|Year : 2019 | Volume
| Issue : 1 | Page : 109-113
Early discontinuation of counselling by survivors of family violence in Papua New Guinea
Psychologist, MA, Anthropologist, Mental Health and Psychosocial Specialist, France
|Date of Web Publication||28-Jun-2019|
7 Impasse Barbier, 92110 Clichy
Source of Support: None, Conflict of Interest: None
Family and sexual violence are common and widespread in Papua New Guinea, especially against women. The author describes her reflections about reviewing the psychosocial support mode of intervention according to the needs of survivors of family violence at the Family Support Centre within Tari Hospital in the southern highlands of the Hela Province, while working as a psychologist supervisor from 2011 to 2012. It draws on a feedback exercise with survivors, intended to ask about their satisfaction with services and the reasons for not returning for follow-up counselling sessions. The answers provided valuable insights for the adjustment of care in a culturally appropriate manner to survivors’ needs.
Keywords: counselling, Papua New Guinea, survivors of family violence
|How to cite this article:|
Acosta P. Early discontinuation of counselling by survivors of family violence in Papua New Guinea. Intervention 2019;17:109-13
| Introduction: the country|| |
The independent state of Papua New Guinea (PNG) is an Oceanian country that occupies the eastern half of the island of New Guinea and its offshore islands in Melanesia, a region of the southwestern Pacific Ocean. Most of the population lives in customary communities, where nearly 40% lives a self-sustainable natural lifestyle organised in strong traditional social groups based on farming (World Bank, 2010). Subsistence economies are common whereby gender roles define that women are responsible for food crop production, small livestock rearing or fishing, housekeeping and child care (United Nations, UN, 2013). Tari is the largest government administration centre that has been set up in what the Huli people consider their country (Hela Province, in the central mountains of the main island). They number over 250,000 people (PNG National Statistical Office, 2014) and are grouped in clans and sub-clans. Family and sexual violence are common and widespread in the country, especially against women. According to the World Report (Human Rights Watch, 2017), it ‘is one of the most dangerous places in the world to be a woman (…)’ (p. 417). This article presents a personal reflection regarding the provision of psychosocial support to survivors of family violence at the Family Support Centre (FSC), established within Tari Hospital in the Southern Highlands of the Hela Province.
Family and sexual violence
Different forms of violence are observed in PNG, where the most common are domestic violence, intimate partner violence and sexual violence. Domestic violence is defined as the ‘(…) violence that takes place within the home or family between intimate partners as well as between other family members’ (Inter-Agency Standing Committee, 2015, p. 321). Intimate partner violence is specific to ‘violence occurring between intimate partners (married, cohabiting, boyfriend/girlfriend or other close relationships’ and sexual violence includes ‘rape, sexual slavery and/or trafficking, forced pregnancy, sexual harassment, sexual exploitation and/or abuse, and forced abortion’ (Inter-Agency Standing Committee, 2015, p. 321 and 322). In the local context of Tari, the concept of ‘family violence’ was coined and is used throughout this article to make reference to the violence perpetrated by any member of the household, regardless of the age and gender of the survivor or the perpetrator, as the concept of family has a broad meaning and includes persons who live in the same household or compound, such as blood relatives, co-wives and members of extended family (i.e. in-laws).
The extent of family and sexual violence in the country is difficult to quantify due to under and nonreporting, as official data is unavailable (Eves, 2006; UN, 2013). Most survivors do not report the violence through the judicial system, except for the village court systems in some areas; and the health care system’s data collection only documents the number of injuries treated but not their cause (Eves, 2012).
According to the report addressed to the Family Violence Action Committee in July 2000 (Institute of National Affairs, INA, 2000), family violence is the most extensive form of violence, whereby the most frequent forms ‘(…) are wife-beating, marital rape (i.e. forced sex by a husband with his wife), physical abuse of children by parents, the sexual abuse of children by close family members (incest) or by members of the household, the sexual harassment or rape of babysitters and domestic workers, and physical assault between co-wives in polygamous marriages’ (corroborated by the United Nation’s report in 2013). Based on the Law Reform Commission’s (LRC) research conducted in the 1980s, the report states that two-thirds of wives interviewed had been hit by their husbands with some wives also hitting their husbands, mainly for self-defence reasons; 67% of women in rural areas had been beaten by their husbands and 66% of husbands had been beaten by their wives (INA, 2000). Respondents legitimated physical violence against wives on the part of husbands in cases where the woman is perceived as not behaving according to her role (65% husbands and 55% wives held that belief).
The injuries most frequently reported by provincial hospitals treating survivors of family violence are broken bones, head wounds, organ damage and severe lacerations and cuts as a result of using bush knives (INA****, 2000). According to the analysis of hospitalised cases of violence in the Southern Highlands carried out by the United Nations (2013), half of all cases of girls and single women took place within the family and were perpetrated by a relative (37% by a brother/stepbrother; 20% by a father/stepfather; 20% by a cousin and 19% by an uncle); 94% of female survivors knew their assailant; and 75% of all cases, whether against men or women, involved a male perpetrator (as cited by UN, 2013, p. 5). Fulu, Jewkes, Roselli, and Garcia-Moreno (2013) found in the UN Multi-country Cross-sectional Study on men and violence in Asia and the Pacific that the prevalence of perpetration of partner violence (physical, sexual violence or both) in the province of Bouganville in Papua New Guinea was 80% among the sample of male respondents.
The LRC study found that most of the women interviewed stated physical violence by their husbands as being coupled with emotional (verbal abuse, insults and shaming), social (isolation from family and friends, sometimes even locking them up for hours and days) and denial of resources (deprived or destitute of money earned by themselves) (INA, 2000).
Causes and consequences of family violence
Common causes of family violence against women, particularly in rural areas, are sexual jealousy (including the husband’s adultery for which the wife gets beaten if she complains or enquires about it); the wife’s failure to fulfil her duties (including refusing sexual intercourse; household chores not performed to husband’s satisfaction, i.e. not having food ready on time or not looking after the pigs) or behaving in an unacceptable manner (i.e. going somewhere without permission, playing cards, gossiping, embarrassing the husband in public and so on); and dislike of the spouse (sometimes resulting from arranged marriages) (Eves, 2006; INA, 2000). Single women can also be subjected to discipline by any of their male relatives if they are perceived as being disobedient, disrespectful, flirty, lazy, stubborn or uncooperative (UN, 2013). Polygamy has also been identified as a cause of violence that usually begins with the neglect of the first wife and her children and that can escalate to physical and sexual violence resulting, in some cases, even in murder. According to Eves (2006), some changes in marital relations are exacerbating factors, for example the practice of polygamy was limited to men who could provide for more than one family, since a separate house had to be built for the second wife with its own garden plot, sometimes in different villages. Current practices nowadays involve men whether rich or poor marrying multiple women resulting in co-wives living in the same house and sharing the same garden plot, as well as serial marriage whereby the first wife is abandoned for another one. Associated risk factors to intimate partner violence have been identified, such as absence of high school education (61.2%) with physical violence only; experiences of child emotional abuse on the part of the abuser (93.9%); childhood physical abuse (78.6%); witnessing abuse of the mother (66.3%) and alcohol misuse (49.3%) with perpetration of physical and sexual violence (Fulu et al., 2013). In terms of relationships, the factors identified refer to quarrelling (34.4%) associated to both physical and sexual violence and having one sexual partner associated to physical violence only (53.2%) and emotional or economic violence only (58%) (Ibid).
Regarding the underlying causes, several authors and documents coincide in indicating that violence is normalised in the country and there is a widely shared perception that ‘wife beating’ is a normal part of married life (Eves, 2006; INA, 2000; UN, 2013). The legitimisation of the husband’s violence against his wife rests in the practice of bride–wealth transactions, which are perceived as providing entitlement to men over the woman’s labour, sexual services and obedience. Moreover, violence is legitimate under ‘(…) the prevailing ideology which holds that it is an appropriate corrective for wives (and children) who fail in their prescribed obligations and duties’ (Eves, 2006, p. 12). As a result of this standard of masculinity, the use of violence is seen as a normal and justified way of conflict resolution (including marital) and anger expression.
Traditional gender and power relations dictate absolute control (and the maintenance of it) of men over women, objecting to any exercise of women’s agency and using violence as a means of reinforcing such control (Eves, 2006) (acting out the fear of losing it). Current changes in gender relations are further contributing factors, for instance, in the case of residential segregation. Based on Eves’ (2006) field work in Chimbu, Western and Bougainville provinces, the dichotomy of the genders is changing or even disappearing, as ‘(…) virtually all men live together with wives and kids, a living arrangement unheard of prior to the colonial period’ (p. 39). In Tari, the imposition of Christian practices, like the one about the need for nuclear families to live together (father, mother and children), is one of the causes or contributors to intimate partner violence because men and women do not know how to live together. Before colonial times and the arrival of Christian missionaries, men used to live separately from women and children in the ‘houseman’ with other men where they used to cook for themselves. Nowadays, some men are living with their wives and they do not know how to communicate with each other on a daily basis (H. Wardlow, personal communication, 21 July 2012).
The consequences range from the physical impact of pain and injuries to the psychological and social effects of family and sexual violence. Injuries can be so severe and may lead to impairment, reduced mobility, sexually transmitted infections, especially HIV and fistulas or incontinence in the case of sexual aggression with the subsequent hygiene difficulties leading sometimes to social isolation and stigmatisation (). The experience of violence may reduce women’s ability to function and care for themselves and their children; it may result in trauma-related reactions, such as sleeping difficulties, intrusive memories (flashbacks, nightmares) and anxiety that may become permanent and develop in severe psychological conditions.
Users of Tari’s family support centre
The FSC provides medical and psychosocial support to survivors of sexual and family violence within a hospital setting. I worked at the centre from 2011 to 2012 as a psychologist in charge of the supervision and ongoing support of the lay counsellors, who were responsible for providing counselling as a routine part of care and who were trained in basic counselling skills and confidentiality. They would provide a space for survivors to talk about their fears and concerns, helping survivors go through the crisis, providing options, information and resources to them to be able to make informed decisions about the care they wanted to receive. When necessary, options for physical safety were discussed with survivors, including the possibility of staying in the centre’s safe house if they wished to do so.
At that time, the majority of users were women and children who would present with serious injuries as a result of punching, kicking, slapping or involving different kinds of objects used as weapons (e.g. knives, bush knives and umbrellas). However, perpetrators were not exclusively men, as they could also be harmed by women, and female perpetrators were also identified in some cases, usually co-wives. Sometimes the aggressors were individuals known to the survivor (friends, neighbours, etc.) and members of the family, or extended family. Intimate partner violence was observed, including acts of physical and/or sexual violence, emotional (psychological) abuse and controlling behaviours by a current or former partner.
Insights into (dis)continuation of counselling sessions
My predecessors and I had been observing through internal monitoring that over 50% of the centre’s users only came for one visit and did not return in more than a month to the appointment given by the counsellors for a follow-up counselling session. I decided to ask female survivors of family violence about their perceived quality of care and the emotional support needs. Using an interview guide, my questions referred to how they felt the first time they came to the centre, what they appreciated about the service, what they did not appreciate about it, whether they felt that confidentiality was respected, how they felt in the conversations with the psychosocial counsellors, what they liked about it, what benefits they could identify from the conversation, what were the main difficulties that they encountered when coming back for follow-up visits and what recommendations they could make to improve the services.
The respondents reported experiencing positive feelings in the conversations with the counsellors, as they could express their concerns and talk about what had happened; however, no specific benefits were identified. Some pointed out the distance from their homes to the hospital as a difficulty for them returning for a follow-up visit, and the lack of transportation. Interestingly, some of them agreed on not feeling the need to return to the FSC if no medical follow-up was required and, especially, if they have received compensation for the harm done to them by the perpetrator of the violence. I could also observe that survivors often came mainly expecting to obtain a medical report to claim compensation, as there was insufficient awareness at that time in the area of the medical and psychosocial services available at Tari District Hospital.
Traditional behaviour was very common among users in the described area, where ‘traditional ways of barter and negotiation’ still persist, ‘using pigs to pay for brides and to settle compensation claims’ (Lomas, 1988). People who experience any wrongdoing could bring the matter for the consideration of the village court that applies customary law to resolve conflict between two or more parties. In the event of physical violence, the survivor may claim compensation from the perpetrator and the members of the court decide the number of pigs that must be paid and if any other monetary compensation is needed. As a matter of fact, some respondents clearly stated that once the issue was settled by the village court, they would feel relieved and able to move on and leave the dispute behind.
Western representations of effective psychological interventions
The programmatic concern about more than half of the users benefiting from only one counselling session at the FSC in Tari is grounded on western representations of what constitutes effective psychological interventions and users’ knowledge and awareness of the needs for such interventions and their benefits. It is assumed that several sessions and ongoing support are more likely predictors of a perception of improvement by users on their presenting complaint and functionality, based on the belief shared by mental health professionals about counselling and therapy as a process that takes time and that would result in better outcomes if a process is engaged. For example, the evaluation carried out in 2012 of the FSC run by MSF in the city of Lae found that 81% of users who benefited from two or more counselling sessions reported improvement in their presenting complaint and 75% in their functionality; and the proportion that stated perceiving an improvement was slightly higher with the higher number of counselling sessions (MSF, n.d.).
According to Swift and Greenberg (2012), early discontinuation of therapy is considered a problem in western contexts because it hinders the delivery of effective psychological interventions and dropout rates that have been studied for more than two decades. The conceptualisation of effectiveness is based on the benefits of follow-up sessions, such as making it possible for the counsellor or therapist to determine the user’s satisfaction with the experience, and being able to assess the plan of action drawn and committed to in the first session with the person. Particular situations, such as experiencing traumatic events, are considered to be required for longer, for the therapy to prove beneficial, as well as people presenting multiple problems, being unclear about the sources of their distress, serious impairment in daily functioning or people experiencing significant life changes (American Psychological Association, 2018). However, it is now acknowledged that some people may feel relief following a single session of therapy or counselling, and the World Health Organisation declared that single session therapy, defined as a therapeutic approach for any presenting concern, was a model with potential and in need of further research (as cited by Paul & van Ommeren, 2013, p. 8).
The answers from the survivors provided me with a change in perspective with the understanding that social conditions and inequalities leading to distress needed to be taken into consideration, as well as what it meant for survivors to come to terms with and recover from experiences of violence. Moreover, the change in perspective implies the importance of adopting an emic approach, which considers ‘(…) “mental illnesses” and distress as subjective experiences, influenced by culture, meaning they should be studied in their particular cultural context’ (Mills, 2014, p. 24). Psychological distress does not occur in isolation from cultural norms and traditional gender roles and power relations in the case of survivors of sexual and family violence. These experiences of violence are hardly overcome with the mere support of a mental health worker without the necessary acknowledgement and reparation of the wrongdoing, which is determined by the specific cultural practices of a human group. Alleviation of suffering is not only associated with cultural concepts of distress and the identification of an appropriate cultural idiom to label distress, but also with how those concepts address the perceived cause, rather than the signs of distress only (Kohrt, Mendenhall, & Brown, 2015).
Asking survivors for feedback allowed the team of service providers and the agency to gain insights into the provision of psychosocial care in a culturally appropriate way. Greater attention was paid to the causes of psychological distress of survivors as well as the resolution processes needed for them to be able to cope and overcome their experiences of violence. This attention was paid not only through supervision sessions with counsellors, but also in the cross training in counselling of health workers and the subsequent supervision with them. Health workers would provide medical care and counselling, using their skills and knowledge to address the survivor’s presenting complaints and provide support in probably only one session. The feedback had some programmatic implications, as the outcome measures like the average number of follow-up sessions were not interpreted as a challenge anymore. The feedback exercise also highlights the relevance and importance of asking users about their viewpoints to improve service adequacy and quality.
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Conflicts of interest
There are no conflicts of interest.
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