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13
Cultural Considerations in the Treatment
of Mental Illness Among Sexually Abused
Children and Adolescents: The Case of
Bali, Indonesia
Cokorda Bagus J. Lesmana, Luh Ketut Suryani, Niko Tiliopoulos
Abstract
Childhood and adolescence sexual abuse can have long-lasting and devastating effects on personal and interpersonal growth and development. Sexually abused children tend to exhibit higher rates of poor school performance, aggressive be-havior, PTSD (posttraumatic stress disorder), or depressive symptomatology, as well as social and relational deicits (e.g., age-inappropriate sexual behaviors). The trauma following such abuse can further affect neurodevelopment and phys-iology, aggravating mental or physical problems in adulthood. Early symptom recognition and appropriate interventional applications are important factors in successfully treating or even preventing the development of mental disorders in such cohorts. A central element of effective treatment is the selection of treatment targets. Cultural considerations are rarely or peripherally considered in sexual abuse treatment strategies. Western-trained psychiatrists and clinical psychol-ogists tend to overlook or underestimate such factors in cross-cultural settings, resulting in interventional efforts that may interfere with traditional approaches to healing, and potentially contributing to a transgenerational cycle of trauma. By using Bali (Indonesia) as a focal culture, in this article we discuss the ef-fects of cultural elements and showcase their potential contribution and sys-tematic implementation into a holistic and sensitive interventional model for the treatment of mental illness in childhood and adolescence sexual traumatization.
2015 Wiley Periodicals, Inc.
Child Sexual Abuse
Child sexual abuse (CSA) violates the trust, safety, and age-appropriate de-velopment that should be a natural part of a child’s and adolescent’s life. Its frequency and deeply harmful impact make it one of our most serious psychosocial problems with potentially lasting long-term costs and conse-quences to individuals, families, and communities.
A brief deinition of CSA refers to any sexual activity—for example, fondling of genitalia, incest, rape, sodomy—that the child or adolescent cannot understand or give consent to or that violates the law (World Health Organization, 1999). It can involve noncontact sexual exploitation, for ex-ample, indecent exposure or voyeurism (American Psychiatric Association, 2013). Meta-analytic and epidemiological data suggest that the average global prevalence of CSA is 11.8–13.8% with higher rates among girls (18– 19.7%); Africa shows the highest rates of CSA (approx. 34%), while the low-est appear in Asia (approx. 10%) and Europe (approx. 9%; Barth, Bermetz, Heim, Trelle, & Tonia, 2013; Pereda, Guilera, Forns, & G ´omez-Benito, 2009; Perez-Fuentes et al., 2013; Stoltenborgh, van Ijzendoorn, Euser, & Bakermans-Kranenburg, 2011).
CSA can have lasting psychological effects on personal and interper-sonal growth throughout the lifespan. These psychological outcomes can be grouped under PTSD/trauma symptoms,internalizingandexternalizing
problems (Lalor & McElvaney, 2010; Maniglio, 2009; McLean, Rosenbach, Capaldi, & Foa, 2013; O’Brien & Sher, 2013; Perez-Fuentes et al., 2013; Young & Widon, 2014). Internalizing symptoms refer to depression, anxi-ety, paranoid ideation, self-harm behaviors, guilt, shame, self-injurious and suicidal ideation or behavior, and low self-esteem. Externalizing symptoma-tology includes conduct problems, attention deicit/hyperactivity disorder, poor academic performance, marital or familial dysregulation, social impair-ment, substance abuse, hostility and aggression, inappropriate or high-risk sexual behavior and preoccupation, and further polyvictimization in adult-hood. CSA has also been identiied as a general, nonspeciic risk factor for negative health outcomes, such as cancer or heart disease, as well as epige-netic dysregulation and brain or neurodevelopmental abnormalities (e.g., Anderson, Teicher, Polcari, & Renshaw, 2002; Choi, Reddy, Liu, & Spauld-ing, 2009; De Bellis, Spratt, & Hooper, 2011; Felitti et al., 1998; Tomoda, Navalta, Polcari, Sadato, & Teicher, 2009).
Treatment
meta-analyses on the eficacy of psychosocial interventions on sexually abused individuals under the age of 18 on average reveal medium effect sizes (Harvey & Taylor, 2010; Trask, Walsh, & DiLillo, 2011). The reviewed studies tended to possess a single-disorder, linear session sequence—for example, exclusively treating PTSD or depressive symptomatology, usually through some form of cognitive therapy—and were almost exclusively con-ducted in individualistic societies.
Weisz (2004, 2014) questions the utility of single-disorder treatments for children and adolescents and proposes the development of innovative psychotherapies through a deployment-focused model. Such a model oper-ates on transdiagnostic protocols, that is, protocols that simultaneously address comorbid symptomatology, for example, by concurrently treating PTSD and depression when both are present, while contextually consider-ing the speciicity of client needs and interventional settconsider-ings. Furthermore, since minimal evidence exists regarding the effectiveness and applicability of current CSA interventions in collectivistic cohorts (e.g., Murray et al.’s [2014] work in Zambia), a need for the development of culturally compe-tent biopsychosocial treatments is becoming evident (Murray, Nguyen, & Cohen, 2014). For example, cultural norms appear to affect the likelihood of CSA cases being diagnosed or even disclosed by a child, as well as the reporting of such abuse to authorities (Fontes & Plummer, 2010). Since cul-tural elements appear to be present in the reporting of CSA cases, culcul-tural components should be considered in designing treatment programs, partic-ularly in collectivistic societies (Kanukollu & Mahalingam, 2011; Plummer & Njuguna, 2009).
Combining the earlier developments and considerations, we propose that an expanded, culturally sensitive, and informed deployment-focused model may be a more effective approach to the treatment of sexually abused children in collectivistic cultures. Hereinafter, we demonstrate the eficacy of such a model using Bali (Indonesia) as a case culture. We irmly believe that the model described next can be adapted to the parameters of other collectivistic cultures and successfully applied accordingly.
Case Focus on Bali
deviate from mainstream Hinduism. In fact, it is this cultural uniqueness of the Balinese society, combined with its collectivistic structure, that has made it the focus of major anthropological and sociological research (e.g., Bateson & Mead, 1942; Edge, 1996; Geertz, 1973; Suryani & Jensen, 1993).
Balinese Cultural Elements of Relevance to CSA
The Balinese culture possesses a pervasive spiritually based system that em-phasizes relationships to foster solidarity and cooperation within the nu-clear family, the extended family, and the community. In Bali, family and community are tightly enmeshed and interdependent. Children are highly respected, a respect irmly rooted in the Balinese belief that children are reincarnated ancestors whose souls are physically reborn into the bodies of infants. Since the souls of ancestors are highly revered and worshipped, it follows that their reincarnated physical form is similarly honored and wor-shipped. Such child worship, embedded in religious beliefs, forms the basis for the degree of respect, sustained attention, love, and devotion shown to children and appears to be a signiicant contributor to the formation of se-cure childhood attachments to primary caregivers. Furthermore, due to the closeness and support of both the nuclear and extended families, children tend to attach to more than one primary caregiver, that is, parents, older siblings, and extended family members.
As a culture-wide value, maintaining balance and control of impulses and actions is respected, valued, and indeed expected. Any deviation from this norm would be interpreted as inappropriate at best and as evil spirit possession at worst. Preservation of relationships with others takes prece-dence over nearly all other values in society, and the abuse of children, whether physical, sexual, or psychological, would disrupt the sociocultur-ally deined boundaries of a relationship with another person.
Traditional Healing and Western Psychiatry in Bali
while they regard the process as continuing for a long time and the patient as being responsible for their own health.
Evidence suggests that Balinese people tend to seek treatment origi-nally from the Balians; however, subsequently approximately 76% of them seek further treatment from psychiatrists. Interestingly, of those ones who have been treated by psychiatrists, approximately 80% return to the Balians for further treatment (for a detailed description of such practices and beliefs see Suryani & Jensen, 1992; Suryani, Lesmana, & Jensen, 2006).
A Culturally Sensitive Approach to the Treatment of CSA
Over the past 12 years or so, we have been developing and implementing in Bali a treatment that integrates the earlier approaches into a holistic model of biopsychosocial intervention (Lesmana, Suryani, Jensen, & Tiliopoulos, 2009; Lesmana, Suryani, Tiliopoulos, & Jensen, 2010; Suryani, Lesmana, & Tiliopoulos, 2011). The model recognizes and respects the importance and interconnectedness of every person’s mind, body, and spirit, as well as the ways these elements are inluenced by and in return affect, positively or negatively, one’s sociocultural relationships and religious/spiritual beliefs. Rather than following a single-disorder treatment approach and isolating interventional foci (such as the psychobiological focus of the psychiatrist or the spiritual focus of the Balian), the model eclectically combines all of them, primarily at an idiographic level, in order to treat the individual as holistically and with as much cultural sensitivity as possible. In essence, this approach is an expanded, culturally sensitive, and informed deployment-focused model.
schoolteachers and school counselors, and community leaders who are re-sponsible for maintaining healthy communication and reporting relevant mental health state changes of community members (a detailed description of the approach is presented in Lesmana et al., 2010).
Since 2004, we have treated 102 children with CSA who were victims of 38 sex offenders. The mean age of the children was 12.17 years (SD=
3.35 years), while 52 were male (51%). The children’s mental health state was reassessed a week after the last treatment session, six months later, and in many instances four years thereafter. Their symptoms were evalu-ated through the ICD 10 interview protocol, as well as through parent and teacher reports. No residual symptoms relating to their trauma have been observed in any of the children yet.
Conclusion
Culture implementation is a potential and systematic contributor into holis-tic and sensitive interventional models for the treatment of mental illness outcomes of childhood and adolescence sexual traumatization. Mainstream psychotherapeutic approaches to CSA arguably still possess questionable levels of eficacy and external validity, which may be reduced further in the absence of an acculturated agenda. In areas in the world, such as Bali, where a relatively homogenous collectivistic cultural and spiritual infusion per-meates all aspects of life, such therapies need to follow an integrated, mul-timodal, and synergic approach to intervention. Such an approach would mobilize modern psychotherapeutic techniques and medication, while re-specting and responsibly utilizing the traditional health practices and reli-gious beliefs of the focal human geography.
In conclusion, it is our conviction that through the prudent and sys-tematic implementation of holistic and culturally competent strategies, a development of mental health deployment-focused models can be achieved that offer a fair and effective service to the population.
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COKORDABAGUSJ. LESMANAis an associate professor, Department of
Psychia-try, School of Medicine, Udayana University, Denpasar, Indonesia, and can be
reached via email atcokordabagus@unud.ac.id
LUHKETUTSURYANIis a professor, Suryani Institute for Mental Health, Denpasar,
Indonesia, and can be reached via email atsuryani@suryani-institute.com
