Managing the mental health effects of domestic violence

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Managing the mental health effects of domestic
violence

• Dr. Roxane Agnew-Davies
• Greater London Domestic Violence Project
• London South Bank University

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Objectives

• Consider impact of domestic violence
• Review the role of the professional
• Explore issues in working relationships

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Domestic violence is physical abuse

• Murder
• Suffocation, choking
• Throwing objects
• Shooting, stabbing
• Pushing or shoving
• Slapping or punching
• Twisting arms
• Breaking bones
• Bending fingers back

• Stamping on toes
• Using an object as a weapon
• Banging head, Drowning
• Kicking, Biting
• Burning, scalding
• Punching or kicking tummy
• Forcing to take drugs
• Cutting or stabbing
• Tying up, starving
• Pouring over acid or petrol

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Domestic violence is sexual abuse

• Rape vaginal, anal, oral with penis or objects
• Forced prostitution
• Forced sexual acts with others
• Sexual acts with animals
• Cutting or disfiguring breasts
• Chemicals poured into labia
• Refusal to practice safe sex or allow
  contraception
• Forced into pornography

• Genital mutilation
• Sexual abuse of children
• Forced sex after childbirth, operations causing
  infection, haemmhorage or ruptures
• Religious prohibitions ignored.
• Deliberately infecting
• Threats to get compliance
• Sexual insults

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Women experiencing domestic violence

• Primary trauma
• impact of abusers
• physical, sexual and emotional abuse
• Secondary victimisation
• impact of responses of friends and family
• impact of professionalsand society responses

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DomesticViolence and Mental Distress

• Golding (1999) 41 studies
• Magnitude a large association between variables
• Consistency replicated over places, persons,
  times
• Temporality symptoms occur after onset of D.V.
• Gradient greater exposure to violence linked to
  greater risk of symptoms
• Experimental when violence stops, mental health
  improves when violence returns, mental health
  deteriorates

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Goldings findings

• Women experiencing domestic violence are
• 4 x more likely to suffer PTSD
• 4 x more likely to suffer from depression
• 4 x more likely to feel suicidal
• 6 x more likely to abuse alcohol
• 6 x more likely to abuse drugs

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Psychological impacts of domestic violence

• Include anxiety, depression, drug overdoses,
  eating problems, post-traumatic stress disorder,
  sleep disturbances, suicidal ideation, substance
  abuse (Williamson, 2000 Walby, 2004).
• 31 of British women asked about the worst
  incident of domestic violence said it caused
  mental or emotional problems (Walby Allen,
  2004)
• 60 women across England who separated from their
  abusive partners said they left because of fears
  for their mental health (Humphreys, 2003).

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Other findings

• Of 1871 women in Irish GP practices, 2/3rds women
  with depression experienced domestic violence
  (Bradley et al, 2002)
• Self-harm has become of concern in the UK
  particularly in young Asian women, linked to
  experiences of domestic violence and forced
  marriage ( Forced Marriage, 2004 NAWP Silent
  Scream).

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Coping strategies

• Legal strategies
• Formal help-seeking
• Informal help-seeking
• Escape strategies
• Separation
• Hiding
• Appeals to abuser

• Compliance
• Resistance
• Self-defence
• Manages children
• Personal strategies
• Numbing
• Faith

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Hostages at homePost-Traumatic Stress

• A normal reaction to an abnormal event
• 3 characteristics
• Intrusive Events
• Avoidance
• Arousal

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Memories Flashbacks

• I see his fistthe knife
• He pops into my head
• I have nightmares
• I cant sleep

• Flashbacks
• Intrusive memories
• triggered by
• external or internal events
• ... still being abused

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Feeling numb (Avoidance)

• I dont want to talk about it
• I dont feel nothing
• Ive just gone blank
• I just want to put it behind me

• Defensive avoidance
• Dissociation
• Substance use
• But springs
• and self-protection

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Substance use and Violence

• 15 x more likely to misuse alcohol 9 x more
  likely to misuse drugs Stark Flitcraft, 1996
• 40 Asian women in treatment for alcohol misuse
  are experiencing domestic violence EACH Project,
  2000
• Abusers may introduce substances to increase
  control and dependency
• Abusers can undermine treatment
• May excuse violence on grounds of use
• Women are likely to be doubly stigmatised
  unable to access any suitable sources of support

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More on substance use

• Stella project
• www.gldvp.org.uk
• www.womensaid.org
• www.alcoholconcern.org.uk/servlets/doc/961

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Stress, eggshells and red alert(Anxiety and
arousal)

• Im so scared of him
• of what he will do next
• I wake up shaking
• why is it taking so long?

• Fear when in real danger
• Hyper-vigilance in context of threats
• Hyper-arousal triggered by intrusive events
• Anxieties about future

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Factors that increase duration and severity of
PTSD

• On-going (not post)
• Multiple rather than single event
• Trauma caused by human not nature
• Abuser known to victim not stranger
• Experience personal not collective
• Trauma occurs in previously safe place
• Rape or sexual abuse
• Previous abuse or violation
• Secondary victimisation

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Complex PTSD I

• I am all over the place on a roller-coaster
• difficulties regulating affect incl. mood, anger
• I day-dream all the time I go blank
• altered consciousness (amnesia, dissocn.)
• Im so ashamed no-one understands
• altered self-perception (helplessness, guilt, a
  sense of defilement difference from others)

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Complex PTSD II

• he saidI am.. hell find me
•      altered perception of perpetrator
• theres no-one youre an angel
•      altered relationships incl. distrust,
  fail to self-protect, search rescuer
• what god would allow this?
• altered belief system (faith, despair)

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Feeling down (Depression)

• Ive failed (he has made me believe)
• Im so ashamed (about what he made me do)
• I cant stop crying
• I cant be bothered (because hell just..)

• Negative thoughts
• (after emotional abuse)
• Disrupted planning
• (after physical abuse)
• Lack of positive events
• (after isolation)
• Suicidal ideation
• (to escape abuse)

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Anger (difficulties with affect)

• A volcano ready to explode
• Furious because she
• Snaps at the kids..
• So aggressive
• Wish hed

• Anger management?
• Assertion training?
• Is anger violence?
• .
• Or a normal, healthy reaction?

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Self-esteem (altered self-perception)

• Its my fault I failed
• I cant help it       
• Whatever you want
• Ill never be the same
• I cant believe I did that
•      Im going crazy
• I should have got over it

•   Self-acceptance
•   Self-responsibility
•   Living purposefully
• Self-assertiveness
•     Personal integrity
• Living consciously
• Brandon, 1994

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Physical self esteem

• He said I was a fat cow
• I cant wear skirts
• I see the scar
• Im reminded every step

• Anorexia?
• Bulimia?
• Paranoia?
• Personality disorder?
• Or
• the effects of abuse

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Altered relation with perpetrator

• The Stockholm Syndrome
• traumatic bonding
• omnipresence
• Not as simple as
• but she loves him
• she always goes back

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Common concerns altering relationship with you
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Impact of domestic violence on a woman coming to
you

• Avoidance -
• does not attend
• Startled easily -
• cant concentrate
• Powerless -
• sees you as rescuer
• Furious -
• leaks anger

• Blamed
• - blames herself or you
• Traumatic bonding
• - eager to please
• Mourning
• - flat, apathetic
• Vulnerable
• - acts tough

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I want to know if you can sit with pain, mine or
your own, without moving to hide, or fade it or
fix it
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Challenges for professionals working with
domestic violence

• Fear of offending clients
• Myths hook us too
• Feelings of inadequacy and frustration
• Feeling dumped upon
• Lack of training or time
• Coping with the stigma

• Inability to cure DV
• Defending against being overwhelmed
• Close identification from own experience abuse
• Fear of opening Pandoras box
• Absorbing until collapse

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The miracle worker

• Offers support examines
• attitudes understands DV
• collaborates with others advocates acts as role
  model can cope with complexity deals with own
  anger tolerates horror and terror respects
  believes creates support system

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Good practice

• Display information posters,leaflets
• Ask unaccompanied women
• Document suspicions or disclosures
• Give key messages
• Refer
• National help-line 0808 2000 24 7

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As witnesses to domestic violence

• We can
• Know the trauma will somehow be replayed
• Explore the effects on our attitudes/beliefs
• Look after ourselves

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Secondary effects of domestic violence

• Also called vicarious traumatisation
• traumatic counter-transference
• Are a normal reaction
• to working with domestic violence
• And therefore
• No-one should work with trauma alone

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Connecting our reaction with her difficulties

• Woman is numbing
• Woman is grieving
• Woman is furious
• Woman feels helpless

• Worker feels pressure to invade her space
• Worker allows special demand eg extra time
• Worker feels fear, or defensive - aggressive
• Worker feels helpless
• impatient or powerful

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How does the work affect the worker?

• Physical
• - Sleeping problems
• - Fear reactions
• Emotional
• Irritable
• Sad
• Angry
• Overwhelmed

• Cognitive beliefs
• Trust (all men danger)
• Safety (no safe place)
• Power (have none/all)
• Behaviour
• - denial of feelings/numb
• - self medication
• - sickness, absences

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How do you take care of you?

• Physically
• Psychologically
• Emotionally
• Spiritually
• Professionally

• Eat Exercise
• Focus - achievements
• Get angry
• Nature faith action
• Supervision Pacing

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Managing conversations

• Dont take it personally! See the shadows
• Ask a woman
• Is that what (the abuser) made you feel?
• Is that what he said to you?
• What happened that you had to learn to..?
• Focus on safety
• Ask how to make meetings feel safer
• Model taking care of your own safety

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Respect yourself/the worker

• Do you have enough information?
• Are you/is she taking blame inappropriately?
• What stage is the woman at?
• What are you asking of yourself/her?
• The woman is in control (and therefore we are not
  responsible for her choices)

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Endorse strengths- hers and yours

• Counteract abuse
• criticism
• blame
• Recognise strength
• courage
• creativity
• perseverance

• Who was the cause of the problem?
• Reattribute causes of
• distress or problems to domestic violence
• Hold abuser accountable

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Set Boundaries

• Set
• Clear limits
• Agreed time
• Agreed duration
• Contact between meetings
• Agreed number/end

• Watch and
• -resist omnipotence
• -tolerate differences with respect
• - be careful with self-disclosure
• - monitor temptation to breach limits or push
  boundaries

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Discuss goals

• Goals should be realistic
• achievable
• chosen by woman
• Our role should be explicit
• defined by limits
• empowering
• to recognise progress

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Get the ending right for yourself

• An opportunity to learn about completion
• You will never end if all problems have to be
  solved provide the tools not the answers
• You have the right to manage your own ending,
  whatever the client chooses

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Ideal supervision

• Safe structure
• Regular meetings
• Acknowledges feelings
• Respects rather than criticises

• Offers open door in response to crises
• Promotes staff well-being
• Offers support empowerment
• Models the process

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Mental health and domestic violence

• It is not the woman who is the problem
• It is not you who is the problem
• It is the domestic violence
• that is the problem

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Dr. Roxane Agnew-Davies

• Mental Health Advisor,
• Greater London Domestic Violence Project
• Senior Research Fellow,
• London South Bank University
• RoxaneDavies _at_ aol.com
• 0797 495 2313 0208 399 4504