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Transcript of Managing the mental health effects of domestic violence Dr. Roxane Agnew-Davies Greater London...
Managing the mental health effects of domestic violence
Dr. Roxane Agnew-DaviesGreater London Domestic Violence Project
London South Bank University
Objectives
• Consider impact of domestic violence
• Review the role of the professional
• Explore issues in working relationships
Domestic violence is physical abuse
• Murder• Suffocation, choking• Throwing objects• Shooting, stabbing• Pushing or shoving• Slapping or punching • Twisting arms• Breaking bones• Bending fingers back
• Stamping on toes• Using an object as a weapon• Banging head, Drowning• Kicking, Biting• Burning, scalding• Punching or kicking tummy• Forcing to take drugs• Cutting or stabbing• Tying up, starving• Pouring over acid or petrol
Domestic violence is sexual abuse
• Rape: vaginal, anal, oral: with penis or objects
• Forced prostitution • Forced sexual acts with
others• Sexual acts with animals• Cutting or disfiguring breasts• Chemicals poured into labia• Refusal to practice safe sex
or allow contraception• Forced into pornography
• Genital mutilation• Sexual abuse of children• Forced sex after childbirth,
operations causing infection, haemmhorage or ruptures
• Religious prohibitions ignored.
• Deliberately infecting• Threats to get compliance• Sexual insults
Women experiencing domestic violence
Primary trauma
impact of abusers
physical, sexual and emotional abuse
Secondary victimisation
- impact of responses of friends and family
- impact of professionals’and society responses
DomesticViolence and Mental Distress
Golding (1999): 41 studies• Magnitude: a large association between variables
• Consistency: replicated over places, persons, times
• Temporality: symptoms occur after onset of D.V.
• Gradient: greater exposure to violence linked to greater risk of symptoms
• Experimental: when violence stops, mental health improves; when violence returns, mental health deteriorates
Golding’s findings
Women experiencing domestic violence are:
• 4 x more likely to suffer PTSD
• 4 x more likely to suffer from depression
• 4 x more likely to feel suicidal
• 6 x more likely to abuse alcohol
• 6 x more likely to abuse drugs
Psychological impacts of domestic violence
• Include: anxiety, depression, drug overdoses, eating problems, post-traumatic stress disorder, sleep disturbances, suicidal ideation, substance abuse (Williamson, 2000; Walby, 2004).
• 31% of British women asked about the worst incident of domestic violence said it caused mental or emotional problems (Walby & Allen, 2004)
• 60% women across England who separated from their abusive partners said they left because of ‘fears for their mental health’ (Humphreys, 2003).
Other findings
• Of 1871 women in Irish GP practices, 2/3rds women with depression experienced domestic violence (Bradley et al, 2002)
• Self-harm has become of concern in the UK particularly in young Asian women, linked to experiences of domestic violence and forced marriage ( Forced Marriage, 2004; NAWP Silent Scream).
Coping strategies
• Legal strategies• Formal help-seeking• Informal help-seeking• Escape strategies• Separation• Hiding• Appeals to abuser
• Compliance• Resistance• Self-defence• Manages children• Personal strategies
– Numbing
– Faith
Hostages at home:Post-Traumatic Stress
A normal reaction to an abnormal event
3 characteristics:
Intrusive Events
Avoidance
Arousal
Memories & Flashbacks
I see his fist…the knife
He pops into my head
I have nightmares
I can’t sleep
Flashbacks
Intrusive memories
triggered by
external or internal events
... still being abused
Feeling numb (Avoidance)
I don’t want to talk about it
I don’t feel nothing
I’ve just gone blank
I just want to put it behind me
Defensive avoidance
Dissociation
Substance use
But springs…and self-protection
Substance use and Violence
• 15 x more likely to misuse alcohol & 9 x more likely to misuse drugs Stark & Flitcraft, 1996
• 40% Asian women in treatment for alcohol misuse are experiencing domestic violence EACH Project, 2000
• Abusers may introduce substances to increase control and dependency
• Abusers can undermine treatment • May excuse violence on grounds of use• Women are likely to be doubly stigmatised &
unable to access any suitable sources of support
More on substance use:
• Stella project:www.gldvp.org.uk
• www.womensaid.org• www.alcoholconcern.org.uk/ser
vlets/doc/961
Stress, eggshells and red alert(Anxiety and arousal)
I’m so scared… of him
…of what he will do next
…I wake up shaking
…why is it taking so long?
Fear when in real danger
Hyper-vigilance in context of threats
Hyper-arousal triggered by intrusive events
Anxieties about future
Factors that increase duration and severity of PTSD
• On-going (not post)• Multiple rather than single event• Trauma caused by human not nature• Abuser known to victim not stranger• Experience personal not collective• Trauma occurs in previously safe place• Rape or sexual abuse• Previous abuse or violation• Secondary victimisation
Complex PTSD I
‘I am all over the place; on a roller-coaster’difficulties regulating affect incl. mood, anger
‘I day-dream all the time; I go blank’altered consciousness (amnesia, dissocn.)
‘I’m so ashamed; no-one understands’altered self-perception (helplessness, guilt, a sense of defilement & difference from others)
Complex PTSD II
‘he said…I am..; he’ll find me…’
altered perception of perpetrator
‘there’s no-one’; you’re an angel’
altered relationships incl. distrust, fail to self-protect, search rescuer
‘what god would allow this?’
altered belief system (faith, despair)
Feeling down (Depression)
I’ve failed (he has made me believe)
I’m so ashamed (about what he made me do)
I can’t stop crying
I can’t be bothered (because he’ll just..)
Negative thoughts
(after emotional abuse)
Disrupted planning
(after physical abuse)
Lack of positive events
(after isolation)
Suicidal ideation
(to escape abuse)
Anger (difficulties with affect)
A volcano ready to explode…
Furious because she…
Snaps at the kids..
So aggressive…
Wish he’d…
Anger management?
Assertion training?
Is anger violence?
….
Or a normal, healthy reaction?
Self-esteem (altered self-perception)
Its my fault; I failedI can’t help it Whatever you wantI’ll never be the same I cant believe I did that
I’m going crazyI should have got over it
Self-acceptance
Self-responsibility
Living purposefully
Self-assertiveness
Personal integrity
Living consciously
Brandon, 1994
Physical self esteem
He said I was a fat cow
I can’t wear skirts
I see the scar
I’m reminded every step
Anorexia?
Bulimia?
Paranoia?
Personality disorder?
Or…
the effects of abuse
Altered relation with perpetrator
The Stockholm Syndrome
‘traumatic bonding’
‘omnipresence’
Not as simple as
‘but she loves him’
‘she always goes back’
Common concerns altering relationship with you
Questions about violence
Anxiety and arousal
Numbing and avoidance
Fear for safety Depression Anger
Intrusive memories
Sleeping difficulties
Difficulties in assertion
Unusual signs Lack of self-esteem
Grief and loss
Parenting issues
Loss physical self-esteem
Making sense of it all
Impact of domestic violence on a woman coming to you
Avoidance -
does not attend
Startled easily -
can’t concentrate
Powerless -
sees you as rescuer
Furious -
‘leaks’ anger
Blamed
- blames herself or you
Traumatic bonding
- eager to please
Mourning
- flat, apathetic
Vulnerable
- acts tough
I want to know if you can sit with pain, mine or your own, without moving to hide, or fade it or fix it…
Challenges for professionals working with domestic violence
Fear of offending clients
Myths hook us too
Feelings of inadequacy and frustration
Feeling dumped upon
Lack of training or time
Coping with the stigma
Inability to ‘cure’ DV
Defending against being overwhelmed
Close identification from own experience abuse
Fear of opening Pandora’s box
Absorbing until collapse
The miracle worker
Offers support examinesattitudes understands DVcollaborates with others
advocates acts as role model can cope with complexity deals with own anger tolerates horror and terror respects believes creates support system
Good practice
• Display information: posters,leaflets
• Ask unaccompanied women
• Document suspicions or disclosures
• Give key messages
• Refer
• National help-line 0808 2000 24 7
As witnesses to domestic violence
We can
Know the trauma will somehow be replayed
Explore the effects on our attitudes/beliefs
Look after ourselves
Secondary effects of domestic violence
Also called ‘vicarious traumatisation’
‘traumatic counter-transference’
Are a normal reaction
to working with domestic violence
And therefore
No-one should work with trauma alone
Connecting our reaction with her difficulties
• Woman is numbing
• Woman is grieving
• Woman is furious
• Woman feels helpless
• Worker feels pressure to invade her space
• Worker allows special demand eg extra time
• Worker feels fear, or defensive - aggressive
• Worker feels helpless
impatient or powerful
How does the work affect the worker?
Physical
- Sleeping problems
- Fear reactions
Emotional– Irritable
– Sad
– Angry
– Overwhelmed
Cognitive beliefs– Trust (all men danger)
– Safety (no safe place)
– Power (have none/all)
Behaviour
- denial of feelings/numb
- self medication
- sickness, absences
How do you take care of you?
• Physically
• Psychologically
• Emotionally
• Spiritually
• Professionally
Eat; Exercise
Focus - achievements
Get angry
Nature; faith; action
Supervision; Pacing
Managing conversations
Don’t take it personally! See the shadows…Ask a woman
Is that what (the abuser) made you feel?Is that what he said to you?What happened that you had to learn to..?
Focus on safetyAsk how to make meetings feel saferModel taking care of your own safety
Respect yourself/the worker
Do you have enough information?
Are you/is she taking blame inappropriately?
What stage is the woman at?
What are you asking of yourself/her?
The woman is in control (and therefore we are not responsible for her choices)
Endorse strengths- hers and yours
Counteract abuse
criticism
blame
Recognise strength
courage
creativity
perseverance
Who was the cause of the problem?
Reattribute causes of
distress or problems to domestic violence
Hold abuser accountable
Set Boundaries
Set
Clear limits
Agreed time
Agreed duration
Contact between meetings
Agreed number/end
Watch and-resist omnipotence-tolerate differences with
respect- be careful with self-
disclosure- monitor temptation to
breach limits or push boundaries
Discuss goals
Goals should be realistic
achievable
chosen by woman
Our role should beexplicit
defined by limits
empowering
to recognise progress
Get the ending right for yourself
An opportunity to learn about completion
You will never end if all problems have to be solved – provide the tools not the answers
You have the right to manage your own ending, whatever the client chooses
Ideal supervision
Safe structureRegular meetingsAcknowledges
feelingsRespects rather
than criticises
Offers open door in response to crises
Promotes staff well-being
Offers support & empowerment
Models the process
Mental health and domestic violence
It is not the woman who is the problem
It is not you who is the problem
It is the domestic violence
that is the problem