Cultural considerations in the treatment of mental illness among sexually abused children and adolescents The case of Bali, Indonesia.
Lesmana, C. B. J., Suryani, L. K., & Tiliopoulos, N. (2015). Cultural considerations in the
treatment of mental illness among sexually abused children and adolescents: The case of
Bali, Indonesia. In E. L. Grigorenko (Ed.), The global context for new directions for child and
adolescent development. New Directions for Child and Adolescent Development, 147, 109–116.
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 behavior, 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 physiology, 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 psychologists 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 effects of cultural elements and showcase their potential contribution and systematic implementation into a holistic and sensitive interventional model for the
treatment of mental illness in childhood and adolescence sexual traumatization.
2015 Wiley Periodicals, Inc.
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT, no. 147, Spring 2015 2015 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com). • DOI: 10.1002/cad.20092
109
110
GLOBAL CONTEXT FOR NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT
Child Sexual Abuse
Child sexual abuse (CSA) violates the trust, safety, and age-appropriate development 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 consequences 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 example, 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 lowest appear in Asia (approx. 10%) and Europe (approx. 9%; Barth, Bermetz,
Heim, Trelle, & Tonia, 2013; Pereda, Guilera, Forns, & Gómez-Benito,
2009; Perez-Fuentes et al., 2013; Stoltenborgh, van Ijzendoorn, Euser, &
Bakermans-Kranenburg, 2011).
CSA can have lasting psychological effects on personal and interpersonal growth throughout the lifespan. These psychological outcomes can
be grouped under PTSD/trauma symptoms, internalizing and externalizing
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, anxiety, paranoid ideation, self-harm behaviors, guilt, shame, self-injurious and
suicidal ideation or behavior, and low self-esteem. Externalizing symptomatology includes conduct problems, attention deicit/hyperactivity disorder,
poor academic performance, marital or familial dysregulation, social impairment, substance abuse, hostility and aggression, inappropriate or high-risk
sexual behavior and preoccupation, and further polyvictimization in adulthood. CSA has also been identiied as a general, nonspeciic risk factor for
negative health outcomes, such as cancer or heart disease, as well as epigenetic dysregulation and brain or neurodevelopmental abnormalities (e.g.,
Anderson, Teicher, Polcari, & Renshaw, 2002; Choi, Reddy, Liu, & Spaulding, 2009; De Bellis, Spratt, & Hooper, 2011; Felitti et al., 1998; Tomoda,
Navalta, Polcari, Sadato, & Teicher, 2009).
Treatment
The main objectives of CSA treatment are to deal with speciic and the
most prominent mental health sequelae of the sexual abuse, and to decrease
the risk of future sexual victimization. However, only a rather low number of reliable studies of CSA interventional effectiveness exist. Two recent
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT • DOI: 10.1002/cad
CULTURAL CONSIDERATIONS IN THE TREATMENT OF MENTAL ILLNESS
111
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 conducted 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 operates 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 considering the speciicity of client needs and interventional settings. 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 competent 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 cultural elements appear to be present in the reporting of CSA cases, cultural
components should be considered in designing treatment programs, particularly 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
Bali is one of 17,000 islands that form the archipelago of Indonesia—the
fourth largest nation in the world (Badan Pusat Statistik, 2012a). Most of
the 3.9 million inhabitants of Bali are Hindu (83%; Badan Pusat Statistik,
2012b). The Balinese Hindu religion is unique. Although it has roots in India, it was developed largely in Java. It has been inluenced by Buddhism, by
the aboriginal Balinese culture, and by Balinese pre-Hindu animistic and ancestral cults (Jensen & Suryani, 1992). Furthermore, its relatively isolated
nature—being practiced almost exclusively on the island of Bali—makes
it a unique sect, having both function and content that at times largely
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT • DOI: 10.1002/cad
112
GLOBAL CONTEXT FOR NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT
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 emphasizes relationships to foster solidarity and cooperation within the nuclear 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 worshipped. 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 secure 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 precedence over nearly all other values in society, and the abuse of children,
whether physical, sexual, or psychological, would disrupt the socioculturally deined boundaries of a relationship with another person.
Traditional Healing and Western Psychiatry in Bali
In Bali, two types of psychotherapists exist: the Western-trained, hospitalbased psychiatrists and the spiritual (traditional) healers, known as Balians.
Although often psychiatrists and Balians aim at the same symptoms and
problems, important differences in treatment premises, theories, methods,
techniques, and modalities exist. Balians focus on the healing of illness
based on spiritual beliefs, psychiatrists on the treatment of psychobiological disorders. Psychiatrists tend to rely on external manipulations, such
as medication, cognitive, or otherwise therapy; treat illness and symptoms
concurrently; and view the treatment goals largely achieved when symptoms disappear. Thus, after the completion of a successful course of treatment, both patients and therapists may assume a complete, or near complete, recovery. Balians may use traditional medicine, but their main aim is
to “reset” the body systems so that they regulate themselves harmoniously,
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT • DOI: 10.1002/cad
CULTURAL CONSIDERATIONS IN THE TREATMENT OF MENTAL ILLNESS
113
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 originally 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 deploymentfocused model.
Through this model, victims of CSA are initially clinically interviewed
(ICD 10 interview protocols), in order to identify the presence of potentially severe symptomatology that may require a pharmacological intervention. However, the focus of the approach is to bring the individual back
into a state of psychological balance. This is achieved through guiding the
child or the adolescent to perform intentional self-care—that is, actively pay
attention to their mind, body, and spirit—and the involvement of culturespeciic agents. The children are advised to meditate twice daily (a practice
that is well respected in the Balinese culture) and to visit or revisit a Balian
to receive further spiritual healing and guidance. The families are encouraged to perform puriication ceremonies in order to cleanse the spiritual
burden that resulted from their exposure to the illness. Furthermore, the
children’s families, both nuclear and extended, and communities are offered
workshops, many times in the temple or other religiously holy places, educating them on the relevant issues in a meaningful and respectful language
to their culture and local customs. Public dialogues are frequently set up,
where affected families and interested individuals are openly invited and encouraged to participate, exchange information, and receive further advice
and support. Mutual support groups are created by the families, neighbors,
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GLOBAL CONTEXT FOR NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT
schoolteachers and school counselors, and community leaders who are responsible 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 evaluated 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 holistic 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 permeates all aspects of life, such therapies need to follow an integrated, multimodal, and synergic approach to intervention. Such an approach would
mobilize modern psychotherapeutic techniques and medication, while respecting and responsibly utilizing the traditional health practices and religious beliefs of the focal human geography.
In conclusion, it is our conviction that through the prudent and systematic 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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COKORDA BAGUS J. LESMANA is an associate professor, Department of Psychiatry, School of Medicine, Udayana University, Denpasar, Indonesia, and can be
reached via email at [email protected]
LUH KETUT SURYANI is a professor, Suryani Institute for Mental Health, Denpasar,
Indonesia, and can be reached via email at [email protected]
NIKO TILIOPOULOS is a senior lecturer at School of Psychology, The University
of Sydney, Sydney, Australia.
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT • DOI: 10.1002/cad
treatment of mental illness among sexually abused children and adolescents: The case of
Bali, Indonesia. In E. L. Grigorenko (Ed.), The global context for new directions for child and
adolescent development. New Directions for Child and Adolescent Development, 147, 109–116.
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 behavior, 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 physiology, 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 psychologists 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 effects of cultural elements and showcase their potential contribution and systematic implementation into a holistic and sensitive interventional model for the
treatment of mental illness in childhood and adolescence sexual traumatization.
2015 Wiley Periodicals, Inc.
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT, no. 147, Spring 2015 2015 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com). • DOI: 10.1002/cad.20092
109
110
GLOBAL CONTEXT FOR NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT
Child Sexual Abuse
Child sexual abuse (CSA) violates the trust, safety, and age-appropriate development 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 consequences 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 example, 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 lowest appear in Asia (approx. 10%) and Europe (approx. 9%; Barth, Bermetz,
Heim, Trelle, & Tonia, 2013; Pereda, Guilera, Forns, & Gómez-Benito,
2009; Perez-Fuentes et al., 2013; Stoltenborgh, van Ijzendoorn, Euser, &
Bakermans-Kranenburg, 2011).
CSA can have lasting psychological effects on personal and interpersonal growth throughout the lifespan. These psychological outcomes can
be grouped under PTSD/trauma symptoms, internalizing and externalizing
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, anxiety, paranoid ideation, self-harm behaviors, guilt, shame, self-injurious and
suicidal ideation or behavior, and low self-esteem. Externalizing symptomatology includes conduct problems, attention deicit/hyperactivity disorder,
poor academic performance, marital or familial dysregulation, social impairment, substance abuse, hostility and aggression, inappropriate or high-risk
sexual behavior and preoccupation, and further polyvictimization in adulthood. CSA has also been identiied as a general, nonspeciic risk factor for
negative health outcomes, such as cancer or heart disease, as well as epigenetic dysregulation and brain or neurodevelopmental abnormalities (e.g.,
Anderson, Teicher, Polcari, & Renshaw, 2002; Choi, Reddy, Liu, & Spaulding, 2009; De Bellis, Spratt, & Hooper, 2011; Felitti et al., 1998; Tomoda,
Navalta, Polcari, Sadato, & Teicher, 2009).
Treatment
The main objectives of CSA treatment are to deal with speciic and the
most prominent mental health sequelae of the sexual abuse, and to decrease
the risk of future sexual victimization. However, only a rather low number of reliable studies of CSA interventional effectiveness exist. Two recent
NEW DIRECTIONS FOR CHILD AND ADOLESCENT DEVELOPMENT • DOI: 10.1002/cad
CULTURAL CONSIDERATIONS IN THE TREATMENT OF MENTAL ILLNESS
111
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 conducted 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 operates 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 considering the speciicity of client needs and interventional settings. 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 competent 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 cultural elements appear to be present in the reporting of CSA cases, cultural
components should be considered in designing treatment programs, particularly 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
Bali is one of 17,000 islands that form the archipelago of Indonesia—the
fourth largest nation in the world (Badan Pusat Statistik, 2012a). Most of
the 3.9 million inhabitants of Bali are Hindu (83%; Badan Pusat Statistik,
2012b). The Balinese Hindu religion is unique. Although it has roots in India, it was developed largely in Java. It has been inluenced by Buddhism, by
the aboriginal Balinese culture, and by Balinese pre-Hindu animistic and ancestral cults (Jensen & Suryani, 1992). Furthermore, its relatively isolated
nature—being practiced almost exclusively on the island of Bali—makes
it a unique sect, having both function and content that at times largely
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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 emphasizes relationships to foster solidarity and cooperation within the nuclear 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 worshipped. 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 secure 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 precedence over nearly all other values in society, and the abuse of children,
whether physical, sexual, or psychological, would disrupt the socioculturally deined boundaries of a relationship with another person.
Traditional Healing and Western Psychiatry in Bali
In Bali, two types of psychotherapists exist: the Western-trained, hospitalbased psychiatrists and the spiritual (traditional) healers, known as Balians.
Although often psychiatrists and Balians aim at the same symptoms and
problems, important differences in treatment premises, theories, methods,
techniques, and modalities exist. Balians focus on the healing of illness
based on spiritual beliefs, psychiatrists on the treatment of psychobiological disorders. Psychiatrists tend to rely on external manipulations, such
as medication, cognitive, or otherwise therapy; treat illness and symptoms
concurrently; and view the treatment goals largely achieved when symptoms disappear. Thus, after the completion of a successful course of treatment, both patients and therapists may assume a complete, or near complete, recovery. Balians may use traditional medicine, but their main aim is
to “reset” the body systems so that they regulate themselves harmoniously,
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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 originally 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 deploymentfocused model.
Through this model, victims of CSA are initially clinically interviewed
(ICD 10 interview protocols), in order to identify the presence of potentially severe symptomatology that may require a pharmacological intervention. However, the focus of the approach is to bring the individual back
into a state of psychological balance. This is achieved through guiding the
child or the adolescent to perform intentional self-care—that is, actively pay
attention to their mind, body, and spirit—and the involvement of culturespeciic agents. The children are advised to meditate twice daily (a practice
that is well respected in the Balinese culture) and to visit or revisit a Balian
to receive further spiritual healing and guidance. The families are encouraged to perform puriication ceremonies in order to cleanse the spiritual
burden that resulted from their exposure to the illness. Furthermore, the
children’s families, both nuclear and extended, and communities are offered
workshops, many times in the temple or other religiously holy places, educating them on the relevant issues in a meaningful and respectful language
to their culture and local customs. Public dialogues are frequently set up,
where affected families and interested individuals are openly invited and encouraged to participate, exchange information, and receive further advice
and support. Mutual support groups are created by the families, neighbors,
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schoolteachers and school counselors, and community leaders who are responsible 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 evaluated 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 holistic 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 permeates all aspects of life, such therapies need to follow an integrated, multimodal, and synergic approach to intervention. Such an approach would
mobilize modern psychotherapeutic techniques and medication, while respecting and responsibly utilizing the traditional health practices and religious beliefs of the focal human geography.
In conclusion, it is our conviction that through the prudent and systematic 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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COKORDA BAGUS J. LESMANA is an associate professor, Department of Psychiatry, School of Medicine, Udayana University, Denpasar, Indonesia, and can be
reached via email at [email protected]
LUH KETUT SURYANI is a professor, Suryani Institute for Mental Health, Denpasar,
Indonesia, and can be reached via email at [email protected]
NIKO TILIOPOULOS is a senior lecturer at School of Psychology, The University
of Sydney, Sydney, Australia.
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