Practice blog

Louisa Steele has worked across women’s specialist services and the homelessness sector for the past ten years, in both frontline and strategic roles. Louisa is currently the Housing First and Homelessness coordinator at Standing Together Against Domestic Violence and is working on developing the Housing First model for women experiencing multiple disadvantage and domestic abuse.

Research has shown that domestic abuse is the most common cause of depression and other mental health difficulties in women. Alongside this, we also know that gender-based violence and abuse is a key cause of homelessness for women. The links then between experiences of abuse, complex trauma and homelessness are clear, but survivors still struggle to access affordable, stable housing that is so crucial to their recovery. It is time then, to shine a light on the fact that mental health issues, whether diagnosed or undiagnosed, act as a major barrier to accessing housing for survivors of abuse. We also need to start thinking about what it will take to begin untangling this major system blockage and look to new approaches to advocacy and support that could make all the difference.

Several studies have shown how survivors experiencing multiple disadvantage, defined as the concurrence of poor mental health, substance use, homelessness and gendered violence, struggle to access space in women’s refuges, as most are not resourced to address the complexity of these issues. Conversely, homelessness pathways and services i.e. supported accommodation, may have good links with mental health services and be better resourced to deal with issues around mental health, but be less equipped to provide support around domestic abuse, or women-only options.  A survivor’s mental health diagnoses, combined with their experiences of abuse, become a considerable barrier in both cases, leaving survivors with mental health issues with few options. 

Many women present to local authority housing teams with a combination of vulnerabilities around mental health, domestic abuse, substance use or physical health and are routinely turned away, without even the opportunity to make a homelessness application, let alone be considered for statutory duty. For survivors who have experienced abuse and trauma through engagement with services in the past, and therefore already have little reason to trust services, this can be catastrophic, pushing them back into the hands of the perpetrator and with little choice but to resort to risky survival strategies to keep a roof over their head.

What is more, mental health services are all too often the ‘empty seat’ at multi-agency conferences that I have attended for survivors with mental health issues and additional, multiple needs. It is a well-known fact that many trusts knock back referrals for survivors with ‘dual diagnosis’, those with mental health and substance use issues, leaving vulnerable survivors largely unsupported. Without appropriate support from mental health services to help survivors address and manage their trauma or their diagnosis, survivors are more likely to self-medicate, be unable to work or manage their benefits. This will in turn increase their risk of eviction and eventually make it hard for them to manage a tenancy without considerable support. The fact that mental health services are so difficult to access continues to be a major issue; even if a survivor does obtain housing, they are likely to need specialist support and advocacy to help them access mental health services and get the support that they need.

All survivors – but especially those with mental health issues – need more than just a ‘roof over their heads’. A home, with the safety and security that comes with this, takes a good deal of time and support to build. A survivor of domestic abuse with mental health issues, struggling though trauma, stigma and fear might need someone to help them open their post if they are too scared to, to chase their care co-ordinator, to manage their housing benefit claim, and to be that positive relationship and source of emotional support that can make all the difference.

The Housing First model originated in New York, as a solution for people with entrenched mental health issues who were long term or recurrently homeless. It has since spread across the US and Europe, and the evidence clearly shows that providing housing and teaming it with flexible, wrap around, unconditional support works. Housing First means that a survivor of domestic abuse isn’t judged on the basis of their mental health diagnoses, and housing isn’t conditional on whether that survivor is ready for treatment. The Housing First philosophy understands the links between violence and abuse, trauma and homelessness, and is therefore an effective – although woefully underfunded – option for survivors with mental health needs.

The links between domestic abuse, trauma, poor mental health and homelessness are clear, and the women’s sector has engaged in some amazing work to highlight this point and keep it on the government’s agenda. It is time that housing providers, CCGs (Clinical Commissioning Groups) and mental health practitioners recognise their key role in preventing homelessness and promoting recovery for survivors of domestic abuse.

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

Dr Katherine Pitt is a GP Registrar with a special interest in women’s health. Katherine is also a researcher in domestic violence and abuse at University of Bristol (Academic Clinical Fellow).  She writes here about her professional experiences of how domestic abuse impacts upon mental health.

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 disorder.¹ DVA is associated with an increased risk of suicide.² 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 cause.³ 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 rates.⁴ 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 survivors.⁵ 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.⁶ 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.

Go to our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more.

Go to our Pathfinder mental health profile for blogs and guidance on the mental health sector response to domestic abuse.