Tele-Consultation for the Survivors of Intimate Partner Violence: Guidelines for Mental Health Professionals.

Providing psychosocial interventions through telehealth is an approach to mitigate intimate partner violence (IPV). However, tele-consultation for IPV survivors need to be handled perceptively considering the risk to safety of the survivor and need for emergency support. This article provides strategies to address such issues while providing interventions to IPV survivors using telehealth in the clinical settings. Strategies for screening, assessment, planning psychosocial interventions, and termination of sessions are also summarized with supportive guidelines.

World Health Organization (WHO) remarks that worldwide, one in three women have undergone at least one form of violence by their intimate partner at some point in time. Intimate partner violence (IPV) refers to all forms of violence, including physical, sexual, and emotional abuse and controlling behaviors such as isolating a person from family and friends, constantly monitoring them, and controlling their finances, education, employment, and medical care.

Though psychosocial interventions are available to address IPV, logistic issues have been a barrier to the availability and accessibility of such services. These challenges can be overcome by adopting telemedicine, which refers to the technology-driven delivery of healthcare services. Tele-consultation can be provided via real-time and/or asynchronous modes. Real-time interactions can be carried out via video-conferencing software, mobile applications, video-chat platforms (e.g., Skype/Facetime), audio mode such as phone call/VOIP, mobile apps, text-based methods (using chat-based applications such as specialized smartphone apps for telemedicine), websites and other relevant internet-based systems, and/or general messaging/text/chat platforms (e.g., WhatsApp, Google Hangouts, Facebook, Messenger). Examples of asynchronous means include email and fax. After the onset of the COVID-19 pandemic, technology-driven psychosocial interventions have become a familiar phenomenon and widely acceptable globally.

WHO recommends that every healthcare professional be trained to identify and address psychosocial distress associated with any form of violence against women, children, and older adults. Mental health professionals (MHP) play a vital role in a multi-sectoral response to IPV, including screening, identifying those who have been subject to or are at risk of violence, appropriate referral to specialized services, and follow-up in the community.

In India, National Tele-Mental Health Programme was launched by the Government of India with the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, as the nodal center to network with 23 tele-mental-health centers of excellence across the nation. In addition, a series of telehealth guidelines have been prepared for MHPs,[6-9] based on the framework of the Medical Council of India. These are getting gradually implemented in various clinical settings. Providing technology-driven psychosocial support for IPV survivors requires specific pre-requisite skills compared to conventional face-to-face sessions. It involves risks to privacy, confidentiality, and digital and physical safety. If not handled sensitively, the violence may increase. For example, the perpetrators may monitor the survivors’ call history and browsing history. When they find out about the survivor reaching out for formal or informal help, the use of violence may increase, eventually leading to drop out of the survivor from seeking help, either by choice or force, which may prevent attaining the goal of the service provider. Therefore, this paper attempts to provide practical guidelines for assessment and essential soft skills for the MHP delivering tele-counseling to individuals experiencing IPV.

The guidelines apply to both new patients and follow-up patients transitioning from in-person consultation to teleconsultation mode. The process of recruiting individuals experiencing IPV for teleconsultation is explained in Figure 1. Strategies to be followed in recognizing and responding to IPV during teleconsultation are given in . In this article, tele-session refers to individual psychotherapy and/or crisis intervention delivered using technological tools. The duration of the session is similar to the conventional mode of delivery, and the session notes must be documented the usual way.

Figure 1.

Process of Recruiting a Survivor for Tele-Consultation

Case Identification and Assessment

The primary aim of MHP is to create a safe environment for the survivor to disclose IPV. Rarely does self-disclosure occur during a health/mental health screening. Many a time, the survivor may not be forthcoming about IPV. Some of the commonly reported causes for non-disclosure of IPV include lack of privacy, presence of an abusive partner in the vicinity, fear/threat of further violence from partner, embarrassment/shame, and fear that their story may not be believed.[11-13] Therefore, the MHP should have adequate skills to pick on “red flags” associated with IPV, such as unexplained injuries, wearing long sleeves in summer to hide injuries, low self-esteem, and constantly looking up to the partner for minor decisions while the patient is reporting some other psychosocial concern.

Responding to a Disclosure of IPV

During tele-sessions, MHP may have limited control over the survivor’s environment. The abusive partner may walk in or find out about the help sought by the survivor, which could lead to an escalation in violence. To ensure the safety of the survivor, discuss cues to communicate the presence of the perpetrator near them a priori ( , subsections c & d).

A few relative contradictions to teleconsultation are when a survivor: (a) is at risk of harm, (b) has thought of committing suicide, (c) expresses a homicidal idea, and (d) shows signs of cognitive impairment. The survivor should be encouraged for an in-person consultation or referred to the nearest emergency health service by providing adequate information. It is also important to assess the benefits and risks of providing tele-session.

Planning and Offering Psychosocial Intervention

The initial stage of therapy should focus on building therapeutic relationship and offering immediate first-line psychological aid to alleviate the survivor’s distress. The intervention should be guided by two fundamental principles of a woman-centric approach: respect for women’s rights and the promotion of gender equality.[4,14,15] Safety planning is one of the important components of the intervention to prevent further violence targeted towards self and/or their children (Table 1, subsection j).

Table 1.

Guidelines for Tele-Consultation—Strategies for the MHP for Identifying and Responding to Survivors of IPV

Step 1: Case Identification and Assessment		Assessment Questions
a)	•  Screen all the women who have an intimate partner, irrespective of relationship issues.•  Offer universal education and share resources on IPV support.	•  “How are the things at home?” •  “I ensure every client I work with has information about IPV support so that it can be stopped or prevented in future….” •  “You may feel free to call or share your difficulties with me.” •  Would it be OK if I sent you a list of available resources?”
b)	•  Handling the technical difficulties during the tele-sessions.	Check at the beginning of the session about predictable technical issues such as low battery, expected power shut down, and poor network. Offer to reschedule at a later point in time.
c)	•  Prepare to address the survivor’s safety during the tele-sessions.•  Be cognizant of red flags such as injuries or non-verbal behavioral cues that may indicate that the survivor is at risk of immediate danger by the perpetrator.  Example: Not making eye contact (if using a video session), hearing adult voices in the background, prolonged silence/pause (if using telephone session).•  If red flags are present, frame the topic using a general statement and then, if safe, follow up with a question more specific to IPV.	•  “While we are in the middle of a session, if you feel threatened by the presence of your spouse/partner, you may indicate it to me using our agreed code.”•  Predetermine gestures or signs and symbols that will not alert the perpetrator, such as nodding “yes” or “no”; raising a hand; using a common hand gesture; using a code word such as “rose”/ “water,” switching to a neutral topic such as weather, menstruation, room décor; texting a particular mutually agreed on emoji, etc.•  “Sometimes, the session may be interrupted by your spouse/partner, which I may not be aware of. In such situations, do you want me to reach out to you to ensure your safety?”•  If not, say, “Let me know that you need help, by sending me agreed-upon codes, so that I can call the emergency support team right away.•  If yes, then proceed with the following direct questions•  “Is it a convenient time to talk?”•  “Is it safe for us to speak right now?”•  “Do you feel safe with your partner right now?”•  “Do you feel afraid of your partner?”•  “Have you been physically hurt by your partner?”•  “Does your spouse (or partner) control what you do, whom you see or talk to, or where you go?
d)	•  If you suspect IPV, but the survivor refuses to disclose it, acknowledge the survivor’s response and indicate that you are available to help if they feel their safety is threatened.•  Provide information on available community resources that the survivor can use in the future during a crisis or share with family and friends.	•  “I know it is hard to talk about what you are going through…. I am concerned about you and would like to know how things are at home. Is everything OK with you at home?” •  “I ask these to all the women, especially when I see injuries. Is everything OK with your relationship? Is anyone hurting you?” •  “I often come across women who have been experiencing trouble at home.” •  “I am concerned about you and your children’s safety. Do you feel safe in your relationship?” •  “Thank you for sharing your concern about your relationship. If anything bothers you and you become worried about the safety of yourself and your children, feel free to talk to us.”
Step 2: Responding to a Disclosure of DV/IPV		Assessment Questions
e)	•  Acknowledge the disclosure•  Re-check if it is safe to talk further.•  During the session, pay attention to their tone and provide verbal cues encouraging the survivor to express her feelings.	•  “Talking about relationship issues with others can be challenging….”•  “It appears like you have been dealing with this violence from your spouse/partner for quite some time now.”•  “I am glad you have made an effort to seek support. It must have been hard all along. How have you been handling it alone?”•  “I am worried and concerned about your safety and health….”
f)	•  Assess the risk of danger to the survivor and her children.•  The survivor may be unable to leave home due to their spouse/partner’s use of coercion and control.•  Emphasize that violence is never OK.•  Reassure that help is available.	Specific questions related to risk assessment are:•  “Are you in immediate danger recently?”•  “Has violence gotten worse of late?”•  “Is it happening more often than before?”•  “Has your spouse/partner used a weapon on you before?”•  “Has your spouse/partner been using alcohol or drugs excessively in recent times?”•  “Has your spouse/partner anytime threatened to kill you and/or your children?”
Step 3: Planning and Offering Psychosocial Interventions		Assessment Questions
g)	•  Listen and validate their feelings	•  “It must have been difficult for you to talk about this.”•  “ Whatever may be the situation, abuse is unacceptable.”•  “It is not your fault. You are not to be blamed for your spouse/partner’s behavior.”•  “You are not alone. You don’t deserve to be abused.”
h)	•  Work with the situation as prioritized by the survivor.•  If required, provide referral to relevant service providers such as legal support, police, or NGO.	•  “If I could help you with one thing right now, what would you want it to be?”
i)	•  Explore their support system.•  Survivors of IPV may often experience isolation. You may be one of the few individuals to whom they may be talking.	•  “It appears like you are all alone dealing with your problem right now.” •  “Do you have a friend or close relative with whom you can share your worries?” •  “Would you feel OK if we get connected in the future to know what is happening with you?”
j)	•  Assess the risk of immediate danger and make safety plans.	Indirect assessment•  Assess the physical environment by asking the survivor to show their space/ background.•  Other safety practices such as deleting internet browsing history, call history, and text messages to the therapist and creating a separate confidential email account for easy communication with the therapist should also be used.Direct questions•  “I am worried about the safety of you and your children. We can together discuss and plan for your safety.”•  “Who all can access your mobile phone or computer/laptop? Would it be OK if you delete the caller history or messages from your gadget so that your partner won’t find it out?”•  “Could you rename the information shared with you and save it as a hidden/password-protected file?”
k)	•  Help to deal with stressors due to relationship issues	•  “During this stressful situation, what things do you do to feel better?” •  “I have contacts of a few resources that may help you find new ways to take care of yourself. Would you like to have them?”
i)	•  Document referrals and future plans. Schedule a follow-up tele-visit.

DV: domestic violence, NGO: nongovernmental organization,

IPV: intimate partner violence, MHP: mental health professional.

Safety skills include recognizing cues or signs of potential danger. For example, the therapist should help the survivor identify those behaviors and traits of the perpetrator that have been associated with violence in the past, in addition to stressors such as relationship difficulties, lack of privacy, increased substance abuse, loss of employment, and financial constraints. The therapist should share a list of safety resources available in the community, such as contact of the local police station, women’s helpline numbers, local shelters, and nearby hospital facilities, taking into account what communication device the survivor is using (e.g., password-protected text messages, email to the private account of the survivor).

Teach digital safety, that is, to delete the therapist’s call history immediately after the session to prevent getting exposed if perpetrator tends to track the survivor’s actions. Also discuss strategies she has adapted in the past to prevent violence. Safely skills include planning how she might respond in different situations, including emergencies. Advice to keep a bag with all essential items (including essential documents) for easy exit in case of emergency, hide harmful items away from the perpetrator, know and recognize early signs of potential violence, know where to go in case of crisis, identify safe zone to take shelter in the house/neighborhood, rehearse to safely exit home along with the children, and train children to make emergency calls in case of crisis.

When providing online sessions, technical difficulties are common. A backup plan for services should be discussed with the client to avoid interruption with service delivery. When an element of risk to safety is involved, the therapist must wait for the client to initiate the call. If unable to reconnect with the client, the therapist can initiate a call to the local emergency women’s helpline number for further help.

Organizational Responses to IPV

After the COVID-19 pandemic started, the modality of delivery of psychosocial services has shifted from face-to-face intervention to online intervention, to some extent. The launch of the National Tele-Mental Health Programme in India has given new impetus to reach the unreached through technology, to provide quality mental health services and care to people of all ages. Healthcare institutions should have a policy and framework to implement telehealth interventions for IPV survivors. The digital divide, where most people cannot afford and access telehealth services, needs to be addressed.

Conclusion

The authors attempted to aid the MHP to identify and address IPV issues using telemedicine in clinical settings. The article highlights the need for MHP to be mindful of the safety issues and appropriate intervention strategies while delivering psychosocial care using telemedicine. As the digital divide for accessing and affording telemedicine is gradually declining, the researchers in IPV must actively develop evidence-based standard operating protocols for technology-driven emergency preparedness and IPV-focused service delivery.