Practice blog

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.

Tags: 

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

Tags: 

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. 

Tags: 

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  

Tags: 

'Young people deserve a better response' - the importance of age appropriate support for young people experiencing domestic abuse

Lucy McDonald is SafeLives’ Training Development Officer for Scotland. In this blog she talks about the importance of a specialist, age appropriate response for young people experiencing domestic abuse and the benefits of our 'Responding to young people' training. 

In the early 2000s as a keen new graduate, I was working occasional shifts in a hostel for young homeless people. This is where I first encountered domestic abuse, although I didn’t immediately realise it at the time. 

Many of the young residents were in relationships and I recall the ongoing exasperation and disdain from staff about the regular ‘dramas’ around these relationships – the constant ‘on-off’ status and regular ‘arguments’. During one of these so-called arguments I remember one of the young women sustained injuries to her face and head. While the staff  responded with care and empathy around the physical harm,  there was no real understanding of the dynamics of the situation and her vulnerability, never mind the escalating risk that was boiling up under that roof. I don’t recall anyone naming the behaviour of the young man as ‘domestic abuse’, and I very much doubt he was challenged about his role in the relationship, his sense of entitlement or taking responsibility for his actions.  

Pressure was put on the young victim to take control, end the relationship and ‘sort herself out’. There was no risk assessment, no safety plan, no effective support put in place. There was frustration about her lack of engagement with staff. Shortly after the violent incident she disclosed she was pregnant and I remember much speculation in the staff room about whether she was being truthful or not. There was no belief or validation, nor any consideration of what the pregnancy might mean for her

Young people deserve a better response than this. Thankfully there is now much greater awareness about domestic abuse, coercive control and risk. The dialogue is shifting from ‘it’s her own fault’ to ‘he needs to be challenged’. At SafeLives, we cover these topics in detail in our  Responding Safely to Young People Experiencing Domestic Abuse training session. We want to make sure that anyone experiencing domestic abuse gets the right response for them – whoever they are. 

We begin by looking at brain development of adolescents to consider why their risk taking behaviour may differ from that of adults. Then we consider the nuances of how ‘domestic abuse’ and coercive control may develop in relationships between young people, including how, among other things, the language may be quite different. Then we go on to consider safe and effective communication and practical interventions with both the young victim and the person causing harm. We spend time looking at SafeLives’ Young Person’s Dash Risk Checklist and how to involve young people effectively in its application.  Finally we explore support and safety planning, with emphasis on building resilience and support networks for young people.

If you work with young people in any capacity, this practical session will consolidate your understanding of the specific dynamics of domestic abuse for these young people and equip you with practical tools to address the risks and support needs. It will support you to engage effectively and consider how you might create lasting change for that young person. And, as with all our training sessions, you will get a chance to interact and share ideas with a range of practitioners from across Scotland.

We’ve delivered this training in Aberdeen, Shetland and Scottish Borders.  We are now taking the session to Glasgow and Stirling.

Glasgow
Monday 25th June
Apply now

Stirling
Tuesday 4th September
Apply now

Cost: £95 for statutory organisations and £75 for voluntary sector

Find out more