Managing the mental health effects of domestic violence

Dr. Roxane Agnew-DaviesGreater London Domestic Violence Project

London South Bank University

Objectives

• Consider impact of domestic violence

• Review the role of the professional

• Explore issues in working relationships

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

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

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 professionals’and society responses

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

Golding’s 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

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).

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).

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

Hostages at home:Post-Traumatic Stress

A normal reaction to an abnormal event

3 characteristics:

Intrusive Events

Avoidance

Arousal

Memories & Flashbacks

I see his fist…the knife

He pops into my head

I have nightmares

I can’t sleep

Flashbacks

Intrusive memories

triggered by

external or internal events

... still being abused

Feeling numb (Avoidance)

I don’t want to talk about it

I don’t feel nothing

I’ve just gone blank

I just want to put it behind me

Defensive avoidance

Dissociation

Substance use

But springs…and self-protection

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

More on substance use:

• Stella project:www.gldvp.org.uk

• www.womensaid.org• www.alcoholconcern.org.uk/ser

vlets/doc/961

Stress, eggshells and red alert(Anxiety and arousal)

I’m 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

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

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.)

‘I’m so ashamed; no-one understands’altered self-perception (helplessness, guilt, a sense of defilement & difference from others)

Complex PTSD II

‘he said…I am..; he’ll find me…’

     altered perception of perpetrator

‘there’s no-one’; you’re an angel’

     altered relationships incl. distrust, fail to self-protect, search rescuer

‘what god would allow this?’

altered belief system (faith, despair)

Feeling down (Depression)

I’ve failed (he has made me believe)

I’m so ashamed (about what he made me do)

I can’t stop crying

I can’t be bothered (because he’ll just..)

Negative thoughts

(after emotional abuse)

Disrupted planning

(after physical abuse)

Lack of positive events

(after isolation)

Suicidal ideation

(to escape abuse)

Anger (difficulties with affect)

A volcano ready to explode…

Furious because she…

Snaps at the kids..

So aggressive…

Wish he’d…

Anger management?

Assertion training?

Is anger violence?

….

Or a normal, healthy reaction?

Self-esteem (altered self-perception)

Its my fault; I failedI can’t help it       Whatever you wantI’ll never be the same I cant believe I did that

I’m going crazyI should have got over it

  Self-acceptance

  Self-responsibility

  Living purposefully

Self-assertiveness

    Personal integrity

Living consciously

Brandon, 1994

Physical self esteem

He said I was a fat cow

I can’t wear skirts

I see the scar

I’m reminded every step

Anorexia?

Bulimia?

Paranoia?

Personality disorder?

Or…

the effects of abuse

Altered relation with perpetrator

The Stockholm Syndrome

‘traumatic bonding’

‘omnipresence’

Not as simple as

‘but she loves him’

‘she always goes back’

Common concerns altering relationship with you

Questions about violence

Anxiety and arousal

Numbing and avoidance

Fear for safety Depression Anger

Intrusive memories

Sleeping difficulties

Difficulties in assertion

Unusual signs Lack of self-esteem

Grief and loss

Parenting issues

Loss physical self-esteem

Making sense of it all

Impact of domestic violence on a woman coming to you

Avoidance -

does not attend

Startled easily -

can’t 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

I want to know if you can sit with pain, mine or your own, without moving to hide, or fade it or fix it…

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 Pandora’s box

Absorbing until collapse

The miracle worker

Offers support examinesattitudes understands DVcollaborates with others

advocates acts as role model can cope with complexity deals with own anger tolerates horror and terror respects believes creates support system

Good practice

• Display information: posters,leaflets

• Ask unaccompanied women

• Document suspicions or disclosures

• Give key messages

• Refer

• National help-line 0808 2000 24 7

As witnesses to domestic violence

We can

Know the trauma will somehow be replayed

Explore the effects on our attitudes/beliefs

Look after ourselves

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

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

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

How do you take care of you?

• Physically

• Psychologically

• Emotionally

• Spiritually

• Professionally

Eat; Exercise

Focus - achievements

Get angry

Nature; faith; action

Supervision; Pacing

Managing conversations

Don’t 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 safetyAsk how to make meetings feel saferModel taking care of your own safety

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)

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

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

Discuss goals

Goals should be realistic

achievable

chosen by woman

Our role should beexplicit

defined by limits

empowering

to recognise progress

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

Ideal supervision

Safe structureRegular meetingsAcknowledges

feelingsRespects rather

than criticises

Offers open door in response to crises

Promotes staff well-being

Offers support & empowerment

Models the process

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

Dr. Roxane Agnew-Davies

Mental Health Advisor,

Greater London Domestic Violence Project

Senior Research Fellow,

London South Bank University

RoxaneDavies @ aol.com

0797 495 2313 0208 399 4504