Support needs of survivors of violence against women in urban India: a prospective analysis of client records

Article history

The contractual start date for this research was in April 2018. This article began editorial review in July 2022 and was accepted for publication in March 2023. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The Global Health Research editors and publisher have tried to ensure the accuracy of the authors’ research article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.

Copyright statement

Copyright © 2024 Daruwalla et al. This work was produced by Daruwalla et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaption in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2024 Daruwalla et al.

Objectives

We wanted to understand the range of responses that a service for survivors of violence against women should be able to provide, based directly on the needs of clients. We used record-based information to understand women’s concerns and expectations in seeking help. We examined how they reached services, how they described their concerns, and what they said they expected. Of particular interest was the need for multiple strands of support. We aimed to quantify the proportions of clients who required crisis intervention, police action, legal input, and medical, psychological and psychiatric support.

Setting

Based at the non-government organisation Society for Nutrition, Education and Health Action (SNEHA), the Programme on Prevention of Violence Against Women and Children has provided support to over 13,000 survivors of violence against women since 2001. Services are open to all – particularly residents of informal settlements in Mumbai – and are delivered by postgraduate counsellors at six community and three public hospital counselling centres. Counsellors are trained in domestic violence, counselling techniques, mental health first aid, suicide prevention, ethics in counselling, and facilitating family meetings.

The services are supported by a telephone helpline and e-mail contact if the survivor is unable to physically visit a counselling centre (these were active during the COVID-19 pandemic and protocols for virtual consultation were established). Human resources include community outreach workers, counsellors, legal advisers and visiting lawyers, and clinical psychologists. These are complemented by close liaison with hospital practitioners, the police, District Legal Aid services, shelters, and psychiatrists. The programme also runs women’s outpatient departments in public hospitals that help coordinate with medical interventions for survivors of violence. Primary prevention activities are carried out through community campaigns and work with women’s and men’s groups, leading to individual voluntarism to identify, respond to, and refer survivors of violence.

Support for survivors takes a feminist, intersectional rights-based approach that respects their agency in deciding on the course of action. The response to violence in a woman’s life aims to be holistic in addressing her immediate and long-term needs, recognising trauma and challenging the stigma that accompanies gender-based violence. The hope is that the woman herself drives the outcomes of counselling and intervention, based on her right to choose. Mental health conditions complicate violent environments, and counsellors screen to understand survivors’ mental states and help them cope with their feelings, emotions, and cognitive processes, which violence often heightens or distorts.

Design and participants

We analysed quantitatively a data set of sequential anonymised electronic records entered by counsellors during client registration and support. Participants were all women clients who registered with counselling services in 2019. We excluded records of consultations with men and children.

Data collection and analysis

Counsellors entered information in an electronic relational database in Commcare (www.dimagi.com) after each consultation, intervention, and referral. Modules summarised the survivor’s demographic and crisis profile, including type of abuse, presenting concerns, desires from the consultation, structured risk assessment, screening for symptoms of depression (Patient Health Questionnaire-9; PHQ-9)26 and anxiety (Generalized Anxiety Disorder-7; GAD-7),27 followed by crisis intervention, subsequent counselling, and referral for medical, police and legal help. Analysis of unlinked records involved tabulation of frequencies and proportions in Stata^® 15 (StataCorp LP, College Station, TX, USA).

How did clients reach services and who were they?

Most women consulted after community outreach: 38% (864) were referred by community organisers, 11% (245) by women’s group members, 9% (196) by community volunteers, 8% (177) by previous clients, 4% (87) by programme staff, and 3% (68) by the police. Before attending, 39% (883) had learned of services from a community organiser, 17% (382) from a women’s group member, 9% (208) from a previous client, 8% (181) from the internet, 3% (76) from the police, and 1% (20) from a community campaign.

Table 3 shows that 75% of women clients were aged between 20 and 39 years and that 65% were married; 16% of these marriages were between faiths and 10% between occupational castes. Three-quarters (1741; 76%) of women had at least one child and 7% (167) were pregnant at the time of first consultation. Over half lived in nuclear and over one-third in joint families. Around 80% lived in either informal settlements (zopadpatti) or accommodation originally built for industrial workers (chawls). The majority faiths were Islam and Hinduism, and more than half of women had attended at least lower secondary school. A minority were in remunerated employment, largely in the informal sector. Their partners were more likely to have jobs overall: 41% worked in the informal sector, 18% were self-employed, and 14% worked in the formal sector. A small number of clients (40; 2%) reported at least some difficulty in at least one of the six domains of the Washington Group functional classification of disability. 28

What forms of violence were clients facing?

Clients commonly described intimate partner violence (37%), domestic violence by a family member other than their partner (22%), or both (27%); 2% had faced sexual violence from someone outside the home, 5% were dealing with family conflict, and 1% with neighbourhood conflict. The predominant forms of violence reported were emotional violence (88%), economic abuse (73%), and physical violence (71%). Two-thirds of clients (68%) reported instances of neglect, 59% of coercive control, and 36% of sexual violence. It was usual for women to have experienced more than one of these forms of violence: only 6% had suffered a single form, while 77% had survived three or more.

What were clients’ main concerns?

Table 4 summarises the issues identified by > 1% of clients as their major concerns. Physical (45%) and sexual violence (19%), and threats of it, were prominent reasons for consultation. The commonest concern, however, was a woman’s distress that she had been denied much-needed money (47%). Although few clients required referral to a shelter, one-third had been compelled to leave their home. Other less common concerns included broken promises of marriage, confinement to the home, pressure to marry, unwanted pregnancy, and non-accidental burns. More than half (59%) of clients consulted with more than one concern, and 25% with four or more.

Notable among the issues that clients thought were at the root of their problems were difficulties in either their adaptation to their expected roles in the marital family or the failure of their partner to live up to theirs; 29% of clients said that their family neglected their needs and 26% that the family exerted too much control over them. Alcohol or drug use by partners (28%) or their mental health (15%) were concerns in a sizeable minority of cases. Emotional violence often involved in-laws and centred on women’s roles as wives and mothers, amplified by financial pressures. That said, client narratives tended to focus on concrete issues such as financial constraint, marital infidelity, neglect of children, and interference by in-laws, rather than on more abstract ideas such as power and control.

What did clients want when they consulted?

Table 5 summarises what clients said when asked their expectations of consultation. Safety for themselves, their children, and their family was a major need. Women wanted counsellors to provide emotional support, take them through their options – including legal action – and help them decide what to do. Reflecting the household nature of violence, 44% wanted counselling for their partner and 32% for their family. Since only 12% of clients expressed a desire to leave their partner or family, and 11% had left the marital home and wanted to go back, the emphasis was on achieving reconciliation and a more tolerable environment. For this to happen, they wanted the counsellor to negotiate with their partner or family to stop the violence. Reflecting the common concern about roles and responsibilities, they wanted to be sure that their children would receive sufficient attention (and money) and that household workloads would be more equitable. This was underlined by their willingness to seek legal help to ensure financial support and protection orders. A common desire was for the police to signal the gravity of the situation to the partner or family by filing a non-cognisable offence (often called an NC: an offence for which a police officer has no authority to arrest without a warrant from a magistrate). It was unusual for women to want to go further by submitting a FIR (a document prepared by the police in response to information about the commission of a cognisable offence for which the police may arrest a person without warrant and are authorised to start investigation or prosecution under Section 498A of the Indian Penal Code).

Risk assessment

Counsellors identified appreciable risk for 79% of clients (Table 6). Common scenarios were physical assault and threat of violence against client or family (20% faced threat to kill). In 18% of cases, physical violence had extended beyond the domestic space to public places, and in 13% there had been an escalation in violence in the period preceding consultation. A quarter of clients had been made to move out of their home, 12% forcibly. The majority of clients (1895; 83%) were screened for depressive symptoms (PHQ-9) and anxiety (GAD-7). Screening suggested moderate or severe depressive symptoms in 39% (744) and moderate or severe anxiety symptoms in 35% (667).

Crisis counselling

Around one-third of clients (721; 32%) required crisis intervention after consultation. Most required one crisis counselling visit (88%) and the remainder generally required two (11%). Counsellors provided psychological first aid for 90%, conducted a formal suicide risk assessment for 79%, and worked with 78% to make a safety plan, including assessing the possibility of an increase in violence in response to women’s help-seeking. Crisis counselling involved clients’ partners in 87% of cases and their families in 37%. Urgent referrals were made to the police in 24% of cases, for medical care in 12%, and for shelter in 1%. Counsellors made home visits to intervene with partners (7%), marital families (14%), and natal families (9%).

Subsequent support

Overall, clients met with a counsellor a median three times [interquartile range (IQR) 2–6, range 1–44]. A single crisis consultation was usually necessary (IQR 1–1, range 1–5), and counsellors made home visits to 31% of clients (n = 715) (IQR 1–2, range 1–12); in 88% of cases, this visit involved discussions with the marital family. Figure 1 summarises the combinations of inputs that clients received: 68% received support from counsellors without referral, while 17% also received legal support (16% from a lawyer as well as a legal counsellor); the bulk of this work was prelitigation and litigation consultation. Almost one in eight (13%) saw a clinical psychologist, and 3% saw a psychiatrist; 7% consulted the police; and 5% received medical support. Overall, this meant that clients had a median seven consultations with a counsellor or other professional (IQR 4–12, range 1–72).

FIGURE 1.

Combinations of inputs that clients received.

Workload and vicarious trauma

The first assumption is demand. Domestic violence is common, and demand for support is potentially substantial. The initial numbers of consultations will be limited, but our service has reached a level of around 200 new clients every month. Although this is a heavy workload for counsellors, the potential numbers are greater because we know that only a minority of survivors disclose, and fewer consult. Community outreach is invaluable – 58% of consultations were triggered by the work of community organisers, women’s group members, and volunteers – but the burden of consultations and the vicarious trauma to counsellors are a source of stress and burnout that we must make efforts to mitigate.

Poverty and economic abuse

In the context of urban India, most clients will be married women with children who live in informal settlements or low-income housing and are not themselves in paid work. Money worries will be prominent: around half of clients said that they were being denied access to and control of finances. Such concerns are likely to be central to fears that they will not be able to survive if they leave their current home. Dependency on the natal family (and the attendant guilt) may cause problems if they have had to leave the marital home, often as a result of eviction.

Multiple forms of violence from multiple sources

Given the overlap between forms of domestic violence, we should assume that clients will have been exposed to more than one: 94% reported two or more, the commonest of which were emotional, economic, and physical abuse. Simultaneously, around half will have suffered violence from family members other than their intimate partner. Although clients reported physical violence, their concerns often turned more on economic and emotional violence that disrupted their day-to-day lives, affected their children, and harmed their self-respect. They expected counsellors to help stop the violence and negotiate with partners and family members for adequate resource provision for clients and their children.

Desire to stay

An assumption that differs from the largely Northern experience described in the literature is that around 90% of clients will want to stay in the abusive family. What they say they want is for counsellors (with or without the help of the police) to interact with their intimate partners and household to achieve a tolerable environment. This falls considerably short of domestic harmony, and testifies to women’s resilience and deep concern for family and children. We are humbled by the idea that women are willing to raise the threat of police, legal, or organisational action to achieve a modicum of self-determination and reduced exposure to physical, sexual, and emotional abuse in an environment in which the satisfaction of basic needs is a daily challenge (see Table 2 for a stark example).

We turn now to the approaches and actions that a responsive service must offer to clients.

Emotional support

Psycho-educational, supportive counselling may improve self-esteem, affect (anxiety, depression, hostility), assertiveness, social support, internal locus of control, coping abilities and self-efficacy, and may reduce the likelihood of repeat violence and improve quality of life. 29 An important requirement is emotional support, summarised usefully in the WHO LIVES approach: Listen, Inquire, Validate, Enhance safety, and Support. 30 Given the decisional balance around consultation and the big step it represents, clients need to feel that counsellors have heard their voices and validated their concerns. Although our clients articulated a need for emotional support, the articulation was retrospective. It is our impression that, before consultation, women often do not see a need for counselling to manage their emotions, feelings, and thinking; they expect solutions. It is also unrealistic to expect that counselling alone will lead to resolution. 31 Recurrence of violence is common, and the hope that women will remain free from violence is often unrealised.

Risk assessment and crisis response

The need for immediate risk assessment reflects the escalation in violence, concern for children, threats, and financial and mental stress that often tip the decisional balance in favour of seeking professional help. The counsellor has to assess risk adequately and help the survivor navigate the available options for mitigation. Some form of crisis response will be necessary in about one-third of cases. Priorities are psychological first aid, suicide risk assessment, and safety planning. The counsellor will usually need to involve the client’s partner and, in around 40% of cases, their family, through home visits in around 30% of cases. This means that counsellors need to have skills in emotional support, psychoeducation, and mediation because these processes will often be called upon. More than one-third of clients will describe symptoms suggestive of depression or anxiety, and 10–15% will be contemplating suicide. The period immediately around first consultation is critical, and counsellors need the training, support, and networks to be able to respond. Along with safety planning, the most important skills are in psychological first aid: only around 15% of clients will need to see a mental health professional. In our context, arranging institutional shelter for clients will only be required in around 2% of situations; a woman’s interim relocation from a high-risk environment more often involves her moving back to her natal home or to the home of a friend or community volunteer.

Enumeration of options

Isolation from the global story means that survivors of domestic violence often feel unable to exercise agency. They want to discuss their options with a counsellor who has experience of the challenges involved in deciding and acting and the likely outcomes. Particularly important in this weighing of options is an understanding of the client’s rights and the realities of legal processes. Statistically, it is likely that the legal path will be fraught with obstacles and setbacks, although – as our data suggest – approaching the police or a lawyer may itself be sufficient warning to trigger improvements in the home situation. The police will be involved in around a quarter of cases, and familiarity with the law and procedures is therefore important. It is likely that the counsellor will do more than refer a client to the police, and she needs to be confident in negotiation with them (and, to a lesser extent, with clinicians) to achieve the desired outcomes. Up to one-fifth (15–20%) of clients will need legal support. This sizeable minority need referral to lawyers (e.g. via free legal aid) or development of a paralegal cadre. We find it particularly useful to have paralegal team members who are able to support clients through the sequence of steps, act as the point person between counsellors, lawyers and courts, and adopt a watching brief. This has the secondary benefit of reducing substantially the demands on legal time.

Programmatic challenges

Over 20 years, our programme has steadily expanded to provide comprehensive services that meet the requirements of clients. Central to these is counselling and the protocolisation of risk assessment and crisis response. Our data confirm that these are, in a sense, the bottom line. Relationships and referrals require coordination, and the burden on counsellors to follow clients up and facilitate their progress is substantial. Although our counsellors aim to resolve clients’ issues and build their agency to make decisions for themselves, the balance has tended to favour provision of resources over addressing clients’ mental health. Long-term follow-up has been challenging and a lot is expected from counsellors with backgrounds in social work. What seems most important is access to clinical and legal services and strong relationships with providers, whether in-house or through regular interaction that develops front-line legal and mental health skills in counsellors and ensures that clients receive adequate follow-up.

Limitations

The record system may have been subject to errors in data entry or systematic differences between counsellor choices. Our analysis assumes that the inputs documented by counsellors in client records were necessary. For some (legal advice, interaction with the police, medical consultation), this assumption is reasonable as they would have arisen from agreement between client and counsellor. In some cases, however, there is a possibility of over- or under-identification of need, and differences caused by different counsellors’ propensities for and choices of referral; for example, more women than were referred might have benefited from seeing a clinical psychologist, and fewer situations might have been categorised as needing crisis intervention. Although home visits were important for follow-up, the data recorded by counsellors do not unequivocally establish their effectiveness. The spectrum of concerns relates to women residents of urban informal settlements and – although we suspect that they are generalisable to a degree – we should be cautious about their application to other populations.