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Practice blog

Best practice responding to domestic violence and abuse in primary care

Annie Howells is the Programme Director for IRIS. The IRIS model is a domestic abuse and violence training, support and referral programme for GP practices. In this blog Annie reflects on the best practice in responding to domestic abuse in primary care. 

We know that domestic violence and abuse (DVA) is a major public health problem with devastating health consequences for women, men and children. DVA has far-reaching consequences for families and communities and is an enormous cost to the NHS. The NHS is often the first point of contact for people who have experienced violence and the response they receive is critical. In fact, the initial reaction of the person they tell and the follow-up within and beyond the NHS can have a profound effect on their future and can impact on their ability to re-establish their life. It is clearly essential that primary care responds to and helps prevent further DVA. So, what should this response look like? 

To begin with, primary care teams need training, not one-off training but on-going training and support that provides information, resources and practical tools for the whole team. This enables clinicians to recognise the signs of DVA, to start making sense of patients presenting symptoms and begin to understand the potential reasons for repeat visits to the surgery: 

“By becoming more aware of the signs and symptoms that suggest abuse…I became much more aware of patients who were living with abuse and the negative impact that this was having on their health outcomes…the penny drops” - GP on the IRIS programme  

To respond appropriately is having the knowledge of how to ask patients about their experiences of DVA in the first place. Through training and on-going support, clinicians gain essential skills in how to ask direct questions about patients’ experiences of DVA. It also prepares them to be ready to hear the answer and to give supportive key messages to patients when they most need it. We know that clinicians want to support their patients affected and so we need to be providing tools and resources to enable this. 

A best practice response clearly includes offering patients a referral to a specialist, independent, DVA service. The more knowledge the primary care teams have of this service the better. Following simple care pathways, which must account for children and risk, appropriate support can be accessed for survivors and perpetrators. Primary care is a busy place and the simpler the referral process the more accessible it becomes. A referral to a named advocate within a specialist service is better for everyone; the clinician, the advocate and most importantly the patient. The advocate can then walk alongside the patient and provide the specialist support they deserve. 

An embedded relationship between the health sector and specialist DVA sector is essential for primary care to respond appropriately to DVA. Working together enables an on-going conversation, a consistent partnership approach that puts patients at the centre. This is integral to delivering a best practice approach, it allows for experts in the right places making services accessible and making a difference to the lives of people who really need it. 

"I just cried. I was just so relieved that somebody, that somebody just said something. And he (the GP) gave me the box of tissues and I just sat and cried and cried and cried. And he said, 'Tell me when you're ready.' And I poured it all out and that's when he said about the specialist worker. He said, there is somebody out there to help me. I'm not on my own. And if I want help, it's there and not to be ashamed of it. Which I was, really ashamed of it. And he said, 'You're not on your own. We can get you this help.' And he did. He really did."  - Survivor who disclosed to an IRIS trained GP

Back to the GP Pathfinder profile page.

Medical Power and Control Wheel

Mel Goodway, National Implementation Manager for IRIS, explains the Medical Power and Control Wheel, guiding and informing healthcare professionals of the importance of responding appropriately to victims and survivors when disclosing domestic abuse. This is part of the GP Pathfinder profile

See the Medical Power and Control Wheel.

Developed by the Domestic Violence Project in Duluth, Minnesota, the Medical Power and Control Wheel displays some of the ways in which healthcare professionals may unintentionally respond poorly to disclosures of domestic violence and abuse (DVA), collude with perpetrators and therefore increase risk, and impact the safety of the victim.  

The aim and primary use of this wheel is to guide and inform healthcare professionals of the importance of responding appropriately to victims and survivors when disclosing domestic abuse. The wheel provides examples of negative or harmful responses that may be given by healthcare professionals in response to a disclosure. A simple summary would be to say that it gives a ‘what not to do’ guide on how to communicate with a victim following disclosure. 

For example, the wheel looks at the importance of only speaking with a victim or survivor when they are alone and understanding the risk and impact of breaching confidentiality and taking the circumstance out of the patient’s hands. Additionally, it warns against asking if the patient has considered leaving the relationship or advising what they could change about their behaviour to ease the situation.

The Medical Power and Control Wheel gives these as examples of harmful responses to help healthcare professionals understand the impact this can cause a victim. We know victims and survivors trust healthcare professionals to respond to their disclosure appropriately and know how to support them following this. The above responses convey to a victim a lack of understanding about their circumstances and places blame on them for not having done something about it.  

The wheel itself is an adapted version of the Power and Control Wheel, created by the same organisation. Produced and distributed by National Centre for Domestic and Sexual Violence, the Medical Power and Control Wheel is widely recognised and used frequently within DVA training for healthcare professionals. The wheel, used in conjunction with other materials, is part of the training provided by the IRIS programme to General Practitioners across the country.  

A review of the common trends found amongst DHR’s (Domestic Homicide Reviews) completed by the Home Office stated the following in relation to healthcare professionals:  

“There have been cases where victims had made disclosures, but they had not been followed up or referred on to the appropriate agencies. In some cases, the review has stated that the healthcare professional had not known what to do when a patient disclosed domestic violence.” (Domestic Homicide Reviews Common Themes Identified as Lessons to be Learned, Home Office 2013.) 

Additionally, the research found that the crucial dynamics of power and control central to domestic abuse were not being recognised. In turn this led to a lack of  understanding about coercive control, something considered as a key risk indictor within DHR’s. As such, the use of this wheel within training is best done when in combination with the power and control wheel, along with a clear explanation as to why these responses are dangerous and damaging to victims.  

We know that healthcare settings are frequently attended and used by women experiencing domestic abuse. Additionally, for many women this is the only safe place to disclose, or the first professional to see them following an abusive incident. As such, it is integral that healthcare professionals know how to appropriately and safely respond to disclosures of DVA. Failure to do this can leave the victim feeling to blame for the abuse, unlikely to disclose again and potentially at greater risk of harm. The Medical Power and Control Wheel helps address this and ensure safety, validation and support for the patient are provided.  

“A life barely half lived”: Domestic abuse practitioners’ experiences of supporting survivors of psychological abuse

Gemma Halliwell is a Research Fellow at the University of Bristol within the Domestic Violence and Abuse Research Group (DVAHG). She is a SafeLives Research Associate and Pioneer.

Domestic abuse is experienced by 1 in 3 women and 1 in 6 men in their lifetime. Yet, these figures are based on reports of physical or sexual violence and there are no consistent estimates about the number of people who have experienced non-physical forms of abuse.

Psychological abuse[1] is hard to define, it overlaps with many other forms of abuse and is inconsistently measured – this means that we are nowhere close to uncovering its true prevalence or impact. Addressing the lack of research in this area, we asked practitioners working in domestic abuse services to share with us their experience of supporting survivors as part of our wider study about ‘Psychological Violence’, commissioned by the Oak Foundation. They told us that psychological abuse is common, often exists in the absence of physical violence but can be misidentified or overlooked. Many felt that psychological abuse is as harmful, if not more harmful than physical violence. Often practitioners quoted survivors saying that they would rather “get a smack in the mouth” than suffer psychological abuse as it is the “worst kind” of abuse. This reflects wider research which has shown an association between psychological abuse and lifelong health issues, particularly mental health concerns like PTSD, depression, anxiety and suicidal thoughts or behaviours. For practitioners, these impacts were often connected to the most common consequence of psychological abuse, significant damage to survivor’s confidence, self-esteem and identity. This had a radiating impact on every aspect of survivor’s lives, often preventing them from feeling like they could manage everyday activities like going to work, making decisions, building relationships with family and presented challenges with parenting. 

“In simple terms, an inability to function without guidance or instruction of another person. Defer decision making to others, including children. No pleasure in anything. No autonomy. A life barely half lived.” DVA Practitioner

Our research found that the biggest challenge to tackling psychological abuse is identifying it in the first place. Practitioners talked about how survivors often struggled to recognise psychological abuse as ‘domestic abuse’ because of the tactic’s perpetrators use to establish and maintain control. Designed to cause confusion, subtle slow and insidious acts of psychological abuse used by perpetrators were often interspersed with warmth and kindness. This caused survivors to doubt their own experiences, thinking they were “going mad” or to minimise the abuse – believing it was not severe enough to warrant help because they hadn’t been hit.

“The fact is victims of psychological violence often don't recognise that they are victims of abuse and therefore the barrier is them knowing they need to access support in the first place.” DVA Practitioner

This, in turn, played into wider social messages that practitioners felt normalised certain aspects of psychological abuse in the media as “romantic” and emphasised that domestic abuse is only synonymous with cuts and bruises. When we asked practitioners where the gaps are in providing support to survivors, they told us that above all we need to increase awareness of non-physical forms of abuse within society and across professional agencies. Lack of understanding about the patterns underpinning psychological abuse and the tactics used by perpetrators - particularly within the police, the courts and child protection services - had significant consequences for survivors. They highlighted how even with new legislation in the UK about coercive control, evidencing psychological abuse is problematic and places significant burden on survivors to prove what had happened. This often resulted in cases being withdrawn from court or civil orders not being granted.

 “Very poor court outcomes. A non-molestation order will only be granted when there is an act of violence or a threat of it, meaning there are no protective measures.” DA Practitioner

Within children’s services and child courts, they talked about how perpetrators could ‘charm’ professionals into being granted access to children which enabled the abuse to continue. Perpetrators of psychological abuse were rarely held accountable for their actions and could often fly below the radar of services.

“So many of the people I work with have to go through the ordeal of family court and hand over their children to an abuser, because a Judge has ruled that without a criminal conviction the perpetrator doesn’t pose a risk - demonstrating a clear lack of education around what [psychological] abuse actually is.” DVA Practitioner

Lack of training, a universal definition and standardised assessment tools meant that psychological abuse is rarely identified by wider agencies. Access to support for psychological abuse is also in short supply according to practitioners, particularly mental health and long-term care services. Practitioners told us that the shortage of resources across agencies had led to rising ‘risk-thresholds’ and prioritisation of physical forms of abuse, which often resulted in survivors not being able to access the support they needed.

As a society and in the delivery of frontline services, we have a responsibility to identify and respond to domestic abuse - whatever form it takes. For as long as the image of domestic abuse is synonymous with “a smack in the mouth”, we create barriers which inhibit the visibility of psychological abuse to both survivors and professionals. The outcome of this is that perpetrators of psychological abuse are often able to escape accountability and are not challenged to stop. There will always be a need for crisis care and interventions that address severe forms of physical abuse. But as research shows, underpinning almost every domestic homicide review is a continued and sustained pattern of psychological abuse – which has often been misidentified as ‘medium risk’, falling below the threshold for intervention. Our findings highlight the urgent need to increase both public and professional awareness of psychological abuse, for training of wider agencies, and for sustainable funding that increases long-term support options for survivors and their children.

[1] The wider research project focussed on Europe where the term Psychological Violence is commonplace. Findings showed that UK practitioners identified most strongly with the term psychological abuse.

SafeLives' research into psychological abuse

Jen Daw, Research Analyst at SafeLives, explains the key findings and process behind the 'Psychological Violence' report, just launched.

In 2018, the Oak Foundation funded SafeLives to conduct research around ‘Psychological Violence’.  This European wide research aimed to establish a clear and consistent definition of ‘Psychological Violence’ and amplify the voices of survivors. We also reviewed the legislative frameworks in place across Europe, assessing their ability to protect survivors and their children.  

The research took an ‘empowerment and participatory approach’ grounded in the lived experiences of survivors.  The mixed-methods project was co-produced by survivors and practitioners. Survivors led research design, assisted in development of data collection tools and conducted interviews and focus groups.  An independent expert panel fed into every stage of the process, ensuring that the research truly reflected and gave voice to the survivors.  We had an amazing response from survivors and practitioners to our surveys with 600+ survey responses from practitioners and over 400 from survivors.  Survivors gave their time to take part in interviews and focus groups and spoke freely and in depth about their experiences.  Many thanked us for an opportunity to contribute to this topic.  From this engagement, it became clear this was a topic survivors and practitioners wanted to talk about and get acknowledged.  When we analysed the data – it confirmed why. 

Survivors told us ‘psychological violence’ is extremely hard to recognise as abusive.  They described its creeping nature often using the ‘frog in water’ analogy.  At the beginning of the relationship survivors described their partners as ‘the ideal companion’.  Some talked of being ‘love-bombed’ and completely charmed with compliments and constant communication.   

Survivors discussed numerous acts of covert abuse.1 They described experiencing gendered criticisms, put-downs, insults about their appearance, parenting or cooking/housekeeping.  They also talked about the abuse being masked in normalised ideas of love and romance.  These hidden abuses also included psychological manipulation such as projecting blame, refusing to take accountability, ‘stonewalling’2, the ‘silent treatment’ and ‘gaslighting’3.    

“He made me feel like I was crazy. I apologised for things I hadn't even done just to try and keep the peace. I always felt guilty for everything and nothing at the same time. I was emotionally exhausted; I would cry all the time” (Survivor) 

Survivors described further tactics such as insults presented as a joke, presenting differently in public to private, using their social status to gain the upper hand or present the victim as unstable, and using a victim’s vulnerabilities such as mental health difficulties or immigration status. 

“I am a strong woman…I always thought I would leave a man who treated me badly. But it creeps up on you. They are very clever and manipulative” (Survivor) 

Many survivors described ‘walking on eggshells’ throughout the relationship to try and keep the peace. They also explained why they remained in the relationship after abusive incidents.  They communicated how partners used ‘dosing’.4  Over three-quarters (80%) of survivors said their partner promised to change saying they recognised their issues after an abusive incident or if they tried to end the relationship.  Some survivors said they saw this as a ‘return to hope’ that the person they knew at the beginning would return.  This could escalate to more intense psychological manipulation with 5 in 10 (49%) survivors saying their partner suggested they would take their own life if the relationship ended. 

He would threaten to harm himself or kill himself if I tried to end the relationship…he would call me "his angel" and tell me that he couldn't live without me or cope…so I felt that I couldn't leave him” (Survivor) 

Many survivors portrayed the difficulty of explaining what was happening to them with many noting they didn’t access support as “who would believe me” without any proof of physical harm.  A few noted how they ‘wish they’d been hit’ to have something tangible as evidence.   

“Many, many times I wished he would hit me, so that I could know for sure it really was abuse, so there would be proof, so that I had a clear reason to leave the marriage, and a clear reason to justify and explain it to others. He was so charming; no-one would ever believe me otherwise” (Survivor) 

Our findings highlight the urgent need to increase both public and professional awareness of psychological violence, for earlier identification, and to give any victim or survivor a supportive, understanding and appropriate response to this insidious and extremely harmful form of domestic violence and abuse.   

Read more about psychological abuse

Read the full report

 

The unintended consequences of the NHS’s Partnership with Amazon’s Alexa service

Aliya Bakheit is the Digital Strategy Analayst at SafeLives. In this blog she discusses why the new partnership with Amazon Alexa and the NHS may be detrimental for those living with domestic abuse.

Last week, we learnt that the UK government has announced a new partnership with Amazon Alexa and the NHS. The output of which will allow people who have access to Amazon’s voice-assisted technology to get expert health advice via the device. The technology will automatically search the official NHS website when UK users ask for health-related advice.

The idea is to support patients, especially the elderly, blind and those with accessibility issues to take more control over their healthcare and to ultimately reduce demand on our already overwhelmed NHS. Security experts have already warned about the lack of privacy surrounding the partnership, but Amazon is making it clear that it doesn't share information with third parties or build profiles on its customers. In a statement to the Times, the firm has said: "All data was encrypted and kept confidential. "Customers are in control of their voice history and can review or delete recordings."

While this initiative is certainly an innovative development in utilizing digital tools to address healthcare needs, here at SafeLives, we believe that further research is required to fully investigate the safety implications for people living with domestic violence in coercive and controlling relationships. And considering that one in five people will experience domestic violence in their lifetime, this is not an insignificant concern. This technology often has default settings that exposes the user’s search history, and this information could potentially be weaponised should a perpetrator obtain these transcripts - which are easily downloadable - putting the survivor at significant and increased risk as well as blocking potential routes for seeking support.

In this specific context also, this initiative could lead to more health-related questions being asked of Alexa (perhaps around pregnancy or birth control) which could be discovered by perpetrators. We know that a third of all domestic abuse begins in pregnancy, so this is a particularly risky time for survivors, and makes them ever more vulnerable to the abuse escalating should the perpetrator uncover the Alexa transcripts.

In order to understand these potential risks, gaps and opportunities presented by technology in the context of domestic violence and abuse, SafeLives, Snook and Chayn undertook a collaborative research project, 'Tech vs Abuse’, commissioned by Comic Relief in January 2017. This research was carried out over six months and gathered insights from over 200 survivors of domestic abuse (over 18 years old) and 350 practitioners who support them. There were concerns about the potential for further coercive control made possible by the ‘internet of things’ within people’s homes, such as the Amazon Alexa device. Overall, there was a sense that the perpetrator was always one step ahead. This resulted in a lasting fear of using technology, both by survivors and practitioners. They viewed technology as potentially dangerous, both during abusive relationships and recovery. Women chose, or were often advised, to remove all technology from their lives. This left them further socially isolated and with less control.

Making health information more accessible by all is generally to be welcomed, we know that GPs, nurses and other health professionals are really well placed to identify and respond to domestic abuse – there is no substitute for a trained, empathetic person who can ask the right questions at the right time. The research highlighted in our Cry for Health report, shows that nearly nine out of ten (86%) referrals to hospital Idvas came from hospital departments and we know that a high percentage of domestic abuse cases are first uncovered during a visit with a health care practitioner, midwife or community nurse practitioner in particular. There are obvious risks associated with obtaining your health advice online; however not being physically seen by someone who is trained to spot for signs of distress and abuse is a considerable one.

As part of the Government’s new Domestic Abuse Bill launched on Tuesday, it has been outlined that ‘from April 2020, NHS England are planning for Independent Domestic Violence Advisors (IDVAs) to be integral to every NHS Trust Domestic Violence and Abuse Action Plan, as part of the NHS Standard Contract.’ This is of course a great step in the right direction, however we believe that anything that prevents potential victims from being seen in person, such as this new partnership with Alexa, could be detrimental to them accessing services and support, ultimately delaying or even obstructing any support that could be provided with potentially unthinkable consequences for the victim and the wider family.

We believe that tech giants have a responsibility and duty to respond to the ever growing need to ensure that the internet is a safe place for all, but particularly for the women and girls who are most likely to be targeted in acts of digital violence that reflect the pattern of abuse experienced offline. The tech industry and the health sector must do more to understand how inextricably linked domestic abuse is with them – and technologies must not be developed without thinking through the unintended implications for those living with abuse, sadly far more than we ever realise.

For more information read the Tech vs Abuse report