Violence against women is common, invisible and ubiquitous, and strongly associated with short- and long-term mental illness. The relationship between violence and mental illness is multi-directional and complex. In SNEHA’s two decades of work in preventing violence against women in Asia’s largest informal settlement in Dharavi, we develop high impact strategies for primary prevention, ensure survivors’ access to protection and justice, empower women to claim their rights, mobilise communities around ‘zero tolerance’, and respond to the needs and rights of excluded and neglected groups.
In the past couple of years, we have officially integrated a mental health component in our intervention. We have adapted the ‘MANAS’ stepped care model on community mental health developed by Sangath, a mental health research organisation. In a stepped care model, identification and psychological first aid begin at the grassroots. The next step is referral to services such as SNEHA’s counselling centre, which provides crisis counselling and psychosocial interventions, and screens women for mental health conditions. The next step is referral to clinical psychologists for diagnosis and therapy. The final step – taken in only a few cases – is referral to a psychiatrist for further intervention that may include medication.
There is modest evidence suggesting that women with mental illness are more likely to be involved in unsafe and abusive relationships, thus increasing their risk of being exposed to gender-based violence. It has been hard for us to determine the cause and effect relationship between violence and mental health. Women predisposed to mental illness who have undergone violence have a higher likelihood of developing common mental disorders due to abuse and ambiguity in relationships. Whereas women who live with mental health conditions suffer violence on account of their inability to perform the role of a care provider in home settings.
SNEHA’s counselling centres have registered over 8000 cases of women survivors of violence in the last 15 years. Interventions for survivors of violence are need-based and require immediate responses to women’s situation and the environment around them. Helping survivors get support for medical assistance, shelter, police complaints and provisional legal orders often takes precedence over counselling and mental health interventions. In our experience, casework interventions tend to stabilise the situation and a long-term counselling process helps the survivor gain confidence to rebuild her self-esteem. Mental health conditions complicate situations of violence and the complex interplay between individual, relationship, community, institutional and societal factors, which put women at risk of experiencing violence.
At SNEHA, we adopt a multi-layered psychosocial approach to working with women survivors of violence. Our field workers and community officers are trained in providing psychological first aid, and our counselors are trained in Rogerian client-centred therapy and other therapeutic interventions like psycho-education, role education and interpersonal therapy. After screening, survivors are referred to clinical psychologists for further assessment and treatment if necessary. Our clinical psychologists use individual and group psychotherapy, Cognitive Behaviour Therapy and Rational Emotive Behavior Therapy. Awareness and destigmatisation campaigns are conducted regularly using participatory methods such as games and street plays in the community, as well as innovative public engagement modes such as the Dharavi Biennale (link: http://www.dharavibiennale.com/).
A successful aspect of our approach to violence and mental health interventions has been that it is non-clinical and holistic. We believe that the social determinants of violence and mental health need to be understood in order to develop psychosocial interventions that work on the continuum of illness to wellness.
Integrating mental health work with our larger prevention of violence against women program has been easier and positive because of the robust community mobilisation component of our program. We enjoy a high level of credibility and trust in the areas we help in and this has helped us integrate two very complex issues. One of the pillars of our model on intervention and prevention of violence against women is a large volunteer base, often women from informal settlements. We have been able to build a cadre of ‘barefoot counsellers’, by training these volunteers to provide psychological aid and a crisis response to women undergoing violence and having mental health conditions. The program has managed to create a need with the community to identify this as an important issue affecting them and also to an extent, remove the stigma associated with mental illnesses.
There are several challenges when working with women survivors of domestic violence who have mental health conditions living in a complex setting of poverty, deprivation and a cultural context that sanctions violence. One is the lack of mental health literacy in communities in informal settlements. Violence is normalised in the day-to-day struggle for stability in a challenging low-resource environment. One of the biggest challenges we face in our intervention is convincing the family about the survivor’s mental health condition, especially when the survivor fails to fulfil her expected role and responsibilities. On the other hand, when she deviates from the expected norms of appropriate behaviour, she is often labelled with a mental health condition. Home-based care or community based support is withheld in such situations and women are often abandoned under the pretext of being of no use to families because of their non-functionality.
A second challenge is the fact that rehabilitation services provided by government and non-government organisations are not inclusive of community support and care. Recovery is seen as a linear process without contribution from the environment and absence of positive stimulus. This puts women in isolation and recovery can be slow. It also makes referral difficult. Our response has been to work with shelter homes, the ICDS, and other NGOs to help them strengthen their capacity for first response and longer-term support.
Here are five things you should keep in mind if you want to integrate mental health within your intervention:
- Secondary interventions pave the way for primary prevention, especially when adapting a stepped care model. Visible interventions to support survivors make people aware of the problem and potential solutions.
- An integrated stepped care model on violence against women and mental health requires a robust community based set-up to link different levels of support and care for identification, response and referral.
- Consistent engagement with communities, understanding their social, cultural, and economic context and the existing support system to address violence and mental health, will help in building effective rapport on issues of violence and mental health
- Working with government institutions such as the ICDS, primary health care centres, tertiary hospitals, government shelter homes and non-government institutions such NGOs and community based organizations help in early identification, referral and providing necessary care.
- Working simultaneously on two complex issues requires time to bring about a change in community perceptions and attitudes towards these issues.