Practice blog

Responding to women's mental health needs

Shirley McNicholas is the Women's Lead for Camden and Islington NHS Foundation Trust. In this blog she talks about the work being carried out within the Trust to respond to the mental health needs of women affected by violence and abuse. In her capacity as Women's Lead, Shirley is also the key lead for the Maracs across both boroughs and has written a Marac protocol for Trust staff.

Camden and Islington NHS Foundation Trust showed its commitment to women early in 1995 when it applied for funding and developed a women-only crisis house as an alternative to hospital. Drayton Park Women's Crisis House has continued throughout this time and has proved to be a successful alternative to acute admission for women who would otherwise be admitted. It provides a unique service in many ways, for example it has a women-only staff team and can admit children with their mothers.  It has a national reputation and is one of the early examples of a trauma informed model of care[1] for women.

Alongside the development of Drayton Park, a women’s user forum became the Trust’s Women’s Strategy Group (WSG) and this group was involved in the Department of Health National Women's Strategy for Women's Mental Health in early 2000. Both Drayton Park and the Women's Strategy group were cited as examples of good practice for other Trusts to adopt.

The WSG is a unique working group with the majority of its core members being women who use services. This group has been operational for over 15 years and works on a range of objectives each year. Over 40 staff members are network members who can attend on a monthly basis, but never outnumber the service user members. This allows for a very strong and confident user base. The group aims to monitor the standards for women in all services and members are also on the Patients Council and Service User Alliance. These members audit the use of the women-only sitting rooms and the general sense of how women experience being on the wards. The group also goes out to a range of sites and meets women where they are, on the wards, in day services etc.  

The group has been involved in a range of recruitment, training and policy developments. They are included in the recruitment of staff at Drayton Park Women's Crisis House, Rosewood the women only acute ward and Ruby Ward – the women only Psychiatric Intensive Care Unit (PICU).  Members were involved in the training of a new staff team on the PICU which included trauma informed practice and understanding self-injury.

The group was consulted on the design and layout of Rosewood and Ruby wards. This meant they were involved in making practical as well as strategic adjustment. For example, ensuring women can control the heating and lighting in their bedrooms.

We have also been involved in exciting newer initiatives. In 2013 the Trust successfully applied to participate in PRIMH (Promoting Recovery in Mental Health). This three year project, funded by the Department of Health and in collaboration with AVA (Against Violence and Abuse), aimed to embed a cultural change in mental health trusts’ response to disclosures of domestic and sexual abuse.  PRIMH took the form of action research with two Mental Health Trusts in England to design and implement a Trust-wide strategy for addressing domestic and sexual violence in relation to both victims and perpetrators. In participating in PRIMH, C&I benefited from intensive consultancy, support and training from the Stella Project Coordinator over a two year period. The project was evaluated by the Institute of Psychiatry, and led by Louise M. Howard, Professor of Women’s Mental Health at King’s College London.  

The Women's Lead and WSG were the Trust leads on this project, which we named Awareness and Response to Domestic and Sexual Abuse (AR-DSA). Beyond the project the AR-DSA network continues and is involved in taking forward a range of objectives such as training and bi-annual White Ribbon Events.  This year it will focus on Sexual Violence within mental health services and due to concerns for student nurses and recent research about domestic abuse within the nursing population, we are collaborating with Middlesex University in examining Sexual Safety within our services.  The CQC are also interested in this topic and will be presenting their findings.

It is a challenge to continue to have women's champions in all services but the WSG keeps an oversight for the Trust. The Trust, the WSG and Women's Lead are committed to increasing understanding and practice of trauma informed models of care/environments and this will impact positively on women.

 

 

 

 

 

 

 

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

 


[1] (Trauma informed or Trauma denied: Principles and implementation of trauma informed services for women: Denise Elliot: Journal of Community Psychology Volume 33, No 4  466 471 )

 

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Young people, domestic abuse and mental health

Susie Hay is the Head of Research, Evaluation and Analysis at SafeLives. She is also a practising child and adolescent psychotherapist.

Where to start when talking about young people, mental health and domestic abuse…

I have been a practising child and adolescent psychotherapist for the past nine years. During this time, I have worked with young people and young adults presenting with a host of different mental health challenges ranging from low mood, depression, anxiety, self-harm (in varying forms), low self-esteem, to suicidal ideation, substance misuse and identity issues – to mention but a few. These conditions also tend to be accompanied by a spectrum of destructive coping strategies.

What became apparent early in my career working within the Youth Counselling Trust was that domestic violence and abuse and the associated trauma had touched the lives of over 80% of my clients in one form or another. However, this was rarely the identified issue, event or reason for being referred into the counselling room. Rather the presenting condition or coping strategy was the catalyst for voluntary (or involuntary) referral into the therapeutic environment.

This is especially shocking when we consider the findings of our Insights briefing on children living with domestic abuse:

“One in five children have been exposed to domestic abuse. SafeLives estimates that around 130,000 children in the UK live in households with high-risk domestic abuse; that is, where there is a significant risk of harm or death.  Our latest Children’s Insights dataset has found that at the time they start school, at least one child in every class will have been living with domestic abuse since they were born.  For some children, this exposure to abuse does not only start early, but persists into later childhood. Of all the children in our dataset who had been living with abuse for their whole lives, over a third (37%) were more than five years old.

Combined with information on the percentage of all children who have been exposed to domestic abuse in their homes, we estimate that at least one child in every reception school class has been living with abuse for their whole life”.

For the majority, parents, carers or educational staff initiated the referral into the service; young people very rarely referred themselves. I suspect this was due to the stigma associated with ‘mental health’ and a lack of knowledge of the support available.

However, a pattern did emerge. The aim of adults making referrals was primarily about ‘stopping’ certain behaviours, rather than ’understanding’ why the young person might be behaving in that way in the first place.

One issue repeatedly presented by young clients either living in abusive households or in abusive intimate relationships themselves, was a sense of helplessness. Due to their age, limited support provision, and an inability to live independently, young people had limited choices. They felt the only option was to ‘endure’ rather than feeling a sense of control over what they could do to improve their situation and in turn their mental health.

This was true for both young men and young women; however, the coping strategies varied with young men presenting as disruptive and aggressive; and young women presenting as withdrawn and demonstrating higher levels of self-harm.

So, when considering this age group, how can practitioners respond? Counsellors and mental health practitioners need to have good knowledge about domestic violence and abuse, and when making assessments need to ask questions about family dynamics. This needs to be done in a creative, evocating way as some young people will not know that they are living with domestic abuse; this may be all they know and they may not yet recognise it as abusive.

Additionally, therapists need to understand effective risk assessment and how to respond appropriately. Domestic abuse is a safeguarding issue and needs to be addressed as such. This can place a pressure on the therapeutic relationship, but we all have a duty of care to protect children.

The impact domestic abuse has on development and sense of self is huge, and we see this reflected in some of the recent research in Adverse Childhood Experiences (ACEs).

As a child that was exposed to domestic abuse throughout adolescence, I know first-hand that support for young people and their mental health is fundamental. In my case, I developed an eating disorder; accompanied by self-loathing, low mood and social anxiety. During this period, this felt all consuming – and even now in adulthood, it can influence how I feel in social situations and my levels of self-acceptance. Although there was no physical violence, the psychological abuse and coercive controlling behaviour eroded my sense of self and created a general sense of uncertainty and fear whenever I was home.

So what helps? From my experience being open, honest, respectful, non-judgemental and creative are the key components to engaging with young people. Faking it is pointless, young people see straight through it and you lose any credibility that you might have had with them. We need to remember that this might be the first time they are discussing their mental health and/or exposure to domestic abuse and therefore we need to be ourselves if we expect them to be the same! I have found that saying things aloud makes it extremely real for some people and in some cases this in itself can be challenging and traumatic.

Trauma exposure during this pivotal time of neurological and identity development can go on to influence us throughout our life and can shape our coping strategies as adults and parents. Let’s not do young people an injustice by only seeing their symptoms; let’s properly consider what might be going on for them within their homes and relationships and what they need to feel safe and achieve positive mental health.  We have a responsibility to encourage young people to talk about their mental health and to celebrate the courage this takes.

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

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 health 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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