Practice blog

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 Health 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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Developing a supportive housing model for survivors of domestic abuse

Natalie Blagrove is a Senior Knowledge Hub Advisor at SafeLives. For the last six months she's been seconded to Shared Lives Plus, our partner in a new pilot to develop and test supportive housing options for survivors of domestic abuse.

I recently wrote about the domestic abuse project I have been seconded to work on for Shared Lives Plus; six months on I thought it was time for an update. It’s been a busy six months, with some real highlights as well as some challenges.  

The good stuff  

Supported by the local domestic abuse services, I visited two of the pilot sites to hold survivor consultations. It’s so important to get the thoughts, ideas and opinions of people with lived experience and it’s something that both Shared Lives Plus and SafeLives feel is crucial to any successful project. I have to say, I was a little nervous about presenting this idea to survivors.  Would they like it, would they think it was rubbish? Fortunately, the vast majority of the women I spoke to saw a place for Shared Lives; a safe place to live with a carefully matched and approved Shared Lives carer in the carer’s home. They thought there was a place for this type of accommodation in a survivor’s road to recovery, perhaps when moving on from refuge. It could be a way to help survivors build their confidence before moving on to live independently. All of this was music to my ears, giving me the confidence to move the project forward. 

“Being a sufferer of domestic violence makes you vulnerable, so being in a loving caring home is what’s needed.” 

 “A family environment would aid in emotional healing and the building of trust and confidence. I had no stable family so had to learn through trial and error what a stable family was.” 

Challenges 

I have to admit, the challenges have mainly been finding the right people to talk to in the pilot areas – who knew it would take so much detective work? Building those relationships is so important though, if we’re to make the project a sustainable success.  

From the survivors I spoke to, there were also some concerns about the risk associated with a project like this: 

“One of the issues I see is if an abuser was to find the victim and cause damage to property or the people whom the victim was living with.” 

“The challenges would be in keeping everyone safe.” 

However, with careful planning and collaborative working with the necessary stakeholders we believe that a Shared Lives arrangement can offer an alternative housing option that is both safe and supportive.  

What do we hope to achieve?  

For me, this is simple. I want to be able to give victims and survivors of domestic abuse more choices when it comes to housing. The Shared Lives model won’t suit everyone, but having spoken to survivors and professionals, I believe it will suit some. So, we need to make this work. We need local authorities, domestic abuse services, Shared Lives Schemes, service users and other stakeholders working together to ensure that survivors have a range of options available to them.   

“I feel I haven’t got a right to complain.” [about poor accommodation]

“Beggars can’t be choosers.” 

Next steps 

Over the next few months, we’ll be looking to develop the framework that will support this housing model, exploring issues such as referral pathways, risk management and moving on. This won’t necessarily be easy but, working together with a clear goal in mind – and a plan to get there – we can develop Shared Lives in a way that keeps survivors of domestic abuse safe and secure, and helps them to rebuild their lives. 

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We need to make people safe, sooner - regardless of who they are or where they live

In this blog Jane Evans, Senior Research Analyst at SafeLives explores the findings from our recent National Briefing on length of abuse and access to services. Jane talks about why it is so important we develop our understanding of the length of time people experience abuse for and the barriers to accessing support. 

The average length of time someone will live with domestic abuse before getting help is three years. This is a statistic I’ve heard countless times since working for SafeLives, but it’s so important that we don’t stop questioning why, or thinking about what it really means.  

Three years is a long time. Just think about the last three years of your life and what has changed for you in that time. Now imagine that throughout those years your life was dominated by a fear of someone close to you, perhaps even a fear that they would kill you.  

That's why SafeLives' research team has been trying to unpick this statistic and understand the barriers to getting support sooner. Sadly, what we found is that three years is just the beginning for many people; who you are, and where you are, has a significant impact on how fast you can expect to get the help you need.  

If you live in Scotland you are likely to experience abuse for a year longer (four years) before accessing support. For those at risk of ‘honour’-based violence (HBV) the average length of abuse is five years. And those aged over 60 will typically experience abuse for a staggering six and a half years before getting help. Our Whole Lives report and our Spotlights on older people and HBV explore some of the barriers for these groups. But for each person there is a unique set of circumstances behind the numbers, and it is the way these circumstances intersect that influences how long it takes to get help. 

For example, one factor might be your living situation. Victims living with the perpetrator will experience abuse for an average of six years. This is not so surprising when we consider that many will see this as a choice between staying with their abuser and putting themselves at risk of homelessness. We know that those who are older or experiencing HBV are more likely to be living with the perpetrator of abuse and may have added barriers to disrupting their home life, such as disabilities or a strong reliance on their local community. It is combinations like this that can leave people 'hidden' from services for so long.  

This research is also a reminder that getting support isn’t as easy as picking up the phone, even if there is someone waiting on the other end of the line. Referring yourself to a domestic abuse service is daunting, especially if your abusive partner or family member has made you feel unworthy, that you won’t be believed, or that the abuse is your own fault. Those who self-referred into services typically experienced abuse for almost five years before doing so. The good news is that professionals can help by spotting the abuse early and making this referral on behalf of the victim. Those referred into services by the police or health had experienced the abuse for less than half that time (2.1 years) when they got help. 

These are just some of the complex and wide ranging factors our analysis has identified. Our briefing paper outlines the full findings, as well as recommendations for change. We will continue to explore all of these circumstances, and how they influence access to services, through our Spotlights series. We will also continue to work with services to collect vital data on these issues through our Insights outcome measurement tool. We hope this research will fuel conversations about how we can make people safer, sooner, regardless of who they are or where they live. 

Read the full briefing paper

Insights 
Insights is our easy to use, flexible outcome measurement tool, enabling you to collect, interpret and use evidence to improve your understanding of how your service is helping victims of domestic abuse. You’ll also benefit by sharing in our learnings as our research team analyse the entire dataset to identify what effective support for victims, survivors and their families looks like across the UK.  

Find out more or contact the team at rea@safelives.org.uk  

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