Existential Psychotherapy to Improve the Meaningfulness of Life in Advanced Stage of Cervical Cancer Patients: A Case Study

in patients with cervical cancer. This existential crisis can affect various aspects of the meaningfulness of life for patients. Cancer patients feel they are unable to do anything because of decreased function, feel lonely, and develop a bad self-image so that they are socially isolated. Patients feel that they have no hope for their future and feel hopeless. This makes its existential meaning blurry so that it loses hope and desire and is unable to set goals in life [3]. One treatment that can be applied to overcome the problem of existence in cervical cancer patients is psychotherapy. Psychotherapy aims to change awareness, provide insight into potential development and increase self-knowledge so


I. INTRODUCTION
Data from the Centers for Disease Control and Prevention (CDC) reported cancer as the second cause of death in the United States.In the United States, there were 1,735,350 new cancer cases in 2018 with a total of 609,640 deaths.It is estimated that the incidence of new cancer is 4,750 cases and there are 1,670 deaths from cancer every day.In 2013 in Indonesia, the prevalence of cancer is estimated at 347,792 people.The Ministry of Health of the Republic of Indonesia in the guidebook for the implementation of world cancer day 2022 reported that cervical cancer ranks second most with 36,633 cases or 9.2% of the total cancer cases in Indonesia.The first sequence is breast cancer [1].
Cervical cancer is commonly found in women in Latin America, Africa, and other developing countries in Asia, including Indonesia.The crude incidence of cervical cancer in Indonesia is 27 per 100,000 women.With a cumulative risk of 0-74 years of age of 2.7%, and a mortality ratio of 0.57.The WHO report obtained data on the incidence of cervical cancer by age per 100,000 women in Indonesia of 24.4.Hospital-based data in Indonesia reports 40 thousand new cases of cervical cancer each year.Based on pathology-based cancer data at 13 pathology laboratory centers, cervical cancer that has the highest number of sufferers in Indonesia, which is approximately 36%.These data may be related to several other facts, such as less than 1 in 10 girls in the main target cohort in 2020 have received a dose of HPV vaccination, less than 1 in 10 women have been screened for cervical cancer in the last 5 years [2].
Patients with cervical cancer have a high risk of experiencing mental health problems such as depression and anxiety disorders, lower quality of life, and increased need for spiritual care from professional service providers health.This has an impact on increasing existential issues which include emotional, psychological, and spiritual areas in patients with cervical cancer.This existential crisis can affect various aspects of the meaningfulness of life for patients.Cancer patients feel they are unable to do anything because of decreased function, feel lonely, and develop a bad self-image so that they are socially isolated.Patients feel that they have no hope for their future and feel hopeless.This makes its existential meaning blurry so that it loses hope and desire and is unable to set goals in life [3].
One treatment that can be applied to overcome the problem of existence in cervical cancer patients is psychotherapy.Psychotherapy aims to change awareness, provide insight into potential development and increase self-knowledge so that individuals get motivated to do the right things.Existential psychotherapy is expected to help patients find the meaning of their lives.Therefore, this study aims to determine whether existential psychotherapy can improve the meaning of life of cervical cancer patients.

II. RESEARCH METHODS
The research method used in this study is a qualitative method with a phenomenological approach to cervical cancer cases.Qualitative research is used to be able to uncover social problems, so it requires in-depth exploration.The Case study is research where the researcher carefully investigates a program, event, activity, and process of the research subject.Researchers collect complete information by using in-depth data collection tools.

A. Research Subject
The research subjects were 2 patients with advanced cervical cancer who were being treated or treated.The first subject in this study with the initials MS.A 49-year-old woman, last elementary school education.The subject works as a housewife and helps her husband's business.The subject was diagnosed with cervical cancer 1.5 years ago and is currently undergoing routine hemodialysis at Prof. dr.I.G.N.G Ngoerah 2 times a week with a duration of 4.5 hours.The second subject had the initials NPWCD, a 30-year-old female, last high school education.The subject works as a private employee but after being diagnosed with cancer, the patient stops working and becomes a housewife.The subject was diagnosed with cervical cancer 1.5 years ago and is currently undergoing routine hemodialysis at Prof. dr.I.G.N.G Ngoerah 2 times a week with a duration of 5 hours.

B. Method of Collecting Data
Methods of data collection using observation and semistructured interviews to dig up in-depth information about the psychological condition of the subject, especially exploring the psychological condition of the subject.Information relevant to issues relevant to the subject's existential problems by using the questionnaire The Meaning in Life Questionnaire and Purpose in Life Test [4].

C. Reliability
The method used to test the reliability of this study is the triangulation method, by checking data from various sources in various ways and at various times.This is done by conducting interviews (allo-anamnesa) with significant other subjects.Significant others who became a source of triangulation were the subject's husband and children while undergoing hemodialysis at Prof. dr.I.G.N.G Ngoerah.In addition, the subject's data and medical records when he was a patient at Prof. Hospital.Dr. I.G.N.G Ngoerah was also included as a source of checking.

III. RESULTS AND DISCUSSION
The extensional view places the importance of the concept of human value itself above itself.This self-concept is considered very important in determining one's existence.One of those who elaborated on the existential view used was the existential view put forward by Rollo May.The existential view emphasizes that humans can determine and show their existence.An existence that can make humans more meaningful is shown by essential aspects or positive things from the humans themselves.Existential psychotherapy approach model helps clients find the meaning of their lives.Individuals are encouraged to approach their potential to live authentically.Thus, a feeling of acknowledging and accepting oneself positively will grow.This allows individuals to interpret their lives well [5].
Based on the results of the study, it was found that both subjects experienced several existential issues.The subject knows that cervical cancer is difficult to cure so the subject feels afraid, and anxious and feels that her life has no future anymore.Existential concerns experienced by the two research subjects include the inevitable death, feelings of social isolation, loss of meaning in life, and loss of freedom and dignity.The meaninglessness of the subject occurs because the subject cannot find a purpose in life in this cervical cancer disease and is unable to create values that can give meaning to life.
The subject feels that there is still stigmatization due to her cancer which can worsen her self-image.The use of chemotherapy drugs or radiotherapy also affects the subject's negative feelings.This all becomes a challenge for the subject to find the meaning of his life.The meaninglessness of the subject causes the subject to eventually experience sadness, loneliness, feeling alone, empty, and hopeless.This makes the subject not know how to process for the better.By suffering from cervical cancer, the subject described his life as static [5].Moreover, one of the NPWCD subjects lost his job after getting cervical cancer.When subject patients return to their homes, they often still think negatively about what they are undergoing treatment for.Subjects also feel depressed because they do not have a source of income.In addition, the subject has few relatives, so he does not get social support [6].
Considering these data and facts, proper treatment is needed for both subjects, namely existential psychotherapy.This psychotherapy aims to increase the meaning of the subject's life in dealing with his suffering.The direction of existential psychotherapy used is to give the subject awareness about the importance of developing positive values.Positive values in existential psychotherapy include the subject being aware of his current condition, knowing his potential, and developing hopes, beliefs, and new goals in life.In the end, the subject is expected to be able to grow meaning in his life and be able to feel that he is a meaningful individual so that he can develop himself to a better/authentic growth [6].The existential psychotherapy approach consists of 7 sessions which are divided into three stages, namely the pre-psychotherapy stage, the psychotherapy implementation stage, and the post-psychotherapy stage.The following details the existential approach to psychotherapy sessions used to address the subject's problems:

A. Session 1: Building Trust
This session aims to establish closeness and foster trust between the subject and the researcher.In this early stage, I build trust with both subjects through active and reflective listening, honesty, and openness to both perspectives of the subject's life.This initial phase is a crucial phase because it will affect the entire phase of the patient's psychotherapy.The result is that the two subjects can establish good relations with the researcher.

B. Session 2: Identifying Problems
In this session, the subject identifies the events they experience, and the problems caused by these events.On the subject of MS, she feels she is a burden to her family, especially her husband.The subject is currently in the anger phase.The subject felt angry about why he was experiencing pain like this.The subject felt angry because he had been diligent in praying and had never hurt other people.The subject feels bored and empty, and his life has no purpose.Every day feels the same, namely undergoing cancer treatment and having dialysis 2 times a week.The subject feels hopeless and says that his life is pointless.The subject felt why he had to be born into this world if, in the end, he had to suffer from cancer like this.The subject experienced a "loss of dignity" himself.In the NPWCD subject, the subject is still in the bargaining phase.The subject has not been able to let go of his assumptions about cancer treatment which adds to his life's misery.The subject hopes to be cured of endstage cancer with chemotherapy drugs and radiotherapy.The patient said he should still be able to have a brilliant career at this young age.The subject also felt insecure about the side effects of the treatment which included hair loss, blackening of the skin, and disturbances.The subject feels that her "freedom of life" has been lost because of her cervical cancer.The subject no longer has meaning and purpose in life.

C. Session 3: Realizing Current Situation
The subject begins to realize and accept his current situation.Both subjects finally realized that they were in the terminal stage of cervical cancer.On the subject of MS, he prioritized the activities he would do for the rest of his life.The MS subject realized that since he was sick, he blamed more on the situation, and in the end, he just shut himself up.The subject realized that with herself busy struggling with her illness, she was not taking care of her husband.She realized that it was not her illness that kept her away and a burden for her husband, but herself the cause.The subject realized how to think he faced his most important illness.The subject realizes that the most important thing at this time is her husband and children.In the NPWCD subject, she finally realized that she was in a terminal stage of cervical cancer where treatment aims to relieve pain or uncomfortable symptoms as a result of her cervical cancer, not to cure it in the real sense.The NPWCD subject realized that when he was healthy he worked to earn money to make his children happy.While working, he realized that he was too busy so his initial goal to make his children happy was forgotten.Most of their children are cared for by their grandmothers.The subject realized that when he worked, he felt more "burden" than happiness.The burden of deadlines, dealing with clients, and even overtime on weekends.The subject then realized, when he was sick and stopped working, he spent more time interacting with his children.Both subjects began to prioritize activities in their lives.

D. Session 4: Potential Search
This session aims to make the subject aware of their potential.In this session, the subject begins to realize their strengths of himself and develops them into potential.MS subjects realized their potential, namely cooking.She started doing her hobby of cooking and sometimes made some small cakes that were left at the stalls around her house.On the subject of NPWCD, she realized her potential, namely in embroidery.Hobbies that he had been forgetting because he was busy working.The two subjects finally began to fulfill their potential.

E. Session 5: Helping Engagement in Life
In this session, the subject begins to explore hopes, goals, beliefs, and what efforts he will take so that he can express himself.In the MS subject, for example, her children and husband helped her to buy cooking ingredients for cake recipes that the subject wanted to try.In the NPWCD subject, for embroidery, her husband helped the subject buy cloth, sewing, thread, and needles and looked for patterns that the subject wanted to embroider.

F. Session 6: Discovery of Meaning
In this session, the subject begins to realize that he is a person who has potential and interprets his life positively.Subject MS felt happy when some small children around his house said that the cakes were delicious, and they could buy them.The subject feels that even though she has cervical cancer, at the current time she can give happiness to others.The patient feels that his life has meaning because he can see the smiles on the faces of the children who buy his cakes.The patient also feels that he is valuable when his husband and children can sit together at the dining table, chatting while enjoying the food he cooks.Something he had rarely done before.In the second subject, namely the NPWCD subject, he found an important meaning for himself.He can make embroidery which he displays in his living room.Despite the hiccups, the subject enjoys the process.He can do hobbies that make him also spend precious time for him at this time, namely taking care of his two young children.A moment that money can't buy for the subject.

G. Session 7: Evaluation and Termination
After being given extensive psychotherapy treatment, the subjects filled their days with meaningful activities according to their respective potentials.The subject begins to develop positive things in himself such as realizing his current condition, potential, goals, hopes, and beliefs.This makes the subject start doing positive activities that make his life meaningful.Subjects better recognize their potential to develop positive activities.The MS subject realized her potential and that she had a talent for cooking, while the NPWCD subject realized her talent in embroidery.This makes MS subjects fill their daily activities by cooking for their families.While NPWCD subjects make embroidery that can be used as home decoration so that their work can still be remembered and focuses on enjoying the rest of their life by filling happiness with their children.Through positive activities, the subject finds the meaning of his life again.Individuals who begin to realize positive things in themselves such as goals, beliefs, and hopes can make them develop themselves towards better personal growth.Individuals can choose what actions make themselves meaningful so they can organize their lives.The discovery of positive things can make the subject reach its proper state.This makes the subject no longer feel stagnant and static in life.The subject has realized that he has positive things about himself that change his perspective.The subject is also aware that with these positive things he can outsmart the boundaries that confine him.
Existential psychotherapy focuses on development based on the positive.In addition, existential psychotherapy focuses on the present moment and what that person will become in the future.Existential psychotherapy provides conditions for maximizing self-awareness and self-growth.Removing barriers to optimizing personal potential.In addition, existential psychotherapy helps subjects find and use the freedom to choose by expanding their self-awareness.Existential psychotherapy also helps subjects to be free and responsible for the direction of their own lives.Existential psychotherapy is oriented towards each subject having the ability to expand his consciousness and decide for himself the direction of his future life.The patient must realize that he is not a victim of past conditions, but now he must become the architect in redesigning his life.The patient must free himself from his fear.

IV. CONCLUSION
Both subjects with advanced cervical cancer had many problems, obstacles, and subjective complaints that made it difficult for them to plan their future.Existential psychotherapy can open opportunities and opportunities to discover one's potential and realize it in his future life.The subject begins to realize the positive things about himself such as potential, goals, hopes, and beliefs.In addition, existential counseling makes subjects carry out activities that can develop them in a positive direction.This made the subject do positive things when he returned from Prof. Ngoerah General Hospital so that he feels more meaningful.Therefore, existential psychotherapy is effective in increasing the meaningfulness of life in both patients with advanced cervical cancer.

CONFLICT OF INTEREST
Authors declare that they do not have any conflict of interest.