Policy blog

Mental health support must be part of the response to domestic abuse

Charities, campaigners and a small but growing number of MPs have done a brilliant job over the last fifteen years in raising awareness of mental health: tackling the myths, encouraging people to talk, and reducing the stigma. We know now that anyone can experience mental health problems, or have a friend or family who is struggling. That one in four stat has stuck.

Mental Health Awareness Week is a considerable campaign that illustrates this progress and moves it along further. Just one look at Twitter shows you thousands of people are sharing content, insight and stories. They are talking to one another. All with the hashtag #MHA2016.

We could learn a lot from these campaigns in the domestic abuse sector. How do we reduce stigma and tackle stereotypes? How do we encourage people to be comfortable talking to one another? To know what to do if you're worried about a friend or family member? How do we lift the lid on another painful, difficult and very personal subject?

We could also do a great deal more to highlight the interrelated issues of mental health and domestic abuse. The teams behind Mental Health Awareness Week decided this year to have a particular focus on relationships, something we greatly welcome.

Despite evidence indicating a direct relationship between experiences of domestic abuse and heightened rates of depression, trauma and self-harm, signs of domestic abuse are often missed when providing mental health support. Mirroring this, mental health issues may not be acknowledged and effectively addressed when a person discloses domestic abuse to a service or support worker.

Our data has found that 16% of those living with serious abuse have considered or attempted suicide as a result of abuse. There is an urgent need to acknowledge abuse and mental health as interrelated issues, and enable people to access to support they require. People don't live their lives in siloes, and it's therefore crucial that we break down the silos in our responses to different problems people might face in their lives.

Domestic abuse comprises any incident or pattern of controlling, coercive, threatening or violent behaviour - whether it be physical, psychological, sexual, financial or emotional. This causes significant psychological consequences, including anxiety, depression, suicidal behaviour, low self-esteem, inability to trust others, flashbacks, sleep disturbances and emotional detachment. Abuse within an intimate or familiar relationship also leaves victims particularly susceptible to post traumatic stress disorder (PTSD).

The collective evidence of the impact abuse has on mental health means we now know that as many as 60% of psychiatric in-patients are experiencing (or have experienced) domestic abuse. However, due to real or perceived barriers such time pressure, lack of training and limited resources, professionals and frontline staff are not always able to spot, assess and address abuse. Not only does this inadequately address the needs of patients in a holistic way, but an exclusive focus on a patient's mental health can make the abuser, and their impact, invisible, or even lead to blame for a situation being wrongly assigned to the victim. This hides abuse under multiple layers of misunderstanding or incomplete understanding, and makes patients - people - more vulnerable to domestic abuse.

Training of frontline professionals needs to be high quality and consistent. Yesterday, the Home Secretary addressed over 100,000 police officers about the need for them to keep improving their response to abuse and vulnerability. That must include the ability to recognise mental health issues when attending incidents of abuse, and understanding that when they go to a scene where someone is in a high state of distress, abuse may be a factor. Healthcare professionals must recognise both physical and psychological experiences of control, coercion and abuse when dealing with patients, and links must be forged between health specialists and domestic abuse specialists.

An effective approach to mental health and domestic abuse must address the often complex needs of those suffering abuse. We cannot respond to one issue a person is facing effectively without recognising, acknowledging and dealing with others - if we want to see people well, happy and safe. 

Time and money continue to be tight. However, to provide wraparound support for people that actually responds to the complex nature of people's situations is not only the right response, it is the most rational. The public health sector must be part of the solution to domestic abuse; it cannot be a police or judicial response only. Many people feel more comfortable disclosing in a health setting; later this year, we will be publishing research to show the impact of including health in the response to domestic abuse.

Providing a holistic response, that is as tailored as people are complex, we greatly increase the chances of them becoming safe, and crucially - staying safe.

Follow Diana Barran on Twitter: www.twitter.com/dianabarran

The power of 'humble data'

I was recently interested to read this blog by Joe Ferns. Joe is a Director at the Big Lottery Fund, which supports a number of SafeLives' projects - including our Insights service. He was reflecting on how the organisation evaluates the impact of the grants it gives. A number of the points Joe made really resonated with the experience we have had at SafeLives over the past few years, as we have tried to capture, aggregate, understand and use more data about the work of the many small specialist domestic abuse services around the country through our Insights service.

Joe talks about having sense of purpose, being clear why you are keeping the data.  We were clear that we wanted the voice and experience of the victim to be captured systematically and then analysed and shared with those who needed to hear it, everyone from the frontline practitioner, the manager of the service, commissioners, funders and policy makers. We aim never to ask for a practitioner to record any data that they would not normally keep for the purposes of good case management. Our Insights dataset has information on over 50,000 adult victims, children and young people collected by about 50 different domestic abuse services. 

And it has been the humble data - the data about who accesses services, where they access them, how long they have to wait before getting help and what their needs are - that have proved to be powerful and actionable.

A few examples…

  • Domestic abuse has a terrible impact on the mental health of both the victim and their children.  But our data showed major variations in levels of disclosure of mental health problems – from under 10% to over 60%.  The obvious question is why. What emerged is that the setting of the service and confidence of the practitioner are key to eliciting a disclosure.  Domestic abuse practitioners based in hospitals saw twice the level of disclosure than their colleagues in community settings.  Local services are using this information to negotiate co-location in A&E or with the local mental health team.  The result?  Big increases in disclosures and a better response for victims.
  • We can see the lack of provision for older women, many of whom live with abuse for over 20 years before they get help. This is a simple message for funders to hear and respond to in their grant making. Other messages about inequality of access that have relevance to funders, commissioners and policy makers are crystal clear in relation to barriers for B&ME victims to the criminal justice system, for working women to refuge provision and for LGBT communities. You can read more about these findings in our latest publication, All Welcome.

None of this is to say that outcome data isn’t important. Of course it is. The joy of the humble stuff – especially when it is aggregated - is that the evidence is solid, the messages self-evident and the resulting action benefits those who we are aiming to support in a way that no charity analysing its work on its own could reasonably do. And crucially, it can often be achieved without a big price tag attached.

We'd like to dedicate this blog to the extraordinary work of the services using Insights across the UK. Your rigour and dedication means we can learn more than ever before about the challenges victims face and the difference your interventions make.

This post was first published on 26 April 2016 on the Big Lottery Fund's blog.

The Government’s new Violence Against Women and Girls Strategy is an important moment – abuse isn’t straightforward and women need both early intervention and crisis support to be available

Today is International Women’s Day. It’s also the day the Government publishes its refreshed strategy to tackle violence against women and girls

The stats on violence against women are staggering. Worldwide, almost one third (30%) of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner. Closer to home, two women are murdered every week in the UK, and a further 100,000 are at high-risk of being murdered or seriously harmed by their partner. 

The Government’s new strategy contains three key elements that could make a real difference to the lives of women and girls living with abuse:

  • early intervention

  • local commissioners appointing specialist domestic abuse services in a coherent, effective and sustainable way

  • addressing the behaviour of perpetrators.

It is really encouraging to see the Government recognise the importance of these factors. 

Building important innovation on firm foundations

At SafeLives we believe passionately in innovation. We also believe that innovation should be built on firm foundations. It is vital that this innovative shift complements rather than replaces current provision, especially those supporting victims of high-risk domestic abuse. SafeLives’ research has shown that we have just half the number of Independent Domestic Violence Advisors (Idvas) as are needed to ensure those victims in the greatest danger get effective support. Provision is patchy at best, and the subsequent impact on professionals’ caseloads – and, ultimately, the quality of support offered to victims – is of real concern. 

Everybody’s business – earlier intervention

Domestic abuse is so much more than a criminal justice issue – for instance, we know that victims are 5 times more likely to be in regular contact with health professionals than the police. Our evidence also shows that victims of domestic abuse are frequent users of physical and mental health services, typically accessing them 13 times before receiving support from a domestic abuse service. These two facts alone make increased leadership from the Department of Health vitally important and we call on Ministers there to share their plans to implement the strategy, alongside the Home Secretary and Communities Secretary. 

Domestic abuse victims need a single point of referral for all safeguarding concerns including domestic abuse, substance misuse, mental ill-health and neglect – allowing us to identify vulnerable women and girls as early as possible and recognising that domestic abuse cannot be understood as an isolated problem. It needs to be approached holistically, something that impacts the whole family and a range of vulnerabilities. 

The role of local commissioners

The Government is right to say that local provision for victims of abuse is too fragmented. The importance of good commissioning cannot be overstated. Local authorities, health commissioners and Police and Crime commissioners could do much more with existing funding if they worked together in a more co-ordinated way.  

Asking ‘why doesn’t he stop?’ not ‘why doesn’t she leave?

Last month, we launched Drive. This pilot project is in partnership with Respect and Social Finance, Police and Crime Commissioners in three areas and supported by the Lloyds Bank Foundation for England and Wales. It is an intervention to challenge the most dangerous perpetrators of domestic abuse.

We know from talking to women that they want their partners or ex-partners to receive specialist intervention to stop the abuse. We must respect and respond to this. While refuges around the country are turning victims away due to lack of space, less than 1% of perpetrators get any specialist intervention to address their behaviour. They need to be held accountable and this strategy signals the Government’s intention to improve the situation. 

Abuse is complicated – provide help when women need it

The Government’s new strategy is an important moment, marking their continued commitment to tackling violence against women and girls for the next four years. We hope those responsible for implementing it will keep in mind that abuse is complicated not linear. Innovation is vital, and so are the gains made over the past ten years. If we want to keep more families safe we should push ahead while not forgetting the vital gains which have got us this far. 

Early intervention is key to reducing domestic abuse

This blog is an extract from Diana's article for the Journal of Family Health, Vol 26, No 1.  Click here to read the piece in full.

Setting up a national charity was never part of the plan. I was a hedge fund manager, interested in social issues, with a head for numbers. It seemed like a logical step for me to join the team at New Philanthropy Capital (NPC), a charity that ensures funding and fundraising is as effective as possible in creating long-term social change. I took on a large piece of research at NPC: looking at our national response to domestic abuse. The results were stark - it was a problem that ran through so many other issues such as mental health, substance misuse, child poverty – and abuse at home was often a common factor. And yet it was the hardest issue to raise money for. It was a hidden problem affecting thousands of families, yet its many isolated victims were suffering in silence.

Establishing SafeLives

SafeLives (then known as Caada) was conceived and set up almost 11 years ago, on my kitchen table. I wanted to approach domestic abuse with evidence underpinning the forefront. The funding that was available back then was largely being spent on refuges – a crucial part of the response to domestic abuse – but one that was only helping a small minority of victims. It seemed that we were missing valuable opportunities to intervene earlier and with more effective methods, to get people safe. Surely our starting point should be to try and keep women safe in their own homes?

It was also clear that that the response to domestic abuse was very siloed, with little joint work between the police, children’s services and health practitioners and the specialist charities working supporting women. This limited the impact of their eorts, all too often leaving practitioners feeling defeated and victims in unsafe situations. I asked myself: ‘What would I want for my best friend? How could we increase her choices?’

Responding to risk – the first decade

We began by establishing the following:

Creating the role of an Idva (independent domestic violence advisor).
This single practitioner provides one point of contact for victims to navigate the various services and steps to being free from abuse. We created the first formal qualification to reduce the postcode lottery of services for victims and give practitioners the skills and confidence that they needed.

Getting local services talking to one another and sharing information.
There are many services a victim may come into contact with in their pathway to safety, many within the health sector. To make interventions more effective, professionals need to view the whole picture. In response, we set up Maracs (multi-agency risk assessment conference) for agencies to come together to work through the issues. These include mental health workers, substance misuse workers, social workers, housing offcers, probation staff and many more. There are now 270 Maracs in England and Wales who supported over 80,000 cases last year, involving over 100,000 children.

We established a risk identification tool called Dash.
This helps professionals quickly understand the situation and be more con!dent in their response ensuring that resources followed risk. 

We started collecting national and regional data and evidence to inform policy and practice.
There are so many brilliant charities and services across the UK, working tirelessly to help and their insight wasn’t being utilised. We collect data from these services and feed it into the national narrative.

We also felt that it was important to have a risk-led response, prioritising those 100,000 victims who are suffering serious harm or even murder, and their children. This means every high-risk victim should be assigned a dedicated domestic violence professional (an Idva) supporting them to live in safety. And it means frontline services must work together to protect them and their family.

The future

And now we look forward to the next 10 years. A lot has been achieved, with the invaluable support from numerous local services and agencies. No one organisation can tackle domestic abuse in isolation; partnerships will make a better future possible. Our aim for the next decade is about getting it right first time for every member of the family where there is domestic abuse. Our research shows that victims disclose abuse on average five times before they get an adequate response and on average, live with abuse for almost three years – with many suffering for a far longer time. We want to address the gaps in services for those living with medium-risk abuse, for those who are still in relationships with the perpetrator, for those with complex needs (substance misuse and mental health) and ensuring we have an effective response for children and young people.

We are testing a new initiative to challenge perpetrators to stop their abusive behaviour. Over the past 10 years, we have done a better job of keeping a current partner safe, but little to prevent abusive men from repeating their behaviour with a new partner. If we are ever to reduce the number of victims, we must reduce the number of perpetrators: getting to the root of the problem.

Early intervention hubs

We are also going to pilot some early intervention hubs, which will look at all safeguarding risks across a whole family – breaking down the silos that exist today. We hope that these will give us the opportunity to intervene as early as possible to address not just domestic abuse, but wider safeguarding issues for adults and children. We believe that health professionals have an important role to play in these, both in terms of the links they can make between, for example, mother and child, and also between substance use and mental health problems. This will be crucial in developing better safety plans for vulnerable families.

We all have points of contact with the NHS, whether it be a nurse, a GP, a midwife - the public trusts health care professionals. Victims have poorer health than the average person, be that physical health or mental health
complications. They tell us that they want to disclose, but they don’t know where to turn. We believe there is great opportunity for the health sector to help fill this gap and identify those victims who might not want to contact the police. In recognition of this close relationship between the victim and the health sector, we want all health workers to be trained to spot the signs of abuse. Health care professionals need to make sure they make the link between the risk to the adult and the risk to the child, and that they act upon it. And children need to receive specialist domestic violence support, tailored to their needs and linked to the help their parents are getting.

Early intervention on the frontline

We also want to advocate for Idvas to be placed in all hospitals and maternity units, not just some. We are carrying out a comprehensive study on the impact of hospital-based Idvas and the profile of the victims that
they support. We look forward to this being published and working with policy makers and frontline staff to create a more coherent, joined up response to get victims the help they deserve and need to be safe.

We know resources are stretched, time and money are tight. Early intervention – with victims, children and perpetrators – is key to reducing domestic abuse: from a human perspective and an economic one. This is where our focus lies for the next 10 years – making sure we respond to each member of the family in a coordinated way. Health care professionals and health practitioners working on the frontline will be crucial in making this happen.

Change in legislation recognises control is at the centre of domestic abuse

From 29 December, 'controlling or coercive behaviour in an intimate or family relationship' will become illegal. It does not need to be physically violent; it does not even need to be physically threatening, but it is abuse. From now, you can be tried in a criminal court and face up to five years in prison if found guilty of it.

When I talk to people about this new legislation, I get a mixed reaction. How can we legislate for something that is so 'personal'? How will we manage given that the police and courts are struggling to deal with domestic abuse already? As one person put it - "we still can't deal with black eyes and broken bones properly - what difference will this make"?

I do understand the scepticism. Despite the rise in identified cases reported on by HMIC two weeks ago, domestic abuse continues to be under-reported, poorly understood and hidden. How is more legislation going to change that?

The law is a reflection of a society's morals, our sense of right and wrong; our right to be able to live a life free from fear of another. Make no mistake, being in a controlling and coercive relationship snatches this right away. It is terrifying; its impact on the victim and their children is both profound and long-term.

We work with friends and families of victims who have been murdered. They are not survivors - it is too late for them. Abuse can happen to anyone and these courageous friends and relations are from all walks of their life; each story is unique and heart-breaking. When you talk to them, the common thread is the immense control the perpetrator exerted over the victim. Their stories ended in the most unimaginable horror. These relationships began with the victim becoming isolated, checked up on, chased, manipulated, humiliated, followed, harassed, stalked - controlled and coerced. 

If you have an abusive partner or family member, simply living your life is a problem. Trying to make everyday decisions independently becomes an excuse for further abuse. Perpetrators want control over their victim and when they feel their grip loosen, their behaviour often gets worse. We see time and time again, whether it be financial, emotional, physical or sexual abuse - control is at the centre. That is why we recognise the value of this legislation. It illustrates the serious nature of control and coercion and empowers the police to act on it, early.

So often, victims only get proper help when it's too late. We want them to get support before they have to move home, move town, move their children to a new school, go to hospital; before they are injured, before they are killed.

SafeLives advocates for early intervention. If this legislation helps police officers recognise and take abuse seriously from the outset it will have made a powerful difference. Of course, we must be cautious about the implementation of this new law. We must work hard to train those people charged with identifying coercive control - not just the police but also health professionals, housing officers, teachers, social workers. We must work out how to support frontline professionals to use this legislation to make meaningful improvements to current support and provision.

This new law also speaks to the victims of domestic abuse up and down the country. It sends a message about the experience they're having. And that is why we must do what we can to promote it and raise awareness.

Domestic abuse campaigns and adverts often depict terrible scenes: pictures of women covered in bruises and men with their fists in the air. And this absolutely happens, and is a huge and abhorrent problem; indeed 100,000 people a year live are at risk of being murdered or seriously injured by a partner/ex-partner. However, not every victim of abuse will recognise this scene. We must raise awareness that where there is coercion and control, whether a relationship is violent or not, it is still abuse. For people whose decisions, choices, lives are not wholly theirs anymore - whose relationship has become a source of fear: it has never been acceptable, it has always been dangerous, and now it is illegal.