Domestic abuse and mental health: a GP’s perspective

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 disorder¹. DVA is associated with an increased risk of suicide². 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 cause³. 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 rates⁴. 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 survivors⁵. 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. 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.