A Qualitative Study to Understand the Nature of Abuse Experienced by Persons with Severe Mental Illness

Abstract

Persons with Severe Mental Illness (PwSMI) living in the community are considered high-risk groups for victimization. However, the nature of violence experienced by PwSMI is not well understood in India, which limits the effectiveness of clinical interventions to prevent revictimization. The Key Informant Interviews (KIIs) and Focused Group Discussion guides were developed, content validated, and pilot tested. A total of 27 KIIs and 5 focus groups were conducted with 14 PwSMIs, 19 experts, and 18 caregivers. Thematic analysis was done using Braun and Clarke's six stages of thematic analysis. The saturation of themes was determined using the Comparative Method for Themes Saturation (CoMeTS). Some of the themes and subthemes that emerged were (1) Physical Abuse (physical restraining, hitting, spitting), (2) Psychological Abuse (living in a controlling environment, criticized, neglected, scapegoated, symptomization of emotions and behavior),(3) Sexual Abuse (sexual assault, reproductive coercion, sexual exploitation), (4) Social Abuse (teased or labeled, social deprivation, abandonment, discrimination, and exclusion), and (5) Trauma in formal care (Coercive treatment practices, seclusion, negative attitude of staff, surreptitious prescribing of medicines, patronizing behavior). Abuse experienced by PwSMI has significant treatment and health care costs and an increased burden on families and society, so comprehensive psychosocial care and support are needed to prevent revictimization.

Background

Psychotic Spectrum Disorders such as Schizophrenia, Bipolar Disorder, and Major Depressive Disorder are considered Severe Mental Illnesses (SMI). Despite no universal and consistent definition, the concept of SMI has remained significant and valuable because of its external and predictive validity, which helps identify patients with chronic illness and severe levels of disability (Tasa-Vinyals et al., 2020). As per WHO estimates, 264 million people are affected by Depression, 45 million people are affected with Bipolar Disorder, and 20 million are affected by Schizophrenia and other Psychosis (Reddy, 2019). The National Mental Health Survey in India from 2015 to 2016 reported the lifetime prevalence of psychiatric disorders to be 13.7%, with a current prevalence of 10.6% (Murthy, 2017).

Over several decades, researchers have focused on violence perpetrated by a Persons with Severe Mental Illness (PwSMI), giving little consideration to the severity and chronicity of mental disorder that makes a person susceptible to all kinds of abuse (Latalova et al., 2014). It is estimated that 5% to 64% of men with SMI and 6% to 37.7% of women with SMI have experienced physical abuse; sexual abuse ranges from 3% to 22.9% for men with SMI and 2% to 62% for women with SMI; psychological abuse ranges from 39% to 83% for men with SMI and women with SMI; domestic violence ranges from 14.8% to 95.2% among men with SMI and 10% to 67% among women with SMI, and criminal victimization ranges from 3.5% to 70% in the mixed psychiatric sample (de Vries et al., 2019; Khalifeh et al., 2016; Rani et al., 2022).

The literature emphasizes how social norms and customs, as well as contextual factors such as poverty, homelessness, unemployment, the severity of symptoms, poor compliance with medications, and personality characteristics like impulsivity, emotional dysregulation, and difficulty trusting and forming healthy attachment patterns, can make PwSMI vulnerable to abuse multiple times throughout their lives (Bhatia et al., 2016; Bhavsar et al., 2019; de Vries et al., 2019).

There is a lack of primary data, especially in countries like India, which explored the types of abuse experienced by men and women with SMI seeking psychiatric outpatient services. Shrivastava and Shrivastava (2013) highlighted the importance of studying abuse experienced by PwSMI in the Indian context since most PwSMI lives in communities and are mainly cared for by family members or relatives. Also, the kind of abuse PwSMI are exposed to would be moderated by demographic factors (e.g., birth rates, life expectancy, and death rates) as well as sociocultural factors (e.g., negative stereotypes, patriarchy, cultural normalization of abuse), which differ from those living in higher income countries (Ran et al., 2016).

Getting a broader perspective on abuse experienced by PwSMI is crucial by engaging key stakeholders (such as PwSMIs, caregivers, mental health professionals, and Non-Government Organizations working in mental health settings as experts). By involving key stakeholders, the authors will be able to get a better understanding of the types of abuse that PwSMI experience and create a sense of ownership by interpreting the findings from their viewpoint. This study aims to conduct a qualitative inquiry to explore PwSMIs, caregivers, and expert views on different forms of abuse experienced by persons with psychiatric disorders.

Methods

Data collection was done in the outpatient department of psychiatry in a tertiary care mental health institution in Bengaluru, South India, from January to June 2019. PwSMI were included if they were 18 years or above, diagnosed with Bipolar Affective Disorder, Schizophrenia, Schizoaffective Disorder, and Recurrent Depressive Disorder as per criteria of ICD-10, have been identified as abuse on screening, and have been maintaining well based on Guy's (1976) Clinical Global Impression (CGI) scale scoring (≤4) which indicated the severity of participants illness. Psychiatric social workers, clinical psychologists, psychiatrists, community health workers, lawyers, social activists, and grassroots nongovernmental organizations were considered experts who raised awareness about violence against PwSMI, enabled them to fight back, advocated for the protection of PwSMI's human rights, and supported trauma survivors with Severe Mental Illness in reintegration and rehabilitation.

As the study focused on collecting in-depth information about these professionals' experiences, perceptions, opinions, and knowledge, all of them had to have 10 years of experience. A caregiver was considered part of the study if he or she lived with a PwSMI and was at least 18 years old.

Ethical consideration

The Institutional Review Board (IRB) and Human Ethics Committee have approved the study. The study was conducted following the ethical guidelines given in the 1964 Declaration of Helsinki, revised in 2013. To protect the identity of participants, a code number was assigned to the transcripts, and the study results were reported without any identifying information.

Measures

Key Informant Interview (KII) Guide and Focused Group Discussion (FGD) Guide were developed by the research team, validated by six experienced mental health professionals, and pilot tested on two PwSMI, experts, and caregivers. The interview guide is attached as Table 1.

Table 1.

Interview Guide

Domain	Questions and probes
Types of abuse	(1) What forms of physical abuse can a person experience after developing mental illness? (Probes: Physical abuse could invade a person's physical space and make them feel physically uncomfortable. E.g., punching, slapping, kicking) (2) What forms of sexual abuse can a person experience after developing mental illness? (Probe: Violating a person's bodily integrity. Sex without consent or using physical force or verbal threat if a person with mental illness refuses to give consent) (3) What are different forms of psychological abuse can a person experience after developing mental illness? (Probes: Acts that make a person feel humiliated, afraid, confused, powerless, and overwhelmed. Ex.: coercive control, insults, humiliation, withdrawal of affection) (4) What are different forms of social abuse can a person experience after developing mental illness? (Probes: Behavior aims to cut off from family, friends, or community. Ex.: Perpetrator making them look bad or ruin their reputation in front of others.) (5) What forms of institutional abuse can a person experience after developing mental illness? (Probes: Attitude and behavior of government-run or private health care centers and institutes staff toward persons with mental illness. Ex.: forceful treatment, not treating a person with mental illness with respect or not involving them in the treatment-related decision)

Domain

Questions and probes

Types of abuse

(1) What forms of physical abuse can a person experience after developing mental illness?
(Probes: Physical abuse could invade a person's physical space and make them feel physically uncomfortable. E.g., punching, slapping, kicking)
(2) What forms of sexual abuse can a person experience after developing mental illness?
(Probe: Violating a person's bodily integrity. Sex without consent or using physical force or verbal threat if a person with mental illness refuses to give consent)
(3) What are different forms of psychological abuse can a person experience after developing mental illness?
(Probes: Acts that make a person feel humiliated, afraid, confused, powerless, and overwhelmed. Ex.: coercive control, insults, humiliation, withdrawal of affection)
(4) What are different forms of social abuse can a person experience after developing mental illness?
(Probes: Behavior aims to cut off from family, friends, or community. Ex.: Perpetrator making them look bad or ruin their reputation in front of others.)
(5) What forms of institutional abuse can a person experience after developing mental illness?
(Probes: Attitude and behavior of government-run or private health care centers and institutes staff toward persons with mental illness. Ex.: forceful treatment, not treating a person with mental illness with respect or not involving them in the treatment-related decision)

Procedure

Interview process

Written informed consent was taken from all the participants with the assurance of confidentiality. The KIIs and FGDs were conducted among PwSMIs, experts, and caregivers in a single session, ranging from 45 to 60 min. Debrief followed after each KII and FGD. Twenty-seven KIIs and Five FGDs were conducted with 14 PwSMI, 19 experts, and 18 caregivers. Data collection stopped after reaching a saturation point at the 27th KII and the fifth FGD. The lead researcher, who is a trained psychiatric social worker, facilitated the KIIs and FGDs. In addition, she has attended various workshops, training programs, and webinars on conducting qualitative research on sensitive topics such as violence.

Data processing

The audio recordings of the interviews were transcribed and translated by the lead researcher, who was fluent in Hindi and English, and the lead researcher also checked the accuracy of the transcriptions by matching them with the audio recordings. A codebook was developed. Later, the final list of codes was imported into ATLAS.ti.v.7 for mapping and connecting the themes. The lead researcher maintained field notes and reflexive journals during data collection and memos while analyzing transcripts. An independent investigator who was not part of the research did cross-coding of data (30% of the primary data set selected at random) to verify the consistency of the themes and subthemes with the transcripts. The disagreement between the lead researcher and the independent investigator over the themes and subthemes was resolved through discussion to reach a consensus.

Data analysis

Thematic analysis was carried out to search for patterns and connections between themes and subthemes using Braun and Clarke's (2006) six stages of thematic analysis (Supplementary Table S1). To decide whether saturation of themes was achieved so that the lead researcher could proceed further with interpretation, she compared her themes using the Comparative Method for Themes Saturation (CoMeTS, Constantinou et al., 2017). Theme saturation worktables are attached as Supplementary Tables S2.1 to S3.

Results

Overall, 51 participants were recruited for the study. The process Map for the Recruitment of the Participants is described in Figure 1.

FIG. 1.

Process map for recruitment of the participants for qualitative study. PwSMI, Persons with Severe Mental Illness.

The caregivers' profiles are shown in Table 2. Approximately 38.9% of caregivers were older than 50 years. Most were males (77.8%), 44.4% were married, 16.7% were not formally educated, and 27.8% worked part-time or full-time. The average monthly income of caregivers was Rs. 10,000 or more. Most (55.6%) belonged to a nuclear family, originated from a rural area (61.1%), and were Hindu by religion. About 72.2% of caregivers had over 10 years of experience, and most were siblings (55.6%). 38.9% of caregivers spent more than 12 h with a PwSMI in 24 h, and 55.6% had diagnosed medical conditions. A majority of caregivers had good social support (72.2%), mostly through their families (55.6%), who provided emotional support (61.1%).

Table 2.

Frequency Analysis of Subthemes and Codes (n = 51)

Subtheme	Codes	n (%)
Physical abuse	Physical restraining	11 (21.57)
	Hitting	18 (35.29)
	Spitting	10 (19.60)
Psychological abuse	Living in a controlling environment	16 (31.37)
	Criticized	23 (45.09)
	Scapegoated	24 (47.05)
	Neglect	36 (70.58)
	Symptomizing their emotions and behaviors	21 (41.17)
Sexual abuse	Sexual assault	12 (23.52)
	Reproductive coercion	11 (21.57)
	Sexual exploitation	14 (27.45)
Social abuse	Teased or labeled	20 (39.21)
	Social deprivation	22 (43.14)
	Abandonment	17 (33.33)
	Discrimination and exclusion	20 (39.21)
Trauma in formal care	Coercive treatment practices	19 (37.25)
	Seclusion	11 (21.57)
	The negative attitude of staff	16 (31.37)
	Surreptitious prescribing of medicines	19 (37.25)
	Patronizing behavior	17 (33.33)

A description of the experts' profiles can be found in Table 3. The table shows that over half of the experts were males and older than 50 years. Most were married (78.9%) and educated to the postgraduate level (84.2%). Among the experts, 21.1% were community health workers, 14.6% were NGO directors, and 15.8% were psychologists. An average number of experts worked in urban areas, whereas others worked in rural areas (47.4%). Over 47.4% of the participants had incomes over Rs. 60,000. Around 84.2% had more than 11 years of experience. The areas of expertise of 31.6% were community psychiatry, and 26.3% were mental health law and policy. About 26.3% of the experts contributed to lobbying, networking, and advocating, whereas 15.8% worked on legal and ethical issues Table 4.

Table 3.

Caregivers Profile (n = 18)

Variables	n (%)
Age (years)
18–28	2 (11.1)
29–39	4 (22.2)
40–50	5 (27.8)
>51	7 (38.9)
Gender
Male	14 (77.8)
Female	4 (22.2)
Marital status
Single	3 (16.7)
Married	8 (44.4)
Separated	6 (33.3)
Widowed	1 (5.6)
Education
Not literate	3 (16.7)
Primary school	2 (11.1)
Middle school	2 (11.1)
High school	2 (11.1)
Preuniversity	3 (16.7)
Graduation	3 (16.7)
>Postgraduation	2 (11.1)
Others	1 (5.6)
Occupation
Self-employed	4 (22.2)
Part-time	5 (27.8)
Full-time	5 (27.8)
Homemaker	2 (11.1)
Retired	2 (11.1)
Monthly income (INR)
0–5000	3 (16.7)
5001–10,000	6 (33.3)
>10,001	9 (50)
Religion
Hindu	10 (55.6)
Muslim	5 (27.8)
Christian	3 (16.7)
Domicile
Rural	7 (38.9)
Urban	11 (61.1)
Types of family
Nuclear	13 (72.2)
Joint	5 (27.8)
No. of years of caregiving
<5	2 (11.1)
6–10	3 (16.7)
>11	13 (72.2)
Relationship with patient
Parent	5 (27.8)
Spouse	3 (16.7)
Sibling	10 (55.6)
Duration of stay with the patient in 24 h
<3	4 (22.2)
3–6	6 (33.3)
6–12	1 (5.6)
>12	7 (38.9)
Known diagnosed medical condition
Yes	10 (55.6)
No	8 (44.4)
Support system
Yes	13 (72.2)
No	5 (27.8)
Sources of support
Family	10 (55.6)
Others	3 (16.7)
More than one	5 (27.8)
Types of support
Financial	2 (11.1)
Emotional	11 (61.1)
More than one	5 (27.8)

INR, Indian Rupee.

Table 4.

Experts Profile (N = 19)

Variables	n (%)
Age (years)
29–39	3 (15.8)
40–50	6 (31.6)
>50	10 (52.6)
Gender
Male	10 (52.6)
Female	9 (47.4)
Marital status
Single	3 (15.8)
Married	15 (78.9)
Divorced	1 (5.3)
Education
PUC	1 (5.3)
Graduation	2 (10.5)
>Post-graduation	16 (84.2)
Occupation
Director, NGO	3 (15.8)
Social activist	4 (21.1)
Psychologist	3 (15.8)
Lawyer	2 (10.5)
Psychiatrist	1 (5.3)
Psychiatric social worker	2 (10.5)
Community health worker	4 (21.1)
Domicile
Urban	10 (52.6)
Rural	9 (47.4)
Monthly income (INR)
10,000–30,000	4 (21.1)
30,001–60,000	6 (31.6)
>60,001	9 (47.4)
Working experience (years)
6–10	3 (15.8)
>11	16 (84.2)
Area of expertise
General hospital	2 (10.5)
Women mental health	3 (15.8)
Public mental health	2 (10.5)
Community psychiatry	6 (31.6)
Mental health law and policy	5 (26.3)
Any of the above	1 (5.3)
Major contributions in their field
Research on medical and cultural anthropology	2 (10.5)
Legal and ethical aspects of mental health care	3 (15.8)
Member of core committee to frame policy	2 (10.5)
Lobbying/networking and advocacy	5 (26.3)
Others	2 (10.5)
More than one of the above	5 (26.3)

The PwSMI profile is shown in Table 5. The table indicates that most of the PwSMI (64.3%) belong to the age group of 29 to 39 years. Half of the PwSMI were males (50%), while the other half were females (50%). Over 35.7% were single, educated up to graduation (35.7%), and doing a part-time job (28.6%) with a monthly income of Rs. 7000 and above. Most participants hailed from urban areas (71.4%) and came from a nuclear or joint family. Schizophrenia or Bipolar Affective Disorder was the most commonly diagnosed disorder (35.7%). Many participants had medical comorbidities such as hypothyroidism and vitamin B12 deficiency (28.6%). Nevertheless, many participants also had psychiatric comorbid conditions such as depression (14.3%), anxiety, or psychosis (7.1%).

Table 5.

Persons with Severe Mental Illness Profile (N = 14)

Variables	n (%)
Age (years)
18–28	1 (7.1)
29–39	9 (64.3)
40–50	3 (21.4)
>60	1 (7.1)
Gender
Male	7 (50)
Female	7 (50)
Marital status
Single	5 (35.7)
Married	4 (28.6)
Separated	1 (7.1)
Divorced	2 (14.3)
Widowed	2 (14.3)
Education
Primary school	2 (14.3)
Middle school	2 (14.3)
High school	2 (14.3)
PUC	1 (7.1)
Graduation	5 (35.7)
Postgraduation	2 (14.3)
Occupation
Unemployed	2 (14.3)
Self-employed	2 (14.3)
Part-time	4 (28.6)
Full-time	3 (21.4)
Student	2 (14.3)
Homemaker	1 (7.1)
Monthly income (INR)
3500–7000	6 (42.9)
7001 or above	8 (57.1)
Domicile
Rural	4 (28.6)
Urban	10 (71.4)
Types of family
Nuclear	7 (50)
Joint	7 (50)
Primary caregiver
Mother	8 (57.1)
Sibling	1 (7.1)
Spouse	4 (28.6)
Children	1 (7.1)
Support system
Yes	13 (92.9)
No	1 (7.1)
Clinical diagnosis
Schizophrenia	5 (35.7)
Bipolar affective disorder	5 (35.7)
Schizoaffective disorder	2 (14.3)
Recurrent depressive disorder	2 (14.3)
Comorbid conditions
(I) Medical comorbidities
Hypothyroidism	4 (28.6)
Obesity	2 (14.3)
Vitamin B12 deficiency	4 (28.6)
(II) Psychiatric comorbidities
Depression	2 (14.3)
Psychosis	1 (7.1)
Anxiety	1 (7.1)
Duration of illness (years)
2–5	5 (35.7)
6–10	2 (14.3)
>10	7 (50)
Current symptoms
Depressive symptoms	7 (50)
Negative symptoms	4 (28.6)
Any of the above	3 (21.4)
Treatment history
Yes	12 (85.7)
No	2 (14.3)
Types of treatment
Magico-religious	7 (50)
Medical	6 (42.9)
Psychological	1 (7.1)
Family history
Yes	7 (50)
No	7 (50)
No. of family members
1 Member	2 (14.3)
>1 Member	5 (35.7)
Relationship with patient
First-degree relative	2 (14.3)
Second-degree relative	5 (35.7)
Treatment taken
Regular	11 (78.6)
Irregular	3 (21.4)
No. of hospital admission
1–5 times	13 (92.9)
>5 times	1 (7.1)
No. of relapse
None	2 (14.3)
1–5 times	12 (85.7)
Reasons for relapse
Family-related factors	8 (57.1)
Nonadherence to medication	6 (42.9)

The average duration of illness of the participants was more than 10 years. The majority of participants (85.7%) were treated for mental illness, with magico-religious treatment on average. Most participants (78.6%) were taking regular treatment, and about 92.9% had previously been admitted one to five times for inpatient care. Over 85.7% of the participants had a history of multiple drug defaults with one to five times relapsed.

Many subthemes emerged within each theme, presented as a thematic map in Figure 2. Frequency analysis of subthemes and codes are shown in Table 2.

FIG. 2.

Thematic map of type of abuse.

Types of abuse experienced

Participants discussed various forms of abuse experienced by the PwSMI, including physical, sexual, psychological, and social abuse. Trauma in formal care is also a vital aspect of discussions.

Physical abuse

It includes restraint, hitting, and spitting. Restraint refers to restricting the freedom of movement of a participant. Hitting involves striking participants with hands, feet, or household objects that can be used as weapons, such as sticks, knives, or other household items. In spitting, saliva is released from the mouth of the perpetrator, which participants perceive as an act of contempt or anger.

Physical restraining

Some participants reported how physical restraint is a socioculturally accepted way of protecting a PwSMI from being abused by others. One of the participants expressed his opinion as follows:

“I was informed that in this village, there is this boy who has been chained. Chaining was a very common factor in most cold places of India… So, when we met the father and tried to explain to him not to do that, he reported that if he did not, the boy would enter someone's home and ask for food. Many times, he was beaten up by the villagers.” [FGD1:03, Community Worker]

Hitting

Many participants described how they were abused by their partner under the influence of the substance. One of the participants states:

“My husband would come drunk and bang my head on the wall, hit me, or throw things at me. The next day even getting up and doing daily work was so difficult.” [KII: Pt.5]

Another participant says:

“Family members hit or lock patients inside the house in situations where patients become out of control. Patients think the family is their enemy and even shout or scream or do whatever they like.” [KII: Carg. 4, Brother]

Spitting

Some participants described spitting as a form of abuse they experienced and how they coped with it. One of the participant's reports:

“Now I have learned to live with it.Every time when my husband gets angry, he spits on me. I have been staying with that man for the last 18 years, so I have become used to it. It is so humiliating. I feel why I am alive. However, I cannot leave him…Where will I go? I am not educated or working. I am alive or being with that man only for my daughter.” [KII: Pt.14]

According to another participant, spitting is used by the perpetrator as a form of abuse because:

“It is socially and culturally acceptable way to show power, control, anger, and disrespect towards the mentally ill.” [KII: Exp. 7, Social Activist]

Psychological abuse

This type of behavior is characterized by living in a controlled environment, being criticized, scapegoated, neglected, and symptomizing participants' emotions and behaviors. Living in a controlled environment is defined as the perpetrator asserting power and dominance over the participants' day-to-day lives. The act of criticism refers to dislike or disapproval of the participant's behavior, which is perceived as deliberate to avoid performing the role and responsibilities expected from the participant. The act of scapegoating involves blaming participants for an event that has occurred in the perpetrator's life. The act of neglect deprives participants of adequate clothing, food, and shelter. Furthermore, it refers to ignoring the emotional needs of participants. Symptomizing participants' emotions and behaviors involve linking their emotional expression and day-to-day behavior to their psychotic symptoms.

Living in a controlling environment

One of the participants shared about his client's life:

“The mother would decide everything.what he will wear.what he will eat…how he should talk and what he should watch on television…If the son got frustrated as he was not allowed to do anything on his own, the mother would threaten to put him in a rehab home and never bring him back.” [FGD1:02, Psychiatrist]

Criticism

One of the participants shares:

“I was constantly humiliated by my brothers. My elder brother and his wife would tell me I was lazy and not working. Eat like buffalo. My younger brother was crueler as he poured water on me if I slept till late… What can I do? Medicines make me very drowsy.” [KII: Pt.4]

Scapegoating

One of the participant's reports:

“Every time something goes wrong, he blames me for that. No money, you are the reason…no rest… you are the reason…fight with someone… you are the reason…He often said that my face was unlucky, and after I started staying with him, his business was not going well…” [KII: Pt.11]

Another participant opines:

“I mean to say that is one-way perpetrators try to cope with things going wrong in their life, especially those who have always blamed others for their problems. Patients become a soft target as they are ill, helpless, and dependent on the family.” [FGD 3:03, Psychiatric Social Worker]

Neglect

Most participants reported that another form of psychological abuse is family neglecting the patient's basic needs, but it is difficult to identify as it is done subtly. One of the participants states:

“Not giving them adequate food, clothing or patients forced to live in a separate house… their house does not have fresh paint, no electricity, plumbing, no proper ventilation. It is much more common but is not visible in public unless you stay with the family. Even family does not realize that or patients themselves do not realize it as abuse.” [FGD1:03, Community Health Worker]

Another participant laments:

“I know we as a family struggle even to eat a handful of rice, and something like chicken is a luxury that we enjoy once in a while. We never had enough food at home to feed all of us. I am ok with that…but the problem is when the family just ignores me…It is also because I am not earning and bringing money.” [KII: Pt.8]

Symptomizing their emotions and behaviors

One of the participants explains how families subconsciously symptomize patients' emotions and behavior without realizing that it is a kind of abuse and how it impacts patients. He says:

“If she becomes too happy, my wife and son feel she is not ok. She likes reading books a lot, so she stays up late at night…Her mother became so worried and often went and asked her to see the doctor. She (wife) feels her (daughter's) mania may be returning. I can see how frustrated and suffocated it makes my daughter.” [KII: Carg. 5, Father]

Sexual abuse

This includes reproductive coercion, sexual assault, and exploitation. A behavior aimed at controlling a participant's reproductive choices is defined as reproductive coercion. It consists of a range of behaviors such as pressure, manipulation, emotional blackmail, threat, and the use of physical violence. An act of sexual assault occurs when a participant is forced, coerced, or threatened into performing a sexual act against their will. Sexual exploitation occurs when a perpetrator takes advantage of participants' vulnerable and dependent states by forcing them to witness and participate in sexual acts.

Sexual assault

One male participant describes being humiliated by his wife every day for sex. He states:

“My wife would insult and mock me and say I am not man enough to have sex with her…Multiple times she forced me to do it, and if I refused, she told me she would have an affair or sleep with another man as I had lost my manhood and could not make love and satisfy her.” [KII: Pt.2]

Many participants reported how lack of awareness about mental illness can often perpetuate sexual assault by the partner. One of the participants opines:

“My husband forces me to sleep with him every day. He scolds me for being so cold while making love. He does not understand it is because of my illness.Depression takes away all your feelings and ability to show love.” [KII: Pt.8]

Reproductive coercion

One of the participants shares how reproductive coercion can be perpetrated by the partner, which can have severe consequences on physical and mental health. She reports:

“I remember one of my clients complaining about how her husband forced her to become pregnant by putting so much pressure on her, and when she refused to do so, he threatened to leave her. She was worried about being on medication and conceiving, so she stopped her medicines. She conceived but became highly symptomatic and needed to be admitted and lost her baby due to medical complications.” [FGD5: 01, Psychiatrist]

Another participant expresses how she feels when her partner makes the reproductive decisions without involving her. She states:

“I feel so helpless…giving birth to a child is a gift, but it has become a curse for me…and when I was pregnant for the fifth time, he would insist on having sex even a few days before delivery; as a result, I lost my baby and was hospitalized for almost a month.” [KII: Pt.9]

Sexual exploitation

One of the participants opines:

“Sexual violence almost becomes the cost a person must pay for the care they get from family or relatives. I do come across many of these problems. Often what limits me from taking any action is that the victim does not want any action to be taken as they fear consequences in the form of abandonment or retributions.” [KII: Exp. 7, Social Activist]

Another participant reports:

“That is what is happening… Having a person with mental illness at home referring especially women with mental illness… Women with long duration of illness are used and exploited for family's day-to-day needs both physically and sexually. The spouse or any relative who may be bringing this woman to the hospital or providing money for expenses may force her to sleep with him, and if this woman refuses to do so, threats of negative consequences and withdrawal of support will be given.” [KII: Pt.4]

Social abuse

It consists of teasing or labeling, deprivation, abandonment, discrimination, and exclusion. Being teased or labeled refers to making fun of a participant's mental illness or relating their illness to their identity to annoy, embarrass, irritate, or upset them. Social deprivation corresponds to the experiences of participants from low socioeconomic backgrounds. Their inability to live a decent life due to lack of resources further exacerbated their financial and social problems. The act of abandonment occurs when a parent, sibling, spouse, or any individual with a duty to look after a participant deserts the participant with the intention of wholly abandoning the participant with no regard for the participant's health and safety as a result of financial hardships or emotional exhaustion.

Discrimination and exclusion refer to negative stereotypes and prejudices against PwSMI. These stereotypes and prejudices cause discriminatory behavior against participants, such as refusing to rent them a house or hire them for a job.

Teased or labeled

One of the participants states:

“Once I got this illness, it became a stamp that I think will be with me until I am alive. My neighbour's children tease me and call me ‘crack.’ My neighbourhood friends consider me ill and do not even talk to me. I feel it is quite normal to feel left out.” [KII: Pt.10]

Another participant shared his feelings and emotions about being labeled and teased at the workplace. He reports:

“I feel that once you become mentally ill, you become invisible to everyone. You are demeaned, isolated, and degraded.” [KII: Pt.1]

Social deprivation

Many participants described social deprivation as a common experience for those living in poverty and with mental illness. One of the participants reports:

“Their daily struggle is…they do not have food to eat or a proper roof on their heads, or they do not have fersi on their floor. where people go to work early in the morning and come back late at night. Spending time interacting or celebrating their happiness within the community is a luxury they do not enjoy daily.” [KII: Exp. 2, Community Health Worker]

Abandonment

One of the participants reports:

“When I was in Salem (Tamil Nadu), I remember that there was this girl whom the family discarded…left on the railway station. She might be sixteen or seventeen years old, and she was just left out because of her mental illness, and in due course of time, I found that she became pregnant.” [KII: Carg. 6, Father]

Discrimination and exclusion

One of the participants reported how he experiences discrimination in his day-to-day life. He states:

“I am educated and working as a software engineer, but the moment I told the landlord about my illness, they refused to give me a house for rent…Not only that, I have so many cousins, and one or the other keeps getting married, but I have never been invited to attend their weddings.” [KII: Pt.1]

Another participant vents out his frustration as:

“I tried so many times to get a job…However, I do not know how they came to know I am not normal. They would tell me this place was not suitable for me. If they find something which suits my profile, they will give me a call which never happens. Some recruiters have even stepped forward and suggested I try somewhere else where more people like me are.” [KII: Pt.3]

Trauma in formal care

It includes coercive treatment practices, seclusion, the negative attitude of hospital staff, surreptitious prescribing of medicines, and patronizing behavior. Treatment practices involving coercion include forcing participants to undergo treatment, locking them in a room, and tying them up if they become restless or violent. Seclusion involves locking participants in a separate room to isolate them from other patients. The negative attitude of hospital staff describes how doctors, nurses, and attendees communicated with participants whenever they came for a consultation or were admitted. Surreptitious prescribing of medications is characterized by the behavior in which a psychiatrist suggests to the participants' families that they administer medicines covertly through food or drink without the participants' knowledge. Patronizing behavior refers to authoritative and disrespectful behavior, which occurs when treating psychiatrists behave rudely, apathetically, and dominantly toward the participants.

Coercive treatment practices

One of the participants shared her experiences of hospitalization. She reports: “At the previous clinic where I was admitted, their doctor used to keep me locked inside the room, and sometimes when I was screaming then they used to tie me up, and staff members who were like a two-headed monster to me will hold me tight and inject the medicines….” [KII: Pt.10]

Another participant says:

“The psychiatrist would often convince the family to go for Electroconvulsive therapy (ECT) without patient consent, forcefully give medicine, or do a depo injection…It is used as compulsion by the psychiatrist.” [KII: Exp. 7, Social Activist]

Seclusion

Some participants described how they felt when isolated in the hospital ward. One of the participants states:

“I still get nightmares. I cannot forget those days when my family put me there for months altogether.I was treated worse than animals. We were locked separately in a room, and the doctor or nurse would not even come to see us daily. It seems we were living in a graveyard where all were dead and devoid of emotions.” [KII: Pt.11]

The negative attitude of staff

One participant reported the staff's negative attitude as a shared experience which the participant believed most of the PwSMI go through in one way or another while seeking treatment. She states:

“It is very rare for people to report, you know, very healthy or positive experiences of hospitalization. I am not saying that hospitals are bad or positive, but people's perception of hospitalization invariably is negative. We hear stories of abuse of having been beaten up or called names by staff in institutions, deprivation, attacks, molestation.” [FGD1:02, Psychiatrist]

Surreptitious prescribing of medicines

One of the participants shares:

“This is a kind of chemical abuse. It numbs you emotionally because of the kind of drugs you were given. The doctor would often ask the family to mix it with food, tea, coffee, or juice if a patient is not willing to take medicines orally.” [KII: Exp. 4 Human Rights Activist]

Patronizing behavior

One of the participants states:

“I have seen how doctors will talk with so much authority. They do not even bother to make eye contact with you. Not give you a chance to speak…Gets irritated for repeating the same thing again and again…Give you advice without even trying to know what you want.” [KII: Pt.14]

Another participant shares how a sense of superiority can make mental health professionals judgmental in attitude. He reports:

“I think sometimes we need to de-learn certain things… We tend to sympathize with the family and antagonize patients. We have already made up our minds.” [FGD4:01, Social Activist]

Discussion

The present study examines the victimization experienced by PwSMI. The result showed that the participants had varied experiences of abuse. Some common forms of physical abuse reported were physical restraint and hitting, which is consistent with the findings of Khalifeh and associates (2015a), which focused on reporting domestic violence experienced by PwSMI who are receiving mental health services. As McCarthy (2017) reports, spitting, one of the most humiliating forms of physical abuse, has also been reported by the participants in the present study. Spitting is often a socioculturally accepted way of showing disrespect and hostility toward a person with mental illness, highlighting the power and control that perpetrators hold on the victims (Dinos et al., 2004; Dubreucq et al., 2021).

Psychological abuse was considered a subtle form of abuse in the present study. Commonly identified psychological abuse was coercive control, criticality, and symptomizing emotions and behaviors. Gonzalez-Blanch and associates (2014) reported that psychological abuse was most underreported and was considered a covert form of discrimination and microaggression experienced by PwSMI.

Social abuse in the form of being teased or labeled, social deprivation, discrimination, and exclusion was reported as the everyday experience of some participants in the present study. PwSMI who are migrants and belong to a lower caste, and ethnic-minority communities are often more likely to face prejudice, discrimination, and social deprivation due to their marginalization. In addition, this intersects with their perceived mental health experiences (Bowleg, 2012; Jiloha, 2010; Mfoafo-M'Carthy and Huls, 2014). Richter and Hoffmann (2019) also point out that PwSMI is marginalized because they are often deprived of job opportunities and decent living standards due to low income, poor social support, and lack of civic engagement.

There is also a need to highlight how mental illness, stereotypes, prejudices, discrimination, and exclusion can be linked to patriarchal honor in India. Stereotypical viewpoints about PwSMI are quite common. Often, they are considered persons with personality flaws bringing disgrace and dishonor to the family and people associated with them (Bhatia et al., 2016; Kilmartin, 2005). PwSMI is expected to control their emotions, stop acting out on their symptoms, and expected to appear normal (Barn, 2008; Busfield, 1988; Tasa-Vinyals et al., 2020).

Sexual assault, reproductive coercion, and sexual exploitation were the everyday experience of women with SMI (Alhusen et al., 2020; Chandra et al., 2003; Khalifeh et al., 2015a; Tasa-Vinyals et al., 2020), as also reported by the female participants in the present study. Research has consistently indicated that sexual abuse can lead to unintended pregnancy, physical injury, and increased psychological distress and trauma in women with SMI (Alhusen et al., 2020; Khalifeh et al., 2015b; Norman et al., 2010). They are more vulnerable to sexual assault because of impaired judgment, limited reality testing, increased dependency on their partner, impaired functioning, and difficulty asserting themselves in a relationship (Bonugli et al., 2010; Chandra et al., 2003; Rani et al., 2022).

Interestingly, the present study also indicated that PwSMI is also traumatized in formal care as they were subjected to coercive treatment practices, seclusion, negative staff attitude, surreptitious prescribing of medicines, and patronizing behavior of the medical staff. There is not much evidence of victimization within the mental health care system, so the nature of abuse within mental health care institutions largely remains unknown. In two cross-sectional surveys, PwSMI self-reported violent and nonviolent forms of victimization within mental health care facilities.

The studies indicated that 31% to 51.2% of PwSMI reported physical abuse, 8% to 10.6% reported sexual coercion and assault, 40% reported theft, and 63% were traumatized by coercive treatment practices (Rossa-Roccor et al., 2020; Wallsten et al., 2006). Some of the coercive treatment practices experienced by PwSMI were being pinned down by psychiatric staff, involuntary admission, physical restraint, forceful medication, and seclusion, which worsened symptoms and led to retraumatization (Cohen, 1994; Steinert et al., 2013).

One of the limitations of the present study is that it focuses on participants' recollections of abusive experiences after developing mental illness, which might be influenced by difficulties related to recovery from illness, medication, ability to function in day-to-day life, and their present emotional state coloring their experience of abuse and perspective about it. This study has other limitations, such as focusing only on severe mental illness and interviewing participants at a single tertiary hospital's outpatient psychiatric department. Therefore, the findings of this study cannot be generalized to other settings or participants with other mental disorders than those included in this study.

It is also important to note that culture influences the meaning people impart to their illness and their way of making sense of the subjective experience of being victimized and distressed (Reddy, 2019). Therefore, it is possible that the present study could not capture the experiences and perceptions of all the ethnically diverse populations in India.

Nevertheless, the strength of the present study was that a diverse perspective was taken into consideration by interviewing heterogeneous participants-PwSMI, caregivers, mental health professionals, social activists, and NGO personnel by triangulating the data through multiple sources (i.e., KIIs and FGDs). Another strength of the study was the larger sample size, which, often in qualitative research designs, enhances the quality and adequacy and contributes to information-rich data, as Vasileiou et al. (2018) pointed out. Future research should concentrate on carrying out a longitudinal study to ascertain how the experience of abuse was influenced by the events that occurred in PwSMI's lives and the critical moments and processes that were involved and influenced their experiences.

Conclusion

Abuse experienced by PwSMI is a significant public health concern, as demonstrated in the present study, that PwSMI can experience different forms of abuse. One of the most common forms of abuse reported in the present study was physical abuse, mainly caused by difficulties managing mental illness and changes in behavior and personality. Psychological abuse was one of the most subtle forms that was difficult to recognize and acknowledge as abuse, but was part of participants' everyday life. Sexual abuse was associated with bruises, power struggles, dominance, humiliation, oppression, dehumanization, and devaluation of the participants. Social abuse was an intersection between the participants' multiple identities, such as gender, ethnicity, education, employment, and socioeconomic status. Trauma in formal care was an expression of participants' traumatic experiences within a mental health setting. It induced a sheer sense of helplessness and powerlessness and made the participants passive recipients of services.

Contrary to popular belief, PwSMI is most likely to be victimized by someone within the community than being the perpetrator of violence. Usually, they are cared for by immediate or extended family members. The caregivers or family members thus play a vital role in protecting PwSMI from victimization. The family, rather than normalizing the abuse or blaming the person for it, should help PwSMI to seek formal support. In addition, PwSMI symptoms and behavior can change with the severity and chronicity of the disorder, making it difficult for the family to manage them. Also, the family should regularly discuss the issues they face managing PwSMI at home with mental health professionals.

As part of a community-coordinated approach, mental health professionals need to collaborate with other stakeholders, such as caregivers, lawyers, and nongovernmental organizations, to raise awareness about abuse, provide resources for seeking help, and develop violence prevention programs that utilize indigenous resources.

Footnotes

Authors' Contributions

A.R. and K.J.R. contributed to the study concept and design. A.R. collected data, analyzed, and interpreted it. All the authors contributed equally toward article drafting, revision, and the final article. All authors gave their approval to the final article submitted here.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding from any source has been received to conduct the study.

Supplementary Material

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