Domestic violence is becoming recognised as a serious public health issue. Country studies have shown that between 16 and 40 per cent of women in the Asia and Pacific region had suffered violence by their intimate family members. (1) The medical profession must be sensitised to provide special support services to the victims of this violence who are predominantly women and children. One initiative in this regard was a collaboration between the Mumbai Municipal Corporation and the Centre for Enquiry Into Health and Allied Themes to set up Dilaasa, a crisis centre for women, in the municipality-run Bhabha Hospital, Bandra. (2) Also, a recently published study has documented the various approaches of mental health professionals and support groups providing refuge to the victims of domestic violence in India. (3)
Depression caused by domestic violence is manifested in a range of physical and psychological symptoms. On marriage, women routinely lose access to various social networks and family support systems which might have sustained them and enabled them to respond effectively when faced with domestic violence.
The words ‘etic’ and ’emic’ are of Latin origin, and refer to monolithic and pluralistic perspectives or analytical frameworks. Medical anthropologists and social psychologists have borrowed these words from anthropology to describe approaches to mental illness.
The universalist or etic approach uses diagnostic categories such as neurosis, schizophrenia, psychosis, mania, phobia and paranoia. Such labelling does not take cognisance of the physical, sexual or psychological violence that women may experience and cope with on a daily basis. This medicalisation of mental health as expressed in the Draft National Health Policy 2001-III has been criticised because it further victimises the victim. (4) Also, the current dependence on pharmacological and shock therapy has many undesirable consequences.
The emic approach evaluates the phenomenon of mental illness in its cultural context. This could include a community intervention strategy to provide security to victims of domestic violence. Culturally sensitive counselling takes into consideration women’s personal predicaments in a specific socio-cultural environment. Such an approach has enabled state protection to victims of domestic violence and the enactment of statutory provisions to safeguard their interests. There is also evidence of the efficacy of approaches such as hypnosis, supportive therapy, re-education, desensitisation, group psychotherapy, family therapy and psychoanalysis. (5)
The relationship between the medical professional and the person seeking support is an unequal one. In the case of women, this inequality is compounded by the subjugation of women by a patriarchally structured psychiatric system. Because of the biomedical nature of psychiatry, and the focus on treating symptoms, mental health professionals do not take into consideration the power relations within which women live. A diagnosis of mental illness might be a way of labelling people as ill and treating them as impersonal objects, (6) ignoring the impact of socio-cultural and socio-demographic factors.
In India, there is little evidence of preventive and promotive efforts in mental health. This marginalisation of mental health concerns results from the understanding that mental distress is a manifestation of an individual problem and not directly related to social oppression. (7)
The experiences of support groups have revealed the value of individual counselling by professional counsellors in a non-threatening environment. At the same time, through mutual counselling, women with similar experiences can empower each other by narrating their problems and finding solutions.
Mainstream mental health professionals are often unable to provide women with the counselling they need. A stereotypical understanding about women’s role in the family and society governs their psyche. If the ‘mentally ill’ woman does not fit in that mould, she is declared ‘socially incompetent’. Mainstream counselling can also reinforce the subordination-domination relations between men and women.
Women can face domestic violence for breaking traditional barriers imposed by a male chauvinist value system that has mental health consequences. Professionals must realise that their ethical duty is to empower the victim, not to marginalise her by declaring her ‘mentally unfit’. Sexual abuse whether by family members or others has serious psychological consequences. Mental health practitioners who are aware that a patient is a victim of such abuse are ethically bound to help her move out of that situation, rather than using chemical therapy to treat the symptoms.
Inmates of shelters for victims of domestic violence need a democratic space for brainstorming and finding avenues to move forward in their personal and work lives. Doctors here should encourage shelters to create an informal and congenial set-up. Managements need to understand that there is a story behind every unusual behaviour, and they must learn what this story is. A programme conducted by a panel of psychotherapists and psychoanalysts can enable staff to respond to post trauma stress disorder among inmates with empathy rather than victim blaming.
Assigning diagnostic labels to victims of domestic violence can result in their stigmatisation and ostracism. Family members and the community are known to have used mental health professionals to declare women ‘unfit’ to live in the family, to be a parent, to function as an autonomous individual or to take up a job. Families are known to have used a woman’s mentals health episodes to take away her property rights, or the right to live in a matrimonial or parental home. ‘Madness certificates’ given by mental health professionals are used by husbands to divorce or desert their wives, or throw them out of their matrimonial homes.
Such women get confined to mental asylums as per the directives of the Mental Health Act, 1987. Once dumped in a mental asylum, it is impossible to get out even after complete recovery. “Women in mental hospitals have fewer visitors, are abandoned or tend to stay on longer than men within the institution. There are fewer voluntary patients among women than among men. Even in adjudication for a woman’s institutionalisation, the official discourses are often coloured by the sex role stereotypes that the judges, police officials and the staff in mental hospitals uphold.” (9) A social worker remarks after a visit to a mental hospital: “The interaction with female patients made me sadder. Almost all of them were abandoned/ dumped by families or the police and court got them admitted after they hit rock bottom. Most were forced to face violent situations in their lives and had painful and atrocious accounts to tell. In many cases, one could see (although without an in-depth study, one cannot claim and prove) that the mental distress, ill health, had its roots not in a person’s biology or psychology, but in society, in our social environment.” (10)
The wall of secrecy about the administration of drugs, surgery and electro-convulsive therapy needs to be condemned by citizens’ initiatives and ethical medical practitioners. The serious and long-lasting side effects of the biomedical approach need to be highlighted. Our mental hospitals need to focus on psychotherapy and counselling which involve therapies that produce positive results with few or no negative side effects.
The only sure way out of repeated attacks of mental illness is to make women’s material reality more secure, liberating and healthy. Developmental counselling aims at removal of chronic conflict situations in women’s lives that are associated with high mental health morbidity. It is based on the understanding that the doctor’s or counsellor’s commitment is a necessary condition for counselling success. (11) It increases self-direction and evolves better problem solving and decision-making abilities. This is the axis around which human rights therapy or counselling revolves. It emerged in the wake of the liberationist social movements as an alternative to the bio-medical approach.
The most successful healer is one who avoids victim blaming and provides patient listening. (12) Those with communication disabilities need special help. (13) At the same time, “Reversing the process of alienation by consciously building community networks is a must. Mental health professionals should be seen in the community rather than in the secure institute or clinics.” (14)
There is an urgent need to sensitise and train general practitioners and other health personnel on mental health issues caused by domestic violence. Health posts and public hospitals must have social counsellors who are in touch with voluntary organisations providing institutional support to women in social distress. Doctors should discuss domestic violence and mental health in the electronic and print media, and remind the profession of its ethical duty to victims’ needs. (15)