Addressing Domestic Violence within Healthcare Settings

Women experiencing violence most often decide to seek legal action only after the violence has escalated and that too without having any documentary evidence. The Dilaasa crisis centres at two public hospitals in Mumbai since 2001 have been established out of the recognition that the public health system is an important site for the implementation of anti-domestic violence intervention programmes. The crisis centres therefore straddle both discourses of public health and gender. The paper offers critical insights into the model and its impact in terms of its ability to reach out to women who are undergoing abuse and offer them multiple services in one setting.

REVIEW OF WOMEN’S STUDIES

Addressing Domestic Violence within Healthcare Settings

The Dilaasa Model

Padma Bhate-Deosthali, T K Sundari Ravindran, U Vindhya

Women experiencing violence most often decide to seek legal action only after the violence has escalated and that too without having any documentary evidence. The Dilaasa crisis centres at two public hospitals in Mumbai since 2001 have been established out of the recognition that the public health system is an important site for the implementation of anti-domestic violence intervention programmes. The crisis centres therefore straddle both discourses of public health and gender. The paper offers critical insights into the model and its impact in terms of its ability to reach out to women who are undergoing abuse and offer them multiple services in one setting.

Padma Bhate-Deosthali (padma.deosthali@gmail.com) is with the CEHAT, Mumbai. T K Sundari Ravindran (ravindrans@usa.net) is with the Achuta Menon Centre for Health Science and Studies, Thiruvananthapuram. U Vindhya (u.vindhya@gmail.com) is with the Tata Institute of Social Sciences, Mumbai.

T
his paper critically reflects on the Dilaasa model, a health sector intervention for survivors of domestic violence. While the women’s movement in India has been engaged with the issue of domestic violence for over three decades now, with campaigns, legal advocacy and support/case work being the predominant modes of engagement, violence against women has not been seen as a public health concern. This has been so, despite accumulation of evidence on the farreaching physical and mental health consequences of violence of domestic violence (Jesani 2002; Bhate-Deosthali et al 2005). The Dilaasa project – consisting of two public hospital based crisis centres in Mumbai – represents the first such attempt in India to work with the public health system. It was established through a joint initiative of the Centre for Enquiry into Health and Allied Themes (CEHAT),1 a Mumbai-based non-governmental organisation (ngo) and the Brihanmumbai Municipal Corporation (BMC). Originally established in a municipal hospital, K B Bhabha Hospital, Bandra in 2001, Dilaasa has since been replicated in three more sites: another municipal hospital, K B Bhabha Hospital, Kurla, Mumbai, at a medical college hospital in Indore and a civil hospital in Shillong. The Mumbai-based crisis centres were formally handed over by CEHAT to the staff of the BMC in 2006. Since then, CEHAT has been providing mainly technical support, and Dilaasa has been functioning as a project of the BMC.

The study is based on (1) an external evaluation of the project carried out in 2010, and (2) an analysis of case records of the centre from 2001 to 2006. The external evaluators reviewed project documents such as annual reports, process documentation of trainings, reports of the crisis centres, and of the intervention research conducted; and carried out interviews with the staff of CEHAT responsible for the project and the staff of the Bhabha hospitals at Bandra and Kurla. In addition, data from case records of survivors (2001-06) of the Dilaasa crisis centre were analysed to understand their sociodemographic profi le, their entry into Dilaasa, and the type of violence experienced by them.

This paper offers critical insights into the model and its impact in terms of its ability to reach out to women who are undergoing abuse and to offer women multiple services in one setting. It makes the case for upscaling the model and for bringing about changes in health policy to recognise the role of health professionals and health systems in preventing domestic violence and caring for survivors.

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Economic & Political Weekly

REVIEW OF WOMEN’S STUDIES

1 Placing Dilaasa within the Women’s Movement

“When the women’s movement burst forth onto the public stage in the years following the Emergency, it did so most dramatically under the banner of ‘violence against women’ ” (John 2008: 227). It was issues of rape and “dowry deaths” that galvanised formation of women’s protest groups, bringing violence against women as an issue into the public domain in the 1970s. Internationally, the rise of the women’s movement in the 1960s brought to light this hitherto invisible problem, which eventually led to its recognition as a major public health issue and a violation of the human rights of women. Milestones included the passing of the first resolution against violence against women by the United Nations General Assembly in November 1985; the formulation of “Women’s Rights as Human Rights in 1993 with the adoption of the UN Declaration on the Elimination of Violence against Women”; and the appointment of the UN Special Rapporteur on Violence against Women. Since then, much has been done to gather evidence on the dimensions of the problem and to create awareness on the issue.

The Indian women’s movement first drew public attention to violence against women in the early 1980s when it organised a campaign against the gender-biased judgment by the Supreme Court in the case involving the rape of a young tribal girl, Mathura, by policemen. The anti-rape struggle that began in Mumbai with the establishment of the Forum against Rape in 1980 raised the issue of male violence for the first time in India in addition to class and caste violence (Kumar 1993). The following decades witnessed agitations, mass campaigns, public education, legal reform and advocacy to raise awareness about domestic and sexual violence and eliminate them. Support groups to provide help to individual women facing domestic violence were started and services such as legal aid and shelter homes were set up by autonomous women’s groups and NGOs. Legal strategies too were evolved such as the amendments to laws on rape, the most significant being shifting the onus of proof to the accused in cases of custodial rape; the amendment made to Section 498A of the Indian Penal Code in 1983 that formally recognised “mental and physical cruelty to wives” as a crime, the laws pertaining to dowry deaths and sati, the Supreme Court guidelines for sexual harassment at the workplace, and the introduction of the law criminalising sex-determination tests (Bhate-Deosthali et al 2005; Burte 2008).

Violence within the family drew serious attention through dowry deaths or bride burning and later, the issue of battering. It was also realised that women faced domestic violence that were not necessarily related to dowry demands alone. Silence and social stigma over the issue of domestic violence were broken when women publicly fought against the abuse experienced in the “safe haven” of the home (Agnes 1990, 1992; Kumar 1993; Burte 2008). The feminist slogan “the personal is political” was used to effectively demystify the “private” space of the home, making it possible for individual women to come forward and share their agony and pain. The movement brought to the fore the assertion that all women have the right to violence-free lives and that domestic violence inhibits women from realising their rights and full potential in all

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aspects of their lives – in social, economic and political spheres. The state also responded to the growing pressure created by the sustained campaigns taken up by these groups on the issue of violence. During the 1980s and 1990s, the establishment of free legal cells, family counselling centres, family courts and special cells at police stations initially formed in Mumbai, and subsequently, in several places across the country, created many spaces for victims of domestic violence. These have helped individual women, and to a certain extent, sensitised the public systems to respond to the issue of domestic violence.

In 2005, the landmark legislation, “The Protection of Women from Domestic Violence Act” (PWDVA) was enacted, making it the fi rst significant law in India to recognise domestic violence as a punishable crime, extending its provisions to those in live-in relationships also, and to provide for civil remedies such as emergency relief for the victims and ensuring women’s right to the matrimonial home, in addition to legal recourse.

Defining domestic violence as “any act that harms, injures, endangers, the health, safety, life, limb or well-being of the person or tends to do so”. PWDVA includes “physical, sexual, verbal, emotional abuse or intention to coerce her or any person related to her to meet any unlawful demand for dowry or any other property/valuable security” ...[and] “also have the effect of threatening her or any person related to her” (PWDVA, 2005). The act recognises public health facilities as service providers and mandates that all women reporting after domestic violence must receive free treatment and information/ appropriate referral to protection officers under the act. The Act is the result of cumulative efforts made by women’s movement for a law that provides specific remedies for women experiencing domestic violence, whereby they could approach the state directly and get a protection order to stop violence in the home without having to put the husband behind bars or having to leave her matrimonial home to escape violence (Jaising 2002). Under the aegis of the Lawyers Collective that drafted the bill, the implementation of this law too has been monitored annually since it was passed and consistently drew attention to the continuing challenges such as scarce budgets, problems with nature of appointment of protection offi cers under the law (contractual vs regular, independent charge vs additional charge), lack of training of police and judges on the law (Lawyers Collective and Women’s Rights Initiative 2011).

While the women’s movement’s engagement with the problem of violence finds several forms, its interface with the health system has been a complex one. In many instances the women’s movement has had to take an antagonistic stance against the health system as, for instance, in its confrontation against its role in the implementation of coercive population policies, its lack of sensitivity in dealing with reproductive and sexual health needs of women and the overall lack of gender sensitivity within the system. At the same time, the movement, in its attempts to sensitise the system, has highlighted several lacunae in the existing health system, as for example, drawing attention to the failure to document important forensic evidence in the event of sexual assault, which severely

REVIEW OF WOMEN’S STUDIES

limits survivors’ ability to attain justice. Working with the health system becomes critical in the efforts to address domestic violence against women for several reasons. Most often women experiencing violence decide to seek legal action only after the violence has escalated but they have no documentary evidence to prove it. Health providers fail to document the woman’s history of victimisation as well as recent episodes of violence, which are critical in divorce and criminal cases to seek compensation. When women victims of violence present themselves at the emergency room or other departments of hospitals, they are usually treated for their physical symptoms and no further probing is done. However, working closely with the health system has not been among the strategies employed by the women’s movement in its struggle against gender-based violence (Jesani 2002).

The Dilaasa centre, set up in 2001, seeks to address precisely this gap. It has emerged out of the recognition that the public health system is an important site for the implementation of anti-domestic violence intervention programmes, for more than one reason. Public hospitals are often the first contact for survivors as violence of any form causes physical and/or psychological trauma. Women survivors may or may not report to domestic violence but will seek treatment. Furthermore, medical evidence forms important documentary evidence. There is fairly extensive evidence that domestic violence has an impact on women’s health in myriad ways – both directly and indirectly – and can lead to chronic debilitating conditions and even death. Apart from injuries, disability, mental health consequences of violence include feelings of anger and helplessness, self-blame, anxiety, phobias, panic disorders, eating disorders, low self-esteem, nightmares, hyper vigilance, heightened startle response, memory loss and nervous breakdowns. Self-harming behaviour is also a serious consequence of victimisation and includes refusal of food and drinking, suicide ideation and attempts, and generally neglecting oneself and one’s health (WHO 2005; Campbell and Lewandowski 1997; Heise et al 1994).

2 The Dilaasa Model
2.1 Dilaasa’s Perspective on Domestic Violence

The ideological position guiding the Dilaasa project can be described as twofold: (a) locating the importance of domestic violence as an issue within the larger societal context of gendered inequalities and violence, and (b) pushing for recognition of domestic violence as a public health concern within the medical context that is largely unresponsive to issues perceived as falling beyond the medical purview. The Dilaasa project, therefore, straddles both these discourse – of public health and of gender – and represents an example of the conflation of the two, demonstrating its viability and achievability in practice. The concept of public hospital-based crisis centres is well-established globally, and lessons learnt from such centres in the United States, Malaysia and Philippines shaped the conceptualisation of this project. In the context, in India, which is presently witnessing weakening of national and local

68 public institutions with the healthcare needs of those living in urban low income settings getting marginalised despite a high density of public and private healthcare providers and institutions, Dilaasa’s venture is a modest attempt to plug this gap.

2.2 Organisational Structure and Mechanisms

Dilaasa was set up with the following strategic objectives:

  • (a) partnership of an NGO with the public health system,
  • (b) sensitisation of the public health system to domestic violence and institutionalisation of domestic violence as a legitimate public health concern, and (c) building the gender-sensitisation capacity of the hospital staff.
  • The distinctiveness of this initiative lies in the fact that it was conceptualised as a joint project in terms of human resources and management. The team, consisting of professionals from CEHAT and the staff deputed by the public hospital, was led by the medical superintendent of the hospital. All decisions regarding the project on the policy or programme were taken jointly by CEHAT and the hospital management, facilitating creation of a sense of ownership of the project among the hospital staff.

    Dilaasa was created as a department of the hospital so that there could be clarity on the chain of command and decisionmaking processes, and on the definition of roles of doctors, nurses and social workers. Since the project director was the medical superintendent of the hospital, it was possible for her to make various systemic changes to integrate this programme within the hospital setting. Her role in involving the hospital staff unions, in deputing staff for training and subsequent responsibilities, and in ensuring that other facilities and resources were made available, proved to be vital to the continued functioning of the project. Within a few years, once the concept was demonstrated and administrators and health providers were convinced that domestic violence was indeed an important public health issue, an enhanced sense of ownership of the project was seen from within the health system.

    This attitude of the hospital staff is best demonstrated by the fact that the replication of this centre was carried out by a core group of another hospital out of a sense of deep concern for women reporting at this hospital. Another hospital’s core group went beyond this and identified the poor management of sexual assault and demanded support from CEHAT in improving their response to the issue (Ravindran and Vindhya 2009).

    3 Major Components of the Model

    The Dilaasa model comprises a public hospital-based crisis centre for women which provides counselling services informed by a feminist perspective to which women are referred from within the hospital and from other health facilities. In its pursuit to provide comprehensive care at one place, Dilaasa liaises with Majlis, a Mumbai-based legal services organisation for legal support to Dilaasa clients; and with several shelters that provide temporary or permanent shelter. Linkages with community-based organisations and/or mahila mandals too have been established so that women coming to the centre could be referred to them for local support and other needs if any. The

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    second major component of the model is training of health providers and all other staff of the hospital.

    3.1 Women’s Referral to the Dilaasa Crisis Centre

    Women are referred to the crisis centre not only from the casualty, but also from the outpatient and inpatient departments. This is because the casualty department deals mainly with serious injuries, and hence, could be tapping only a small proportion of cases of violence. Cases coming to the outpatient department (OPD) with less serious injuries could go unreported. Doctors and nurses in all departments of the hospital have been trained to ask screening questions and identify women experiencing domestic violence. Women from OPDs are provided medical care, referred to casualty for medico-legal documentation and then referred to the crisis centre. If the woman is admitted in the hospital, the counsellors are called to the ward to speak to the woman concerned.

    In addition, crisis centre staff visit the casualty department everyday and make sure that all women registered as medicolegal cases (MLCs) get the services of the centre. Referrals to Dilaasa are also made from other hospitals and health facilities of municipal corporation. Besides referrals, with increasing publicity, women are now found to come on their own, after having heard of the services provided by the centre.

    Systems have been introduced to track the referral process. The hospital’s case sheet has been modified to stamp “Referred to Dilaasa” on the case sheets of women reporting injuries. The hospital’s management information system (MIS) has been modified to include a field in which casualty medical offi cers can keep a daily record of women referred to Dilaasa. This report is sent to the project director. When women present themselves at the crisis centre, the counsellor first obtains the woman’s consent after explaining the services provided by Dilaasa. An intake form is filled with details of the woman’s socio-demographic characteristics and past history of violence. This is followed by counselling.

    3.2 The Counselling Process

    There is a marked difference between the mindset of a woman who steps into Dilaasa and another who may go to any other counselling centre. A woman coming to Dilaasa has been referred by a hospital staff when she comes to the hospital for treatment and may not be prepared to talk about personal issues, especially domestic violence. The time factor is another distinguishing one which poses a challenge as women coming to Dilaasa are rarely able to sit for more than 45 minutes unlike other counselling centres where counselling sessions are longdrawn. Their follow-up, therefore, depends on their fi rst contact with the centre. Dilaasa’s counselling practice is embedded in a strong feminist framework (Worell and Remer 2003).

    Feminist counselling practice questions abuse; it provides the necessary tools and strategies that equip women with skills that facilitate healing and stop violence. While keeping the individual’s experience in focus, feminist counsellors strive to provide a larger picture of how clients’ problems, fears, insecurities, and negative self-cognitions are entwined with

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    patriarchal values and social constructions. This awareness, coupled with an emerging voice and the skills to resist dominant norms, allows clients to locate the source of their distress not within themselves, but in the social context.

    In addition to making connections between the personal and the political, it is the creation of a space where women can be heard with respect, sensitivity, genuineness, and without being blamed. Women have overwhelmingly said that Dilaasa indeed provided a non-threatening atmosphere which was facilitated by counsellors, as revealed in the following excerpts from interviews with the survivors.

    I felt… like… I could share whatever problem I had with them and I could get a direction, help from them for future, what I must do next. …They [the counsellors] nicely heard everything I said. When they were listening to me, thus, I also felt that I should tell them everything that’s happening with me. They also listened very well and explained the steps ahead. When two friends are talking, then they talk right from the heart. This Dilaasa also makes you talk from your heart. I feel benefited by it. I was very confident that all these things would remain confi dential, so I could talk freely (Counselling Impact Study 2004, CEHAT, unpublished).

    Safety assessment and planning form essential components of counselling women facing domestic violence. In addition, efforts to provide multiple sources in consonance with women’s needs are made as, for instance, there are referrals for medical help, preparation of a medico-legal statement and registering of a police complaint if needed. The goals for counselling are set up in consultation with the woman after an understanding of her expectations. An appointment for follow-up counselling is fixed at the end of the counselling session. Women who are afraid of returning home because of threat of violence are admitted “under observation” for a period of 24 hours, which allows time for working out the next steps such as referring the woman to a shelter or finding a safe space with relatives/friends. Extending her stay at the hospital also provides her necessary time and space to make a decision. Quality control measures in place for counselling include case reviews on a regular basis in the presence of an expert. The needs of the woman user are at the centre of the functioning of the crisis centre. Utmost importance is given to ensure the safety of the woman user, to her healing, and adhering to the principle above all of “doing no harm”.

    3.3 Impact of Counselling

    Interviews with survivors showed that they provided the most positive feedback for the rapport the counsellors had been able to establish with them and the counsellors’ ability to make them relax and open up. They appreciated that the counsellors treated them with regard and without being condescending or patronising; that they did not blame the woman for her problems; and that they validated the woman’s experiences of abuse.

    Till today I could not tell anybody what I had hidden in my mind that how the people from my in-laws side are. They never allowed me to go to the neighbours, not to any relatives nor even to my mother. That is why I could not talk to anybody. I kept everything in my mind only. After coming to Dilaasa and talking to [the counsellor], I opened up

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