Reasons for Not Seeking Professional Help by Abused Refugee Women: A Qualitative Study

Method

Results

Descriptive and Demographic Results

Participants’ age ranged between 15 and 45 years (M = 29 years). Most of the women have low educational level (n = 23 women, 76.7%). Most of the family household monthly income in U.S. dollars was less than US$100 (n = 19, 63.3%), and the family income resources were from United Nations Higher Commission of Refugee (UNHCR) financial support (n = 24, 80%) and personal salary (n = 6, 20%). All women were unemployed and Muslims. Only two women (7.6%) were without children where the rest have. Women’s husbands were the perpetrators (n = 30, 100%). Regarding violence exposure, most of the women (n = 19, 63.3%) had experienced IPV in the past 6 months and 27 women (90%) did not report the IPV directly and voluntarily. Almost all of them (n = 29, 96.6%) did not ask any protection services (except one woman), and 15 women (50%) tried to ask informal and unprofessional help from their friends. For more information, see Table 1.

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Table 1.

Characteristics of the Study Participants.

Item	n =30	%
Age
15–25 years	10	33.3
26–35 years	8	26.7
36–45 years	12	40
Educational level
Low educational level (illiterate, primary education)	23	76.7
Intermediate level (middle school, secondary vocational education training)	4	13.3
High educational level (secondary school education and university)	3	10
Income level
≤US$100	19	63.3
US$101–US$150	10	33.3
>US$150	1	3.3
Family income resource
UNHCR financial support	24	80
Personal salary	6	20
Number of children
No children	2	6.7
One child to three children	12	40
Four to six children	11	36.6
More than seven children	5	16.7
Violence exposure
Past 6 months	19	63.3
Past 12 months	6	20
Past 18 months	5	16.7
Previous violence reporting
Did not report	27	90
Reported violence	3	10
Asking help and support from specialized centers
Did not ask for any protection services	29	96.6
Asked for informal and unprofessional help from their friends	15	50
Asked for support from specialized centers	1	3.3

UNHCR = United Nations Higher Commission of Refugee.

Factors affecting help-seeking behaviors for IPV refugee women

Five factors were found to affect women’s help-seeking behaviors, they included misconceptions about IPV problem; difficulties to access and approach different care centers; lack of awareness of the negative consequences of IPV; unaware, negative expectations, negative experiences and incorrect thoughts about IPVs’ services; and psychological and physical health difficulties.

Theme 1: Misconception about IPV problem

Although all interviewed women felt uncomfortable in their current marital relationship due to IPV, 23 women (76.6%) did not feel that they need help because of this problem, even if we considered it a problem, it will disappear soon. Twenty-five women (83.3%) did not consider their IPV problem serious enough to seek professional help. One interesting finding was two thirds of the interviewed women (n = 20) did not recognize the partner’s aggressive behaviors as a human right violation, but they considered it a normal reaction. Furthermore, several women (86.6%) stated that they did not consider solving IPV problems as their highest priority in the meantime as basic needs were more important. The following quotation clarifies this:

I am a refugee woman, raised 5 children without any income resources [just UNHCR support], every morning I have opened my eyes to different needs, pains, and suffering. IPV is not my priority now.

Twenty-two women (73.3%) think violence is limited to physical type while emotional, sexual, or psychological types were not recognized as violence or a personal violation.

Theme 2: Difficulties to access and approach different care centers

Twenty-nine women (96.6%) were earning less than US$150 monthly. All of the interviewed women were living in the north of Jordan, where 20 women (66.6%) lived in a refugee camp and the rest of them live in poor scattered villages. All participants indicated that they faced difficulties to access and approach different care centers as a result of high transportation costs, lack of accessibility, low transportation quality, and long-distance between their homes and located caring centers.

All interviewed women faced legal problems due to illegal residence in Jordan. Twenty-seven women (90%) thought that they could not move freely because of their illegal residence. Fifteen women (50%) believed that the police would arrest if they left the camp without prior approval of the camp administration. The following illustration clarifies this:

I have lived in the Zaatari refugee camp since the crisis began in Syria. It was not allowed for us to move out of the camp freely, and some of the needed services were offered out of it. Therefore, facing violence was better than facing police and detention.

One of the women mentioned the following statement about security problems that prevented her from receiving help outside the camp:

If you wanted to get out of the camp, you were under the risk of facing outside community hostility; I have been subjected to a lot of sexual harassment because I was a refugee woman, it was better to seek help from a friend or a family member.

Theme 3: Lack of awareness of the negative consequences of IPV

This theme has three components: (a) lack of awareness of the relationship between IPV and marriage dysfunction, (b) lack of awareness of the negative impact of observing violence on children, and (c) lack of awareness of the relationship between IPV and different physical complaints. The researchers asked all women if they suffered from unknown physical complaints. Twenty-three women (76.6%) answered positively, but at the same time, none of them justified their complaints to IPV exposure. Consequently, they did not disclose the IPV to their doctors. The following illustration clarifies this:

For a long time, I was beaten, kicked, and insulted by my husband. At the same time, I used to visit health centers’ doctors to deal with unexplained physical complaints in my head, back and abdomen. I have not thought before that these complaints might be associated with IPV.

All ARWs expressed having negative feelings such as guilt, sleep problems, loss of appetite, unsecured, and lack of interest with any activity combined with poor concentration. Twenty-three women (76.6%) indicated that they did not link their psychological complaints to IPV. One woman illustrated the following:

I have suffered from a low mood in the morning, no interest, long periods of crying, and isolation. I have repeatedly had different suicidal thoughts, but my children’s responsibility stopped me. You know this was the first time that I talked about my suffering; I needed to rethink all these feelings concerning my experience of violence.

Witnessing IPV by children was affecting their mental, social, and emotional health. Fifteen women (50%, most of them had sufficient educational level) stated that, if children witnessed violence, their mental, social, and emotional development would be hampered negatively. These women indicated that they tried to hide the abuse from their children (verbal, physical, and sexual ones). As a result of this, these 15 women had participated in some LCOs’ activities about IPV. The following quotation clarifies this:

I knew that violence could hurt my children’s mental health and hampers their development at different levels, I used to behave as nothing had happened in front of them.

On the other side, 15 women (50%) did not believe that witnessing IPV could hurt their children. These women were deprived of any local activities regarding women’s empowerment and violence programs. The following quotation clarifies this:

When I was a child, I had witnessed many different violent events in my original family, nothing happened to me. The same for my children, they did not suffer from any problems.

Theme 4: Unaware, negative expectations, negative experiences, and incorrect thought about IPVs’ services

Twenty-nine (96.6%) women tried to solve their marital problems by themselves. They have never asked for any formal help from LOCs (e.g., police, protection shelters, mental health professional\family physician). Just one woman asked help from the police department and reported severe physical violence. Most of them (23 women, 76.6%) did not believe that the police’s help would solve their problem. A woman illustrated:

Oh my God . . . this was the first time to know that such service was available for refugee women in Jordan. I thought that the protection services and interventions against violence were exclusive for Jordanian women.

All ARWs have never sought professional help for their marital difficulties. Twenty women (66.6%) thought that seeking help could cause a personal scandal and would be interpreted as a personal weakness. Furthermore, asking for outside help was considered a taboo. Half of them were sure that no one will understand them if they decided to report their suffering to the police or LOCs. One woman illustrated:

This was my first time to talk about my IPV experience, speaking to outsiders was not recommended and considered odd. No one could understand you well. It was better to keep your problems inside your home.

Most of them (21 women, 70%) thought that their counselor, mental health professional, or physician were not capable of handling their problems. Twenty-five (83.3%) women thought that they would not benefit from the services. Women did not believe in the services’ providers and their abilities in providing any kind of help. This hampered them from asking professional support. One woman said,

One day I decided to speak about IPV with the counselor during my visit to LOCs. She hardly listened, so I did not think that any good change would happen.

Fear from negative expected outcomes was influencing women’s behaviors to seek help and professional support. Twenty-five women (83.3%) believed that asking help would eventually lead to divorce and separation from their children and families. Furthermore, it could hurt their families because of the possibility of expelling the perpetrator (husband) and returning him to his country of origin (deportation), which might increase their family suffering.

Some women (21, 70%) were refraining from seeking professional help due to the expected low privacy procedures from professional staff. The following quotation clarifies this:

I did not trust to discuss my issues with strangers, I was a refugee and afraid that they would send my husband away. You should, therefore, be so careful when you decide to share any personal information with these professionals.

Another remarkable issue was related to the possible women’s misunderstanding of the interaction between IPV exposure and the resettlement process in the UNHCR. Nine women (30%) thought that if they reported any IPV incidents to UNHCR or other organizations their resettlement process would be hampered. The following quotation by woman clarifies this:

I have heard from my neighbor who was abused by her husband, if any abused woman has reported her IPV, the UNHCR would help her immediately, but her resettlement file would face difficulties.

Theme 5: Psychological and physical health difficulties

Half of the abused women (50%) reported depressive symptoms (sadness, loss of interest in activities, loss of pleasure, fatigue, excessive crying, feeling of guilt, sleep difficulties, worthlessness, and helplessness). Seven women (23.3%) were referred before to mental health clinics for their depressive symptoms.

One woman indicated the following depressive symptoms:

Depression for me came out of nowhere and hit me like a ton of bricks. I could not eat, sleep or connecting with pleasure and enjoyment. I was an IPV victim with a traumatic history, I could not stand up again.

Five women (16.6%) suffered from physical limitations resulted from exposure to torture. Three women (10%) suffered from leg amputation resulting from different war accidents. One amputee woman mentioned:

As you see I had a physical disability, I could not work or go out of my home.… I hoped that IPV’s services could be modified to be mobile and provided their services at home.

Discussion

Although our participants were having common reasons for not seeking professional help, each woman has her unique story to tell. We understood each woman’s personal experience and kept conscious about our position to not to generalize women based on race, class, nationality, or status. We recognized that our nationality as Jordanians informs our research. We kept our personal position in mind all the time, so we could present out findings with integrity and contemplation (Berrien, 2018). Refugee women have experienced many serious stressful events because of oppression, war, migration, and resettlement (Refugee Health Technical Assistance Center, 2011). For the Syrian refugee women, political oppression intersects with other forms of oppression, such as racism, classism, religious, and sexism oppression (Berrien, 2018) that powerfully affected women’s experiences, specifically being a refugee who has experienced IPV.

We found some factors affecting ARWs’ decision for seeking professional help. These factors included: misconceptions about IPV problems; difficulties to access and approach different care centers; lack of awareness of the negative consequences of IPV; unaware, negative expectations, negative experiences, and incorrect thoughts about IPVs’ services; and psychological and physical health difficulties.

Our participants had misconceptions about IPV. The main important result of this study was, although participated ARWs were dissatisfied with their marriage relationship, they did not consider themselves as IPV victims and this could be their husbands’ view of point, but we did not ask about the husband in our study. This might affect women’s seeking help behaviors and resulting in a lack of motivation for seeking professional help. This result went with other studies line (Alotaby et al., 2012; Damra et al., 2015; Qasem et al., 2013) which reported that women tended not to disclose or ask for help for IPV as they considered it as usual family interaction.

The results revealed that dealing with violence was not a priority for ARWs, because of their suffering from difficult living situations inside and outside refugee camps. All interviewed women faced various problems such as low income (less than US$100 monthly), living in rented homes, living in refugee camps, facing persecution and; difficulties in traveling due to illegal residency in Jordan with significant fears and distrust. This result was congruent with McColl and Johnson’s (2006) findings, which indicated that the majority of psychiatric suffering of refugee individuals were not only related to violence experience but also associated with persecution, social isolation, and separation from families.

Women did not consider the aggressive behavior of their partners as dangerous and violent. This could be understood in light of abused woman’s changing stages theory by Burke and her colleagues (2004). Burke et al. (2004) described the change in abused women as a gradual process with several stages. The first stage: precontemplation, which could be defined as: A woman does not recognize the partner aggressive behaviors like violence and is not motivated for action. The second stage: The contemplation can be described as the abused woman identifies the problem as a kind of abuse; this stage is followed by increasing awareness and weighs the benefits and disadvantages of enrolling in the changing process. Burke et al. (2004) described additional two processes, which help IPV victims to move from the precontemplation to the contemplation stage, which are consciousness-raising and therapeutic alliance (helping relationships). Unfortunately, most of our participated ARWs were still in the precontemplation stage and they had a low level of awareness toward the violence’s negative consequences and did not ask for any professional help. So, they were not ready to move into the contemplation stage.

Another finding was women’s difficult living conditions (camps and illegal residency) resulted in difficulties to access and approach different care centers. Our finding is supported by Prosman et al. (2014) study, who found that IPV refugee victims have materialistic problems to access professional help. Women’s limited resources and their illegal residence made it difficult to access care. Furthermore, women thought that they might lose their freedom if they were arrested by police or they might face community hostility and sexual harassment. All these factors were preventing women from approaching health centers. Abused women’s conservative behaviors toward approaching health centers could be understood through the perspective of conservation of resources theory (COR), which is among the most popular attempts to describe interpersonal regulation and coping processes with stress (Hobfoll, 2012). Based on COR, people are consciously aware that their resources are under the risk of loss or are unstable, they are more likely to move toward decreases possible stressors rather than increases personal resources within contingent domains (Hobfoll, 2011). This process can interfere with ARWs behaviors toward experienced violence. All interviewed women were living in difficult situations and limited personal resources, they tended to save and keep their present or current resources (e.g., living with family, freedom, being close to her children) rather than fighting violence and abuse and adapting self-empowerment behaviors.

Not seeking professional help might be related to women’s lack of awareness of violence’s negative consequences on themselves and their children. For that reason, some of them tried to neglect their problems, sufferings, and not asking for help. A woman in an early stage of change like our sample lacks the awareness of what exposure to violence does to her children (Lemmey et al., 2001). According to Burke et al. (2004), a woman who is in a late or advanced stage of change can recognize the violence impact on her children and herself. Such a woman is ready to be in a change process and she will take action to eliminate violence, which was not the case with our study participants.

Our findings are similar to Randell et al. (2012) work, who have divided all factors, which can affect an abused woman for seeking help, into two broad categories, internal and external motivators. The importance of labeling the husband’s behaviors as abusive by the IPV victim and woman’s awareness of the abuse consequences are examples of internal motivators. While negative experience with provided services and health staff is an example of external motivators. Furthermore, our findings are congruent with Zink et al. (2003), who found that lack of awareness among women of the impact of violence on the physical and mental health of their children could lead them to lose their motivation for asking professional help which is highly recommended.

Our findings showed that all women reported that they were having negative somatic feelings, where most of them indicated that they did not link their complaints to IPV. This could be explained that these women might relate their physical complaints to their suffering from displacement and limited financial resources rather than from violence.

Our study also revealed that ARWs had a lack of awareness, negative expectations, negative experiences, and incorrect thoughts about IPVs’ services, which led them not to ask professional help. The incorrect thoughts about IPVs’ services could be explained by the gap between the offered health services and the needs of ARWs. This gap ended up in making women not motivated to accept the services and seek professional help. Our findings are similar to Jordan Population and Family Health Survey results (Department of Statistics & ICF International, 2013), which showed that victims of IPV did not consider the available services (LOCs or other health centers) as helpful resources for dealing with their family and marital problems or distress. Moreover, our findings are supported by Morrison et al. (2017) study, as they reported that abused women’s mistrusts with health care providers and counselors’ capacities are considered as the main problem that faces providing services to IPV victims (Morrison et al., 2017).

The results revealed that some interviewed women have faced physical and mental health problems (e.g., depression, amputation, and movement limitations), that prevented them from asking help. The result is consistent with Raj and Silverman’s (2002) study, who reported that ARWs might experience high levels of depression, mainly because of asylum, trauma, torture, rape, and witnessing acts of war and destructions, in addition to their daily suffering from IPV. The depressive symptoms could prevent women from asking help, because of the lack of hope for changing to a better life. Furthermore, these results are consistent with Guruge et al. (2012) findings, who found that a substantial proportion of the refugee women had experienced physical and mental health impairments as a result of various types of violence inside and outside their families. Another study finding which supported ours was done by Javanbakht and her colleagues (2019), who have revealed that depression and anxiety rates were the highest among newly resettled in the U.S. Syrian refugee women. Also, they found that a high prevalence of possible psychiatric disorders was related to trauma exposure (e.g., violence, torture) and stress.

Most of the participated ARWs tried to solve their marital problems with their husbands by themselves. They preferred asking for help from their relatives or friends rather than receiving professional help. This could be discussed in light of the emerged wrong expectations and thoughts toward professional help (e.g., incorrect relationship between their resettlement process and IPV exposure). This result highlights the importance of working to change these incorrect thoughts and cognitive contents by LOCs, UNHCR staff, and other care providers.

As researchers, we need to understand the extent of the IPV problem by getting into women’s stories to understand the pressure of their displacement, culture, and norms, as well as the gender-based violence that they were facing. We, as researchers, are trying to contact policymakers to get them involved in understanding the actual reasons for seeking help for the IPV that the women faced and the changing pattern of IPV since displacement from Syria. Such an understanding could help in preparing programs to prevent violence among refugees.

Conclusion

Most of the ARWs of our study group is depending on receiving informal support but not professional help. Most of the interviewed women were unaware of the possible negative consequences of abuse, faced different difficulties for approaching services (logistics or personal), had incorrect thought and negative perceptions toward receiving professional help; suffered from psychological and physical difficulties which, resulted from long exposure to war. All of these barriers can hinder women from asking for professional help. Family counselors with other professionals (e.g., physicians, social workers, and refugee workers) can play an important role in recognizing ARWs and facilitate their access for help.