DR. Ruth Jones OBE

1. domestic abuse & people with care & support needs (physical & learning disabilities & mental health) DR. Ruth Jones OBE

2. Domestic abuse • Domestic Abuse is recognised at a local, national and international level, as a serious human rights and public health issue, that has a significant cost the health and wellbeing of those who experience it, their families, and society. BUT…. • We know relatively little about the experiences of people with physical and learning disabilities, and mental health issues, in relation to domestic violence in comparison to the general population of known ‘victims / survivors’ in the UK • We know that domestic abuse can lead to disability and poor mental health in those that experience it AND • We do know however, that those with disabilities, and mental health issues are more vulnerable to being ‘victims’ of domestic abuse

3. Domestic abuse can LEAD TO PHYSICAL DISABILITY • Research consistently shows that domestic Abuse can result in physical injury (including physical disabilities) and mental health issues (low self-esteem, depression, anxiety, suicidal ideation etc.) (Campbell, 2002; McGarry & Simpson 2011, NICE 2014; SafeLives 2019) Quotes from McGarry and Simpson research (2011) He was extremely abusive and he put me into the hospital quite few times. The consequences on my health now [. . .] I have had a major bone problems, and I had to have an operation on my spine, and I am questioning whether that was to do with the beatings. I’ve got arthritis and I had a lots of broken bones when he was doing this, so whether that impacted [. . .] I’m sure that this possibly did impact up on me now [. . .] Like now I can hardly walk, and I have to go in a wheel chair to go about (Participant 1: 63 years). I’ m waiting for a hearing aid and now [. . .] I got severely bashed on my ear, and I’m told that I can’t hear at all in this ear, and I’ve been told that it is perforated eardrum (Participant 8: 76 years).

4. People with disability experience domestic abuse • Women with a long-term illness or disability (self-declared) are more likely to be victims of domestic abuse compared with those without a long-term illness or disability according to the Crime Survey England and Wales (ONS, 2018). This is supported by academic evidence (Rich, 2014; Thiara 2016) • More than 50% of disabled women in the UK may have experienced domestic abuse (Magowan, 2004) • More disabled men experience domestic abuse than non-disabled men, with the risk to a disabled man being similar to that to women in general (PHE, 2015) (male and female perpetrators)

5. Disabled people are twice as likely to experience domestic abuse than non-disabled people. (Magowan, 2003; Women’s Aid, 2007; Human Rights Watch, 2012; Thiara 2016)

6. Two small scale studies of women with learning disabilities and domestic abuse found that the levels of physical violence they had experienced were particularly high and of high risk (e.g. use of weapons, threats to kill) • Disabled people who are experiencing domestic abuse are twice as likely to have planned or attempted suicide (22% vs 11%) (Safe Lives, 2017) – showing an overlap between disability and MH

7. MENTAL HEALTH People who experience poor mental health are more likely to have experienced domestic abuse (Trevillion et al. 2012) • 40% of high-risk DA victims report having mental health issues (SafeLives 2015) • 16% of victims report that they have considered or attempted suicide as a result of the abuse, and 13% report self-harming (SafeLives 2015) • Domestic abuse has significant psychological consequences for victims, including anxiety, depression, suicidal behaviour, low self-esteem, inability to trust others, flashbacks, sleep disturbances and emotional detachment (CTC 2014) • Between 30 and 60% of psychiatric in-patients had experienced severe domestic abuse (2010) • Exposure to domestic abuse increases the onset, duration and reoccurrence of mental health issues AND • Men and women with mental health problems are at an increased risk of experiencing domestic abuse

8. Intersectionality • Intersectionality is the interconnected / overlapping nature of social categories such as race, sexual orientation, religious affiliation, disability and gender etc. (culture) as they apply to a given individual • Intersectionality creates layers of vulnerabilities • Intersectionality can make a person more vulnerable to domestic abuse & less likely to have access to services and protection • Example – Learning disability & Forced marriage (Forced Marriage Unit 2019) • •In 2018 75% of forced marriage cases were women -17% men (8% unknown) • 93 cases (5.3%) involved victims where there was a learning disability • •A disproportionate number of cases with a learning disability were male (58% female 37.6% male)

9. perpetrators Research indicates that the majority of abusive partners of people with physical, learning and MH conditions, generally do not have physical or learning disabilities themselves. Research suggests though, that they tend to: • Have mental health issues and/ or drug and alcohol dependency • make threats of self-harm / suicide / threats to murder • a history of abusing previous partners / children • Are known to be cruel to animals • Are controlling It should be noted however that research is limited.

10. Coercive control “Abusive intimate partners exploit the challenges presented by the disability, knowing that this will seriously limit a their ability to take action” (Ballin and Freyer 2012:1085) domestic violence and disability

11. It is difficult to seek help if you can’t walk, talk, hear, understand etc. but also.. • Abuser may threaten that leaving the relationship will result in institutionalisation - An effective way of preventing them from seeking help? • Who has the power and control? • Dr Michelle McCarthy (2015) highlighted how victims with all kinds of disabilities and needs, are subjected to the same forms of domestic abuse as non-disabled victims, but with an intensification of coercive control, which plays on the victims’ impairments • It is vital then for professionals to understand coercive control, look for it and evidence it

12. Professional responses • Domestic Abuse services that cater for those with needs related to disability are few and far between - resource issues (Thiara, 2011) • Disabled victims typically experience abuse for a longer period of time before accessing support (3.3 years' average length of abuse vs 2.3 years) (Safe Lives, 2017) We do not know very much at all about the attitudes and practices of those whose role it is to support those with care and support needs who experience Domestic Abuse, but research suggests: • There is a lack of training & information about Domestic Abuse in relation to those with care and support needs, amongst professionals is common. (Thiara, 2011) • Of an estimated 16,000 disabled people experiencing high risk domestic abuse, an estimated 13,600 either are not supported by a MARAC, or their disability is not identified by the MARAC process (Safe Lives, 2017) (18% of MARACs do not record disability). • In 2015-2016 - None of the 925 referrals of disabled victims to domestic abuse services were from adult safeguarding (Safe Lives, 2017) • Only 9% of known disabled victims were engaging or accessing adult safeguarding services in 2015-16 (Safe Lives, 2017).

13. Safeguarding adults Statutory guidance in relation to the offence of controlling or coercive behaviour states that it should be dealt with as part of adult and/or child safeguarding and public protection procedures. Both the March 2016 statutory guidance in relation to sections 42-46 of the Care Act 2014 (DH, 2016) and the April 2016 guidance in relation to section 7 of the Social Services and Well-being Act Wales 2014 (Welsh Government, 2016) include coercive control. This means that a local authority’s duty to make (or ask others to make) safeguarding enquiries and determine what action is needed to protect ‘an adult at risk’ are triggered by ‘reasonable cause to suspect’ that an adult with health and social care needs is experiencing coercive control (where their needs prevent them from protecting themselves).

14. What you can do • Understand and be aware of signs of coercive controlling behaviour (wheel) • Follow safeguarding policy / protocols • Safe Enquiry – In a way that ensures the potential perpetrator will not easily become aware of the enquiry – never discuss concerns in front of potential perpetrator • Don’t be afraid to ask direct questions & listen to what is being said – and what is not said • Use advocates as necessary (IDVA, ISVA, IMCA) • Risk assessment and safety planning (DASH and refer to MARAC if appropriate), • Keep ‘victim / survivor’ wishes central to the safeguarding if possible (make safeguarding personal) • Record information accurately and SHARE INFORMATION • Support ‘victim / survivor’ including supporting engagement with the criminal justice process (if wanted)

15. Making an unpopular / risky decision i.e. staying in an abusive relationship does not mean a lack of mental capacity but…. • In particularly complex in situations a person may have impaired capacity to make a decision due to the impact of the abuse they are experiencing. Abuse may affect their ability to weigh up the risks and benefits of that decision. This situation has been discussed in case law: • “In my judgment… inherent jurisdiction can be exercised in relation to a vulnerable adult who, even if not incapacitated by mental disorder or mental illness, is, or is reasonably believed to be, either (i) under constraint or (ii) subject to coercion or undue influence or (iii) for some other reason deprived of the capacity to make the relevant decision, or disabled from making a free choice, or incapacitated or disabled from giving or expressing a real and genuine consent.” (Per Munby J in A Local Authority v (1) MA (2) NA and (3) SA [2005] EWHC2942, at paragraph 77) (Inherent Jurisdiction of the High Court (Safeguards people who do not lack capacity, but their ability to make decisions has been compromised because of coercion, undue influence or constraints on their circumstances) In a Court of Protection judgement (A Local Authority v DL, RL & ML [2010] EWHC 2675) and a subsequent judgement by the Court of Appeal it was agreed that ‘inherent jurisdiction’ could be used in such a circumstance. In the case, the elderly parents of a 50 year old man referred to as DL were constrained from exercising their decision making capacity due to his coercive and controlling behaviour towards them (DL v A Local Authority & Others [2012] EWCA Civ 253). Local Authorities can therefore apply to the Court of Protection for relevant orders to protect people who are not able to make decisions due to the level of coercion and control being exercised over them.

16. Note of caution.. It should not be assumed that the presence of any kind of disability will automatically indicate abuse /coercive control, but it may increase vulnerability, and awareness of this fact is key. In a review of data on coercive control, Hamberger et al (2017) found 3 consistent elements that define it. • Intentionality or goal orientation in the abuser (they know what they are doing) • a negative perception of the controlling behaviour by the victim • deployment of a credible threat This is in line with the Serious Crime Act 2015, Section 76 (1), which defines coercive control as • behaviour on the part of the perpetrator which takes place ‘repeatedly or continuously’ • ii) behaviour that had a ‘serious effect’ on the victim; meaning that it has caused the victim to fear violence will be used against them on ‘at least two occasions’, or it has had a ‘substantial adverse effect on their day to day activities’ AND • iii) the alleged perpetrator must have known that their behaviour would have a serious effect on the victim, or the behaviour The idea that coercive control is routinely driven by the intent of a perpetrator to achieve a particular goal and is consistent with research (Stark, 2007; Day and Bowen, 2015) Some studies suggest that particular behaviours may be coercive without the perpetrator recognising them as such (Dutton et al, 2005; Ehrensaft et al, 1999), but most research indicates perpetrators are aware that their behaviour is coercive and have a clear goal in mind, which is to exert power over the victim.

17. Dementia • Reduced cognitive function - can lead to increased aggressive behaviours - Perpetrators often do not know what they are doing, aggression is not intentional (see coercive control) • BUT - Where someone who is either perpetrating or experiencing domestic abuse develops dementia - the onset of the dementia is likely to lead to an escalation in the severity of the abuse (Knight and Hester 2014) • The most dangerous people in the study were men with a history of being domestic violence perpetrators who had developed dementia and who had been physically abusive at some point in the past. In all of these cases, domestic abuse escalated to severe injurious physical abuse.’(Knight and Hester (2014 p12) • This was a small scale study (looking at 22 case records) and evidence is scant - so findings should be read with caution - but it raises important considerations for practice, especially around how practitioners make safe enquiries. • Pre- dementia abuse is evidence to suggest coercive control, particularly if any post dementia abuse is aimed at one person only (the victim), but a mental capacity assessment would still be needed to consider current level of cognition and culpability for action • “The dementia has changed him — he’s not the same man I fell in love with and married so many years ago. He gets suspicious and angry a lot. He screams at me, he yells at our son, he shouts at the postman. He has even punched the caregiver who comes to help him bathe. I suppose we can cope, but I’m worried” • “He used to hit me, but now he hits me… a lot” Its always me. He is lovely to everyone else. I can’t cope”. • Some research also, to suggest DA might cause dementia in victims.

18. references Ballin, M. and Fryer, M. (2012) Self-defence among women with disabilities: an unexplored domain in domestic violence cases, Violence Against Women, 18,9 1083-1107. Campbell, J.C., (2002). Health consequences of intimate partner violence. The Lancet,359 (9314), pp.1331-1336. CTC (2014), Website of the US Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention Home Office (2015) Controlling or Coercive Behaviour in an Intimate or Family Relationship Statutory Guidance Framework December 2015. Available online: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/482528/ Controlling_or_coercive_behaviour_-_statutory_guidance.pdf Home Office (2019) Forced Marriage statistics 2018 {Online} Available at file:///D:/Forced_Marriage_Unit_Statistics_2018_FINAL.pdf (Accessed 13rh June 2019) Howard, L.M., Trevillion, K., Khalifeh, H., Woodall, A., Agnew-Davies, R. and Feder, G. (2010), Domestic violence and severe psychiatric disorders: prevalence and interventions in ‘Psychological Medicine’ (2010), 40 ,881-893. Cambridge: Cambridge University Press Knight L and Hester M (2014) ‘Domestic abuse and dementia. What are the characteristic features and patterns of longstanding domestic abuse following the onset of dementia?’ Safe (Winter 2014) 10-14. McCarthy, M., Hunt, S. and Milne‐Skillman, K. (2015). ‘I Know it was Every Week, but I Can't be Sure if it was Every Day: Domestic Violence and Women with Learning Disabilities. Journal of applied research in intellectual disabilities. McGarry, J. & Simpson C. (2011) Domestic abuse and older women: exploring the opportunities for service development and care delivery. The Journal of Adult Protection, 13 (6) 294-301. McNamara, J. and Brooker, D. (2000) The Abuse Disability Questionnaire: a new scale for assessing the consequences of partner abuse, Journal of Interpersonal Violence, 15,2, 170-183. NICE (2014) Domestic violence and abuse: multi-agency working Public health guideline [PH50] National Institute for Health Excellence ,

19. references PHE (2015) Disability and domestic abuse: Risk, impacts and response. London: Public Health England. Available online: https://www.gov.uk/government/uploads/system/uploads/attachmen t_data/file/480942/Disability_and_domestic_abuse_topic_overview_FI NAL.pdf Rich, K., 2014. “My Body Came Between Us” Accounts of Partner-Abused Women With Physical Disabilities. Affilia SafeLives (2015), Getting it right first time: policy report. Bristol: SafeLives. SafeLives (2015), Insights IDVA National Dataset 2013-14. Bristol: SafeLives. Safe Lives, 2017) Disabled-people-and-domestic-abuse. Spotlight http://safelives.org.uk/knowledge-hub/spotlight-2-disabled-peopleand-domestic-abuse Bristol: SafeLives Thiara, R. et al (2011) Disabled women and domestic violence: responding to the experiences of survivors. London: Jessica Kingsley Publishers. Thiara 2016 Understanding disabled women's experiences of abuse. [Blog]. Available at: http://www.safelives.org.uk/practice_blog/understanding-disabledwomens-experiences-domestic-abuse Walter-Brice, A. et al (2012) What do women with learning disabilities say about their experiences of domestic abuse within the context of their intimate partner relationships? Disability and Society, 27,4, 503-517 Welsh Government (2016) Social Services and Well Being (Wales) Act 2014 Codes of Practice (2016) Guidance on Safeguarding. Working Together to Safeguard People - Volume I – Introduction and Overview. Available online: http://gov.wales/docs/phhs/publications/160404part7guidevol1en.pdf Yoshida, K. et al (2009) Women with disabilities and their experiences of and issues related to the context Yoshida, K. et al (2009) Women with disabilities and their experiences of and issues related to the context and complexities of leaving abusive situations, Disability and Rehabilitation, 31, 22, 1843-1852.