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Domestic abuse: how can Community Mental Health Nurses respond?

Kathryn Lake is a Mental Health Community Nurse for the Norfolk and Suffolk Foundation Trust.  She has previously worked as an advocate for those experiencing domestic abuse and has been involved in public awareness raising campaigns such as “Norfolk Says No”. In this blog, Kathryn offers Community Mental Health Nurses practical guidance on responding appropriately to domestic abuse.

Domestic violence and abuse is becoming a public health emergency which costs lives, and negatively impacts on the long-term health of individuals, families and their communities. Women who have experienced domestic violence and abuse generally have poorer health than other women. Health issues include chronic problems with digestion, kidney and bladder function and headaches, poorer pregnancy outcomes, lower birthweight babies, eating disorders and substance misuse.

Recognition

Recognition by community mental health nurses is vital to be able to address the underlying cause of poor health, promote positive wellbeing and increase social inclusion to aid recovery. From personal experiences and years of research, women who are experiencing domestic abuse are unlikely to ask for help or disclose unless they are directly asked by healthcare professionals.

And as difficult as it is for victims of domestic abuse to talk about, we too as healthcare professionals find it difficult to approach such an emotive subject for many reasons. However, the World Health Organisation highlights the important role that healthcare providers have in recognising and responding safely to domestic abuse. 

Assessing

As community mental nurses we must be vigilant to psychological indicators such as:

  • Anxiety, panic attacks, stress and/or depression;
  • PTSD symptoms
  • Substance misuse;
  • Sleeping and eating disorders;
  • Self-harm
  • Suicide attempts,
  • Missed appointments/rescheduling appointments

You may also notice other factors that warrant exploring;

  • That the person seems nervous, ashamed or evasive;
  • They are uncomfortable or anxious in the presence of their partner;
  • They are accompanied by their partner, who does most of the talking;
  • They give an unconvincing explanation of the injuries or their mental wellbeing;
  • They have recently experienced a relationship breakdown
  • They are reluctant to follow medical and health promotion advice.

Enquiry

We need to be confident in the enquiry of abuse and be direct with the questions. Yes, this depends on how well you know the person and what indicators you have observed. But either way we should begin with these questions:

  • 'How are things at home?'
  • 'How are you and your partner relating?'
  • 'Is there anything else happening that may be affecting your health?'

Even if we have misread the situation or cues, research has found that this has not damaged the therapeutic relationship but actually demonstrates positive regard for the patient’s wellbeing and situation.

Specific questions linked to our clinical observations that could be asked:

  • 'You seem very anxious and nervous. Is everything all right?'
  • 'When I see injuries like this, I wonder if someone has hurt you?'
  • ‘When I hear you recall your symptoms, I wonder if it’s a response to someone hurting you?’
  • 'Is there anything else that we haven't talked about that might be contributing to you feeling this way?'

More direct questions could include:

  • 'Are there ever times when you are frightened being at home with your partner/family?'
  • 'Are you concerned about your safety or the safety of your children?'
  • 'Does the way your partner treats you ever make you feel unhappy or depressed?'
  • 'I think there may be a link between your illness and the way your partner treats you. What do you think?'

Responding to a disclosure

Our responses as community mental health nurses can have a profound effect on a person’s willingness to disclose and seek guidance and support. It is vital that we are aware of how we respond:

  • Demonstrate active listening: being listened to can be the most empowering experience for a survivor of domestic abuse. Give eye contact, sit with them and give them time to talk.
  • Validate feelings: use statements such as "that must have been so very frightening for you."
  • Validating the decision to disclose: tell them "It must have been difficult for you to talk about this." "I'm glad you were able to tell me about this today.'
  • Emphasising the unacceptability of the violence or abuse: tell them "You do not deserve to be treated this way."
  • Give information: provide information about domestic abuse and the services and options available.

Safety

It is imperative to assess the person’s safety and the safety of any children involved. You could ask questions along the lines of;

  • Are you safe? Are your children safe?
  • Do you need an immediate place of safety?
  • If immediate safety is not an issue, ask about future safety.
  • Do they have a plan of action if they need to leave quickly?
  • Do they have emergency telephone numbers?
  • Help draw up an emergency plan: Where would they go if they had to leave? How would they get there? What would they take with them? Who do they have for support?
  • Document these plans for future reference and include them in their care plan.

Just as we reassure victims of domestic abuse that they are not alone in this situation – we need to remember as community mental health nurses that we too are not alone in this. We have the support of our colleagues, safeguarding leads, clinical supervision and other professionals to seek support, advice and guidance to ensure the safety and wellbeing of the patients we work with and ourselves.

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

Collaboration between Idvas and Community Psychiatric Nurses

Vickie Crompton is the Domestic Abuse and Sexual Violence Partnership Manager for Cambridgeshire and Peterborough and has been responsible for the domestic abuse and sexual violence partnership since 2010.  In this role Vickie commissions domestic abuse services, manages the Idva services and chairs the Marac.

Across Cambridgeshire and Peterborough there were around 1,600 cases that came to Marac in 2017/18.  1,600 cases where victims suffered a trauma by someone close to them, in isolation from their community, in their homes and in most if not all cases, the trauma was repeated rather than an isolated incident.  All factors which make reaction to trauma especially severe.  It has been estimated that 64% of abused women have post-traumatic stress disorder (PTSD), compared to 20% of military personnel who have seen combat.  So for Marac cases alone, this would equate to over 1,000 people.  Clearly Marac cases are the tip of the iceberg and the actual number is much higher.

In response, all Idvas working in Cambridgeshire and Peterborough receive the three-day Mental Health First Aid course.  The course has improved understanding of symptoms of mental ill-health, enabled Idvas to respond effectively and also helped them manage their own mental health and levels of resilience in what is a demanding and stressful occupation.

In 2014, work was carried out across the partnership, and more specifically with the Office of the Police and Crime Commissioner, to fund “Mental Health Pathfinders” – Community Psychiatric Nurses (CPNs) who worked alongside Idvas, refuges and outreach.  Their role was two-fold; to support staff to support their clients and to direct intervention where appropriate. 

The CPNs were employed by the Mental Health Foundation Trust and were able to access appropriate support where required.  When women arrived in the refuge with significant mental health needs, the CPN was able to ensure they had the correct medication and were linked into the local service provision. The CPNs were also able to teach the Idvas techniques which the Idva could then pass on to their clients. For example, a young woman who suffered from panic attacks was unable to contemplate how she would give evidence in court.  Her Idva taught her ‘grounding techniques’ and when the time came for the trial she was able to manage her anxiety and give evidence. 

The funding and arrangements have altered over time, however we were able to retain the CPN provision until this summer when further funding could not be found (although the search continues!). There are now two CPNs located in the Victim and Witness Hub, funded by the Office of the Police and Crime Commissioner, and professionals are able to seek their advice and support in relation to the victims they are working with.

Across the area we now have a network of around 170 professionals who are not domestic abuse specialists, but are the “DA Champion” for their own organisations. They meet quarterly to receive information, advice and bite sized learning in relation to domestic abuse.  The autumn workshops are focussing on domestic abuse and the impact of trauma on mental health. In addition to this, all DA Champions are given a copy of the AVA Complicated Matters Guide, as this clearly sets out issues of both mental health and substance misuse in relation to domestic abuse.

As a partnership we are currently seeking additional funding to support children who have experienced domestic abuse, in particular with their mental health, and being able to process what they have experienced.  Embrace – Child Victims of Crime, currently deliver 6-20 sessions of trauma based Cognitive Behavioural Therapy to young people aged 13-19 (up to 24 where there are additional needs).  This is delivered by a network of therapists, at a location suitable to the young person, with no waiting list for treatment.  As a partnership this is a service we are proud of, as it enables them to cope and recover from the trauma they have experienced.

Given the dynamics of abuse, it should be assumed that any domestic abuse victim and survivor is likely to have some negative impact on their mental health.  It is vital that as both specialist providers and as general professionals, this is understood in order that those affected receive the best possible response from all of those working with them.

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

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A view from the frontline: the role of the Mental Health Idva

Amber Canham is a qualified social worker with experience of working in a Community Mental Health Team. She has also worked for NDADA in North Devon as a Marac Idva, and as a Health Idva. Her most recent role involved creating the Mental Health Idva post. Amber has trained as an EMDR (eye movement desensitisation and reprocessing) therapist and continues to work with adults experiencing post-traumatic stress disorder/trauma symptoms alongside delivering domestic abuse training. 

About our service

For several years our organisation had noticed an increase in the amount of service users and their children who were either reporting or demonstrating severe and enduring poor mental health and signs/symptoms of trauma. We also noticed how difficult it was for our service users to engage with treatment and recovery; there was often months of waiting to see someone and then either nothing could be offered due to lack of services/resources or there would be a further wait (ten months average) for support. We recognised that we needed to offer a service to support those living with domestic abuse, poor mental health and trauma and this led to creation of the Mental Health Idva, funded for four years through the Big Lottery.

Multi-agency working

We established contact with statutory and voluntary mental health services and organisations in our area, to understand the services currently being offered, the referral processes and thresholds. This enabled us to see the gaps in services; we believed it was important to contribute to creating a multi-agency culture of engaging victims of domestic abuse with poor mental health. We also wanted to coordinate a joined up approach that is able to manage risk and to support each person and their family, and which builds on their resources and resilience. Another aim of the project was to support and educate mental health professionals around domestic abuse and the impact this can have on mental health. This not only offered a proactive response for service users but also increased opportunities for engagement.

Referral pathways

One of the priorities was to create clear referral pathways between the Mental Health Idva and the statutory services who would offer emergency care, assessment, and access to therapeutic treatment and medication. Training was delivered to these teams to support them in asking about domestic abuse (routine enquiry) and supporting them with referrals to our service. This created a lot of new multi-agency working.

Engagement

We wanted to offer people a way to engage that suited them; we recognised that our current approach wouldn't always be right. We needed to be creative and flexible, work at the service user’s pace and in their preferred way. We needed to identify their needs and wishes and jointly create a personalised support plan that worked towards short and longer-term goals, and improved their safety and well-being. We wanted to use a trauma-informed approach; understanding the prevalence and impact of trauma and the complex paths to healing and recovery.

We also recognised that engagement styles differ; many were uncomfortable being in a room in an interview style appointment, so I would often meet with them for walks on the beach or the park. This helped reduced the pressure of direct eye contact and we could use the environment as a distraction when talking became too much. It also supported positive mental health techniques such as mindfulness and grounding; being outside and connecting with nature. Exercise is also a great tool to keep mentally healthy.

We had to accept that we wouldn't just be providing a domestic abuse intervention; we would continue to identify and refer to other agencies, but we acknowledged that our advocacy role would also need to extend to helping resolve other issues faced by service users. We couldn't expect mental health to improve unless and until we addressed wider problems such as potential homelessness.

It is an essential part of the role to be able to assess and understand symptoms of mental health problems and to offer tailored support. This may include support with medication, emergency support at home or assistance with admission into hospital. Due to the complexities of this work, it is vital that the Mental Health Idva holds a reduced caseload. I would often spend several hours at a time with one person and would see them several times a week, especially when they were in crisis.

Psycho-education and trauma work – the impact of trauma

Our initial information gathering showed gaps in service, much of this due to limited resources in our area which meant extended waiting times for service users. Often by the time the service was available to them, their mental health had deteriorated to the extent that they were no longer eligible  for the service or they were too unwell to engage.

For many there has been limited opportunity to learn about their own mental health, and so we use psycho-education as much as possible. We talk to service users about trauma; the short and long term impacts and the way adverse childhood experiences (ACEs) can feed into trauma. Once they have this understanding, they are then in a better position to process their own experiences.

Many people that have experienced trauma have been misdiagnosed with conditions such as personality disorders. Knowing their past and/or current diagnosis helps us understand which medications or therapeutic interventions have been tried. It’s also important for us to know what the service users experience of previous interventions has been.

Interventions

Building resilience and working on recovery can include offering medication and therapies. The Mental Health Idva is qualified to offer trauma informed cognitive behavioural therapy (CBT), an approach which focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour, and teaches you coping skills for dealing with different problems. It combines cognitive therapy (examining the things you think) and behaviour therapy (examining the things you do).

Dialectical Behaviour Therapy (DBT)  is a Cognitive Behavioural treatment designed  for people who experience difficulties in managing their emotions and who may have developed ways of coping such as self-harm and attempted suicide. It focuses on mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. We also offer eye movement desensitization and reprocessing (EMDR), which can help with the symptoms of post-traumatic stress.

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

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Tips for mental health professionals working with survivors of domestic abuse

Sarah Hughes has worked for Standing Together Against Domestic Violence for three years as a Mental Health Coordinator, and is studying for an MSc in Mental Health Studies at King’s College University.

Her role at Standing Together involves working with two Mental Health Trusts to improve the service response to survivors of domestic abuse. This includes; training mental health professionals, writing policies and procedures, setting up ‘Domestic Abuse Lead’ networks, improving trust participation in local multi-agency responses and addressing any barriers that may arise whilst implementing a change in practice.

Standing Together is part of the Pathfinder Project; a consortium of specialist domestic abuse services working with healthcare services nationally to build on existing pockets of good practice with the aim of developing best practice.

Domestic abuse is known to be a major cause of mental health problems for women, and yet our mental health services have some distance to travel in fully optimising their role. Much guidance has been released over the last 20 years highlighting the need for a better mental health response to the issue.  Some key components of the response being routine enquiry into domestic abuse in mental health services, women-only services, comprehensive stand-alone Trust domestic abuse policies and a minimum standard of domestic abuse training for mental health professionals.

There are few (if any) Mental Health Trusts in the country that can tick all of these boxes. There is a host of reasons why this may be the case, however one key reason is societal attitudes and beliefs that diminish the importance of women’s mental health and the major factors which contribute to it.

This can be seen as far back as the days of Freud and his discovery of the strange ‘coincidence’ that was the proportion of women with ‘hysteria’ who had been abused at some point in their lives, and as recently as modern literature showing the striking similarities between symptoms of ‘complex trauma’ and symptoms of ‘personality disorder’.

I started working for Standing Together three years ago as a Mental Health Coordinator. I have met and trained hundreds of mental health professionals in that time and there are many things I have learnt about how domestic abuse can be viewed within the mental health service. There are lots of mental health professionals out there who fully understand the link between domestic abuse and mental health and who work hard to ensure a survivor’s safety. However, as is typically the case with people that haven’t had any training on domestic abuse, often there are misconceptions about where it comes from, who perpetrates it, who the victims are and what good support looks like for survivors.

I’ve had mental health professionals say; ‘How do I really know it’s gendered?’, ‘Why do some women continually seek abusive partners?’ and ‘It only really happens in other cultures’. I once had a meeting with a Talking Therapies service lead in which he referred to domestic abuse as a ‘niche’ problem and that the service was more focussed on other things such as getting service users into employment.

Unfortunately, the current mental health service system is not set up to equip professionals to provide a safe and adequate response for survivors, with lack of training on the issue being a major factor.

Here are some ‘practice tips’ for any mental health professionals out there that are unsure of how to work with survivors:

  • Ask a question about it. You’re likely to feel worried about starting the conversation so, be aware of what kind of support you need. However, the more you ‘open the can of worms’, the more familiar you will become with dealing with the response. Something as simple as ‘Are there times when you’ve ever felt unsafe or afraid of somebody at home?’ can be a good way to open up the conversation.
  • Don’t ask the question in the presence of anyone else, even if it seems like a trustworthy partner, family member or friend. The issue of domestic abuse should always be explored with the survivor alone.
  • Listen and believe. Disclosing experiences of domestic abuse can be terrifying for the survivor. Listen to what they are saying and let them know that it’s not their fault, it happens to lots of people and you can help them find support.
  • Don’t tell them to leave. Separation, whether it is from an abusive partner or family member is a time of increased risk to the survivor’s safety. Therefore, the survivor needs to do this when they are ready, if they are ever ready, and with coordinated help from the system.
  • Familiarise yourself with tools that will help you assess the level of risk posed from a perpetrator of domestic abuse. A good one is the Domestic Abuse, Stalking and ‘Honour’-Based Violence Risk Indicator Checklist (DASH RIC). This can be found easily online, along with guidelines on how to use it.
  • Find out what support services are available in your area and use them for both advice for your own practice and a source of invaluable support for survivors.
  • Talk about it with your colleagues - how do they respond to survivors? Are they struggling? Talk to your team about any problems you’re having with responding safely to survivors; it is likely that most other mental health services are having the same issues.
  • Finally, find out what kind of training you can access on the topic. Often the local authority safeguarding boards will offer domestic abuse training days free for health professionals.

Most importantly though, remember that responding to survivors of domestic abuse is core business for mental health services and should not be something to left up to other services. If domestic abuse is a major cause of a woman’s mental health issues (and we know for a large proportion of women accessing mental health services, it is), then the service you provide will be limited in its efficacy if you do not address this cause.

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

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Why mental health support for survivors of domestic abuse is so vital

Donna Covey is CEO of AVA, a leading charity committed to ending gender based violence and our expert partner for this Spotlight. In her blog marking World Mental Health Day and the start of our series, Donna describes why responding to the mental health needs of survivors of domestic abuse is essential, and outlines the progress being made within the domestic abuse sector.

“When you experience domestic violence, your body runs on adrenaline. When you leave that relationship you can feel withdrawn, tired, like you can’t cope, lonely and abandoned. There is no safety net to catch you and it can be easier just to return”

This quote from a survivor shows why speedy access to the right mental health support is as important to a woman's long term safety as a refuge place. Yet all too often, women survivors of domestic abuse are denied the support they deserve.

Most survivors experience mental ill health as a result of domestic abuse. Domestic abuse is the most common cause of depression amongst women; abused women are four times more likely to experience depression than non-abused women[1]. Almost two thirds of domestic abuse survivors experience post-traumatic stress disorder (PTSD) – more than twice the rate experienced by soldiers in combat[2]. Around two thirds of women using mental health services have a lifetime experience of domestic abuse[3].

Yet despite this, mental health services  are poorly equipped to support survivors of domestic abuse, and women are still turned away from refuges because of their poor mental health.

Like everyone else experiencing poor mental health, survivors of domestic abuse face long waiting lists. As one woman told us:

“I said to mental health, how long will it be before someone gets in touch, well, we’ll send a referral through, oh alright then I’ve just tried to commit suicide. You send the referral through, in the meantime who’s going to speak to me? Oh nobody? Okay, well hopefully I’ll be alive when you call next.”[4]

The limited services offered by a cash strapped NHS, where mental health services have been disproportionately cut despite lip service to parity of esteem, means that what is available is often limited to a few weeks’ CBT – often on a group basis, unsuited to supporting a woman experiencing the trauma and shame that is a legacy of domestic abuse.

Despite the high proportion of women with experience of domestic abuse who have poor mental health, evidence shows that mental health professionals feel ill equipped to ask about domestic abuse and respond to disclosures. Work by Diana Rose and colleagues found that many mental health professionals did not see enquiry about domestic abuse as part of their role or within their competence[5].

For many survivors, substance use becomes a necessary coping mechanism, and a number of studies have found that the majority of women in drug and alcohol services have experienced domestic abuse[6]. Yet many NHS mental health services won’t treat a woman’s depression until the substance use stops. And substance use services for women are few and far between. Work by AVA, in partnership with Agenda, found that less than half of all local authorities in England and only five unitary authorities in Wales (22.7%) report substance misuse support specifically for women[7]. Most of these were limited to a weekly women’s group within a generic service, and an equally common type of support for women affected by substance misuse in England was a substance misuse midwife, with this being the most common type of support reported in Wales.

The Department of Health funded AVA to work intensively with two mental health trusts to improve their response to domestic abuse. This project PRIMH (Promoting recovery in mental health) involved training staff, reviewing policies and developing a whole trust response to domestic abuse. The independent evaluation carried out by King's College London found significant increases in the following:

  • knowledge about domestic and sexual violence
  • reported knowledge about why a patient might not disclose domestic and sexual violence
  • what questions to ask to identify potential new cases of domestic and sexual violence
  • what to say/not to say to a patient experiencing domestic and sexual violence
  • confidence levels in using referral pathways for men, women and children

We are committed to sharing this learning more widely through our BARTA consultancy, as well as the Health Pathfinder project looking at an integrated approach to domestic abuse and domestic abuse, together with SafeLives and a number of other partners.

In the Violence Against Women and Girls sector, there has been real progress in developing services that are trauma informed, providing women with the prospect of emotional as well as physical safety. One example is work carried out by Solace Women's Aid, supported by AVA, to develop psychologically informed environments[8], and the outcome of that project can be found here. Unfortunately, pockets of good practice are increasingly being overshadowed by both cuts and a shift to generic provision, which means that women experiencing poor mental health are still finding it hard to access refuge and other services, especially when they are using substances to cope.

There are also brilliant voluntary sector organisations providing trauma informed gender aware support, but they too are under-funded and this is far from a national network. We are proud to be founder members of the  Women's Mental Health Network, alongside many of these providers.

We also know from our work with practitioners that when it comes to Marac and other multi-agency forums working on domestic abuse, statutory mental health services are all too often  the ‘empty seat at the table’.

It is no surprise that a woman who has been subject to abuse and control from the person who is supposed to love her the most ends up traumatised, experiencing depression, anxiety or PTSD, and using substances to cope with the trauma and the shame.

It is shocking, but not surprising, that the right support is not available for these women who deserve it, acting as a massive barrier to their long term recovery. We welcome the opportunity to work with SafeLives to shine a spotlight on this important issue. As always, the last word goes to a survivor:

“I don’t call it mental health, I call it ‘symptoms of abuse’, because to me that’s what it is”

 

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

                                          


[1] Walby and Allen (2004) Domestic Abuse,sexual assault and stalking

[2] Cascardi,OLeary Slee (1999) “Co occurrence and correlates of posttraumatic stress disorder and major depression in physically abused women” Journal of Family Violence

[3] Khalifeh et al , 2014

[4] Mapping the Maze, www.mappingthemaze.org.uk

[5] Rose et al “Barriers and facilitators of disclosures of domestic violence by mental health service users” British Journal of psychiatry 2011

[6] Complicated Matters: a toolkit addressing domestic and sexual violence, substance use and mental ill health : AVA

[7] Mapping the Maze: Services for women experiencing multiple disadvantage in England and Wales , AVA and Agenda 2017

[8] Peace of Mind , AVA/Solace 2017

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