Keeping control:Exploring mental healthservice user perspectiveson targeted violence andabuse in the context ofadult safeguarding

Middlesex University

RESEARCH FINDINGS

Living in fear of abuse and feelingunsafe in all settings was commonacross the service users interviewed

Neglect by mental health staff canbe experienced as targeted abuse byservices users

Staff reported feelingdisempowered, afraid to takeresponsibility, lacking in confidenceto advocate for individuals or to“speak out” about bad practice insuch a system and in mental healthor social work “blame cultures”

There should be more emphasis onuser-led prevention and protection,with safety planning andsafeguarding outcomes agreed withthe service user when care planning

Service users report they needmental health and adultsafeguarding practitioners, policeand housing officers to listen andbelieve them; be accountable andresponsible; to take ownership ofthe issue; and help them pursuejustice

Many people living with mental health problems areat high risk of targeted violence and abuse. Mostadult safeguarding research in mental health hasfocused on service and practitioner perspectives.

Set in England, this research was a qualitativeexploration of service user experiences andconcepts of targeted violence and abuse (oftentermed ‘hate crime’) on the grounds of mentalhealth status. It also aimed to capture mentalhealth and adult safeguarding practitioners andstakeholder responses to these mental healthservice user experiences and concepts..

The Care Act 2014: Statutory Guidance on MakingSafeguarding Personal reforms aim to make adultsafeguarding person-centred and outcomes-focused. The study sought to inform policyimplementation and practice development from amental health service user perspective.

SERvICE USER INTERvIEWS

The majority of service users interviewed were women, sothese findings relate predominantly to women’s reportedexperiences and concepts.

Understandings and experiences of risk and vulnerabilityLiving in fear of violence and abuse and feeling unsafewere common themes across the interviews. Abusers,including some mental health staff, were thought to targetvictims in situations where individuals are vulnerable.

Risk and vulnerability can be experienced andconceptualised by mental health service users who havebeen victims of targeted violence and abuse in ways thatare different to adult safeguarding practitioners.

Levels of vulnerability, risk from others and feelings ofpowerlessness can be determined by a person’s situation,environment, diagnosis and/or relationships. The broadereffects of austerity may exacerbate this for some.Reductions in support packages, absence of preventativesupport and difficulties with accessing services canincrease the risk of crisis, visibility and exposure totargeted violence and abuse by family, friends orneighbours.

Poor housing or unsafe supported accommodation;deprived neighbourhoods with high crime; poor conditionson psychiatric wards; loss of trust in people and services;bullying and social isolation; and certain stigmatisingdiagnoses can expose people with mental health problemsto the risk of targeted abuse or neglect in community,workplace, family and mental health service settings.

Neglect by mental health services and staff can beexperienced as targeted abuse by services users. This caninclude ward staff who “don’t want to see things and tohelp patients”. They can also be at risk of abuse, assault(including sexual) or theft from staff as well as fellowservice users in closed environments such as wards andsupported housing.

Reporting, self-worth and ‘psychiatric disqualification’ Service users reported that recognition and reporting oftargeted violence and abuse can be compromised by themfeeling it is an inevitable part of their life; not feeling orbeing believed because of their mental health status (the“unreliable witness”); not feeling they are “worth it”; andbelieving services will not respond appropriately or in waysthat are additionally harmful.

Some felt that the “burden of proof” was on them. Manyfelt that they, rather than the perpetrators, werecharacterized as the problem. Several had been forced toleave their homes, or to move house several times as aresult of violence, abuse or victimisation.

MethodsThe study used interconnected work streams withdifferent methods: • a literature scoping review; • user-controlled interviews with self-selecting

mental health service users with experience oftargeted violence and abuse recruited throughuser-led organisations and networks (n=23, 92%women, 2 proxy carer respondents);

• practitioner-led adult safeguarding and mentalhealth practitioner and stakeholder focus groupsdiscussing preliminary service user interviewfindings (n=46);

• practitioner-led discussion of findings via twosessions on Twitter using @MHChat inDecember 2016 (n=585) and June 2017(n=139); and

• a ‘sense making’ stakeholder event (n=42)facilitated discussion of implications of thefindings for adult safeguarding in mental health.

The study was mental health service user led. Overhalf the team identified as service user or survivorresearchers, including the Principal Investigator. Itwas co-produced with two practitioner researchersin a team working to a set of shared principles andmethods derived from survivor and emancipatoryresearch.

i FINDINGSBACKGROUND

Life histories, trauma and abuse Nearly all the participants whorecounted a specific incident of mentalhealth-related targeted violence andabuse (including sexual and gender-based violence against women) had alifetime history of experiencingviolence and abuse. The majorityreported a degree of normalisation ofabuse in their lives and recountedlifetime histories of trauma as part oftheir narrative, with a quartermentioning childhood sexual abuse.

Many reported additional multi-factorial abuse and discriminationimpacting on mental health, such asracism, sexism, homophobia anddiscrimination or abuse based ondisability and gender identity fromneighbours, family, colleagues, mentalhealth practitioners and in society.

Positive survival strategies,resourcefulness and perseveranceAs well as reporting negativeresponses such as isolation,

deterioration in mental health and lossof trust, the majority used positivestrategies to cope and seek help usingcreativity, resourcefulness andperseverance. They often had to findboth positive and negative ways tocope in the absence of adequateresponses from services orsafeguarding.

Many were using, or intended to usetheir experiences to help others or toinform change, with several citing thisas a reason for volunteering to beinterviewed.

Experiences of mental health andadult safeguarding responsesJust under half had direct experienceof adult safeguarding but very few hadfound it satisfactory because alertswere not followed up or practitionerssaid the issue was “not in their remit”.Others had not heard of adultsafeguarding, or thought it did notapply to them, either because of theirperception of abuse or because they

believed safeguarding was for otherservice user groups (e.g. children orpeople with learning disabilities).

Generally, participants were unclearabout the role and remit of adultsafeguarding in mental health, withone reporting “even doctors don’tseem to know about it”.

Those who reported incidents foundservices to be “fragmented” andresponses “haphazard”. They said thathealth and social work professionalssometimes “pass the buck” resulting inlong response delays and lack ofsupport. This could then lead to a lossof trust and faith in services, reducinglikelihood of reporting and helpseeking in the future and increasingthe likelihood of disengaging andrisking exposure to harm.

“We just want someone to acceptresponsibility.”

“There was no one to walk with methrough it all…we need empathyand viewing the person as theperson is first and it should beforemost.”

The police were generally reported asfirst point of access in help seeking,with several participants reportingsatisfaction with police responses asthey felt “taken seriously”, and manyhad immediate responses focusing ontheir safety.

Participants said social workers did nothelp if they were inconsistent orinflexible, focused on eligibility, wereuninformed about adult safeguardingand/or had inappropriate responses torequests for help. However, one saidher social worker was affirming andbelieved her which she found veryhelpful.

GPs, therapists, advocates (includingIndependent Mental HealthAdvocates) in community and inpatientsettings, user-led organisations andindependent support groups weregenerally reported as being helpful,

FINDINGS

Risk and vulnerability factors for targeted violence, abuse and neglectagainst people with mental health problems

mainly because individuals werelistened to and believed, even if thepractitioners or organisations hadlimited power to act within thesafeguarding or criminal justicecontext.

MENTAL HEALTH AND ADULTSAFEGUARDING PRACTITIONERAND STAKEHOLDER FOCUSGROUPS

views on vulnerability and riskConsistent with the literature,practitioners generally perceived riskfrom others as being about coercivecontrol by family or friends, abuse byneighbours and financial exploitation.‘Mate crime’ was seen as difficult toaddress as individuals may rely on thepeople who are exploiting or abusingthem, and therefore reluctant to reportthe abuse or pursue a criminal case.

Adult safeguarding leads and policerespondents said that under-reportingled to a lack of data on victimization ofpeople with mental health problems.

Focus group participant responses toservice user interview findings rangedfrom despairing to desensitized, withsome noting that violence or abuse onwards was often seen as a “hazard”rather than a crime.

Participants agreed that closedenvironments such as wards, poorsupported accommodation or housing,deprived neighbourhoods, socialisolation and disconnectedcommunities were circumstances thatincreased vulnerability to targetedviolence and abuse. Sexual safety forwomen on mixed wards was alsomentioned, along with the risks posedby high staff turnover and the use ofagency staff on wards.

The reduction in or lack of access tomental health care and support wasrecognised as increasing vulnerabilityto targeted violence and abuse fromneighbours and others. The

institutionalisation and desensitizationof mental health ward staff was seenby some as risking the safety ofpatients, with police respondentsciting difficulties in accessing wardsand gathering evidence in response topatient reports of crime.

views on professional roles andresponsibilities Data from focus groups confirmed thereports from service users aboutsystematic “buck passing” betweenprofessionals and agencies, with lackof follow up after incident reporting ora complaint. There was a specificexample of professional boundarysetting by a children and families socialworker, when the parent with mentalhealth problems was being targetedfor abuse by neighbours: “I wasexpected to be master of it all…and Iwas saying to her [the victim], it’s notmy area”.

Practitioners reported difficulties intaking individual responsibility forresponding to reports of targetedviolence and abuse in fragmentedsystems and structures where thereare unclear lines of reporting andmanagement. Several cited “blamecultures” in mental health and socialwork can mean that practitioners areafraid to take responsibility or whistleblow for fear of reprisal. Defensivepractice was also highlighted as adifficulty.

Many respondents reported staffdesensitization to targeted violenceand abuse, particularly towards femaleservice users with a history of trauma,multiple needs and unstable lives,which could result in individualblaming, refusal of services or lack ofreferral adult safeguarding.

Experiences of adult safeguarding andmental healthA number of systemic, structural,resourcing and cultural issues inmental health and adult safeguardingwere identified in the focus groups.

Respondents concurred that austerityand cuts to all services and supportused by people with mental healthproblems was affecting service userand carer safety, including reduction incare packages, high staff turnover,understaffing and increased use of“unqualified and agency staff”.

Several observed that ineffectivemanagement of partnership working inmental health and adult safeguardingcan mean that “nobody takesownership”. Some reported lackingconfidence or a sense ofpowerlessness in using safeguardingmeetings and processes because theyfelt that other agencies would not “dotheir bit” or that safeguarding meetingswere held to make plans that resultedin no action, with a fire servicesrespondent remarking that“safeguarding is not an end process initself.”

Inequalities in adult safeguarding wereidentified, with many saying that it wasbetter for older people, and peoplewith learning disabilities than forpeople with mental health problems.Inequalities were also highlighted withthe way child protection functions.Reasons included greater awareness ofsafeguarding for these groups amongprofessionals, service users and thepublic and perceptions that victimprotection was prioritized in children’ssafeguarding.

Police respondents said that a mentalhealth equivalent of the domesticviolence multi-agency risk assessmentconference (MARAC) is needed, whilea number of social workers reportedthat they have no mental healthrepresentatives on their local multi-agency safeguarding hub (MASH).Several social workers reported theimportance of “safety planning” and“safeguarding outcomes” as part ofcare planning.

FINDINGS

Mental health service users’ experiences and conceptsof risk from others, vulnerability and neglect should becentral to adult safeguarding. Their reportedexperiences of targeted violence and abuse shouldcontribute to defining disability hate crime. Anincreased awareness of what adult safeguarding is inrelation to ‘hate crime’ is required.

Histories of trauma; multi-factorial abuse; living withfear and stigma as well as mental distress; psychiatricdisqualification characterised by “not being believed” or“worth it”; and individual blaming should be addressedin adult safeguarding practice in mental health.

Complex situations in people’s lives do not requirecomplicated or fragmented responses from adultsafeguarding, mental health and other services whichmean the person becomes “lost in the process”, riskingdistress and disengagement, potentially increasing therisk to the victim. Staff said they can feeldisempowered, afraid or lacking in confidence to “speakup” or advocate for individuals in such a system.

Powerful and influential independent advocates/peeradvocates may be an approach for supporting serviceusers who have experienced abuse or neglect,especially in mental health services: “A civil, socialworking advocate of some sort.”

Mental health service users and carers needinformation and awareness about adult safeguardingand raising alerts, rights and protections and hate crimeso they can access support and hold professionals toaccount. There should be more emphasis on user-ledprevention and protection, with “safety planning” and“safeguarding outcomes” agreed with the service userwhen care planning.

Adult safeguarding, particularly police and housingpartners, need to be accessible and respond quickly toservice users reporting incidents of targeted violence orabuse and crime in closed mental health environments,such as wards or supported housing.

Service users (and carers) with experience of targetedviolence and abuse and/or adult safeguarding shouldbe members of local adult safeguarding boards, withequal power and influence.

Establishing collective and individual responsibilitybetween agencies and individual practitioners, sharinginformation, developing a common language and opencultures are needed if adult safeguarding is to beperson-centred, accessible and effective for peoplewith mental health problems who are at risk or victimsof targeted violence and abuse, and staff feel supportedand confident to take responsibility, raise concerns andchallenge bad practice.

CONCLUSIONS & IMPLICATIONS

FACILITATED @MHChatDISCUSSIONSTwo Twitter discussions took place withpractitioners to explore findings.

December 2016: Responses to initial service userinterview findings (n=585)

Largely confirmed themes identified; additional andexpanded points were:

• Service users have to live with and manage fearand stigma, as well as mental distress.

• Isolation, loneliness, homelessness or neglect byfamily and friends are risk factors forvictimisation.

• “Being different” or “not belonging” can lead tothe victimisation of people with mental healthproblems.

• Trauma of previous abuse can be replayed inmental health services and supportedaccommodation.

• Austerity and political victim blaming may becreating a permissive culture for abusing peoplewith mental health problems.

• The invalidating effects of diagnoses such as“personality disorder” and being “written off” byservices posing a risk of exposure to targetedviolence and abuse.

• The importance of a safe home and supportivenetwork for protection and prevention.

June 2017: Responses to initial mental health andadult safeguarding focus group findings (n=139)

Largely confirmed themes identified; additional andexpanded points were:

• The possibility of individuals having histories oftrauma and abuse should be accounted for inadult safeguarding in mental health.

• Individuals and situations not fitting ‘criteria’ forsupport can put them in vulnerable positions.

• Practitioners and services need to respondquickly to reports of targeted violence andabuse, otherwise there is a risk ofdisengagement and further harm.

• Service users, carers and staff can all feel “lost inthe process”, confused and disempowered.

• People who “speak up” can fear reprisal.

RESEARCH TEAM

Dr Sarah CarrPrincipal Investigator, Middlesex University (now based at the University of Birmingham)

Dr Alison FaulknerCo-investigator, Independent service user/survivor researcher

Professor Trish Hafford-LetchfieldCo-investigator, Middlesex University

Claudia MegeleCo-investigator, Middlesex University/Independent social media research specialist

Dorothy Gould, Independent service user/survivor researcher

Christine Khisa, Middlesex University service user associate

Dr Rachel Cohen, Research Assistant, Middlesex Universit

Dr Jessica Holley, Research Assistant, Middlesex Universit

www.mdx.ac.uk/about-us/our-faculties/faculty-of-professional-and-social-sciences/school-of-health-and-education/mental-health-social-work-interprofessional/keeping-control

For more information, please contact Dr Sarah Carr: s.e.Carr@bham.ac.uk

The School for Social Care Research was set up by the National Institute for HealthResearch (NIHR) to develop and improve the evidence base for adult social carepractice in England in 2009. It conducts and commissions high-quality research.

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Tel: 020 7955 6238

Email: sscr@lse.ac.uk

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The study represents independent research funded by the National Institute for Health Research (NIHR)School for Social Care Research (NIHR SSCR). The views expressed are those of the authors and notnecessarily those of the NIHR SSCR, NIHR or Department of Health and Social Care,