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Improving responses to domestic violence in secondary mental health services in Wandsworth, South West London

Given the increasing awareness of domestic violence or abuse (DVA) and its prevalence and impact within the general population and amongst users of psychiatric services this study looked at the extent to which domestic violence was related to the mental health needs of a secondary psychiatric service user population in Wandsworth, and how service response to DVA in secondary mental health services in the Borough could be improved. This included considering the potential for more systematic screening for DVA, and developing a new service response based on a peer-mentoring model, as a way to address the long-terms mental health effect of DVA. Psychiatric services users have often contested the dominance of biomedical explanations for mental distress which too often has marginalised more holistic and social explanations and interventions. This has contributed to mental health professionals’ failure to identify and acknowledge abuse, and a failure to ask the question ‘what happened to you?’ (rather than the more standard and individually pathologising ‘what is wrong with you?’).

This study explored how focused efforts to enquire about experiences of DVA and other abuse may need a stronger emphasis if we are to improve service responses and people’s experiences of mental health support from professionals.

To investigate this, we adopted a mixed methods study to: a) establish the extent of domestic violence in secondary mental health services in Wandsworth through examining service users’ files for recorded incidents of violence or abuse, aimed at informing the subsequent qualitative component of the study, and b) elicit the views of a range of stakeholders about adopting routine enquiry into domestic violence in secondary mental health services, together with their views on responding to domestic violence in this population with a peer-mentoring service, as way to address the long-terms effect of DVA. We examined the lifetime exposure to and patterns of violence or abuse (DVA) in a randomly selected sample of services users (N=342) admitted to secondary mental health services, the health and social outcomes of those service users exposed to violence or abuse, and its potential for intergenerational patterns of violence or abuse. The inspection of the patients’ files in the selected sample revealed a high number of service users with recorded incidents of domestic violence or abuse; n=167 (49%) had been exposed to patterns of violence or abuse either as a single or multiple incident in their lifetime. It should be noted, however, that the electronic records did not have a standard question (or a validated tool) to capture information about current or past abuse, and that practitioners did not ask about this routinely. Therefore, there is the possibility of under-recording which is corroborated by research evidence in psychiatric settings highlighting the underreporting and under-disclosing of DVA within health services.

Child abuse was more prevalent (n=109; 31.87%) in the service user group than past domestic violence (n=65; 19.00%), current domestic violence (n=24; 7.00%), and violence outside domestic settings (n=60; 17.54%) (p <0.001 for all pair wise comparisons). Service users were also more likely to have experienced past domestic violence or violence outside domestic settings than have a recorded episode of current domestic violence. An analysis of the gender differences indicated that overall, men were significantly less likely to have any recorded incident of violence or abuse (59.9% (M); 42.9% (F)). A further examination of gender differences in exposure to current domestic violence and past domestic violence, revealed that these were significantly more prevalent in females than males (respectively: current 4.2% (M); 9.7% (F) – past 7.8% (M); 29.7% (F)). Differences in child abuse rates were marginally significant (26.9% (M); 36.6% (F)). Violence outside a domestic setting was comparable between gender groups.

In relation to the type of violence service users had been exposed to in their lifetime, we highlighted that sexual abuse and emotional/psychological abuse were significantly more prevalent in females than males (sexual abuse, 32.0% (F) 12.6% (M); emotional/psychological, 30.8% (F) 19.2% (M)) while differences in physical abuse rates were marginally significant for women. Financial abuse was comparable between gender groups. The comparisons between ethnic groups revealed significantly higher rates of child abuse in White service users (37.4%) compared with Black groupings (24.4%) (Black, Mixed, Asian), and higher rates of violence outside domestic settings in Black groupings (25.6%) relative to ‘Other ethnic group’ service users (4.5%). Differences in rates of past domestic violence between White and Black service users were marginally significant.

In addition to this, we examined the intergenerational pattern of violence or abuse passed from one generation to the next. We found that the proportion of child abuse victims who had (recorded) further incidents of violence was higher (n=58, 53.2%) than the proportion who became perpetrators of violence/abuse (n=45, 41.3%), although the difference was only marginally significant. Female victims of child abuse were numerically less likely than male victims to subsequently become perpetrators of violence/abuse, but were significantly more likely to have (recorded) further incidents of violence.

The comparison between service users without a recorded incident (of violence or abuse) and the service users exposed to any violence and in service users with a history of child abuse indicated significant adverse outcomes across health, behavioural and social domains among the exposed groups. However, our study did not intend to infer causality and/or its direction, as this study entailed a case-file analysis. It was not based on a longitudinal methodology, and did not entail making a comparison of the various diagnoses and their severity associated with the service users in our sample. Therefore, we cannot draw any inferences about the relationship (and its direction) between DVA and mental illness. The qualitative evidence explored the perceptions of service users and staff from various agencies about the relationship between DVA and child abuse and mental health. This indicated the potential importance for service user experience and outcomes of integrating enquiry into those abuses into care and support planning.

Our qualitative analysis of service users and practitioners’ experiences and perceptions of identification practices and responses to domestic violence in secondary mental health services in Wandsworth, brought to light a shared narrative of the need for improving awareness about the nature, extent and impact of domestic violence within psychiatric services. Health promotion strategies may be needed to raise service users’ awareness of the nature of domestic violence or abuse, its physical and mental health impacts, and to eliminate feelings of isolation and fear resulting from their experience of abuse. The qualitative findings indicated that the introduction of routine enquiry about domestic violence was perceived to be likely to raise awareness of abuse among service users and practitioners, which would facilitate a discussion between them that could promote disclosures. The findings highlighted the need for strategies to ensure that people with psychiatric illness who experience abuse are able to speak of their experience, its impact on their mental health and to access mainstream support services and that specific interventions are developed to support the mental health needs of these vulnerable groups.