Handling abuse-related trauma in therapy

Domestic violence and mental health problems have a bidirectional relationship, which means vulnerable individuals (including mental health service users) are at a higher risk of experiencing abuse which in turn puts them at a higher risk for adverse mental health outcomes.

It is important for healthcare professionals to adopt an intersectional approach when treating women facing violence. This involves a “Consideration of where gender intersects with other inequalities/oppressions (sexuality, gender identity, ethnicity, indigeneity, immigration status, disability) to produce unique experiences of violence.”

There are other vulnerable population groups that are at an increased risk of facing domestic violence, like people from the LGBTQIA+ community, children, elderly people, and people with disability. Currently the law provides relief only in situations where the aggrieved person is a woman, but it is important to recognize that the issues faced by each of these groups are unique and need special attention.

Longer durations of violence, its severity and recency, and the experience of more than one form of violence are all associated with higher morbidity. The likelihood of developing depression, anxiety, and substance abuse is much greater for women who have experienced domestic violence than for those who have not.

Witnessing violence can also have a negative impact on the mental health of children, putting them at two to four times higher risk of clinically significant problems. These could include difficulty in social development, academic progress, or early initiation of sexual activity. Children may also develop internalizing symptoms like anxiety and depression, externalizing symptoms like aggression, and trauma symptoms like flashbacks.

In certain countries, it is recommended that health service personnel routinely ask women if they have experienced abuse by their intimate partner, because of the serious health consequences and the low rate of abuse identification by health services.

That said, the World Health Organization (WHO) recognizes that developing countries may have limited resources and referral procedures, and does not recommend universal screening for violence against women. Although, the WHO does encourage health-care providers to raise the topic with women who have injuries or conditions that they suspect may be related to violence.

In the absence of direct questioning, survivors of domestic violence are reluctant to disclose abuse to health service providers. If mental health providers are managing the symptoms of the mental illness but ignoring the cause of the trauma, treatment is less likely to be successful.

Practitioners need to routinely ask women about present or past incidents of domestic violence if they are diagnosed with depression or anxiety, or if they show any other signs of mental distress. They should be able to provide referrals to specialist services and need to be adequately trained to respond to those who disclose domestic violence. This means not focusing solely on medical treatment, but also on referrals and support.

Handling abuse-related trauma in therapy is a series by White Swan Foundation in collaboration with Shakti. This series is a guide for mental health practitioners to help survivors of abuse heal with therapy. This series refers to survivors as women, however, we acknowledge that survivors can belong to any identity. The usage of the word "women" has been used to reflect laws that are focused on women as survivors of domestic violence, and other guidelines that are framed keeping women in mind.

Written by Bhumika Sahani, journalist and social worker by training; consultant at Shakti; and Dr Parul Mathur, resident doctor, Department of Psychiatry, NIMHANS