Intimate partner violence during the COVID-19 pandemic in India: from psychiatric and forensic vantage points

Abstract

The COVID-19 pandemic has created an unprecedented impact on our society, which demands robust action to address the global crisis, which is of significance to psychiatry, as mentioned in the Asian Journal of Psychiatry (Tandon, 2020). Violence faced by women has outrageously increased since the COVID-19 outbreak. According to the World Health Organization, “Intimate partner violence is one of the most common forms of violence against women and includes physical, sexual, and emotional abuse and controlling behaviours by an intimate partner.” (World Health Organization, 2012) The restrictions due to lockdown and quarantine have caused domestic zones to become breeding grounds for intimate partner violence. Abusive individuals may use the restrictions to exert power over the vulnerable ones especially women, restricting access to essential commodities, services and deliver misinformation about COVID-19, thus, stigmatizing them. The enduring exposure of vulnerable persons to abusive individuals and the difficulty in communication due to social restrictions in the present scenario have caused a constraint for the victim to cope with this situation or obtain support (World Health Organization, 2020). Intimate partner violence at home is often under-reported and not adequately addressed at proper forums. It not only curtails human rights but specifically undermines the health, dignity, and security of the women. Although it can occur in both sexes, in a developing country like India with a patriarchal mindset, it is centered mostly around women. In India, women’s ability to resist and disclosure is limited owing to their economic imbalance and social support. The country witnessed a whopping 47.2% of total cases received by the National Commission of women were linked to domestic violence during April and May and a decline in other natural sexual offenses (Pandit, 2020). Various factors related to the perpetrator leading to such violence could be elevated stress levels as a result of restrictions, unemployment, financial worries, an increase in alcohol and substance use, exacerbation of pre-existent psychiatric illness and onset of new mental illness. Literature suggests that intimate partner violence exacerbates with increased alcohol and substance use in partners. Restrictions of lockdown may lead to increased stress, boredom, and in order to negate these feelings, people resort to alcohol and substance use. However, this can further lead to aggravation of anxiety, depressive symptoms, and aggression, especially in persons with personality disorders. Thus, the disturbed psychological health of the perpetrator may negatively affect the psychological wellbeing of the persons being abused. Women living in rural areas have an increased risk of being exposed to intimate partner violence (de Telles et al., 2020). Factors such as lower educational level, younger age, current unemployment, especially amongst those who are daily wage workers, increased responsibilities because of children being at home due to school closures and increased stress in the family, may make them more vulnerable for being abused by their partners (De Lima et al., 2020). In India, section 498 A Indian Penal Code (IPC) protects a woman from cruelty by her husband or relative of husband. However, this section has been quite narrower in its definition since cruelty was confined “to any willful conduct which is of such a nature as is likely to drive the woman to commit suicide or to cause grave injury or danger to life, limb or health (whether mental or physical) of the woman (clause a); or harassment of the woman where such harassment is with a view to coercing her or any person related to her to meet any unlawful demand for any property or valuable security or is on account of failure by her or any person related to her to meet such demand (clause b)” (Central Government Act, 1983). There are limitations to 498A such as the isolated singular act of beating is not covered under the definition and time limit for lodging complaints is three years from the incident. Consequently, an act “The Protection of Women from Domestic Violence Act 2005 was introduced. It is relatively broader, gender-specific, encompasses verbal, emotional, and economic abuses and also contains a part which mentions if the act “has the effect of threatening the aggrieved person or any person related to her by any conduct mentioned in the already mentioned clauses or otherwise injures or causes harm, whether physical or mental”. It strengthens the women’s right to make an application for obtaining relief by way of a protection order, an order for monetary relief, a custody order, a residence order, a compensation order, or more than one such order under this Act (Gazette of India, 2005). To address the challenges of intimate partner violence, various strategies for surveillance, prevention and timely reporting need to be adopted swiftly. Mental health professionals including psychiatrists, psychologists, psychiatric social workers and nurses should make it a routine to enquire from persons constantly about intimate partner violence even if they feel the slightest doubt. They may assess interpersonal issues in patients who are being consulted for substance and alcohol-related problems (de Telles et al., 2020). Various psychological interventions suggested to be useful for victims of intimate partner violence include formal cognitive behavioural therapy (CBT), trauma focused CBT (TF-CBT), acceptance commitment therapy (ACT), mindfulness, interpersonal psychotherapy, skills training in affective and interpersonal regulation (STAIR), cognitive processing therapy, integrative therapies such as motivational interviewing, eye movement desensitisation reprocessing (EMDR), Helping to Overcome PTSD through Empowerment (HOPE, Relapse Prevention and Relationship Safety (RPRS) (Tan et al., 2018). India having an enormous diversity would require culturally competent interventions which focus on women’s support system and their respective community, which would be an efficient way to deal with such violence especially amongst daily wage workers migrant workers. It has been postulated that culturally specific strategies may be assist in reducing the incidence of intimate partner violence and the subsequent evolution of mental health issues (Klingspohn, 2018). Pharmacological management would include anxiolytics, anti-depressant medications, anti-psychotics and hypnotics as per the clinical presentation. Awareness of such issues should be brought to the community, which could make family members and neighbors to be vigilant and also increase reporting of such violence. A multi-disciplinary effort that would include the policymakers, local government, healthcare workers, humanitarian response teams, community workers, surveillance teams, and the public could help combat this menace, especially at this time of the pandemic and during the post pandemic era. (World Health Organization, 2020) Consideration of possible risk factors in the perpetrator and mental health issues they are affected with is important to deal with intimate partner violence. Table 1 shows a list of interventions which may be useful at various stages of intimate partner violence from before its occurrence, that is a preventive stage to treating the survivors. At the same time, it is necessary to address psychological issues such as acute stress reaction, anxiety, depression and post-traumatic stress disorder, in women facing such violence and also children who may be witnesses to it. Table 1 Various modes of stage-based interventions Table 1 Stage Intervention 1 Prevention Strong involvement of community members including local health workers Cultural specific campaign Communication campaign for advocacy, awareness and education via posters, brochures, media and other information technology aids Involvement of local religious leaders 2 Screening Use of empirically validated tools Development of culture specific tools Education of primary health care workers and specialists on evaluation of suspected victims of violence 3 Treatment of survivors Support groups and group counselling aimed at survivors Instilling specific coping strategies in domains such as placating, resistance, informal, legal Cognitive Behavioural therapy (CBT) Trauma focused CBT (TF-CBT) Acceptance commitment therapy (ACT) Mindfulness Interpersonal psychotherapy Skills training in affective and interpersonal regulation (STAIR) Cognitive processing therapy Integrative therapies such as motivational interviewing Eye movement desensitisation reprocessing (EMDR) Helping to Overcome PTSD through Empowerment (HOPE) Relapse Prevention and Relationship Safety (RPRS 4 Managing perpetrators Motivational interviewing Batterer group aimed at perpetrators Strong involvement of community members and local health care workers