ASKING THE QUESTION ABOUT VIOLENCE AND

ABUSE IN ADULT MENTAL HEALTH

ASSESSMENTS

Third Edition November 2014

INTRODUCTION

Aims

To enable staff to take the first step towards providing better support to service users, through routinely enquiring about experience of abuse and violence in mental health assessments

Course outline

Morning

•Why routinely enquire about violence and abuse?

Afternoon

•How should you ask clients whether they’ve experienced violence or abuse?

•What should happen next?

Learning outcomesParticipants will:• Have greater knowledge and awareness of the

potential consequences of violence and abuse

• Have the confidence to routinely ask about violence and abuse as part of assessments

• Be able to respond appropriately to disclosures

Before we begin…

• Introductions• Practical arrangements• Looking after yourself • Confidentiality

WHY ASK THE QUESTION?

What are we talking about?

Child sexual abuse

Domestic violence

Female Genital Mutilation

Coercive control

Forced marriage

Interpersonal violence

Partner abuse

‘Honour’ killings

Physical abuse & neglect

Sexual assault

Rape

Who are we talking about?

People who have past experiences of violence and abuse – as children or adults, or who are currently involved in violent and abusive relationships, and who are often referred to as victims or survivors

Social inequalities, power and risk:

“Whenever one person or group has

more power than the other(s) in a relationship,

the danger of harm increases” (p. 375) 1

So, can you identify the people who are most ‘at risk’ of violence and abuse?

1 Baker-Miller, J. (2008). "VI. Connections, Disconnections, and Violations." Feminism and Psychology 18: 368-380.

How did violence & abuse get recognised as a mental health issue?

1970’s: Named by feminism

1980’s: Media recognition of abuse and violence

1990’s: User voice; social action

2000’s: Policy response; greater focus on men

Service context

• Increased numbers of adult survivors seeking support

• Services developed in the voluntary sector e.g. Rape Crisis, Survivors UK, Women’s Aid

• But many mental health services still not offering service users opportunities to talk about experiences of abuse and violence

CPA guidance states that:

“Questions should be asked by suitably trained staff at assessment about the experience of physical, sexual or emotional abuse at any time in the service user’s life. The response, with brief details, should be recorded in case records/care plans. If the specific question is not asked, the reason(s) for not doing so should be recorded.”

Refocusing the Care Programme Approach, Policy and Positive Practice Guidance, Section 4, March 2008

Barriers to implementing the guidance in Mental Health Services include:

• Few staff have had relevant training• Many are anxious about saying the

wrong thing• Sexual abuse in particular is seen as an

issue to be dealt with by specialists

How common is violence and abuse in the general population ?• 17.5% of girls and 11.6% of boys have experienced severe

maltreatment by a parent during childhood1

• 7.8% of girls and 5.1% of boys have experienced contact sexual abuse1

• 1 in 25 of the population has experienced extensive physical and sexual violence, with an abuse history extending back to childhood. Over 80% are women 2

1 Radford, L, S. Corral, C. Bradley, H. Fisher, C. Bassett, N. Howat and S. Collishaw (2011). Child abuse and neglect in the UK today. London, NSPCC: 2 Scott, S, Williams, J, Kelly, L, McNaughton Nicholls C, McManus, S (2013) REVA Briefing No 1: Violence, abuse and mental health in England. London, NatCen.

How common is violence and abuse in the general population: ?

•35% of women worldwide have experienced IPV or non-partner sexual violence1

•1in 10 of the population have experienced violence from a partner and 1 in 50 extensive violence and coercive control - Over 80% of these are women 2

•Women who experience abuse from a partner typically experience more severe violence and control, fear and serious psychological consequences3

1 World Health Organization (2013). Global and regional estimates of violence against women: prevalence and health violence (Summary). Geneva, World Health Organization. 2 Scott, S, Williams, J, Kelly, L, McNaughton Nicholls C, McManus, S (2013) REVA Briefing No 1: Violence, abuse and mental health in England. London, NatCen. 3Ansara, D. L. and M. J. Hindin (2011). "Psychosocial Consequences of Intimate Partner Violence for Women and Men in Canada." Journal of Interpersonal Violence 26(8): 1628-1645.

How common is violence and abuse amongst people using mental health services?

Sexual Abuse

Physical Abuse

Women (n=2604)

46% 48%

Men (n=1536)

28% 50%

A review1 of 46 studies of women and 31 studies of men using in-patient and outpatient MH services found:

1 Read, J; van Os, J; Morrison, A et al (2005) Childhood trauma, psychosis and schizophrenia. A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavia, 112, 330-350

How common is violence and abuse amongst people using mental health services?

• Studies of severe domestic violence report lifetime prevalence rates amongst MH service users ranging from 30% to 60%1

• Studies find that over 95% of women with major mental health problems including those using forensic services, have long histories of sexual and physical violence2

• Women using services are at increased risk of violent victimisation and sexual exploitation3

1 Howard LM, et al (2010). "Domestic violence and severe psychiatric disorders: prevalence and interventions." Psychological Medicine. 40(6): 881-893: 2 Goodman, L. A., et al (2001). "Recent victimization in women and men with severe mental illness: Prevalence and correlates." Journal of Traumatic Stress 14(4): 615-632: 3 Trevillion, K. et al (2013). Domestic violence and mental health. In Domestic Violence and Mental Health London, RCP Publications.

Understanding differential impacts of violence and abuse- What happened? +

- Who did it? +

- How many times? +

- How long for? +

- Did they tell? +

- Were they believed? +

- Were they blamed? +

- Were they protected? +

Psychological consequences

When significant others are violent or abusive, or appear to be complicit in, or indifferent to what is happening :

•The victim may feel fearful, silenced, shamed and stigmatized

•Their abuser may foster the belief that they are responsible for the abuse and their isolation

•The victim may cope with the trauma by disconnecting from themselves and others

•Their efforts to survive may subsequently be diagnosed and labelled as pathologies

A strong association with mental health

The impact on mental health is very evident from analysis of the Adult Psychiatric Morbidity Survey1 This general population study showed that:

•Over half the people with extensive abuse histories going back to childhood (1 in 25 of the population) were experiencing common mental health disorders (CMDs)

•37% of the people who had experienced extensive physical violence and coercive control in an adult relationship (1 in 50 of the population) also had a CMD

1 REVA Briefing 1 Violence, Abuse and mental health in England. London: NatCen

Long-term consequences of trauma

• Anxiety / fear• Anger / aggression• Unhappiness / depression• Lack of confidence / self-esteem• Feeling dirty / damaged / guilty• Physical health problems• Sleep disturbance• Intrusive memories• Inability to trust others• Problems with sex and relationships

Leaves = presenting difficulties Branches = emotions and psychological effects

Roots = cause(s) of distress

A Respond Tree

Eating disorder

Compulsive behaviour

shame

low self-esteem

pain

fear

inability to trust

guilt

anger

Violence

Sexual problems

Depression

PTSD

Self-harm

Nightmares Anxiety

Phobias

Physical abuse Emotional abuseSexual abuse

An Example Respond Tree

Ways of trying to cope with the impacts of trauma

• Dissociation• Avoiding relationships• Pursuing intense relationships• Keeping busy / self-distraction• Self-medication e.g drugs / alcohol• Self-harm / self injury• Somatisation• Watchfulness

Common service response: diagnosis• Depression• Obsessive-Compulsive Disorder• Eating Disorder• Bi-polar Disorder• Phobias• Psychosis / Schizophrenia• Borderline Personality Disorder• Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder PTSD symptoms spell TRAUMA• Traumatic event(s) occurred• Re-experience of traumatic events as intrusive

thoughts, nightmares, flashbacks • Avoidance of anything associated with the trauma and

emotional numbing• Unable to function – significant social, occupational,

and interpersonal impairment • One Month or more duration of symptoms• High Arousal: startle reaction, poor concentration,

irritability, insomnia, and hyper-vigilance

Borderline personality disorderFive or more of the following (DSM V, 2013):

•Frantic efforts to avoid real or imagined abandonment

•Unstable and intense interpersonal relationships

•Unstable self-image or sense of self

•Self-damaging impulsive behaviour

•Suicidal and self-mutilating behaviour

•Affective instability

•Chronic feelings of emptiness

•Inappropriate, intense anger or difficulty controlling anger

•Stress related paranoid thoughts or severe dissociative symptoms

When services ignore violence and abuse

Clients:

•Don’t get the help they need

•Can be re-victimised by services

•Can have unnecessarily long contact with services

•Staff don’t get the satisfaction of really helping people and seeing their lives change

Why routine enquiry is important

• Asking is the essential starting point

• It creates the possibility of people getting the help they need

• It gives people permission to speak about their experiences

• It tells people that these types of experiences are relevant to their distress

• It provides services with evidence that can inform their development

Why is it important to ask at assessment?

• Survivors want to be asked

• By asking the question at assessment, you are saying it is OK to talk about violence and abuse

• If the question is not asked at assessment it tends not to be asked later

• It reduces the likelihood that these experiences will be challenged, should a case go to court

What survivors want

• Ask as early as possible

• Ask because you really want to know

• Keep asking the question

• Don’t be selective about who you ask

• Respond helpfully

• Follow up with good services

REVA Briefing 3 (2014) Why asking about abuse matters to service users. London: NatCen

LUNCH

HOW TO ASK THE QUESTION

Preparing the service user:

At the start of an assessment:

• Acknowledge that some questions might be difficult or not relevant to them

• Make the boundaries of confidentiality clear: ‘What we talk about is confidential unless

you tell me about any serious risk of harm to yourself or other people’

Asking the question

“Have you experienced physical, sexual or emotional abuse at any time in your life?”

Yes None stated Not asked

If ‘Yes’, record brief detailsIf question not asked, please state reason

Trial run

Ask the question:

“Have you experienced any kind of physical, sexual or emotional abuse in your life?”

Record Keeping: Evidence• Keep records, even if questions haven’t led to disclosure

they might in the future

• Careful record keeping can enable people get justice, welfare benefits and housing

• Careful record keeping supports the efficient flow of information

• Ensure the record can only be accessed by those directly involved in the person’s care

‘The solicitors said there just wasn’t enough evidence on my health records. Nothing to suggest my ex was to blame for my injuries. I was so let down. I thought my doctor had written down everything I said.’ (p. ADD)

Department of Health (2014). Responding to domestic abuse: a handbook for health professionals. London, Department of Health.

Record Keeping: Service development‘Asking the question’ makes it possible for data to be gathered that can help managers to:

•Estimate the size of the NHS violence and sexual abuse workload

•Evaluate the effectiveness of current responses

•Identify gaps in service delivery

•Suggest ways to improve service commissioning

Why children don’t tell

• Not asked or no-one safe to tell• Do not recognise it as abuse• Attached to the abuser• Threatened by the abuser• Believe they are to blame• Afraid of family break up, being sent away or

put into care• Lack the words to describe what’s happening

Why adults don’t tell

• Same reasons as children• Fear of not being believed or getting negative

responses• Feel they should have told when it was

happening• Have repressed the memories• Fear the offender’s reaction• Worried about the impact of disclosure on their

family / community

Particular reasons why men don’t tell

• Difficulty in talking about emotional matters

• Fear of humiliation in court, and/or newspapers

• Ashamed that they weren’t ‘man enough’ to prevent it

• Believing they are the only one

• Afraid people will think they are gay

• If gay, being accused of "asking for it“

Will I become an abuser?

victims

abusers

Why adults do tell

• They now feel safe to do so e.g. - being in a new relationship - living away from home

• Life events trigger memories• Concerned the abuser poses a risk to others• They are asked the question at assessment

RESPONDING TO A DISCLOSURE

Hearing a disclosure – Part one

• Re-assure the client that it was a good thing to tell• Have they told anyone before? How did that go?• Is it an issue that they need help with?• Is this the right time to deal with it?• Do not try to gather all the details• At the end of the assessment ask them how they

are feeling• Check they can access any immediate support

they need

After disclosure of past abuse

• People need to feel safe and supported

• Not all survivors want or need ongoing

help or therapy

• An empathic response may be enough

Hearing a disclosure – Part two

Don’t presume:• They no longer have a relationship with

their abuser• The abuser was a man• They were abused by just one person• You know what they feel or think about it• Children are being protected

Self-help,friends & family support

Guided self-help, support from non-specialist staff, helplines etc

Survivor support groups, counselling

Longer-term therapy

Providing support to survivors

Providing support

“The GP did not provide my counselling – it is provided by a local charity. They advised me that I need people around me. Where I live I don’t have friends there. It affects you, you have no support. You have no one to talk to you are just all by yourself. That’s why this women’s group at the Refugee Council is so important for me. They keep me sane, knowing I will see other women here when I come. Otherwise I wouldn’t see anyone for weeks.” (p. ADD)

Department of Health (2014). Responding to domestic abuse: a handbook for health professionals. London, Department of Health.

Current risks?

• Any immediate implications for their care

• Are they still at risk / in contact?

• Are there safeguarding implications for children?

Assessing Safety

Useful questions:•Is it safe to go home?•What has s/he threatened to do?•What are you afraid might happen?•Have they hurt the children?•What helps you to keep safe? E.g. people, places

Safety Planning

• Review crisis management tactics:

- how do they know it might happen?

- what do they do to reduce the impact?

- how do they manage afterwards?

• Help plan ahead in small practical and achievable steps

• Help identify what they need to stay safe

• Validate their efforts no matter how small

• Encourage them to be proactive when they can

Form a list of safe contacts

• Who do they feel safe talking to – family, friends, professionals, helplines?

• Make a list of names and phone numbers to use in a crisis including when they are available – keep the list at hand.

• Ask friends about their contact limits – how much support are they able to give, how late at night?

What the trust can offer

What other support is available

• SARCs - Sexual Abuse Referral Centres • Rape Crisis Centres• ISVAs/IDVAs – Independent Sexual/Domestic

Violence Advisors• Refuges – Women’s Aid• Legal Advice – Rights of Women• Services for men• The Survivor’s Trust• Local rape support centres and National Helplines

Local voluntary sector services

Safeguarding Children Requirements

• Record what is disclosed and any subsequent actions

• Note the whereabouts of the abuser and whether they could pose a risk to children

• If there is any possibility of child protection concerns contact the Safeguarding Lead

Support for staff

Staff who are well supported will support their clients well.This includes:

• Team support

• Formal supervision

• Access to specific expertise in abuse

• Continuing professional development

Support for staff

• The prevalence of violence and abuse means that there are NHS staff who have past or current experience of domestic violence and childhood abuse and staff who are abusers

• Staff should feel able to disclose abuse and ask for confidential support

• Health services must demonstrate zero tolerance of perpetrators in the workplace

DH, 2014

What is going to be different after today?

Tell the person next to you:

•One thing you are going to do differently from now on

•One thing you would like to do differently in the future

And finally…

• Thank you

• Any final questions or comments?

• Please take 5 minutes to complete the evaluation form