1. Domestic Violence and mental health
Louise Howard
Professor & Head of Section of Women’s Mental Health
2. Domestic violence
“Any incident of threatening behaviour violence
or abuse (psychological, physical, sexual,
financial or emotional) between adults who are
or have been an intimate partner or family
members, regardless of gender or sexuality”
(Home Office 2006)
New definition to include coercive behaviours
and age 16/17 (HO 2013)
3. Domestic violence
Global Burden Disease 2010 project:
• 200 000 deaths/yr attributable to IPV
• 1·5% (1·0—2·1) of DALYs
WHO multi-country study:
• Up to 69% of women report that an intimate
partner has physically abused them at least 1x
• Up to 59% of women report forced sex, or
attempted force, by an intimate partner
• Up to 28% of women report they physical abuse
during pregnancy by an intimate partner
Garcia-Moreno et al 2006; Lozano et al 2013; Murray et al 2013
4. Domestic violence prevalence
British Crime Survey
• Lifetime prevalence rates of isolated domestic
violence are comparable for men and women in
general population
• Women are at greater risk of repeated coercive,
sexual or severe physical assault
• Two women are murdered by their partner or ex-
partner every week in England and Wales
• Higher risk when, or soon after, leaving partner
• 40% female (7% male) homicide victims killed
by current or former partner
Tjaden & Thoennes 2000; Walby & Allen 2004
5. Figure 1. Flow Diagram of Screened and Included Papers.
Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
6. Table 1. Characteristics of included studies (n = 41).
Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
7. Figure 3. Pooled odds estimates for past year intimate partner violence among women with
depressive disorders.
Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
8. Figure 5. Pooled odds estimates for past year intimate partner violence among women with
anxiety disorders.
Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
9. Figure 6. Pooled odds estimates for lifetime intimate partner violence among women with post-
traumatic stress disorder.
Trevillion K, Oram S, Feder G, Howard LM (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740. doi:10.1371/journal.pone.0051740
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0051740
10. Other findings of Systematic Reviews
• Association found for all diagnostic categories
• In men and women
• More prevalent in women
• More studies in women
• Few longitudinal studies
• In longitudinal studies of perinatal populations,
Population Attributable Fraction for PND=12%
Howard et al In Press; Trevillion et al 2012
11. Prevalence of domestic violence
in mental health service users
Median prevalence of lifetime domestic violence
(in high-quality papers):
30% (IQR 26% - 39%) female inpatients
33% (IQR 31% - 53%) female outpatients
One high quality study for male patients:
18.4% for inpatients ;4.4% for outpatients.
Low rates of detection (10-30%)
Howard et al, 2010; Oram et al, In Press
12. Domestic violence and mental health - ?causal
• No diagnostic specificity – increased prevalence
for all disorders
• Severity of abuse ass with severity of symptoms;
symptoms when abuse stops
• Pre-existing mental health problems associated
with being in unsafe environments and
relationships
• Prospective data shows women who are involved
in abusive relationships have higher risk of
subsequent psych morbidity
• Antenatal DV associated with subsequent child
psychological morbidity and adult mental
disorders
• Women who experience domestic violence are
less likely to receive mental healthcare
Ehrensaft et al. 2006; Golding 1999; Howard et al 2010; Trevillion et al 2012
15. How should services respond?
Interventions
• Limited evidence but CBT effective in improving symptoms
and self esteem in women who have left abusive relationships
• Standard psychological interventions that are not adapted for
this population likely to be ineffective
• One small RCT of trauma (not specifically domestic violence)
focussed CBT for patients with severe mental illness
• Intensive (>12 hrs) advocacy for women at a refuge
quality of life, safety behaviours and abuse at 12-
24mths
• Brief advocacy intervention (<12 hrs) improves safety
behaviours
• Telephone intervention for women at a family violence unit
safety behaviours
Ramsay et al, 2009; Howard et al, 2009; McFarlane et al, 2002; Meuser et al, 2008; Sullivan & Bybee 1999
16. Figure 2
IRIS outcomes - Box plot of identification and referrals to advocacy
agencies of women experiencing domestic violence
(Vertical lines denote interquartile range)
Source: The Lancet 2011; 378:1788-1795 (DOI:10.1016/S0140-6736(11)61179-3)
Terms and Conditions
17. LARA pilot study: Intervention
Linking
• Domestic violence training of CMHT staff Abuse and
Recovery through
– 2 didactic/interactive workshops with on-going training
Advocacy
• LARA Advisors trained by mental health
professionals and domestic violence sector
• Clear referral pathways to LARA Advisors
• LARA Advisors integrated within teams
• Control CMHTs
18. LARA pilot study: measures Linking
Abuse and
• Professional knowledge and attitudes: Recovery through
Advocacy
PREMIS (Professional Readiness to Manage Domestic Violence)
• Service user outcomes
– Composite Abuse Scale
– MANSA Quality of Life
– Adult Service Use Schedule
– Safety Behaviour Checklist
– Camberwell Assessment of Need/CAN-M
– Social inclusion
• Process measures
– Referrals and number of sessions (LARA advisors)
– Nature of support provided by advisors
– Experience of the intervention for service users
22. MARACs (Multi-Agency Risk
Assessment Conferences)
•Often police-led - primary focus is to safeguard the adult victim
•Information shared on very high-risk domestic abuse cases
patients
•Attendance incls representatives of local police, probation, health,
child protection, housing practitioners, independent domestic
violence advisors
•Representatives discuss options for increasing the safety of the
victim
•Create a coordinated action plan.
• Victim does not attend the meeting but is represented by an IDVA
• Evaluations have found that their use reduces recidivism, even for
the highest risk patients, and improves professionals’ practice and
the safety of victims and their children
23. What Works for Service Users?
Qualitative data
Linking
Abuse and
Recovery through
Advocacy
Improved health professional response to disclosures:
“This way I’m actually getting help it’s not just been pen to paper;
cause in the past that’s what it was”.
Documentation of abuse:
“It’s a bit of a relief….that if anything did happen to me, you know,
things did go too far at least it was all on record”
Securing safety:
“Yeah speaking to her [Advisor] and asking her to help me do the
door, was a best plus….the door’s safe, so I know that no one can
bust it” .
24. What Works for Service Users?
Qualitative data
Linking
Abuse and
Recovery through
Advocacy
Integrated support:
“I just feel so much better knowing that…I’ve got a support network
around me that I can….talk too or talk about my issues…
beforehand I just felt like a bit isolated, I didn’t have no one”
“I could speak to any of them [referring to Advisors and mental
health professionals]…so I had like two sets of people that I could
contact, which was fantastic”
25. What Doesn’t work for Service Users?
Linking
Abuse and
Recovery through
Advocacy
Professional focus on separation from partner:
“He [referring to professional] wanted me to leave [partner] straight
away and because I didn’t have the strength to do it he said, sort
of, he can’t work with me anymore….I didn’t find that bit helpful at
all, because I thought that he should have supported me
regardless”.
Limited discussion of DV by health professionals:
“I could have done with a bit more support actually. I could have
done with a few phone calls or some letters or some more
information…. the CPN, the team haven’t asked me anything else
about it”
26. + Improvements in quality of life and social
inclusion
Reduction in number of unmet needs
27. LARA Conclusions Linking
Abuse and
• Increased prevalence of domestic violence Recovery through
experienced by mental health service users Advocacy
• Mental health service users experience significant
barriers to disclosure of domestic violence
• Barriers to enquiry are similar to those reported in
other settings; knowledge and practice not optimal
• Training on safe assessment and treatment needed
for mental health professionals
• Integration of multi-faceted intervention (training with
domestic violence advocacy) into mental health
services may be helpful
This presentation presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit
Programme (PB-PG-0906-11026). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the
Department of Health.
28. Acknowledgements Linking
Abuse and
ALSPAC Team:
LARA Team: Recovery
through
Roxane Agnew- Jonathan Evans Advocacy
Davies Clare Flach PROVIDE
Sarah Byford Team:
Gene Feder
Gene Feder Gene Feder
Jonathan Heron
Diana Rose Sian Oram
Kylee Trevillion Morven Leese
Kylee Trevillion
Anna Woodall Debbie Sharp
This presentation reports independent research commissioned by the
National Institute for Health Research (NIHR). The views expressed
are those of the author(s) and not necessarily those of the NHS, the
29. References
Trevillion K, Oram S, Feder G, Howard LM. Experiences of
Domestic Violence and Mental Disorders: A Systematic Review
and Meta-Analysis. PLoS ONE 7(12): e51740.
doi:10.1371/journal.pone.0051740
Howard LM, Trevillion K, Khalifeh H, Woodall A, Agnew-Davies R,
Feder G. Domestic violence and severe psychiatric disorders:
prevalence and interventions. Psychological Medicine 2010 40,
881–893.
Howard LM, Trevillion K, Agnew-Davies R. Domestic violence and
mental health. International Review of Psychiatry October 2010;
22(5): 525–534
Rose D, Trevillion K, Woodall A, Morgan C, Feder G, Howard LM.
Barriers and Facilitators of Disclosures of Domestic Violence by
mental health service users: a qualitative study. British Journal of
Psychiatry. March 2011 198:189-94.
Flach C, Leese M, Heron J, Evans J, Feder G, Sharp D, Howard
LM and the ALSPAC team. Antenatal Domestic Violence and
Subsequent Child Behaviour. BJOG 2011; 118 (11), 1383–1391
Notas del editor
0·9% [0·7—1·2] DALY for sexual violence intimate partner violence, which accounted for 1·5% (1·0—2·1) of DALYs
Service users’ barriers to disclosure of domestic violence.
Professionals’ barriers to enquiry of domestic violence.
A wide range of individual psychological interventions have been demonstrated to show improvements for women with depression and post-traumatic stress disorder including for levels of depressive symptoms, post-traumatic stress symptoms and self-esteem (comprehensively reviewed by Feder et al (Feder et al. 2009). In particular, two trials of cognitive behavioural therapy for women with post traumatic stress disorder who were no longer experiencing violence suggest that cognitive behavioural approaches are helpful (Kubany ES et al. 2003; Kubany ES et al. 2004). There are also studies of group psychological interventions which show improvement in psychological outcomes though these have major methodological limitations (Feder et al, 2009). However, these findings cannot be extrapolated to women still in abusive relationships, nor for women with more severe psychiatric illnesses in contact with mental health services. Domestic violence advocacy
Box plot of identification and referrals to advocacy agencies of women experiencing domestic violence Vertical lines denote interquartile range.
Training manual;
Post Traumatic Stress Disorder Scale (PDS), which has been used to identify PTSD in domestic violence survivors (Foa et al, 1993) and psychiatric outpatients (Foa et al, 1997); Composite Abuse Scale (Hegarty et al, 2005), a validated scale measuring physical and sexual abuse, emotional abuse, severe combined abuse and harassment; Adult Service Use Schedule (AD-SUS), an interview measure of hospital and community health and social services, criminal justice sector resources, accommodation and productivity losses for use in the assessment of costs and cost-effectiveness (Barratt et al, 2006); EQ-5D measure of health related quality of life capable of generating a generic cardinal index of health-related well being to calculate quality adjusted life years (The Euroqol Group, 1990);
Commented on the improved response of MH prof to disclosures of abuse, which in past experiences hasn’t always been positive Process of staff documenting abuse Support from Advisors to improve safety
Integrated support of Advisors and MH prof greatly valued: Spoke of double support for MH and DV problems Ability to speak to both professionals about experiences Advisors able to provide clients with access to Freedom programme – looking at challenging abusers behaviour and meeting with other survivors to talk through experiences
Identified concerns: MH focus on separation from partner Some identified a limited discussion of abuse experiences by prof – Felt because prof felt Advisors responding to DV so they did not bring it up
Our findings suggest that mental health service users experience significant barriers to disclosure of domestic violence. This is concerning as people with severe mental illness are at increased risk of victimisation compared with the general population. Therefore these findings suggest the needs of people with experiences of domestic violence and mental illness are currently being unmet. Our findings regarding barriers to disclosure are similar to those of a recent systematic review of other healthcare settings. Research indicates that women in the perinatal period and people with a mental illness are at an increased risk of domestic violence victimisation. Taking in to account these findings the DoH now recommend Clinicians ask about violence and abuse in both obstetric and psychiatric settings
