The Effect of Gestalt-Based Counseling on the Level of Self-Esteem and Intimate Partner Violence against Pregnant Women: A Randomized Control Trial.

BACKGROUND: Violence against women is a health problem that poses an additional threat to the mother and fetus during pregnancy. Therefore, the present study was conducted to investigate the effect of Gestalt counseling on self-esteem and Intimate Partner Violence (IPV) in pregnant women.
MATERIALS AND METHODS: This clinical trial was carried out on 60 pregnant women who were referred to health-care centers in Kerman, Iran, in 2018. Simple random sampling was performed through lottery. The intervention group (n = 30) received counseling in eight weekly sessions of 45 min using the Gestalt approach. The control group was placed on a waiting list. There was no blinding during the study. Data were collected using a demographic questionnaire, the Domestic Violence Questionnaire designed by Mohseni Tabrizi, and the Rosenberg Self-Esteem Scale before and after counseling.
RESULTS: Differences between the groups in terms of mean score of violence (intervention: t34= 1.81, p = 0.08; control: t34= 1.41, p = 0.16) and self-esteem (intervention: t34= 1.87, p = 0.07; control: t34= 1, p = 0.32) in the pretest and posttest were not significant. Analysis of covariance results showed a significant difference between the intervention 21.79 (10.62) and control groups 21.79 (10.62) in terms of mean (SD) violence (F 1,67= 1.97, p = 0.049) after the counseling sessions. It also showed a significant difference between the intervention 74.47 (14.61) and control groups 66.28 (15.14) in terms of self-esteem after the intervention (F 1,67= 5.02, p = 0.01).
CONCLUSIONS: Considering the impact of the Gestalt approach on IPV and self-esteem, it is recommended that health-care providers be educated about using the Gestalt approach and apply it in communication with women. Copyright:

Introduction

Violence against women is a social, legal, and health problem that poses an additional threat to women during pregnancy.[1] In 48 demographic studies worldwide, it was revealed that between 10% and 69% of women had experienced Intimate Partner Violence (IPV) in their lives.[2] The rate of female-perpetrated violence among Iranian women was reported to be over 60% in the study by Kargar Jahromi et al.[3] In Kerman, Iran, the average rate of violence against women was 55.78%.[4]

Violence during pregnancy increases the risk of low birth weight, hypertension, infection, and anemia[5] and decreases access to prenatal care.[6] It also leads to uterine and abdominal trauma, fetal bone fractures, and uterine rupture,[7] miscarriage, preterm labor, premature rupture of the fetal membranes, and increased risk of prenatal death and cesarean delivery prevalence.[6] Violence against women has a negative impact on other important health priorities, such as maternal health and safety, family planning, sexually transmitted disease prevention, HIV, and mental health.[4]

Experimental studies over the past 15 years indicate that self-esteem is an important psychological factor affecting health and quality of life. As self-esteem grows, a person feels empowered and valued. Self-esteem is one of the most important factors in modulating psychosocial stress and is based on family relationships, social interactions, academic success, body image, and sense of self-worth.[8] Women with low self-esteem do not feel good about themselves and their social and family roles.[4] There is a strong correlation between self-esteem and IPV;[9] however, self-esteem alone cannot combat IPV. The less in control an offender feels, the more they want to hurt others.[10] Moreover, intimate violence deteriorates women's self-esteem.[11] Low self-esteem and fear keep women from leaving the abusive intimate relationship.[10]

One way to promote self-esteem and deal with violence is to empower women through education and counseling. Of the various approaches to this issue in psychology, Gestalt therapy has attracted the attention of many researchers since it is a phenomenological and existentialist-based approach that emphasizes on factors such as human experiences, responsibility of individuals, and individuals' ability to determine present experiences as well as the experiences of clients and therapists.[4] Due to the adverse effects of IPV on women, especially during pregnancy, the present study was conducted to investigate the effectiveness of Gestalt-based counseling on pregnant women's level of self-esteem and IPV against pregnant women.

Materials and Methods

This clinical trial (IRCT20151103024866N11) was carried out in Kerman, a city in southern Iran, in 2018. Data collection lasted for 3 months (September 2018–November 2018). The study population consisted of pregnant women who were referred to health centers affiliated to Kerman University of Medical Sciences for prenatal care.

The study sample consisted of pregnant women who had the inclusion criteria. The study inclusion criteria were age of 18–45 years, a single pregnancy, and minimal literacy in reading and writing. The exclusion criteria included suffering from pregnancy complications, such as bleeding, high blood pressure, preterm delivery, and intrauterine fetal death, occurrence of sudden events during the study, such as loss of a close relative and job loss, having emergency cesarean section, and lack of participation in more than two counseling sessions. Considering a study power of 80%, d = 1.50, and α error of 5%, 30 pregnant women were chosen for participation in each group.

Multistage sampling was performed; stratified sampling was used in the first stage and cluster sampling in the second stage. There are 54 health clinics in Kerman city, Kerman Province, Iran. This city was divided into three districts of upper, middle, and lower in terms of economic-cultural status. There were 18 health clinics in each district. Using random sampling, four clinics were selected from each district. In each district, two health clinics were randomly considered as control group and two health clinics as intervention group, so that the members of the intervention and control groups had no contact with each other.

The names of eligible pregnant women were then listed, and based on the pretest results, individuals who had experienced domestic violence were separated. Thus, 67 people who had been exposed to domestic violence were allocated to the intervention group and 71 people were allocated to the control group. Since there was a possibility of sample loss during the study, although the sample size was determined to be 30 people in each group, 40 people were enrolled. In the experimental group, five people were excluded from the study; two due to lack of regular participation in counseling sessions, two due to preeclampsia, and one because of preterm labor. In the control group, five people were excluded from the study; one because of gestational diabetes, one due to preeclampsia, and three people due to unwillingness to complete the posttest questionnaire. Finally, data related to 35 people in each group were analyzed [Figure 1].

Figure 1

CONSORT flow diagram of the participants

Data were collected using three questionnaires. The first questionnaire evaluated demographic characteristics. The second was the Domestic Violence Questionnaire designed by Mohseni Tabrizi et al.[12] in 2012 with the help of reference books, screening tools, and dissertations and based on the cultural and social conditions of Iran. This questionnaire has 60 questions that evaluate spousal abuse, patriarchal beliefs, family upbringing, and violence learning. The questions are scored based on a 5-point Likert scale (0-4), and the total score of the questionnaire ranges from a minimum score of 0 to a maximum of 240 and it does not have cutoff point. Its validity and reliability have been measured and confirmed in various studies.[1314] In the present study, the Cronbach's alpha coefficient of the questionnaire was 0.83, which shows that the reliability of the questionnaire is sufficient.

The third questionnaire was the Rosenberg Self-Esteem Scale (RSES) which consists of 10 questions. The minimum and maximum total score of the RSES is 0 and 30, respectively. The reliability of this scale has been estimated using the split-half method, and between the Persian and English versions using the Spearman–Brown formula (0.73), which was statistically significant, and the validity of the Persian version has been calculated through test–retest method with a 10-day interval. The correlation coefficient was 0.74.[15]

The participants in both groups filled out the questionnaires before the intervention. In the intervention group, eight Gestalt-based counseling sessions were held in a suitable room in the health-care centers over 8 weeks by a trained midwife who had studied “counseling in midwifery.” Gestalt therapy can enhance self-esteem and reduce intimate violence. It emphasizes increasing clients' awareness of their current needs and internal conflicts. This aim is achieved by the “empty chair” individual exercises, working through projections and retroflection, and assertiveness in the sessions [Table 1].

Table 1

Brief description of contents provided in Gestalt therapy sessions

Session one	Greeting, clarifying the rules and therapeutic intervention, and explaining the concept of self-assertiveness and its benefitsHomework: identifying situations in which a person is unable to express himself/herself and exercise individual rights
Sessions two and three	Projection play, unfinished business, and empty chairs techniques were performed to identify the personal feelings of participants, energy spent on their past relationships, and its emotional outputHomework: having assertive behaviors
Sessions four and five	Hot seat, role-playing about responsibility to recognize their positive values and irrational values of othersHomework: mirror technique and creating a step-by-step plan to achieve the objectives
Sessions six and seven	Reverse role-playing, and playing a desired role in a similar social situationHomework: practicing to say promising and positive statements about the future, acting in real life
Session eight	Summarizing and wrapping-up previous sessions

The counselor had prepared a checklist and table based on the homework of every session that the women had done at home and in the outside environment. In the following sessions, the clients had to bring the completed checklist and table. This showed that they had done what the facilitator had requested from them. Each session lasted 45 min.

Posttest was performed in the intervention group on the last consultation session and in the control group simultaneously. During the intervention period, the control group only attended the prenatal care visits in the health-care centers. Moreover, after the posttest, an educational pamphlet containing a summary of the content of the counseling sessions was provided to the control group participants. In fact, they were placed on the waiting list for counseling intervention upon their request after the intervention period.

The descriptive statistics were reported as frequency, percentage, and mean (SD). To analyze the data, independent t-test, paired t-test, Chi-square test, and analysis of covariance (ANCOVA) were used. The significance level was considered as 0.05. The statistical software used for data analysis was SPSS software (version 22, IBM Corp., Armonk, NY, USA).

Ethical considerations

After obtaining the approval of the ethics committee (IR.KMU.REC 166, 1397), the study was started. Participants were informed of the objectives of the study and a written informed consent was signed by them.

Results

The two groups were homogenous in terms of demographic variables, such as age difference between partners, own and husband's occupation, and education [Table 2]. In the intervention group, the mean (SD) of violence was reduced after counseling to 19.27 (8.19) compared to 20.51 (9.42) in the pretest, but this difference was not statistically significant (t34= 1.81, p = 0.08).

Table 2

Distribution of demographic characteristics by intervention and control groups

GroupVariable		Frequency (%)		Test statistic	df	p
		Intervention	Control
Education of woman	High school	5 (14.28%)	5 (14.28%)	χ2=0.60	2	0.74
	Diploma	16 (45.72%)	13 (37.15%)
	University	14 (40%)	17 (48.58%)
Education of spouse	High school	7 (20%)	12 (34.29%)	χ2=2.85	2	0.24
	Diploma	15 (42.86%)	9 (25.72%)
	University	13 (37.15%)	14 (40%)
Woman’s job	Employee	4 (11.43%)	4 (11.43%)	χ2=2.06	3	0.55
	Manual worker	1 (2.86%)	1 (2.86%)
	Freelance job	0	2 (5.72%)
	Homemaker	30 (85.72%)	28 (80%)
Spouse’s job	Employee	9 (25.72%)	12 (34.29%)	χ2=0.64	3	0.88
	Manual worker	5 (14.29%)	4 (11.43%)
	Freelance job	20 (57.15%)	18 (51.43%)
	Un employed	1 (2.86%)	1 (2.9%)
Woman’s age	Mean (SD)	27.62 (5.62)	27.25 (5.23)	t=0.28	68	0.77
Gestational age		24.71 (9.59)	25.45 (9.09)	t=0.33	68	0.74
Spouse age difference		4.23 (2.84)	3.34 (2.66)	t=1.30	68	0.19

There was a difference in the mean (SD) of self-esteem between the pretest 70.47 (15.12) and posttest 74.47 (14.61) in the intervention group, but it was not statistically significant (t34= 1.87, p = 0.07). There was no significant difference in the mean (SD) of violence between the pretest 21.85 (10.61) and posttest 21.79 (10.62) in the control group (t34= 1.41, p = 0.16). In addition, there was no significant difference in the mean (SD) of self-esteem between the pretest 67.13 (16.35) and posttest 66.28 (15.14) in the control group (t34= 1, p = 0.32) [Table 3].

Table 3

Comparison of the mean score of violence and self-esteem before and after the intervention in the intervention and control groups

Variable	Group	Mean (SD)		t	df	p
		Before	After
Self-esteem	Intervention	70.47 (15.12)	74.47 (14.61)	1.87	34	0.07
	Control	67.13 (16.35)	66.28 (15.14)	1	34	0.32
Violence	Intervention	20.51 (9.42)	19.27 (8.19)	1.81	34	0.08
	Control	21.85 (10.61)	21.79 (10.62)	1.41	34	0.16

Based on the results of ANCOVA, the mean score of violence after counseling in the intervention group was significantly less than that in the control group (F1,67= 1.97, p = 0.04), Moreover, according to the results of ANCOVA, a significant difference was observed between the groups after the intervention in terms of the mean score of self-esteem (F1,67= 5.02, p = 0.01). The mean score of self-esteem in the intervention group was 5.61 points higher than that in the control group [Table 4].

Table 4

Comparison of mean score of violence and self-esteem after the intervention between the intervention and control groups

Variable	Group	Mean (95% CI)	Mean difference (95% CI)	F	df	p
Self-esteem	Intervention	73.22 (70.21, 76.22)	5.61 (1.38, 8.52)	5.02	1.67	0.010
	Control	67.54 (64.53, 70.54)
Violence	Intervention	19.87 (18.95, 20.79)	1.32 (02.61)	1.97	1.67	0.049
	Control	21.18 (20.26, 22.10)

An increase in score was observed in both variables of domestic violence and self-esteem in the intervention group, although it was not statistically significant. In the control group, a decrease in score was observed, although it was not statistically significant. Finally, because the scores decreased in one group and increased in the other group, a large difference was caused in the analysis, and thus, the result of ANCOVA was significant.

Discussion

Findings of the present study showed that the score of violence was decreased in the intervention group after counseling compared to before the intervention; however, this difference was not statistically significant. One of the ways to reduce IPV is to raise awareness and empower women, which has been addressed in this study and has been somewhat effective. Taghdisi et al.[16] increased women's awareness and self-efficacy regarding IPV through an educational intervention based on self-efficacy theory. They found that in order to reduce violence, women should first be aware of violence, its types, and strategies to deal with it,[16] and these results are consistent with that of the present study. Nevertheless, most of the problems of domestic violence are related to the perpetrator of violence and social factors, which may be due to addiction, polygamy, poverty, unemployment, mental illness, stubbornness, patriarchal beliefs, and the lack of appropriate laws to deal with violence against women. Each of these factors requires a separate review and solution. However, in the present study, there was a statistically significant difference in the mean score of violence between the two groups, which shows that Gestalt therapy could be effective in reducing the score of IPV. In this regard, Naeim and Sharif in their study found that teaching life skills to women, which included a set of skills and abilities to effectively deal with conflicts and difficult life situations, can increase marital adjustment and reduce domestic violence against women.[17] Mohtashami et al.[18] showed that some of the reasons for dealing with IPV were self-efficacy, types of domestic violence, mental norms, and attitudes toward dealing with domestic violence. They have suggested that these factors should be used to empower women to deal with domestic violence.[18] In fact, their study showed that one of the ways to deal with violence is to empower women, which is in line with the present study findings. In contrast, Noughani and Mohtashami found that distribution of booklets containing educational materials on the types of violence and its consequences in life and how to deal with it could not reduce domestic violence against women.[19] Perhaps the type of intervention can be cited as a reason for inconsistency with the present study results, because face-to-face training and counseling cover more points and details and face-to-face communication has a greater impact on learning.

The findings of the present study also revealed that the self-esteem score decreased in the intervention group after counseling compared to before the intervention; however, this difference was not statistically significant. Nevertheless, ANCOVA showed statistically significant differences between the mean self-esteem score of the groups, which shows that Gestalt therapy has increased the self-esteem score.

Some studies have confirmed the results of the present study including that by Sodani et al.[20] They revealed that group Gestalt therapy caused an increase in the level of life expectancy and self-esteem of the retired women in the experimental group compared to those in the control group. Furthermore, Saadati and Lashani[21] showed that Gestalt therapy increased divorced women's self-efficacy.

Self-esteem is a factor that can influence people's perception and interpretation of emotional reactions. Preparing for unhealthy changes in self-esteem often begins with stressful and traumatic events. Self-esteem includes a person's sense of self-worth. When a person has a positive evaluation of her/his characteristics and leads her/his beliefs toward positive thinking, she/he can overcome her/his problems and apply a good strategy in her/his relationships.[22] Self-disclosure and unwillingness of women to reveal facts were the study's weaknesses, and the fact that spouses who perpetrated violence were not counseled was a limitation of the study, as few men were willing to state that they were abusive to their wives. Therefore, we tried to reduce this indirectly by empowering women. Future research may apply this method to spouses or compare it to other intervention methods that may yield different results. Pregnant women are a vulnerable group in society and the health of the fetus and newborn depends on the physical and mental health of the mother, and since Gestalt counseling does not require special facilities, this counseling method can be used to increase self-esteem and reduce violence toward pregnant mothers in health centers.

Conclusion

In general, the results of this study showed a decrease in the score of IPV and an improvement in self-esteem of pregnant women who received Gestalt-based counseling.

Financial support and sponsorship

The study was supported by Kerman University of Medical Sciences

Conflicts of interest

Nothing to declare.