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Jan-Mar2003-11(1)
DISCUSSION
Domestic violence, mental
health of women and medical ethics
Vibhuti Patel
Vibhuti Patel
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.
Perspectives on mental health
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)
Power relations in mental health
treatment
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.
Ethical duties
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.
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.
Women and mental hospitals
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.
Developmental counselling
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)
Training programmes
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)
References:
1 Abdullah R. Indicators of women's mental health and well-being. Arrows for Change 2001; 7 (3): 12.
1 Abdullah R. Indicators of women's mental health and well-being. Arrows for Change 2001; 7 (3): 12.
2 Jesani A. Violence against women:
health and health care issues- a review of selected Indian works. Samyukta- a
journal of women's studies 2002; 2 (2) 57.www.samyukta.org.
3 International Centre for Research on Women. Domestic violence in India: exploring strategies, promoting dialogue. Delhi, 2002.
4 Davar B. Draft National Health Policy 2001-III, mental health: serious misconceptions. Economic and Political Weekly 2002; XXXVII (1): 20-22.
5 Shertzer B and S. Fundamentals of counselling. Houghton Miffin Co, Boston, 1968, p 14.
6 Noonan E. Counselling young people. Methuen, London and New York, 1983, p 48.
7 Vindhya U, A Kiranmayi and V Vijayalaxmi. Women in psychological distress: evidence from a hospital based study. Economic and Political Weekly 2001; XXXVI (43): 4081-4087.
9 Davar, B. Women-centred mental health: issues and concerns.Vikalpa: alternatives. Special issue on gender and transformation. Vikas Adhyayan Kendra, Mumbai, 2001; IX (1& 2): 117-130.
10 Joshi L. At the fag end...a visit to Yervada mental hospital. Aaina-a mental health advocacy newsletter, 2002; 2 (1): 7- 8.
11 Dinkmeyer D and E Caldwell. Developental counselling and guidance: a comprehensive school approach. Harvard University, USA, 1970, p 87.
12. Nelson-Jones R. Practical counselling and helping skills. Better Yourself Books, Bombay, 1994, p.12.
13 Amar J. Improving approaches to people with communication disabilities. Disability Dialogue, 2002 January-April. Issue III : 1-12.
14 Shetty H. Prevent suicide, save life. One India, One People. Special issue on prescriptions for healthcare. 2001; (4): 21-22.
15 Seden J. Counselling skills in social work practice. Open University Press, Buckingham and Philadelphia, USA, 1999, p 142.
3 International Centre for Research on Women. Domestic violence in India: exploring strategies, promoting dialogue. Delhi, 2002.
4 Davar B. Draft National Health Policy 2001-III, mental health: serious misconceptions. Economic and Political Weekly 2002; XXXVII (1): 20-22.
5 Shertzer B and S. Fundamentals of counselling. Houghton Miffin Co, Boston, 1968, p 14.
6 Noonan E. Counselling young people. Methuen, London and New York, 1983, p 48.
7 Vindhya U, A Kiranmayi and V Vijayalaxmi. Women in psychological distress: evidence from a hospital based study. Economic and Political Weekly 2001; XXXVI (43): 4081-4087.
9 Davar, B. Women-centred mental health: issues and concerns.Vikalpa: alternatives. Special issue on gender and transformation. Vikas Adhyayan Kendra, Mumbai, 2001; IX (1& 2): 117-130.
10 Joshi L. At the fag end...a visit to Yervada mental hospital. Aaina-a mental health advocacy newsletter, 2002; 2 (1): 7- 8.
11 Dinkmeyer D and E Caldwell. Developental counselling and guidance: a comprehensive school approach. Harvard University, USA, 1970, p 87.
12. Nelson-Jones R. Practical counselling and helping skills. Better Yourself Books, Bombay, 1994, p.12.
13 Amar J. Improving approaches to people with communication disabilities. Disability Dialogue, 2002 January-April. Issue III : 1-12.
14 Shetty H. Prevent suicide, save life. One India, One People. Special issue on prescriptions for healthcare. 2001; (4): 21-22.
15 Seden J. Counselling skills in social work practice. Open University Press, Buckingham and Philadelphia, USA, 1999, p 142.
Vibhuti Patel,
Reader, Centre for Women's Studies, department of economics, University
of Mumbai, Kalina, Santacruz(E), Mumbai-400098. E-mail:vibhuti@vsnl.net