Narrative Therapy with Dalit Female Survivors of Violence

Abstract

Narrative therapy is an evidence-based therapeutic intervention that can help address trauma experienced by women who have experienced violence. Narrative therapists open up new perspectives for their clients by examining moments of strength, vitality, and autonomy, which are often hidden in stories about oppression, suffering, and marginalization. Dalit women who participated in the research revealed how the stories opened up new possibilities for constructing unique narratives. A multiple case study design was used to elicit the responses of female survivors with severe mental illness to physical, sexual, and psychological abuse perpetrated by Dalit and higher caste men.

Background

Having severe mental illness (SMI) impairs a person's ability to work and function normally. These disorders include major depression, schizophrenia, bipolar disorder, and schizophrenia-affective disorder. These disorders are three times more likely to occur in women worldwide. Women are more likely to suffer from SMI owing to social and cultural factors such as gender discrimination in accessing resources, low socioeconomic status, violence against women, human trafficking, and unpaid caregiving. Malhotra and Sharma (2015) and Murthy (2017) estimate the lifetime prevalence of SMI among Indian women to be between 1.3% and 2%. The severe disability and chronic nature of SMI make women with SMI more susceptible to domestic violence and abandonment (Malhotra and Sharma, 2015).

In Dalit communities, women with SMI are subjugated because of their gender, caste identity, socioeconomic status, and mental illness (Singh and Vashistha, 2018). It is not only Dalit men who victimize them, but also dominant upper caste men. The physical, sexual, and psychological abuse that Dalit women experience makes their experience more degrading and dehumanizing (Musahar, 2021).

Through narrative therapy, clients can voice their life stories, creating a way for them to be heard, and for their unique opportunities to shine, which may have remained unnoticed owing to prevailing narratives about suffering or oppression (White, 1998). The term “unique outcomes” refers to circumstances where individuals demonstrate strength and competence despite oppression or moments without being affected by problems that would otherwise discourage or dominate their lives (Draucker, 1998). Participants in this research study shared examples of such unique outcomes with the author. Narrative therapy's ultimate goal is to help women rewrite their life stories, which will be demonstrated through a detailed look at the lives of five women participating in the research.

Thick descriptions of experience: Going beyond the surface of their stories

A thicker description to the client's story should be provided by resisting the client's surface-level narration and making sense of it at the same time. A client's story must not be dismissed, minimized, or pathologized to make sense of and challenge it. Therapists are responsible for exploring alternative meanings to narratives (Draucker, 1998). Practitioners may be able to look beyond the surface story to determine whether the client feels vulnerable, unsafe, isolated, powerless, or uncontrollable, despite the client's apparent confidence (Brown and Augusta-Scott, 2006).

Creating alternative stories: Re-storying dominant discourses

In narrative therapy, practitioners and clients work together to explore unhelpful narratives, devise new stories, and move away from binary notions of knowledge and power (Draucker, 1998). Narrative therapy places a high emphasis on dialog as well as interaction between them. Rather than relying on inadequately developed or thin accounts of the client's experiences, the approach focuses on moving away from formulations that problematically refer to the client as an expert or authority (Combs and Freedman, 2012).

Methods

Data were collected from January to June 2019 in an outpatient psychiatry department of a tertiary health care institution in Bengaluru, South India. Women with SMI were included if they were at least 18 years or older and diagnosed with SMI such as bipolar affective disorder, schizophrenia, schizoaffective disorder, and recurrent depressive disorder as per ICD-10 criteria. In addition, participants were screened for past physical, psychological, and sexual abuse. The participants had to be maintaining well based on Guy's (1976) Clinical Global Impression (CGI) scale scoring (≤4), which indicated the severity of the participant's illness. Human ethics committee and Institutional Review Board (IRB) approval have been obtained for the study. The study followed the ethical guidelines set forth in the 1964 Declaration of Helsinki, as revised and updated in 2013.

Research team members developed a Key Informant Interview (KII) Guide that was validated by six experienced mental health professionals and pilot tested on one woman with SMI Table 1 contains the interview guide. Participants signed informed consent forms with assurances of confidentiality. Five KIIs were conducted in three sessions, lasting 45–60 min. De-brief followed after each KII.

Table 1.

Interview Guide

Domain	Questions and probes
(1) Life stories	(1a) Tell me about your life; you can start from wherever you want. Probes: Important events in life; encourage the participant to think back to a point in their life—childhood, adolescence, early adulthood, or the present day. (1b) If you had to choose the best time, which one would it be? Fondest memories. Probe: What made it special? (1c) What would it be if you had to choose the most difficult time in your life? (1d) What was especially challenging about it? How did you manage to get through it? Probe: Ask for the past or present challenges/concerns/hardest times in their life.
(2) Mental illness perception: past and present	(2a) What was it like for you when your symptoms started? (2b) How did you explain to yourself and others what was happening to you? Probe: Changes in behavior which they notice their understanding of what was happening to them; changes in the way they felt when being around people; changes in how people treated them changes in how they interacted with people.
(3) Experience of being diagnosed	(3a) How has a diagnosis of mental illness impacted your: • Day-to-day life • Self-concept or self-esteem • Desire for connection with others • Social relationships (e.g., interaction with others or preference to be with people or alone) • Views on life in general • View about future • Personal abilities and strengths (3b) After being diagnosed, do you feel your life is meaningful or not, and in what ways? Probe: Impact of the diagnosis on their ability to make life choices; examples of how illness interferes with their life choices.
(4) Experience of being victimized	(4a) What was your day-to-day struggles? Can you describe your experiences? (4b) What factors contributed to violence? Probe: Physical, psychological, social, and financial struggles in their day-to-day life; factors contributed to violence (e.g., the stigma of being Dalit and the label of being mentally ill); the effects of ongoing generational atrocities, exploitation, and discrimination against Dalits. The effects of these on their experience of violence and effects of skewed resources on violence such as inaccessibility to educational opportunities, employment opportunities, economic conditions. (4c) Did you ever heal from those experiences? If yes, describe the process of healing? If no, describe reasons which acted as a barrier in healing? Probe: Factors which helped to piece together their life or continue going on with life such as support system, regularizing their routine; emotional and behavioral reaction. Barriers in terms of external and internal factors such as negative feelings and emotions, lack of social support, stigma.
(5) Exceptions to their problem	(5a) Has there ever been a time in your life when abuse was not part of your life? (5b) Have there been times when you felt you had won the struggle with someone who had hurt you or tried to keep you down? (5c) Was there a time when you stood up for yourself or someone who was hurting you? (5d) Was there a time when you felt a strength you did not know you had? (5e) Has there been instances where you managed to be assertive during violent acts? If answer to the above question were yes, participants were asked to describe those instances If answer to the above question were no, participants were asked to describe reasons for difficulty in being assertive. Probe: Search for different types of stories such as rebellion stories, revival stories, self-worth stories in different time-frame and context.
(6) If you could rewrite your story or add a chapter, what would it be about?

Unique outcome of Dalit women who have had multiple victimization experiences

This study examined and described the meaning of violence in the everyday lives of Dalit women with SMI and the processes they use to heal from such experiences. The lead researcher of this study noted during her interviews with the five women that the women articulated stories that resembled White's (1998) description of unique outcomes, when the participants were asked about such experiences during their interviews. All five women had multiple traumatic experiences. The names and some identifying information of the women have been changed to prevent possible disclosure of their identities. Table 2 describes participants' sociodemographic and clinical characteristics.

Table 2.

Demographic Characteristics of the Participants

Participant No.	Age	Marital status	Education	Occupation	Domicile	Religion	Type of family	Psychiatric diagnosis	DOI	No. of hospital admission	No. of relapse
1	28	Single	Graduation	Software engineer	Urban	Christian	Nuclear	BPAD	5 years	2	2
2	32	Married	Illiterate	Homemaker	Rural	Sikh	Nuclear	Catatonic schizophrenia	8 years	2	1
3	25	Single	Illiterate	Construction worker	Urban	Hindu	Nuclear	Paranoid schizophrenia	15 years	3	2
4	30	Married	Illiterate	Cobbler	Urban	Hindu	Joint	Paranoid schizophrenia	13 years	2	1
5	34	Widowed	Illiterate	Daily wage earner	Rural	Hindu	Nuclear	BPAD	15 years	3	3

DOI, duration of illness; BPAD, bipolar affective disorder.

Lalita

A 28-year-old woman, Lalita, was interviewed to discuss abuse by her boyfriend; however, she also discussed maltreatment throughout her life, including sexual abuse by an alcoholic brother, bullying at school, being sidelined at college because she was a Dalit, and emotional and sexual abuse by her partner. A sense of personal agency emerged as one of her unique outcomes. According to her, she experienced the following: “After I decided to leave my partner knowing the fact that I have no one to turn to. Even thinking about that every day made me cry. But then one day I just packed my bag and left him. I have experienced this throughout my life…Um…I mean people turning their backs on me…or just denying the fact that they abused me…When I left him, I felt so low that I wanted to kill myself…. But then things have been worse for me in the past as well… At one point in life, I was the person who sits and cry. I have internalised the fact that I don't exist for the people so much that I treat my thoughts, emotions, and feelings like they don't exist. But now, at this stage in my life, I have a job and financial stability. After feeling sad about leaving my partner, I focused on my job, did a skill-enhancement course, became part of a big project which gave me the opportunity to travel the world and make good money.”

Mathura

Mathura is a 32-year-old woman who experienced multiple physical and sexual abuse throughout her life. A poignant moment of rebellion and courage characterizes her unique outcome. She tells the story of being brought to an isolated and abandoned house by a man who intended to rape her: “So…he takes me to this ravaged, dark place. There was something scary about it… I am looking around, trying to figure out how to get out, but there is only one front door, and the windows are locked. So, to get out I would have to pass him and then there is a long way to run in the hills and in the rain. So, I look outside the window over to the side. There is a high fence, and I am thinking well maybe I could get out and climb over the fence but then if I am running, I still might run into somebody. This is a terrible place, okay. There are a lot of cases of molestation of women from our community in this area. And, I am also scared uh, what if I run into someone crazy than this man?

You know, I didn't know what to do… So, I am sitting there and I am really scared and also angry. Angry at being a woman and a Dalit. So, he gets into the room where he locked me…he keeps coming nearer and nearer…He comes so near that I could smell his breath. I don't know where this power came from. I pushed him away with all my strength. Because I wouldn't let any man do that to me again, we started wrestling and falling all over the room. Infuriated, demeaned, and molested by men, I let out the anger that had been built up inside me. Now I was angry enough to fight. Uh…So, then we continued wrestling. I fell over on the floor, and he started strangling me. Everything became so dark and hazy…But I did not give up…My hands were still actively looking for anything to hit him back. I got a small piece of stone. I hit his head with all my strength. Standing back, I picked up the chair and said, “I swear to God.”. If you touch me, I will break that window and jump out of it. He still approaches me with a mocking smile. I slammed that chair against his head with all my might and he fainted.”

Rathnamma

Twenty-five-year-old Rathnamma had been raped four times by multiple partners, one of whom tortured her severely. She described her unique outcome, publicly confronting the fourth man who raped her: “Throughout my life, I have suffered extreme deprivation and discrimination, primarily at the hands of Dalit men… The fourth one worked as a contractor for construction company. Like me, he was Dalit, but I wasn't sure how he managed to achieve that power over his fellow women and men. He would hire us, pay us, and supervise the work. He befriended me and raped me. I kept quiet fearing I would lose my job if I utter a word about it. I never spoke to him after that incident. And, uh, I learned later that he raped an unfamiliar girl who joined for work. This girl was eighteen…One day I ran into him in this tea shop….And there was this little girl. Must be fourteen or fifteen. And I saw him…He went over to that girl and introduced himself to her…I thought…Umm…it is not my business, really. But when he walked over and sat down with that girl…All of a sudden it hit me. I was just like oh no… I have seen her here a couple of times in the shop and ran into her whenever I ordered something to eat. I saw him sitting down with her, and it triggered a sudden rage and an intense urge to do something about it. I was like Oh my God! I have not seen her talking to anyone here. I thought she would be the easiest person for him to get to. I felt I had to do something to stop her from getting lured by him. I walked over to the table and I just leaned toward him and looked into his eyes. I said very loudly so that everybody could hear,” “Get the hell away from him. He is a rapist.” She became scared and ran away. He screamed, “Are you out of your mind?” I said again, “You are a rapist.” He just glared at me and walked out.”

Rekha

Rekha is a 30-year-old married mother of three children who works as a cobbler. She had experienced a lifetime of abuse. She was sexually abused as a child by several men within her family, including her grandfather, father, and older brother. In addition, she suffered severe physical, emotional, and sexual abuse in her marriage. However, her unique outcome was that she stood up to her neighbor when he tried to molest her as a teenager. The story she told was as follows: “My family and I have moved to another city. My neighbour saw me on the terrace one day and spoke to me. In the beginning, I liked him, so I went to the terrace to talk to him. However, I can remember that in a meeting with him at some point, he asked me about having hot blood (strong sexual energy) and how I handled it. And then suddenly he grabbed me and commented on my breasts. And I didn't know what he meant, but I knew that it was something that made me feel really uncomfortable. Soon after that incident I started avoiding him. Once he confronted me on the street and I said, “I don't like you. I don't want to see you again.” I was really loud and some passers-by asked if my neighbour was bothering me. Though I was not prepared to face my neighbour, something made me fight back. That was the day I changed completely. I realised the importance of standing up for myself.”

Pavithra

Pavithra is a 34-year-old woman who works as a daily wage earner. In addition, she had an abusive marriage as a result of her queer identity. Her husband was an alcoholic who died of a heart attack. Despite having bipolar affective disorder for almost 15 years, she works as a daily wage earner. Her unique outcome is her determination to continue working to support her family of six, no matter what it takes. She described her perseverance as: “It is not only because I am poor, live in a slum, or am not educated that I face difficulties, but also because I am Dalit. I have been oppressed and repressed by men in my own family and community. And this is because I am sexually attracted to other women and my sexuality is linked to my caste purity. It is not only my caste but my sexuality is a problem as well… I am in a relationship with this woman… She is special… I have decided to live my life with her. We want to support each other… Being born as a Dalit and in a relationship with a woman cannot make me feel fearful, embarrassed and isolated. I will resist… I will fight for my dignity even though I have no support… I am determined to live a respectful life.”

Discussion

Participants of this study have all experienced abuse both within and outside of their families. Dalits have historically been subjugated owing to the Indian caste system's traditional notions of purity and pollution. Dalit women suffering from SMI experience triple oppression because of their caste, gender, and poor mental health. Having a lower social status and power within society limits their ability to support themselves and their families emotionally and financially (Sharma, 2022). Cherayi et al. (2019) observed that Dalit women with SMI are more discredited and devalued in the society, and are considered the poorest of the poor and live in abject poverty. If they do find employment, it will be mostly as wage labor, which is hazardous, laborious, and low paid, accompanied by prejudice and stigma of being a member of a lower caste and mentally ill.

In addition, they experience exclusion or inequality in property ownership, educational, and health care services that is reflected in other studies (Thapa et al., 2021; Yoganandham et al., 2022). These factors reduce social support for these women and reduce their ability to effectively integrate into society (Jose et al., 2014). As a result, they have limited access to political, economic, and social resources, which in turn results in persistent inequalities and constitutes a barrier to advocating for their social rights, which has also been reported by Jose (2016). Furthermore, Dalit women with SMI hold multiple identities that intersect with their gender, sexual orientation, caste, class, and mental health. The lowered social status, economic dependence, and social isolation of Dalit women with SMI often make them vulnerable to coercive sexual acts and physical exploitation by dominant upper caste men as corroborated by Musahar's study (2021).

Lack of personal and social judgment also makes it difficult for these women to identify and prevent high-risk situations. The dominant caste men take advantage of this fact and consider Dalit women with SMI's bodies as their right for sexual fulfillment and privilege for the concerned Dalit women. When it comes to Dalit male perpetrators of domestic violence, perceptions of male power are shaped and influenced by patriarchal discourses that are shaped by a hegemonic Brahmanical caste system that views Dalit women with SMI as being below the status of Dalit women without SMI, and as easy targets for violence because of fluctuations in severity of mental illness, lack of positive social networks, potential guardians to protect them in their community, and lack of information about resources to seek help, which results in poor help-seeking behavior (Singh and Vashistha, 2018).

Narrative therapy provides therapeutic effect by helping Dalit women with SMI reconstruct their self in terms of more positive identity after the traumatic events. As a result, it helps them witness, reflect, resist, challenge, and enable a space for rewriting their story with a sense of power to recount their collective trauma as indicated by other studies (Gómez et al., 2020, Gupta, 2016).

Narrative therapy helped these women re-story their lives in a positive and health promoting way. The women developed more empowering ways of thinking about themselves and their traumatic experiences. The therapy helped to get thicker description of their stories with unique outcomes without dismissing, minimizing, or pathologizing it.

In this research, we examined the narratives of five Dalit women with SMI who have been abused physically, sexually, and psychologically. This limits the possibility of generalizing the findings to a larger population. The fact that only female participants were included in this study further limits its validity as a gender-biased study. Comparative studies will help to understand how sociocultural norms influence the outcomes of violence experienced by Dalit men and women with psychiatric disorders.

Footnotes

Acknowledgments

The authors thank all Dalit women with SMI who participated in the study.

Authors' Contributions

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

Ethical Consideration

The Institutional Review Board (IRB) and Human Ethics Committee has approved the study. The study was conducted by following the ethical guidelines given in the 1964 Declaration of Helsinki, which was revised in 2013. To protect the identity of participants, a pseudo name is given to the participants, and the results of the study were reported without any identifying information.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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