Domestic Violence in Mental Health: Therapeutic and Legal Intersections

Abstract

Domestic violence (DV) is a global public health crisis with devastating and long-lasting consequences for individuals and communities. In the Indian context, DV typically involves violence against women by male family members or relatives, defined as a pattern of behavior used to gain or maintain power and control over an intimate partner. Addressing the overlap between DV and mental health requires mandatory screening of women with mental health concerns for DV, coupled with providing appropriate counseling and support. Public awareness campaigns and efforts to enhance women’s empowerment are imperative to reduce societal tolerance of DV and promote equity.

Introduction

Domestic violence (DV) is a pervasive global public health crisis with devastating and long-lasting consequences for individuals, families, and communities. Addressing this complex issue requires a multi-faceted and coordinated response that transcends the boundaries of any single professional discipline

DV in India is typically the violence suffered by a woman, which is inflicted by male members of her family or relatives.^1,2 It can be defined as a behavior pattern in any relationship used to gain or maintain power and control over an intimate partner. This includes any behaviors that frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, or wound someone. Any family member or relative can inflict DV, whereas intimate partner violence (IPV) is limited to acts of aggression between intimate partners.

There are several DV laws in India. The earliest law was the Dowry Prohibition Act of 1961, which criminalized giving and receiving dowry. To strengthen the 1961 law, two new sections, Section 498A and Section 304B, were added to the Indian Penal Code in 1983 and 1986. Section 84 of Bhartiya Nyaya Sanhita, 2023 (BNS), addresses the same issue. The Protection of Women from Domestic Violence Act (PWDVA) of 2005, ³ a civil law, defines DV as any act, omission, commission, or conduct of the respondent that constitutes DV if it—(a) harms, injures, or endangers the health, safety, life, limb, or well-being, whether mental or physical, of the affected person or tends to do so. This includes physical abuse, sexual abuse, verbal and emotional abuse, and economic abuse; or (b) harasses, harms, injures, or endangers the affected person to coerce her or any related person to meet an unlawful demand for dowry, other property, or valuable security; or (c) threatens the affected person or any related person through conduct described in clause (a) or (b); or (d) causes harm, whether physical or mental, to the affected person in any other way.

Globally, about one in three (30%) of women worldwide have been subjected to either physical and/or sexual IPV or non-partner sexual violence in their lifetime. Worldwide, almost one third (27%) of women aged 15–49 years who have been in a relationship report that they have been subjected to some form of physical and/or sexual violence by their intimate partner. ⁴ The Indian statistics by NCRB reveal that there was a sharp rise in crimes against women in 2022, cruelty by spouses or their relatives accounted for 31.4%, followed by kidnapping and abduction at 19.2%, assault “with Intent to outrage modesty” at 18.7%, and rape at 7.1%. NCRB data also suggests that women feel highly vulnerable in their marital homes, with instances like DV, acid attacks, and dowry deaths being common. ⁵

DV has a profound and lasting impact on the mental health of its victims. The psychiatric implications are often severe and can manifest in a range of conditions. Battered women are not necessarily a homogeneous group, and they may have a variety of mental health issues depending on the type of violence they experience. ⁶ Depression is a common outcome, as victims frequently experience feelings of helplessness and worthlessness that can progress into a major depressive disorder. It was found that female victims of severe male battering were four times more likely than non-victimized women to be depressed and/or attempt suicide. ⁷ Anxiety disorders are also prevalent; the constant fear and hypervigilance can manifest as generalized anxiety disorder, panic attacks, or social phobias. The repeated trauma and fear can put victims at a high risk for developing post-traumatic stress disorder (PTSD). This condition can cause debilitating symptoms like flashbacks, nightmares, and severe anxiety, making it difficult to manage daily life. Interpersonal traumatic experiences are associated with an increased risk of PTSD, ⁸ leading the ICD-11 (World Health Organization’s International Classification of Diseases, ICD-11, 2018) to propose a distinction between PTSD and complex post-traumatic stress disorder (cPTSD). The ICD-11 defines cPTSD as a distinct diagnosis that encompasses the core symptoms of PTSD while adding a specific triad of “disturbances in self-organization.” Typically stemming from chronic or repetitive trauma where escape was impossible—such as long-term DV or childhood abuse—cPTSD manifests as significant difficulties in regulating emotions, a persistent sense of worthlessness or deep-seated shame, and ongoing struggles to maintain meaningful interpersonal connections. ⁹ Essentially, the manual recognizes that these prolonged traumatic experiences do more than cause flashbacks; they fundamentally alter a person’s self-perception and their ability to function within relationships. For some, the intense psychological pain and feeling of being trapped can become overwhelming, leading to suicidal thoughts or attempts and self-harming behaviors as a way to cope. Additionally, some victims may turn to substance abuse, using drugs or alcohol to self-medicate and numb the emotional pain, which can eventually result in addiction. Victims of violence often experience feelings of guilt, shame, and self-blame for the abuse they suffered. This unfortunate response can fuel a vicious cycle: a negative self-image makes it harder for victims to take steps to avoid or leave abusive relationships. Adding to the damage, self-esteem can be further harmed when friends, family, or professionals blame the victim for not preventing the abuse. ¹⁰

These psychiatric conditions are not merely side effects of the abuse; they are often the most difficult and enduring injuries a victim faces. It is for this reason that the role of psychiatrists and other mental health professionals is so critical in providing comprehensive and trauma-informed care.

Discussion

DV is a pervasive issue that has far-reaching effects beyond the immediate physical harm inflicted on victims. Victims of DV often suffer from a myriad of psychological problems, which are likely to be severe and long-lasting. This discussion aims to explore the intricate relationship between DV and mental health, underscoring the necessity for integrated support systems.

A 2018 WHO analysis conducted from 2000 to 2018 across 161 countries revealed that approximately 30% of women worldwide have been subjected to physical, sexual, or both forms of violence, either by intimate partners or non-partners. Intimate partners commit as many as 38% of all murders of women. ¹¹ The National Family Health Survey-5, conducted over 2019–2021 in India, showed that a concerning 26.21% of empowered women were victims of IPV. Less empowered women were 74% more vulnerable to emotional abuse compared to their highly empowered counterparts. ¹² Usually, the risk factors that make women vulnerable to experiencing DV include a lower level of education, lower socio-economic status, poor family support, unemployment, and community norms that give women a lower status. Additionally, lower socio-economic status has been identified as a risk factor for IPV in women.^13,14 In contrast, working women with higher education were found to have higher rates of IPV exposure compared to non-working women. Such disparities may be attributed to factors such as spousal ego and gender-based prejudices prevalent in Indian society. ¹⁵

DV can have a profound and enduring impact on a woman’s life. The physical injuries can be battering-related injuries (lacerations, contusions, blunt and stab wounds, burns, dental and eye injuries). Pregnancy among women who experience IPV is associated with an increased risk of adverse outcomes such as miscarriage, stillbirth, preterm delivery, and low birth weight. A 2013 study revealed that these women were 16% more likely to suffer a miscarriage and 41% more likely to have a preterm birth. ¹⁶

The psychological toll of DV is devastating, and it varies depending on the type, duration, and severity of DV. A vicious cycle can emerge between mental disorders and DV. Mental health conditions can make individuals more susceptible to abuse, while abuse itself can significantly worsen mental health. The behavioral changes commonly observed are self-mutilation, aggressive behaviors, seeking substances, and increased utilization of health services. Systematic review and meta-analysis indicate a significant positive association between DV and mental health disorders, with a relative risk of three for depressive disorders, four for anxiety disorders, and seven for PTSD among affected women. ¹⁷ A significant positive association has been observed between DV and the development of psychotic symptoms, substance misuse, and eating disorders.^18–20 Chronic exposure to abusive environments, especially during childhood, and limited opportunities for escape due to physical, psychological, familial, or societal factors, can contribute to the development of cPTSD, a disorder originally conceptualized by Herman. ²¹ Women subjected to multiple forms of abuse face a significantly increased risk of developing mental health disorders and experiencing numerous conditions simultaneously. Despite a potential decrease in physical and sexual violence, older women still experience high rates of emotional, economic, and controlling abuse, leading to mental health challenges similar to those faced by younger women. ²² Therefore, age is no bar to experiencing violence in a woman’s life. Moreover, children raised in families characterized by violence may suffer from a range of behavioral and emotional disturbances. These experiences can also be associated with both perpetration and victimization of violence later in life.

Psychiatrists play an indispensable role in the DV ecosystem. Their primary focus is on the mental and emotional trauma inflicted by abuse, which is often hidden and can persist long after physical injuries have healed. The following specialized therapies are offered: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), Seeking Safety, Skills Training in Affective and Interpersonal Psychotherapy (IPT), Helping to Overcome PTSD through Empowerment (HOPE), Relapse Prevention and Relationship Safety (RPRS), and Cognitive Trauma Therapy for Battered Women (CTT-BW).

STAIR is an evidence-based, skills-focused form of Cognitive Behavioral Therapy (CBT); its main focus is on reframing cognitions (thoughts) that result from the traumatic experience. It was initially developed to treat individuals with PTSD related to childhood abuse. The therapy follows a phased approach, building from foundational skills: (a) emotion regulation skills, (b) interpersonal skills, and (c) narrative therapy (likely the trauma-focused component).

IPT is an effective, non-exposure-based treatment for PTSD that focuses on how trauma symptoms manifest as interpersonal difficulties (e.g., emotional withdrawal, “interpersonal hypervigilance”). The therapy directly addresses these relationship problems by focusing on one of four main interpersonal areas: grief and loss, role dispute, role transition, and interpersonal deficit.

In India, legal safeguards against DV are primarily established through a combination of specialized statutes and criminal codes. The framework is anchored by the PWDVA (2005), which provides civil remedies and emergency protection, alongside Section 498A of the Indian Penal Code (IPC), which criminalizes cruelty by a husband or his relatives. Additionally, the Dowry Prohibition Act (1961) serves as a critical pillar in this legal structure by specifically outlawing the request or exchange of dowry, a common precursor to domestic abuse.

The procedure under the PWDVA begins with reporting and culminates in court-issued orders, accompanied by penalties for non-compliance. Any person who has suffered DV reports the incident to the Protection Officer (appointed by the state government under Section 8(1)). Upon receiving the complaint, the Protection Officer submits a report of the incident to the Magistrate and the Station House Officer, along with any claim for relief the aggrieved person desires. After receiving the report, the Magistrate directs the Protection Officer to notify all concerned parties, including the Respondents, within two days from the direction, unless an extension is granted. ²³ If the Magistrate is satisfied after hearing the case that DV occurred, they can issue the following orders: Residence order, monetary relief, custody order, compensation order, and non-compliance punishment. In case of non-compliance of the orders, a Magistrate can impose the following punishment: Imprisonment up to a term of one year, or a fine of a maximum of 20,000 rupees.

The term “Aggrieved person” under the Domestic Violence Act, 2005, includes any woman who is or has been in a domestic relationship with the respondent, encompassing a woman related to the respondent by way of marriage (like a wife) or through a relationship like marriage (like a live-in relationship). This protection also extends to women in adoption relationships (such as an adopted daughter), and to family members connected by familial ties, including relations like a daughter-in-law or sister-in-law, as well as those related by blood relationships, such as a mother or sister.

The PWDVA grants several crucial rights and reliefs to an aggrieved woman. These include the right to a protection order to safeguard her from further abuse and a residence order which secures her right to live in the matrimonial home. Furthermore, she is entitled to possession of goods, ensuring she retains access to her personal property. To address her immediate needs, the Act provides for medical assistance and counseling, and the right to shelter. Legal support is also ensured through access to legal aid. For financial and familial security, she can seek a maintenance order and an order regarding compensation and custody. Finally, the court may issue a restraining order to prevent the abuser from approaching her or engaging in specific harmful actions.

Medical facilities have specific duties toward a woman who is an aggrieved person under the Domestic Violence Act. A request for aid must be made in writing under Section 7 by the aggrieved person, a Protection Officer, or a service provider. Crucially, a medical facility cannot refuse medical assistance simply because the woman has not yet filed a domestic incident report (DIR). If no report has been filed, the person-in-charge of the facility must fill out a specific form (Form I) and forward it to the local Protection Officer. Finally, the facility is required to provide the aggrieved person with a copy of her medical examination report free of cost.

A significant part of the psychiatrist’s duty is to serve as an advocate, actively working to empower the individual. This involves ensuring that the aggrieved person is fully and clearly aware of their legal, social, and medical rights. This is not merely a passive explanation; it is an active process of education and support, helping the patient understand the resources and protections available to them. By clarifying these rights—which may pertain to privacy, legal recourse, workplace protections, or access to specific services—the psychiatrist assists the patient in navigating complex systems, and can also issue a DIR in case victims seek such relief and regain a sense of agency and control over their situation. This advocacy role is foundational to the therapeutic alliance, building trust, and facilitating the patient’s journey toward recovery.

Conclusion

DV, a pervasive societal issue, has profound and far-reaching consequences for victims, particularly women. This research delved into the intricate relationship between DV and mental health, highlighting the significant impact of such abuse on psychological well-being.

To address the significant overlap between mental health issues and DV in women, healthcare providers at all levels should receive training to recognize the signs of DV in women experiencing poor mental health or depression. Women with mental health concerns should be routinely screened for DV, and those identified as victims should be offered appropriate counseling and support services within the healthcare setting. Psychiatrists play a vital role in addressing DV by identifying and treating the mental health impacts on victims, such as anxiety, depression, and PTSD. They provide therapy, medication, and safety planning to help victims cope with trauma and minimize risk. Furthermore, psychiatrists collaborate with other professionals, advocate for increased awareness and support services, and work toward policy changes to improve the lives of DV survivors.

Public awareness campaigns are crucial to reduce societal tolerance of DV against women by highlighting its harmful consequences on both individual and community well-being. It is imperative to enhance girls’ education and increase women’s empowerment to eliminate harmful socio-cultural practices and promote societal equity.