Third Edition November 2014

1. ASKING THE QUESTION ABOUT VIOLENCE AND ABUSE IN ADULT MENTAL HEALTH ASSESSMENTS Third Edition November 2014

2. INTRODUCTION

3. 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

4. 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?

5. Learning outcomes • Participants 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

6. Before we begin… • Introductions • Practical arrangements • Looking after yourself • Confidentiality

7. WHY ASK THE QUESTION?

8. 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

9. 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

10. 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 Psychology18: 368-380.

11. 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

12. 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

13. 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

14. 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

15. 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 • 1Radford, 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.

16. 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.

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

18. 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.

19. Understanding differential impacts of violence and abuse

20. 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

21. 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 • 1REVA Briefing 1 Violence, Abuse and mental health in England. London: NatCen

22. 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

23. A Respond Tree Branches = emotions and psychological effects Leaves = presenting difficulties Roots = cause(s) of distress

24. An Example Respond Tree Violence Self-harm Sexual problems Eating disorder Phobias Nightmares Anxiety Depression Compulsive behaviour fear PTSD anger pain shame guilt low self- esteem inability to trust Physical abuse Emotional abuse Sexual abuse

25. 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

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

27. 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

28. Borderline personality disorder • Five 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

29. 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

30. 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

31. 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

32. 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

33. LUNCH

34. HOW TO ASK THE QUESTION

35. 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’

36. 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 details • If question not asked, please state reason

37. Trial run • Ask the question: • “Have you experienced any kind of physical, sexual or emotional abuse in your life?”

38. 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.

39. 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

40. 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

41. 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

42. 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“

43. Will I become an abuser? victims abusers

44. 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

45. RESPONDING TO A DISCLOSURE

46. 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

47. 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

48. 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

49. Providing support to survivors Longer-term therapy Survivor support groups, counselling Guided self-help, support from non-specialist staff, helplines etc Self-help, friends & family support

50. 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.