Practice blog

The impact of mental health on the response to perpetrators of domestic abuse

Jonathan Fowler has extensive experience, going back more than 25 years, as a therapist in (Secure) Psychiatric Settings (working with both violence & severe self-harm /trauma), working at the interface between mental health & the Criminal Justice System, with complex needs, and with Respect accredited DV perpetrator work.  He currently works as a facilitator on the Reprovide perpetrator programme, as a DVPP trainer and external supervisor, as mental health advisor for the Drive programme, and with specialised complex needs services.

Prior to working with male perpetrators of domestic violence, I spent many years as a therapist with survivors of violence; of physical, sexual and emotional abuse. Both in this work, and in my private life I have seen the devastating impact these experiences have on adults and children. It is vital that there are strong services that focus on safeguarding and supporting them. I feel strongly that part of this work must involve working with perpetrators, supporting them to take responsibility for their behaviour and reducing the risk of them abusing current, and future, partners and children. 

Supporting perpetrators to take responsibility becomes more complicated as soon as the possibility of their own mental health problems playing a role in their abusive behaviour arises. Are their mental health problems being presented as an excuse not to take responsibility for their behaviour, or are they an important factor in this behaviour? With some mental health conditions this can seem especially complex, as an inability to successfully manage emotions and/or form stable intimate relationships is at the heart of some problems. This is particularly the case for some of the personality disorders. In practice this need not always be as much as an issue as it seems; our work is always about supporting them to take responsibility, whether they have mental health problems or not. They join a programme in order to be able to take more responsibility.  

The challenges to relating that some mental health problems give, are sometimes more extreme versions, of some of the issues men already address in the work we do with them. An example is having difficulty in taking the perspective of others. A failure to appreciate the perspective of partners will be found in all the perpetrators we work with. How poor they are at doing this will vary. Sometimes their ability is so consistently poor that it is seen as indicating a mental health problem. 

Both in 1:1 work, and group-work we often ask perpetrators to think about and express the perspective of their partners and children. For many men, doing this is an emotionally challenging experience that encourages them to reflect on their behaviour. These men will typically have some perspective-taking skills that they seem to use, for example, in their work life. They fail to do this at home though, with this failure backed up by entrenched and unhelpful beliefs, for example about how men and women should be in relationships. These entrenched ideas become exposed and can be then questioned during this process. Some men will struggle to do this well, and will need more support. Some will have huge difficulties. These difficulties are typically very apparent, not only in their relationship but also, in the rest of their lives; at work, in their interactions with us, and if they are in a group, their interactions with other group members. In role play exercises, for example, I've seen men who seem only able to project their own perspective when role playing their partners or children. They can be shockingly unaware that they are unable to take someone else's perspective. For example, in voicing the perspective of their severely emotionally abused and very troubled son, a man was recently only able to express how much their son missed his father. Encouragements to think about any other feelings they might have, drew a blank. In the most extreme cases these men are not suited to the type of group work we do on perpetrator programmes. Their inability to take other's perspectives can result in constant conflicts with facilitators and other group members, and they are often severely limited in their ability to reflect on their own feelings and thoughts. 

Perpetrator groups are not focussed on working with high levels of conflict within the group, or with an extremely limited ability to reflect on thoughts and feelings. Skilled 1:1 work can help, as can specialised group-work, if available. But the immediate primary focus often needs to be on protecting their family members from them, and working closely with Maracs, probation, police and social services to do this. Ideally sometimes specialised mental health support may be needed, and attempts should be made to get these clients referred for assessment and treatment, if possible. Initiating actions which reduce risk to family members can, of course, impact a lot on these clients and we sometimes need to be aware of increased risks for them, their families, and us. Maintaining a relationship with them through these changes is important, both to help manage risk and to continue to build a relational foundation for further work. It can be hard to balance empathy for their distress, encouragement to them to take responsibility, and ongoing risk-management. Especially if, for example, their distress is expressed through direct or masked threats to us. Recently I found myself balancing empathy for the very painful feelings of loss that arose from a man's reduced and restricted access to his small child, with explaining why these steps had been taken, how he could submit a complaint about the steps we had taken, and gathering information to assess ongoing risk. I could also see, in this situation, how his relationship with this child was totally focused on his own needs, but how little capacity there was to reflect on this. 

Sometimes psycho-pharmaceutical support may be needed in order for some men to be able to engage with the programme we are running. For example, men who have experienced psychosis or the extreme impulsivity of ADHD, can do well on perpetrator programmes if their symptoms are stabilised by medication, and they see taking medication as part of what they need to do in order to effectively take responsibility for their behaviour in their relationship. We may need to monitor that the work we do is not de-stabilising them, and liaise with mental health services around support. Without taking steps to manage their mental health problems, it is not possible to work on further building their ability to take responsibility in their relationship. 

Generally, while mental health issues may complicate the work we do, or in some cases mean that we cannot work with a particular client, they never remove our focus on how the men we work with can more effectively take responsibility for their behaviour. If there appear to be mental health issues, I am interested in how they impact on a client's ability to take responsibility. What implications does this have for support from other services, what does this mean for what they need to focus on in the programme, and what are the implications for how we reduce the risk to their families? 

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

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LGBT+ survivors and mental health

Lindsay Sutherland is a Research Analyst at SafeLives and has primarily worked on the national Insights and Marac datasets. as well as supporting the Spotlights series with data analysis and literature reviews. She recently moved onto SafeLives’ new Big Lottery Fund project in Scotland to provide research support and will also be involved in the evaluation of DA Matters domestic abuse training for Police Scotland which starts later this year.

The Spotlight series continues this month with the topic of mental health. For me, a standout lesson from the series is the importance of joining the dots between layers of identity and need. That might mean applying an intersectional lens to think through how individuals are affected by different systems of discrimination, or considering how multiple needs might interact to fuel disadvantage if left unsupported.

Central to the LGBT+ Spotlight was the troubling finding that victims of domestic abuse who identify as lesbian, gay, bisexual or transgender (LGBT+) are more likely to experience mental ill health. Statistics from our Insights national dataset provide us with a picture of victims who accessed specialist services for support. Two in five had a mental health problem in the previous year; among LGBT+ victims, this rose to over half. Appallingly, Insights data showed that LGBT+ victims were almost twice as likely to have attempted suicide and were more than twice as likely to have self-harmed. Double the proportion of LGBT+ victims were experiencing drug and alcohol addiction compared to non-LGBT+ victims.

Survivors of domestic abuse live through distinctly oppressive and outright dangerous situations. Given this, it may not surprise many to know that various studies[1] highlight increased prevalence of mental ill health among survivors. But our Insights data has highlighted that LGBT+ victims experienced higher levels of each type of domestic abuse and were more likely to have experienced historic abuse from a family member or previous partner. While there is a lack of research to probe these prevalence statistics further at present, what they do show is the complexity of risk that LGBT+ victims face – risk which threatens their safety, and all too frequently harms their mental health.

The patterns in our Insights data reflect a complex picture of wider inequalities in the world. In fact, regardless of whether they have experienced domestic abuse, LGBT+ people are more likely to experience mental ill health. The Mental Health Foundation links this to discrimination, isolation and homophobia in society.[2] The government’s national survey of LGBT+ people found that 40% of respondents had experienced a homophobic, biphobic or transphobic incident in the previous 12 months, committed by someone they did not live with[3]. Our Spotlight partner, Stonewall, has researched the discriminatory experiences LGBT+ people face in all avenues of life from school to work to the world of sport[4]. Not only does this discrimination impact on health, but it may also deter LGBT+ people from seeking much-needed support if they face abuse.

What does all this mean for practitioners and policy makers? The government is attempting to answer this question with their LGBT Action Plan (2018) where they acknowledge the significant impact sexual orientation or gender identity can have on health and wellbeing. Our report, Free to be Safe, full of the voices of LGBT+ survivors, also explored this urgent question. The complexity of need and wider societal discrimination we know LGBT+ victims often face means quick identification leading to effective support is crucial. Services must be ready to proactively identify and engage this vulnerable group, providing support that is sensitive to their particular experiences. In light of what the data we have tells us, mental health support must be considered as a central part of this response.

A wealth of learning material from the LGBT+ Spotlight and policy report is available to support services in this important work. So let’s listen to the voices of survivors who have experienced mental ill health alongside, or as a result of, domestic abuse. At the same time let’s join those dots back to the sixth Spotlight and continue to demand that LGBT+ victims are #FreeToBeSafe and also, well.   

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

 

[1] See 2.2.6 Mental Health Foundation Fundamental Facts (2016) https://www.mentalhealth.org.uk/publications/fundamental-facts-about-men...

[2] Mental Health Foundation (2018) Mental health statistics: LGBT people [online] https://www.

mentalhealth.org.uk/statistics/mental-health-statistics-lgbt-people [accessed 24th July 2018]

[3] Government Equalities Committee (2018) National LGBT Survey: Research Report [online]

https://www.gov.uk/government/publications/national-lgbt-survey-summary-... [accessed

24th July 2018]

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Domestic abuse, mental health and homelessness: the Housing First model

Louisa Steele has worked across women’s specialist services and the homelessness sector for the past ten years, in both frontline and strategic roles. Louisa is currently the Housing First and Homelessness coordinator at Standing Together Against Domestic Violence and is working on developing the Housing First model for women experiencing multiple disadvantage and domestic abuse.

Research has shown that domestic abuse is the most common cause of depression and other mental health difficulties in women. Alongside this, we also know that gender-based violence and abuse is a key cause of homelessness for women. The links then between experiences of abuse, complex trauma and homelessness are clear, but survivors still struggle to access affordable, stable housing that is so crucial to their recovery. It is time then, to shine a light on the fact that mental health issues, whether diagnosed or undiagnosed, act as a major barrier to accessing housing for survivors of abuse. We also need to start thinking about what it will take to begin untangling this major system blockage and look to new approaches to advocacy and support that could make all the difference.

Several studies have shown how survivors experiencing multiple disadvantage, defined as the concurrence of poor mental health, substance use, homelessness and gendered violence, struggle to access space in women’s refuges, as most are not resourced to address the complexity of these issues. Conversely, homelessness pathways and services i.e. supported accommodation, may have good links with mental health services and be better resourced to deal with issues around mental health, but be less equipped to provide support around domestic abuse, or women-only options.  A survivor’s mental health diagnoses, combined with their experiences of abuse, become a considerable barrier in both cases, leaving survivors with mental health issues with few options. 

Many women present to local authority housing teams with a combination of vulnerabilities around mental health, domestic abuse, substance use or physical health and are routinely turned away, without even the opportunity to make a homelessness application, let alone be considered for statutory duty. For survivors who have experienced abuse and trauma through engagement with services in the past, and therefore already have little reason to trust services, this can be catastrophic, pushing them back into the hands of the perpetrator and with little choice but to resort to risky survival strategies to keep a roof over their head.

What is more, mental health services are all too often the ‘empty seat’ at multi-agency conferences that I have attended for survivors with mental health issues and additional, multiple needs. It is a well-known fact that many trusts knock back referrals for survivors with ‘dual diagnosis’, those with mental health and substance use issues, leaving vulnerable survivors largely unsupported. Without appropriate support from mental health services to help survivors address and manage their trauma or their diagnosis, survivors are more likely to self-medicate, be unable to work or manage their benefits. This will in turn increase their risk of eviction and eventually make it hard for them to manage a tenancy without considerable support. The fact that mental health services are so difficult to access continues to be a major issue; even if a survivor does obtain housing, they are likely to need specialist support and advocacy to help them access mental health services and get the support that they need.

All survivors – but especially those with mental health issues – need more than just a ‘roof over their heads’. A home, with the safety and security that comes with this, takes a good deal of time and support to build. A survivor of domestic abuse with mental health issues, struggling though trauma, stigma and fear might need someone to help them open their post if they are too scared to, to chase their care co-ordinator, to manage their housing benefit claim, and to be that positive relationship and source of emotional support that can make all the difference.

The Housing First model originated in New York, as a solution for people with entrenched mental health issues who were long term or recurrently homeless. It has since spread across the US and Europe, and the evidence clearly shows that providing housing and teaming it with flexible, wrap around, unconditional support works. Housing First means that a survivor of domestic abuse isn’t judged on the basis of their mental health diagnoses, and housing isn’t conditional on whether that survivor is ready for treatment. The Housing First philosophy understands the links between violence and abuse, trauma and homelessness, and is therefore an effective – although woefully underfunded – option for survivors with mental health needs.

The links between domestic abuse, trauma, poor mental health and homelessness are clear, and the women’s sector has engaged in some amazing work to highlight this point and keep it on the government’s agenda. It is time that housing providers, CCGs (Clinical Commissioning Groups) and mental health practitioners recognise their key role in preventing homelessness and promoting recovery for survivors of domestic abuse.

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

The role of hospitals in responding to domestic abuse and mental health

Kathy is a Registered Nurse and Head of Safeguarding for East Lancashire Hospitals NHS Trust where she has led the Safeguarding agenda for ten years. She works with a dedicated specialist team of safeguarding leads and practitioners, implementing a safeguarding strategy  that addresses all aspects of safeguarding including domestic abuse.   

Linsey has worked in the domestic abuse sector for nearly ten years as a refuge support worker, outreach support worker, and Idva. Linsey has worked in Liverpool on a pilot project targeting the co-occurrence of mental health, substance use and domestic abuse. She is a qualified cognitive behavioural therapist and works in private practice, alongside her role for East Lancashire Hospitals NHS Trust as a specialist hospital Idva. 

Within East Lancashire Hospitals NHS Trust we have acknowledged the importance of the role we have in responding to domestic abuse. It makes sense that an organisation that serves a population of over 530,000 people will come in to contact with people who are experiencing or at risk of domestic abuse.  And with 8,000 staff who work within our organisation, we need to be sure they can recognise domestic abuse and respond accordingly. 

Every hour of every day, 365 days a year, we are providing a service to someone. We have such a diverse range of service provision, from maternity and children’s services to older people’s specialist services, in-patients, out-patients, community clinical teams, and emergency care. 

We also work closely with multi-agency partners across East Lancashire, Blackburn with Darwen and beyond, and this includes providers of specialist mental health services and also providers of specialist domestic abuse services.  

When SafeLives published ‘A Cry For Health’ in 2016 we saw many parallels between the pilot sites and our own acute hospital trust, and we have used those findings and recommendations to strengthen our approach to recognising and responding to domestic abuse. This has included gaining support to secure the funding for our own full-time Hospital Idva, and she is already making a huge difference with the equivalent of one referral a day in the first three weeks in post. 

The role of hospital staff in identifying that people with mental health problems presenting at A&E may be victims of domestic abuse 

In addition to direct injuries sustained as a result of domestic abuse, there is good evidence to support the fact that those who experience domestic abuse can suffer significant physical and mental health problems.  

We see around 500 people each day in our A&E and Urgent Care Centres. Like any other acute hospital trust we see patients who are predominantly physically unwell, but there are also many people who attend for help, treatment and support for a reason related to mental health. 

People may attend A&E with acute exacerbation of a long-standing mental health condition, intentional overdose of medication or other substances, abuse and misuse of alcohol or drugs, self-harm injuries, anxiety, depression, and risk of suicide. As an emergency service we would engage these patients with the specialist mental health teams and services. However, we also recognise there may be serious safeguarding concerns, including historical or current abuse, which could be contributing to the deterioration in the person’s mental health. It is of great concern that, despite referrals to specialist support services, many patients are not actively involved with those services, and we see the same people coming back through our doors time and time again. However, on a positive note, we have seen patients who may agree to access support after many times of declining help previously. 

Their role in identifying that people with longer term health issues may be victims of domestic abuse 

If we examine the reasons for attendance at hospital for those who have experienced domestic abuse (who are known to us), we can see a picture of poor health including chest pain, recurrent infections, bowel complaints, anxiety and depression.  

When people use our services we also see evidence of direct injury where domestic abuse is suspected, and this may be disclosed or not. Unexplained injuries, or injuries where the explanation doesn’t marry with the damage, can be common, and I am confident that safeguarding is well-embedded within the Trust and the clinical staff would seek the opportunity to safely ask the patient about abuse. 

We are also in a fortunate position with a number of services where clinicians such as nurses, physiotherapists, psychologists, etc will see patients on a one to one basis. Professional and trusting relationships are established, and we have seen unexpected disclosures of domestic abuse that have come ‘out of the blue’ during an out-patient appointment.  On the whole patients feel safe in a health environment, and confidential, professional relationships are expected across the board. 

The Hospital Idva 

Over the last few years East Lancashire has established effective partnership working with the local providers of specialist domestic abuse services. Integrating the Hospital Idva role into our Safeguarding team enabled us to raise awareness of domestic abuse across our clinical services, which led to staff recognising the signs of domestic abuse in their patients. There was increased opportunity for patients to disclose domestic abuse, and the Hospital Idva became involved with the daily ward routines, including attending board rounds to assist staff in identifying patients at risk, and improving their knowledge and understanding of domestic abuse. Input from a number of specialist domestic abuse providers has paved the way for us to gain support for our own dedicated Idva based in the hospital. 

The recent appointment of Linsey to her role as Hospital Idva has already proved to be not just valuable, but vital. The approach of having the Idva embedded within well-established hospital safeguarding teams makes sense. Already Linsey is seen as part of the safeguarding team by the clinical staff she has worked with. 

As Linsey explains, “Previously, as an Idva I was used to going to see clients when they had presented in hospital, but within this new role I am based in the hospital full-time. Because of this, I have found that I am consistently dealing with a complex caseload; the majority being those experiencing some form of mental health problem. Within the first month of being a Hospital Idva, 90% of my caseload has been people with complex mental health issues, including personality disorder, complex PTSD and early signs of psychosis.  

Sadly, the majority of the mental health issues are partly due to historic and current domestic abuse. It has been extremely important to work from a multi-professional, interdisciplinary approach due to the complexity of the cases, working alongside nurses, community Idvas, doctors and of course the mental health teams. As well as the clinical teams within East Lancashire Hospitals NHS Trust I have also been working alongside psychologists, psychiatrists, mental health teams and specialist services, making sure our patients, who are some of the most vulnerable people in our society, have all the support they need and are effectively safeguarded”.  

The future of Hospital Idvas 

We would encourage hospitals to look at what they do to recognise and respond to domestic abuse, and consider what support they can access to bring an Idva into the hospital safeguarding team. We are in a prime position for people to disclose abuse in a safe environment.  

As part of a pilot we have gained support for an Isva (independent sexual violence advisor) to join our team from the new year, and we anticipate a high number of referrals to the Isva. In the next 12 months we will hopefully be able to evaluate the impact of having specialist Idvas and Isvas based in hospitals, and we predict now that disclosures of domestic and sexual abuse will be made much sooner than if the opportunity wasn’t there to see a specialist in hospital. We predict in years to come that the numbers of victims at higher risk will reduce in areas where there is a dedicated resource in the hospitals, as they will have disclosed and sought help and support before they reach that level of risk. The more services can do to raise awareness, recognise and respond to domestic abuse, the better the outcomes for those individuals and families.  

When all is said and done, safeguarding is a process that relies on close partnership working to protect vulnerable adults and children from abuse or neglect, protecting their health, development and well-being, thus enabling them to live free from harm in a safe environment with the support they require. 

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

Domestic abuse and mental health: A GP's perspective

Dr Katherine Pitt is a GP Registrar with a special interest in women’s health. Katherine is also a researcher in domestic violence and abuse at University of Bristol (Academic Clinical Fellow).  She writes here about her professional experiences of how domestic abuse impacts upon mental health.

Working as a doctor in general practice, I had some insight into the mental health consequences of domestic violence and abuse (DVA). However, the time pressure in clinical practice limits what I hear and understand. Recently, by conducting research interviews with survivors of DVA, I gained a deeper insight. They described how corrosive DVA had been to their self-worth, confidence and mental health. Their experience of seeking psychological support was variable. Despite this, they embodied resilience, and a commitment to sharing their experience in the hope it might help others.

The most common health consequence of DVA is poor mental health. There is a three-fold risk of depressive disorders, four-fold risk of anxiety disorders and a seven-fold risk of post-traumatic stress disorder.1 DVA is associated with an increased risk of suicide.2 The trauma experienced by survivors of DVA can be complex, due to the intimate and recurrent pattern of abuse. Poor mental health can be compounded by substance misuse. The survivors I interviewed stated that the mental health consequences of DVA were the most destructive and long lasting. One woman described how her ex-partner had manipulated her so profoundly that she questioned her own sanity.   

Survivors of DVA with mental health problems can face challenges to accessing treatment.  Psychological support which fails to acknowledge the abuse can be ineffective. Worse, it risks implying that the distress experienced has an intrinsic rather than extrinsic cause.3 Couples or family therapy can lead to re-traumatisation and be dangerous.  Trauma therapies may require participants to relive traumatic experiences, leading to high discontinuation rates.4 Survivors with poor mental health and substance dependence may struggle to access psychological therapy due to substance misuse, and struggle to stop misusing substances because of unaddressed trauma. The women I interviewed faced situational challenges. One recounted the all-consuming practical difficulties of resettling in a new place. Another reported being removed from a therapy group when she missed sessions to care for her child. They varied on at what point in their journey they felt able to engage with therapy. 

Psychological treatments responsive to the needs of DVA survivors have been demonstrated to help, and there is reason for optimism. Research studies have supported the benefit of providing therapy specific to the needs of DVA survivors.5 Further research is being conducted into novel therapeutic approaches, such as mindfulness for trauma. GPs, often the first point of contact for people with mental health problems, are being trained to enquire about and respond to DVA by the IRIS programme, which has now reached 10% of practices nationally. Agencies exist motivated to help people with complex needs, namely poor mental health and substance misuse. The women I spoke to testified to the pivotal role of DVA agencies in their recovery. One described how a DVA support group allowed her for the first time to recognise the abuse, and the power of sharing experiences with other women.

DVA is destructive to mental health and treatments that fail to recognise the abuse or specific needs of survivors can be ineffective. In general practice I am grateful that my patients are supported by DVA specialists and know how valuable advocacy is to survivors. Survivors need access to therapy that recognises the abuse that they have experienced, and their specific needs. NICE has called for greater research into what therapies are beneficial in the short, medium and long term.6 The women I interviewed were testimony to psychological resilience. Survivors with the bravery and selflessness to share their story have a powerful role in supporting other people affected by abuse.      

 

Dr Katherine Pitt, BSc MSc MBBS (2013) DCH DFSRH

 

References

  1. Trevillion K, Oram S, Feder G, Howard LM. Experiences of Domestic Violence and Mental Disorders: A Systematic Review and Meta-Analysis. PLoS ONE. 2012;7(12):e51740.
  2. Devries KM, Mak JYT, García-Moreno C, Petzold M, Child JC, Falder G, et al. The Global Prevalence of Intimate Partner Violence Against Women. Science. 2013;340(6140):1527-8.
  3. Trevillion K, Howard LM, Morgan C, Feder G, Woodall A, Rose D. The Response of Mental Health Services to Domestic Violence: A Qualitative Study of Service Users' and Professionals' Experiences. Journal of the American Psychiatric Nurses Association. 2012;18(6):326-36.
  4. Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008;71(2):134-68.
  5. Trevillion K, Agnew-Davies R. Interventions for mental health service users who experience domestic violence. In Howard L, Feder G, Agnew-Davies R, editors. Domestic Violence and Mental Health. Royal College of Psychiatrists; 2013. p.64-77.
  6. National Institute for Health and Clinical Excellence (NICE). Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. 2014.

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