1Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
2Institute of Psychiatry, King’s College London, UK
OVERVIEW
Domestic and sexual violence are both common in people seen in mental health services, with a higher prevalence in women
All mental disorders (including substance use disorders) are associated with an increased risk of being a victim of violence. Women with physical disabilities and learning disabilities are also at increased risk
Domestic and sexual violence may lead to development of mental health problems and/or exacerbation of existing symptoms. Symptoms decrease and psychological therapies are more effective when abuse stops
Most violence is not detected by health professionals; they do not feel confident in asking and victims fear the potential consequences of disclosure
Health professionals must be able to ask about experiences of violence, be familiar with local procedures and be ready to respond appropriately if violence is disclosed, with special consideration for the vulnerabilities of the mentally ill
Domestic violence is a common hidden problem for women attending mental health services and is a major cause of mental ill health globally.
Poor mental health produces 73%, and substance abuse 22%, of the total disease burden of domestic violence in women aged 18–44 years.
The prevalence of any adult lifetime partner violence among psychiatric inpatients ranges from 16 to 94% among women and from 18 to 48% among men. This is often associated with prior childhood abuse.
Identification of and response to domestic and sexual violence experienced by mental health service users is suboptimal. Currently only 10–30% is detected by health professionals.
Mental health service users are often perceived as perpetrators of violence but they are actually more likely to be victims.
Internationally, there are no consistent demographic associations with interpersonal violence (including age, ethnicity and number of children) other than relative poverty (see Figure 15.1).
The majority of service users do not mind being asked about violence when the enquiry is justified, introduced as routine and made by a supportive professional whom they trust.
Emotional abuse is more damaging than physical abuse for a victim’s mental health.
The presence of any mental disorder is itself a possible indicator of violence (see Boxes 15.1 and 15.2). Examples of presentations of related mental illness include:
A middle-aged woman presenting to her GP with depression and old bruising.
A young woman with learning disabilities in obvious distress but unable to state what the problem is.
A mother with schizophrenia presenting with exacerbation of psychotic symptoms.
A young man with panic attacks and symptoms of hyper-arousal.
A woman in A&E who has made a suicide attempt and has a history of self-harm.
A mother with back pain and a recent worsening of alcohol abuse.
Box 15.1 Case study
Sarah Jackson, a 38-year-old woman who is currently experiencing a psychotic breakdown, tells you that she is experiencing hallucinations and is finding it difficult to cope. Sarah has attended with her partner, who asks to sit in on the meeting; he tells you she has ‘gone mad again’ and does not allow her much time to speak. However, she does disclose she is drinking more alcohol than usual.
Suggestions
Ask to see her alone (without her partner present) as is routine.
Ask about her relationship, including specific questions about physical, sexual and emotional abuse.
Give her a key message (see Box 15.3).
Offer information about key services.
Box 15.2 Case study
Anna Turner, a 40-year-old, has attended a number of times this year. She moved to the UK 2 years ago with her husband and has one child, now 8 months old. Anna speaks reasonable English and always attends appointments with her young child. She has recurrent depressive episodes and regularly reports difficulties coping with day-to-day life. She has frequent headaches and today has a black eye.
Suggestions
Ask about her injury.
Ask about other experiences of domestic violence.
Give her a key message (see Box 15.3).
Check whether she is safe to return to her home.
Offer information about key services and discuss options available to her.
Women experiencing domestic violence are more than six times more likely to misuse or develop dependence on alcohol and drugs.
There will be situations in which it is not appropriate to ask about domestic or sexual violence, such as when a patient is agitated, psychotic or acutely disturbed. It is still important to ask when the patient is less disturbed so that a full assessment can be carried out.
Children are at risk even just from witnessing violence to others. Be sure to assess risk to all children and other family members.
Be cautious when receiving a collateral history from a potential abuser. Do not assume their account is accurate and be wary about sharing patient details or plans.
Most domestic violence homicides occur at the point of separation.
Most patients do not mind being asked about violence when it is explained that enquiry is routine (see Chapter 7), the problem is common (one in four women experience domestic or sexual violence at some point) and you can help refer them to expert services. It is vital that a patient feels supported and able to trust their health professional.
Consultations must be private and confidential. Explain where there may be mandatory reporting (for instance if there are safeguarding concerns around the patient or children). Victims may not be able speak openly while their partner or family members are present. Ensure interpreters are independent and not from the patient’s community. As with other consultations, start with open questions and then move on to more closed, specific questions about violence.
An opening approach might be: ‘Who’s at home?’ ‘How are things at home?’ ‘What happens when there are arguments at home?’
More specifically, you might say: ‘Many people I see with these sorts of symptoms have experienced domestic violence or sexual violence. Is someone hurting you or threatening you?’
If they hesitate, you could say: ‘I ask because I am concerned for the safety of all my patients. I want to find out if you need information or support. I will not tell your family or partner about what you say.’
If the patient admits they have been frightened or hurt, you need to document the type of abuse suffered. Ask about physical, psychological (including emotional and financial) and sexual abuse, remembering that each group overlaps with and compounds the impact of the others. It is best to phrase questions in terms of the behaviour of the perpetrator:
Has [your partner/a relative] ever:
kicked, punched, pushed, grabbed or tried to choke or strangle you?
tried to hurt the children?
called you insulting names, made you feel small or insisted on what you wear?
made it difficult for you to see friends/family or leave the house?
forced you into sex even though you don’t want to?
If the patient answers ‘No’, respect their response. Do not pressure patients to disclose violence or assume that a patient is being abused any more than you would assume that they are not. However, note any nonverbal signs such as hesitation or fear in the patient and observe their interactions and relationships, such as whether the partner’s behaviour seems overly protective or controlling. Where violence is denied, the Department of Health recommends documenting ‘violence not disclosed’.
A nonjudgmental, comforting relationship in which you validate what the patient is saying will help facilitate disclosure. Disclosure is a process, so make sure you ask more than once. Make sure the patient is aware of the information and support available and how to access them. You can give information ‘for a friend’. Be ready to assist a woman in increasing her own safety and that of her children where necessary.
