuk membahayakan orang lain secara serius, maka terapis wajib memperingatkan pihak yang beresiko mendapatkan bahaya tersebut mengenai bahaya yang mungkin dihadapinya. Sejak keputusan yang dihasilkan dalam kasus ini, kewajiban terapis untuk memperingatkan pihak ketigapun menjadi semakin luas, meski masih belum benar-benar jelas.

Psikologi Forensik dan Implikasi Kebijakan

Kasus Tarasoff telah memunculkan keputusan kewajiban memperingatkan pihak ketiga bagi psikolog yang kliennya memiliki intensi membahayakan orang lain. Pihak ketiga ini pada perkembangannya dapat dimaknai secara beragam sehingga aturan ini masih meninggalkan ketidakjelasan.

Keputusan mengenai kewajiban untuk memperingatkan ini selanjunya mengarahkan kepada topik evaluasi kondisi psikologis klien dan prediksi perilaku pasien. Kedua hal tersebutlah yang dijadikan landasan tuntutan kepada psikolog ketika gagal memperingatkan pihak ketiga. Yaitu bahwa psikolog seharusnya telah mengetahui resiko munculnya tindakan membahayakan orang lain oleh klien.

Lebih jauh ketika membincang mengenai prediksi perilaku membahayakan orang lain, maka hasil penelitian menunjukkan bahwa  hanya sekitar 33-40% psikolog yang mampu memprediksi secara akurat bahwa kliennya akan membahayakan orang lain. Hal ini memicu kritik, jika penggunaan koin (melempar koin) untuk memprediksi apakah seorang klien dengan gangguan psikologis akan membahayakan orang lain saja lebih baik dari penilaian psikolog, lantas bagaimana seorang psikolog dapat dimintai pertanggungjawaban atas hal tersebut? Seorang psikolog tentu tidak seharusnya dimintai pertanggungjawaban atas sesuatu di luar kompetensinya. Lagi-lagi, ketentuan yang ada di dalam aturan hukum masih menyisakan ketidakjelasan.

Beralih ke isu HIV AIDS, kapankah dan kepada siapakah seorang psikolog harus menginformasikan resiko atau bahaya yang mungkin dimunculkan klien terhadap orang lain atau pihak ketiga? Masih terdapat perbedaan pendapat mengenai hal ini. Sebagian berpendapat bahwa sumber bahaya HIV AIDS adalah virus atau penyakit itu sendiri. Sebagian lain berpendapat bahwa sumber bahaya HIV AIDS adalah perilaku seksual klien. Kedua pendapat ini membawa pada implikasi praktis yang berbeda. Pada pendapat pertama, psikolog akan berkewajiban memperingatkan pasangan klien ketika klien menyampaikan bahwa dirinya terinfeksi HIV AIDS. Sementara pada pendapat kedua, kewajiban tersebut baru muncul ketika diketahui klien memiliki perilaku seksual yang dapat menularkan virus HIV AIDS kepada pasangannya.

Meksi terdapat perbedaan pendapat, pada hakikatnya psikolog yang menangani klien dengan isu HIV AIDS perlu memastikan tingkat keberbahayaan perilaku klien terhadap orang lain, sama seperti kasus lainnya. Penilaian tingkat keberbahayaan tersebut dapat dilakukan melalui penggalian perilaku seksual klien. Akan tetapi, memang masih terdapat kesulitan untuk melakukan kewajiban memberikan peringatan ketika psikolog tidak dapat memastikan secara jelas pasangan seks klien. Di samping itu, kesulitan juga muncul karena penyakit ini seringkali baru terdeteksi setelah sekian waktu pasca infeksi virus. Dengan demikian, sebelum diagnosis dari dokter jelas, psikolog juga belum dapat mengetahui apakah kondisi atau perilaku klien berbahaya bagi orang lain atau tidak.

Victim-Offender Mediation

Program victim-offender mediation (VOM) telah ada di dalam hampir 100 yurisdiksi di seluruh Amerika Serikat (Umbreit, 1993). VOM juga telah meningkat penerapannya di Eropa pada lebih dari 1000 komunitas. VOM memberikan manfaat bagi korban untuk turut berperan serta dalam menentukan hukuman bagi tersangka, menunjukkan dan menyampaikan dampak tindakan tersangka terhadap dirinya, serta menunjukkan kondisi korban secara langsung dan dekat pasca kekerasan atau tindak kriminal. Sementara bagi tersangka atau penyerang, VOM memberikan ruan gbaginya untuk menjelaskan problem personalnya, sudut pandangnya yang dipengaruhi oleh simptom gangguan mental sebagai alasan perilaku atau tindak kriminal yang dilakukan. Dengan pengertian kondisi psikologis tersangka oleh korban, VOM memberikan peluang adanya keringanan hukuman bagi tersangka sekaligus proses hukum yang lebih memanusiakan. Tujuan dari proses mediasi adalah untuk mencapai resolusi konflik secara adil bagi kedua belah pihak dan menghasilkan rencana restitusi yang dapat diterima.

Terlepas dari berbagai varian progam VOM, semua program memiliki prinsip dasar yang sama yang berasal dari prinsip restorative justice. Restorative justice merupakan konsep lama yang menekankan bahwa suatu tindakan kriminal adalah tindakan yang melawan individu di dalam suatu masyarakat, dan bukan sekedar tindakan melawan negara. Prinsip ini selanjutnya membawa konsekuensi dalam penerapan proses hukum yang melibatkan peran masyarakat.

Review Literatur

Bentuk VOM yang berlangsung selama ini sangat beragam. Ragam atau variasi tersebut dapat dilihat dari berbagai aspek, sebagai contoh aspek waktu pelaksanaan. Terdapat VOM yang dilaksanakan setelah kasus masuk pengadilan dan sebelum penjatuhan hukuman. Di sisi lain ada pula VOM yang dilaksanakan dengan tujuan mengupayakan pembebasan bersyarat dengan mengganti kerugian sesuai kesepakatan, yang cenderung dilaksanakan di awal kasus terjadi. Aspek lain yang menentukan variasi adalah tatap muka. Terdapat VOM yang dilakukan secara tatap muka langsung dan ada pula yang tidak. Sementara, secara umum VOM banyak dilakukan oleh lembaga keagamaan, meski lembaga swasta juga ada yang melakukannya.  Di dalam VOM, individu yang berperan sebagai mediator biasanya adalah individu yang telah dilatih sebelumnya atau dapat pula dengan menggunakan pekerja sosial profesional.

Bentuk VOM yang paling populer digunakan adalah Victim/Offender Reconciliation Program (VORP). Model ini dikembangkan pada tahun 1974 di Ontario, Canada dan diterapkan pertama kali di Amerika, tepatnya wilayah Indiana pada tahun 1978. Model ini menggunakan mediasi tatap muka pasca dijathkannya putusan hakim.

Penelitian terhadap dua kasus pembunuhan yang menerapkan mediasi model rekonsiliasi ini menunjukkan efek kelegaan dan penyembuhan yang muncul melalui proses rekonsiliasi. Meski demikian, terdapat kritik yang menyatakan bahwa model ini kurang sesuai dengan prinsip restorative justice, di mana seharusnya:

1.      Harus ada keinginan dan kemampuan untuk mengubah sikap dan pemahaman sebagai hasil dari komunikasi.

2.      Restorative justice menekankan ganti rugi dari pihak pelaku kriminal di mana pelaku tersebut secara aktif menunjukkan upaya pertobatan sebagai akibat dari apa yang telah dilakukannya.

3.      Restorative justice berusaha mengurangi peran pemerintah di dalam proses penyelesaian kasus kriminal di dalam masyarakat dengan memberikan ruang dan peran yang lebih besar kepada masyarakat untuk menyelesaikannya secara damai.

Banyaknya varian VOM mengharuskan munculnya pemahaman adanya perbedaan konsekuensi wujud efektivitas program yang tercapai. Dengan demikian, sulit untuk melakukan penelitian dan menyimpulkan efektivitas program VOM secara umum dan menyeluruh. Meski demikian, penelitian mengenai efektivitas VOM secara spesifik pada tiap-tiap model yang berbeda telah dilakukan.

Efektivitas VOM diukur melalui banyaknya kasus yang terselesaikan, penurunan hukuman bagi residivis, dan tingkat kepuasan korban. Sejumlah penelitian menunjukkan efektivitas yang tinggi pada pelaksanaan VOM, terutama ditunjukkan dengan tingkat kepuasan korban. Akan tetapi, terdapat pula  penelitian yang menunjukkan adanya kegagalan dalam proses VOM dikarenakan faktor keuangan. Perdebatan mengenai perlu tidaknya dilakukan VOM juga muncul dalam berbagai kajian. Terdapat pendapat bahwa pada kasus- kasus tertentu seperti pelecehan seksual, kekerasan dalam rumah tangga,  dan kasus psikopat, sebaiknya tidak dilakukan VOM dengan pertimbangan latar belakang kasus atau keamanan korban dan keluarganya.

Psikologi Forensik dan Implikasi Kebijakan

VOM selama ini memang telah banyak dilakukan. Sayangnya, penerapan VOM tersebut dilakukan oleh banyak lembaga sehingga sulit untuk menyusun kriteria yang terstandar sehingga diperoleh panduan pelaksanaan dan evaluasi VOM yang efektif. Di samping itu, dlama pelaksanaannya banyak mediator yang kurang memiliki pengetahuan di bidang psikologi maupun sosiologi sehingga kapasitas untuk memediasi menjadi kurang optimal. Kondisi ini mengundang kebutuhan untuk menggunakan tenaga profesional sebagai mediator atau dilakukannya pelatihan khusus sebelum seseorang layak menjadi mediator. Penelitian lanjutan diperlukan untuk mengkaji manfaat dan efektivitas keseluruhan program VOM sehingga dapat disusun panduan sesuai yang dibutuhkan.

Terkait kebijakan, idealnya VOM memang terintegrasi di dalam kebijakan hukum suatu daerah. Tentunya dengan panduan yang jelas mengenai penerapannya. Sebagai contoh, kesepakatan sebagian besar peneliti bahwa kasus kekerasan dalam rumah tangga sebaiknya tidak diberlakukan VOM juga perlu dipertimbangkan. Dengan demikian panduan yang ada membantu lembaga yang akan melakukan VOM untuk memilah kasus mana yang dapat diterapkan mediasi dan mana yang tidak. Semakin padatnya penjara juga membuat pengadilan cenderung mendukung program restitusi atau ganti rugi. Hal ini selanjutnya harus diinformasikan kepada masyarakat terkait pertimbangan-pertimbangan yang diterapkan dalam menjatuhkan hukuman dan alternatif dari hukuman penjara.

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