The Efficacy of Cognitive Behaviour Therapy and client-centered Therapy on Treatment of Depressive Symptoms Among Female Domestic Violence Survivors
ABSTRACT
The study was to determine the impact of Cognitive Behavioral Therapy (CBT) among women exposed to domestic violence within Calabar metropolis, Cross River state. The problem of domestic violence is on the increase with cases of assaults being reported on daily basis. This study embarked on finding out how this menace can be mitigated using CBT. In order to achieve the goal of the research, it was important to establish the various forms of domestic violence among the study participants; assess the influence of demographic variables on domestic violence; determine the association of domestic violence with anxiety and depression; establish efficacy of CBT in reducing the levels of anxiety and depression among the intervention group; explore factors associated with the level of effectiveness of CBT, and lastly, establish the impact of CBT on domestic violence among the study population. The study was a mixed method research of both quantitative and qualitative approaches. The target population was women aged 18 years and above living within Calabar metropolis who had been exposed to domestic violence. The data was analyzed applying three approaches: Univariate; Bivariate; and Multivariate Analysis (MANCOVA). Research findings show people mostly affected by domestic violence are women and children. Domestic violence occurs mostly when there is a misunderstanding between partners. The findings show that perpetrators of domestic violence are controlling, on the other hand victims are people who feel worthless and inferior. Eight in ten women (80%) suffer emotional and psychological abuse, economic coercion, physical violence and sexual assault. Only 62% women experience the use of children to control them. Various factors trigger domestic violence especially previous relationships and cultural expectations. The study shows social demographics influence the occurrence of different forms of domestic violence. Sexual assault is highly influenced by household income, while economic coercion is influenced by number of children. Use of children to control the partner is highly influenced by age and marital status. There is a significant association of domestic violence with anxiety and depression because domestic violence leaves victims with negative effects especially depression and anxiety. Findings show that women cope with domestic violence mostly by persevering and few others opt for counseling. The effectiveness of CBT depends on various factors especially the number of sessions attended. Research findings show that African cultural tailored CBT has both short-term and long-term impact on the lives of women exposed to domestic violence and psychological disorders. As part of recommendations for effectiveness of CBT, clients need to attend a minimum of 14 to 16 sessions. In addition, support systems available need to restructure the strategies of alleviating the negative impacts of domestic violence.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Violence is generally known to be within human domains of interactions (Claassen, 2014). It is known to be common in human interactions, and it affects people directly when they are the victims, and indirectly when they witness the event. According to Claassen (2014), violence exists against other social, national, ethnic, racial and religious groups, affecting human lives negatively. In many African states and other parts of the world, there are many victims of political and ethnic cleansing and nepotism, who are suffering due to exposure to violence. Such violence is referred to as communal violence and it causes trauma that subsequently may lead to psychological disorders such as anxiety and depression. There are several forms violence, but this research is concerned with domestic violence, which is seen to be on the rise, as reported in the media (Moses et al., 2010).
A study by Kendall and Hammen (2011) posits that domestic violence is common within societies that are mainly patriarchal. It is a violence that occurs in a home setting, that is, between intimates partners, family members and close allies. This problem alters individual’s lifestyle, as it also causes posttraumatic stress disorders (PTSD). The most affected people world-wide by domestic violence are women and girls (Kendall & Hammen, 2011). Women and girls are also commonly victimized in other social places such as schools and workplace. Generally, they suffer outright discrimination in public sectors and economic endeavors. According to Kendall and Hammen (1995), domestic violence is the leading cause of fatalies in families and globally. On a daily basis women and children live in perpetual fear of not knowing what will happen next. The most common forms of domestic violence are physical violence (slaps, pushing, banging, and whipping, among others), spousal abuse, and sexual assault (Kendall & Hammen, 2011). Evidence based research reports show that cases of domestic violence are rarely reported as a result of challenges to obtaine accurate information. For example, unless specifically asked, women do not volunteer information about their physical and sexual abuse ordeals, perhaps due to fear of contempt and suspicion that the cause of the violence was their fault (Kendall & Hammen, 2011). Domestic violence can also be an economic form of abuse when one intimate partner (IP) makes attempt to control the other partner’s access to economic resources. This reduces the victim’s capacity to support him/herself forcing him or her to depend on the perpetrator financially (Adams et al., 2008).
Attitude towards domestic violence involves perception, cognizance, description and documentation which varies from one country another and from generation to another hence the need for intervention. For example, the laws for preventing domestic violence vary by country. While domestic violence has been illegal in the Western world, for years but it has not been the case in developing nations (Ivana & Oleg, 2005). For example, in 2010, the United Arab Emirates Supreme Court passed a ruling that a man has the right to physically discipline his wife and children as long as there are no physical injuries left on their bodies, regardless of the psychological pain that goes with physical injuries.
According to Ivana and Oleg (2005) and the United Nations International Education Children’s Fund (UNICEF), 90% of women between the age of 15 to 49 years in Afghanistan and Jordan thought that a husband was justified to hit or beat the wife under certain circumstances. In Africa, some countries such as Mali report 87%, Guinea (86%), Lagos (81%) and Central African Republic (80%) of physical assault directed at women and girls. Declining to submit to a husband’s requirements is a reason given to validate domestic violence in developing nations. For instance, 62.4% of women in Tajikistan excuse wife beating if the wife goes out without the partner. When a wife argues with her husband, there is a 68% chance of being beaten and when she declines to have sex with him a chance of 47.9%.
In most African cultures, men had a legal right to use violence to punish their wives and children. Compared to many European countries, this legal right was removed in the late 19th and early 20th centuries. In the 1970s, arrests on criminal offences for domestic violence were very rare, and it only occurred in cases of extreme violence. It was only in the 1990s that vigorous enforcement of laws against domestic violence became a standard policy, but only in the Western countries (Clarke & Kris, 2013). Due to violence in families, women, children and other family members are affected emotionally and psychological (Kendall & Hamman, 2011). This attests to the existence of trauma and depressive disorders among the otherwise healthy society, especially women. According to Briere and Scott (2006), child abuse and neglect have often been observed in women with conversion and somatization disorders. These studies show that there is a close link between severe traumatic experiences and somatization.
Domestic violence has been associated with the commonly known psychological disorders such as anxiety, depression, hysteria, eating disorders, suicidal tendencies, and schizophrenia, among others (Briere, 1996; Ogbuji, 2015). While some perpetrators are known to be psychologically disturbed, any form of violence causes psychological trauma to the victim and in many cases of violence, women and children are the most affected (Ogbuji, 2015). The main common factors that trigger domestic violence are control and power by the heads of households, egoism, financial status, loss of trust, and jealousy. People who have been exposed to domestic violence struggle in their lives, display post- syndrome effects, both personally and professionally (Briere, 1996).
Lack of skills in emotional self-management, interpersonal skills, and social-problem-solving skills are imminent in those exposed to domestic violence. Victims and perpetrators of domestic violence are found to benefit from allied training approaches that show positive effects when addressed, with a reasonably high degree of reliability. Most communities are confused about whether to consider domestic violence a legal or a social problem, while institutions and agencies are known to respond to the needs of women and children who fear for their lives by providing temporary shelter and secret accommodations (Briere, 1996). Many communities are also still experimenting with legal reforms in dealing with issues such as whether to arrest the violent spouses or parents even if the victim does not prefer charges against them. However, psychological services to such women and children are limited and rarely evaluated systematically for their effectiveness. Hence, Cognitive Behavioral Therapy (CBT) has shown a remarkable impact on recovery from domestic violence (Kazdin, 2001).
It is a fact that anybody exposed to violence needs a therapeutic environment for calming, support of emotions and fostering of expression. This enables one to cope with feelings and crisis situations, reducing intense depression incidents, emotions such as anxiety, fear, and tension. Furthermore, there are concerns regarding safety planning, need for housing and other family changes that might result. Therefore, cognitive behavioral therapy would be the appropriate intervention for this research as also supported by Creswell and Clark (2011), to alleviate the problems resulting from domestic violence. One cannot overemphasis that domestic violence has serious consequences on the lives of women, families and countries. The experience is that the abused become abusers at a later stage in life (Black et al., 2011; Dutton, 1994).
Despite its popularity, cognitive behavioral therapy has not yet been highlighted to show its effectiveness in clinical practice, particularly in Nigeria. According to Craighead (1994), learning experiences, or failure to receive or profit from various learning experiences, accounts for the behavioral patterns of an individual. Therefore, a good behavioral modification model is one that provides learning experiences that promote adaptive and pro-social behavioral patterns. Hence, cognitive behavioral therapy involves training clients to engage in certain behaviors in order for them to learn new modes of behavior.
This research was crucial to confirm the current state of affairs in the treatment of cases of domestic violence using CBT. This research, therefore, focused on the efficacy of CBT on women exposed to domestic violence and who have developed psychological disorders, mainly anxiety and depression that may result from it. The researcher identified calabar metropolis in Cross River state because the phenomenon of domestic violence is a common occurrence among residents of Calabar metropolis and other parts of Nigeria (Kimuna & Djamba, 2008; Swart, 2008).
1.2 Statement of the Problem
The research gap is that the use of CBT as a therapy has not been tested as an effective therapy in treating cases of women exposed to domestic violence despite CBT having been in use in Africa for several decades. For example, in Calabar metropolis and other parts of Nigeria, there has not been such a study in the recent times to test the effectiveness of CBT. The cases of domestic violence have frequently been reported in local dailies and on radio and television. This shows there is a rise of domestic violence in not only Calabar metropolis but Nigeria in general, a menace which has to be addressed. Some of the victims choose to go for therapy in secrecy while others, out of ignorance, do not seek therapy at all, even as their situation deteriorates to the extent of being psychologically classified as sufferers of anxiety and depression.
The research aimed at examining the effectiveness of CBT in overcoming the negative effects of various forms of domestic violence, which is reported to be on the rise. This is because the therapeutic techniques and theories available have not sufficiently addressed the menace of domestic violence in Nigeria, particularly in Calabar metropolis. The researcher sought to investigate how CBT can help to alleviate suffering among Calabar metropolis women exposed to domestic violence, and to generalize the success rate to the rest of the regions of Nigeria and Africa. Hence, this research aimed at examining the effectiveness of cognitive behavioral therapy (CBT) in reducing or alleviating anxiety and depression in women exposed to domestic violence.
Of interest to note, CBT techniques have been in use for several decades in other parts of Africa and the world, hence one would expect to find reports showing its success or failure rate, which is not the case. Currently, there is scarcity of research work on the use of CBT to treat cases of domestic violence in Calabar metropolis other regions of Nigeria, despite the frequent occurrences of domestic violence. Seemingly, there is an academic gap between theory and practice in counselling and psychotherapy. Therefore, this study focused on engaging a CBT which is culturally tailored in line with different forms of domestic violence experienced in Calabar metropolis, and Nigeria in general, in order to solve the psychological disorders manifest among the study participants.
It is largely known that domestic violence is on the rise in Calabar metropolis and many other parts of Nigeria and the world in general (Moses et al., 2010). People experience violence which leaves them traumatized and injured. Others lose lives. The laws in place help to somewhat curb the situation, but the real
causes and negative effects of domestic violence, in particular anxiety and depression, remain unattended to in most cases. The study investigated how CBT can help women facing domestic violence to avoid psychological disturbances. Furthermore, it was necessary to establish whether there are factors that influence the occurrence of domestic violence among the study participants. Whenever the psychological problems caused by domestic violence are not addressed in good time, they transform from acute to chronic conditions in which the affected individual loses the capacity to perform ordinary duties and becomes a burden to the immediate family members and the society. Therefore, there was need to examine the intervention to apply after an experience of domestic violence, because women are also exposed to many other forms of challenges in life, including their responsibilities in the society.
Domestic violence occurs in trusting environments, especially among family members, close friends and between neighbors. When this problem occurs, it is poorly reported or kept secret by the victims for various reasons such as stigma, fear of the perpetrator, among others. Consequently, the victims are affected psychologically; they develop psychological disorders such as anxiety and depression. Their families are equally affected and destroyed by the developing disturbances, and they are never the same again. Furthermore, the maltreatment of women, who are the “backbone of the society”, by the perpetrators, is a risk factor for diverse psychopathology and other deleterious outcomes for a healthy nation and families, hampering the expectations of the Nigeria Vision 2030. Hence, the researcher accentuated the effects of domestic violence and the significance of CBT after a traumatizing experience. This means that therapy to reduce levels of anxiety and depression is crucial. Therefore, due to rampancy of domestic violence, the researcher had to investigate and apply therapy to the victims using CBT.
Dimensions of social conditions thought to be risk factors such as women’s social status, gender norms, socioeconomic development roles, among others, pose difficulties especially across cultures, and hence understanding domestic violence, requires research in many social contexts. Similarly, despite the recent scale-up of mental health care and treatment programs in Nigeria, mental health research shows there is need to develop new and more effective methods of treatment. Therefore, this could be one of the reasons why uptake of psychotherapy and counseling services in various facilities has been low, which warranted further investigations, and hence the need for this research.
Research reports show that there is a clear urgency to identify, disseminate, and implement effective psychosocial treatments for maltreated women, in a timely manner. This is because early life maltreatment in an individual is associated with abnormality in brain development and physical illnesses, which is why domestic violence needs deeper investigation and treatment. One bad experience or learning leads to another, for instance the perpetrator of domestic violence may have been abused in childhood (Black et al., 2011).
In addition, counseling centers do not seem to be quite effective in addressing the psychological disorders emanating from domestic violence. The reason identified to account for this problem is that victims of domestic violence opt to go to health facilities for medical assistance for issues such as headaches and blood pressure, to mention a few. In some health facilities, victims of domestic violence are given medical treatment but no psychotherapy for the underlying problem is given to them (McLean, 2003).
Forms of therapy such as trauma focused-cognitive behavior therapy (TF-CBT) have been observed to be superior in improving depressive symptoms in many comparative trials in America and other parts of the world.
This study improves the professionalism engaged in counseling and psychotherapy practices. Of importance, the focus was on the effectiveness of CBT on dimensions of both psychological trauma and cultural systems that govern patterns of daily living, how the cultures create psycho-special ways to assist the members who have suffered significant traumatic events, and how cultures provide the different pathways to healing and integration of extreme stressful experiences. In some societies mental healthcare is delivered by medicine men and women, witchdoctors, traditional healers,
conventional medical practices, culture-specific rituals, and community-based practices that offer forms of social and emotional support for the persons suffering adverse, maladaptive aspects of trauma (Moodley & West, 2005).
This being a research on psychological matters, it aimed at providing a clear description of human behavioral patterns and their underlying psychological processes, as well as providing explanations for the behavior. It goes beyond explanations of the problem to providing answers as to how and why the behavioral patterns, such as domestic violence, come about. The use of experiments, such as having both intervention and non-intervention groups using CBT, made it possible to answer questions about causes of a given behavior. Effectiveness of CBT was achieved by way of helping the participants to rethink the forms of interventions to embrace and move on with their lives. Through experiments, the researcher tested theories and the unobservable mental processes which other researchers may have found difficult to deal with, especially the ones addressing domestic violence and other African women’s issues. In order to test the effectiveness of CBT in dealing with the problem of domestic violence in Calabar metropolis, it was necessary for the researcher to determine the various forms of abuse which women experience, establish how the social demographic variables influence domestic violence, determine the association of domestic violence with anxiety and depression, establish the efficacy of CBT in reducing the levels of anxiety and depression, explore the factors associated with effectiveness of CBT, and establish the impact of CBT in reducing the burden of domestic violence.
1.3 Objective of the Study
The broad objective of the study was to examine the effectiveness of cognitive behavioral therapy among women exposed to domestic violence to mitigate the negative effects of domestic violence. The following were the specific objectives of the research:
- To examine the forms of domestic violence and how demographic variables influence the occurrence of domestic violence among the study sample;
- To examine the association of domestic violence with anxiety and depression among the study sample;
- To establish the efficacy of cognitive behavioral therapy in reducing levels of anxiety and depression among the intervention study sample;
- To explore the factors associated with the level of effectiveness of cognitive behavioral therapy between the intervention and non-intervention study samples; and
- To establish the impact of cognitive behavioral therapy on domestic violence among the study sample.
1.4 Research Questions
The study will seek to answer the following questions:
- What are the forms of domestic violence experienced by women and how do social demographic variables influence these forms of domestic violence?
- How is domestic violence associated with anxiety and depression among the study sample?
- What is the efficacy of cognitive behavioral therapy in reducing levels of anxiety and depression among the intervention study sample?
- What factors are associated with the level of effectiveness of cognitive behavioral therapy between the intervention and non-intervention study sample?
- What is the impact of cognitive behavioral therapy on domestic violence among the study sample?
1.5 Significance of the Study
This section demonstrates the importance of the study to the academia and the society in general. The beneficiaries of this study include victims of domestic violence, service providers, counsellors and social workers, practitioners in mental health facilities, government and private institutions, policy makers, trainers of counsellors, counseling supervisors, clinical and counselling psychology lecturers. The results generated by this study are useful in influencing policy. It is important to note that injuries generated by trauma as a result of domestic violence include the full range of physical, psychological and emotional injuries. Mental health interventions include a wide array of posttraumatic adaptations that are inclusive of symptoms such as mood disorders: major depression, anxiety disorders, dissociative phenomena and substance use or abuse disorders (Spiegel, 1994).
This study adds value to the scholarship around psychology of various schools of thought from both developing and developed countries. It will be helpful in evaluating and discussing the effectiveness of CBT in treating cases of domestic violence and other psychological challenges. It is a multidisciplinary research that cuts across psychology practices and women issues within our societies. Scholars of social sciences develop awareness of different epistemological backgrounds of studies in the social sciences and, in particular, counseling and psychotherapy. It will also provide an opportunity to compare the varied civilization perspectives involved in the research. This research stands to benefit government policy developers, ministries of education and health, and national security, to mention but a few.
This study will also enable scholars to assess and develop social science studies in general at both international and regional levels. This is the desired understanding and acquaintance, which could help in moving beyond historical experiences and misunderstandings of the downtrodden man or woman or, better still, a traumatized person in both the developing and the developed world. All of the above feed into the foundation for good and fruitful communication between the African and Western beliefs, values and practices. It was also important for therapists and their clients in understanding their rights, cultural and spiritual values, as well as in dealing with domestic violence in their communities. In other words, all parties stand a chance to realize what, when, who, how, where and whether they benefit from counseling and psychotherapy, and the potential of restoring the mind to its original state.
1.7 Scope/Limitation of the Study
The study was carried out in five health facilities within Calabar metropolis that were conveniently selected due to limitations of time and other resources. Eligible participants were women previously exposed to domestic violence. The study limited itself to women who are above 18 years because these were assumed to be of childbearing age.
1.8 Definition Of Terms
Cognition: The mental process of acquiring and using knowledge that includes awareness and thinking.
Cognitive Behavior Therapy (CBT): Cognitive Behaviour Therapy is based on assumption that a systematic change of one’s self-statements results into a corresponding reorganization of one’s feelings, thoughts and behavior (Arnkoff & Glass, 1992; Weishaar, 1993).
Cognitive Restructuring: This is a psychotherapeutic technique that gets the client to think about their problems in constructive and rational way leading to personality restructuring.
Domestic Violence (DV): This is also referred to as domestic abuse, family violence, dating abuse, spousal abuse, battering, and intimate partner violence (IPV). It is a pattern of behavior involving abuse of one partner against the other in an intimate relationship such as marriage, dating, cohabitation, or within the family (Dutton, 1996).
Abuse/Assault: This terms are commonly used interchangeably referring to unacceptable behaviour towards another person which infringes on their rights.
Physical abuse: actions which cause body physical injuries such as hitting, biting, among others. Sexual abuse: This occurs when one of the partners is forced into sexual activity when they are not ready or they are prevented from using birth control measures. Sexual assault also includes fondling and exposure to indecent acts to family members who are not of age or willing.
