Practice blog

25th October 2018

Young people, domestic abuse and mental health

Susie Hay is the Head of Research, Evaluation and Analysis at SafeLives. She is also a practising child and adolescent psychotherapist.

Where to start when talking about young people, mental health and domestic abuse…

I have been a practising child and adolescent psychotherapist for the past nine years. During this time, I have worked with young people and young adults presenting with a host of different mental health challenges ranging from low mood, depression, anxiety, self-harm (in varying forms), low self-esteem, to suicidal ideation, substance misuse and identity issues – to mention but a few. These conditions also tend to be accompanied by a spectrum of destructive coping strategies.

What became apparent early in my career working within the Youth Counselling Trust was that domestic violence and abuse and the associated trauma had touched the lives of over 80% of my clients in one form or another. However, this was rarely the identified issue, event or reason for being referred into the counselling room. Rather the presenting condition or coping strategy was the catalyst for voluntary (or involuntary) referral into the therapeutic environment.

This is especially shocking when we consider the findings of our Insights briefing on children living with domestic abuse:

“One in five children have been exposed to domestic abuse. SafeLives estimates that around 130,000 children in the UK live in households with high-risk domestic abuse; that is, where there is a significant risk of harm or death. Our latest Children’s Insights dataset has found that at the time they start school, at least one child in every class will have been living with domestic abuse since they were born. For some children, this exposure to abuse does not only start early, but persists into later childhood. Of all the children in our dataset who had been living with abuse for their whole lives, over a third (37%) were more than five years old.

Combined with information on the percentage of all children who have been exposed to domestic abuse in their homes, we estimate that at least one child in every reception school class has been living with abuse for their whole life”.

For the majority, parents, carers or educational staff initiated the referral into the service; young people very rarely referred themselves. I suspect this was due to the stigma associated with ‘mental health’ and a lack of knowledge of the support available.

However, a pattern did emerge. The aim of adults making referrals was primarily about ‘stopping’ certain behaviours, rather than ’understanding’ why the young person might be behaving in that way in the first place.

One issue repeatedly presented by young clients either living in abusive households or in abusive intimate relationships themselves, was a sense of helplessness. Due to their age, limited support provision, and an inability to live independently, young people had limited choices. They felt the only option was to ‘endure’ rather than feeling a sense of control over what they could do to improve their situation and in turn their mental health.

This was true for both young men and young women; however, the coping strategies varied with young men presenting as disruptive and aggressive; and young women presenting as withdrawn and demonstrating higher levels of self-harm.

So, when considering this age group, how can practitioners respond? Counsellors and mental health practitioners need to have good knowledge about domestic violence and abuse, and when making assessments need to ask questions about family dynamics. This needs to be done in a creative, evocating way as some young people will not know that they are living with domestic abuse; this may be all they know and they may not yet recognise it as abusive.

Additionally, therapists need to understand effective risk assessment and how to respond appropriately. Domestic abuse is a safeguarding issue and needs to be addressed as such. This can place a pressure on the therapeutic relationship, but we all have a duty of care to protect children.

The impact domestic abuse has on development and sense of self is huge, and we see this reflected in some of the recent research in Adverse Childhood Experiences (ACEs).

As a child that was exposed to domestic abuse throughout adolescence, I know first-hand that support for young people and their mental health is fundamental. In my case, I developed an eating disorder; accompanied by self-loathing, low mood and social anxiety. During this period, this felt all consuming – and even now in adulthood, it can influence how I feel in social situations and my levels of self-acceptance. Although there was no physical violence, the psychological abuse and coercive controlling behaviour eroded my sense of self and created a general sense of uncertainty and fear whenever I was home.

So what helps? From my experience being open, honest, respectful, non-judgemental and creative are the key components to engaging with young people. Faking it is pointless, young people see straight through it and you lose any credibility that you might have had with them. We need to remember that this might be the first time they are discussing their mental health and/or exposure to domestic abuse and therefore we need to be ourselves if we expect them to be the same! I have found that saying things aloud makes it extremely real for some people and in some cases this in itself can be challenging and traumatic.

Trauma exposure during this pivotal time of neurological and identity development can go on to influence us throughout our life and can shape our coping strategies as adults and parents. Let’s not do young people an injustice by only seeing their symptoms; let’s properly consider what might be going on for them within their homes and relationships and what they need to feel safe and achieve positive mental health. We have a responsibility to encourage young people to talk about their mental health and to celebrate the courage this takes.

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

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By Susie Hay

19th October 2018

Domestic abuse: how can Community Mental Health Nurses respond?

Kathryn Lake is a Mental Health Community Nurse for the Norfolk and Suffolk Foundation Trust. She has previously worked as an advocate for those experiencing domestic abuse and has been involved in public awareness raising campaigns such as “Norfolk Says No”. In this blog, Kathryn offers Community Mental Health Nurses practical guidance on responding appropriately to domestic abuse.

Domestic violence and abuse is becoming a public health emergency which costs lives, and negatively impacts on the long-term health of individuals, families and their communities. Women who have experienced domestic violence and abuse generally have poorer health than other women. Health issues include chronic problems with digestion, kidney and bladder function and headaches, poorer pregnancy outcomes, lower birthweight babies, eating disorders and substance misuse.

Recognition

Recognition by community mental health nurses is vital to be able to address the underlying cause of poor health, promote positive wellbeing and increase social inclusion to aid recovery. From personal experiences and years of research, women who are experiencing domestic abuse are unlikely to ask for help or disclose unless they are directly asked by healthcare professionals.

And as difficult as it is for victims of domestic abuse to talk about, we too as healthcare professionals find it difficult to approach such an emotive subject for many reasons. However, the World Health Organisation highlights the important role that healthcare providers have in recognising and responding safely to domestic abuse.

Assessing

As community mental health nurses we must be vigilant to psychological indicators such as:

Anxiety, panic attacks, stress and/or depression;
PTSD symptoms
Substance misuse;
Sleeping and eating disorders;
Self-harm
Suicide attempts,
Missed appointments/rescheduling appointments

You may also notice other factors that warrant exploring;

That the person seems nervous, ashamed or evasive;
They are uncomfortable or anxious in the presence of their partner;
They are accompanied by their partner, who does most of the talking;
They give an unconvincing explanation of the injuries or their mental wellbeing;
They have recently experienced a relationship breakdown
They are reluctant to follow medical and health promotion advice.

Enquiry

We need to be confident in the enquiry of abuse and be direct with the questions. Yes, this depends on how well you know the person and what indicators you have observed. But either way we should begin with these questions:

'How are things at home?'
'How are you and your partner relating?'
'Is there anything else happening that may be affecting your health?'

Even if we have misread the situation or cues, research has found that this has not damaged the therapeutic relationship but actually demonstrates positive regard for the patient’s wellbeing and situation.

Specific questions linked to our clinical observations that could be asked:

'You seem very anxious and nervous. Is everything all right?'
'When I see injuries like this, I wonder if someone has hurt you?'
‘When I hear you recall your symptoms, I wonder if it’s a response to someone hurting you?’
'Is there anything else that we haven't talked about that might be contributing to you feeling this way?'

Collaboration between Idvas and Community Psychiatric Nurses

Vickie Crompton is the Domestic Abuse and Sexual Violence Partnership Manager for Cambridgeshire and Peterborough and has been responsible for the domestic abuse and sexual violence partnership since 2010. In this role Vickie commissions domestic abuse services, manages the Idva services and chairs the Marac.

Across Cambridgeshire and Peterborough there were around 1,600 cases that came to Marac in 2017/18. 1,600 cases where victims suffered a trauma by someone close to them, in isolation from their community, in their homes and in most if not all cases, the trauma was repeated rather than an isolated incident. All factors which make reaction to trauma especially severe. It has been estimated that 64% of abused women have post-traumatic stress disorder (PTSD), compared to 20% of military personnel who have seen combat. So for Marac cases alone, this would equate to over 1,000 people. Clearly Marac cases are the tip of the iceberg and the actual number is much higher.

In response, all Idvas working in Cambridgeshire and Peterborough receive the three-day Mental Health First Aid course. The course has improved understanding of symptoms of mental ill-health, enabled Idvas to respond effectively and also helped them manage their own mental health and levels of resilience in what is a demanding and stressful occupation.

In 2014, work was carried out across the partnership, and more specifically with the Office of the Police and Crime Commissioner, to fund “Mental Health Pathfinders” – Community Psychiatric Nurses (CPNs) who worked alongside Idvas, refuges and outreach. Their role was two-fold; to support staff to support their clients and to direct intervention where appropriate.

The CPNs were employed by the Mental Health Foundation Trust and were able to access appropriate support where required. When women arrived in the refuge with significant mental health needs, the CPN was able to ensure they had the correct medication and were linked into the local service provision. The CPNs were also able to teach the Idvas techniques which the Idva could then pass on to their clients. For example, a young woman who suffered from panic attacks was unable to contemplate how she would give evidence in court. Her Idva taught her ‘grounding techniques’ and when the time came for the trial she was able to manage her anxiety and give evidence.

The funding and arrangements have altered over time, however we were able to retain the CPN provision until this summer when further funding could not be found (although the search continues!). There are now two CPNs located in the Victim and Witness Hub, funded by the Office of the Police and Crime Commissioner, and professionals are able to seek their advice and support in relation to the victims they are working with.

Across the area we now have a network of around 170 professionals who are not domestic abuse specialists, but are the “DA Champion” for their own organisations. They meet quarterly to receive information, advice and bite sized learning in relation to domestic abuse. The autumn workshops are focussing on domestic abuse and the impact of trauma on mental health. In addition to this, all DA Champions are given a copy of the AVA Complicated Matters Guide, as this clearly sets out issues of both mental health and substance misuse in relation to domestic abuse.

As a partnership we are currently seeking additional funding to support children who have experienced domestic abuse, in particular with their mental health, and being able to process what they have experienced. Embrace – Child Victims of Crime, currently deliver 6-20 sessions of trauma based Cognitive Behavioural Therapy to young people aged 13-19 (up to 24 where there are additional needs). This is delivered by a network of therapists, at a location suitable to the young person, with no waiting list for treatment. As a partnership this is a service we are proud of, as it enables them to cope and recover from the trauma they have experienced.

Given the dynamics of abuse, it should be assumed that any domestic abuse victim and survivor is likely to have some negative impact on their mental health. It is vital that as both specialist providers and as general professionals, this is understood in order that those affected receive the best possible response from all of those working with them.

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

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By Guest blogger

15th October 2018

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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By Guest blogger

10th October 2018

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.

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

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

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By Guest blogger