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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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Presentation on theme: "Managing the mental health effects of domestic violence Dr. Roxane Agnew-Davies Greater London Domestic Violence Project London South Bank University."— Presentation transcript:

1 Managing the mental health effects of domestic violence Dr. Roxane Agnew-Davies Greater London Domestic Violence Project London South Bank University

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

3 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

4 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


6 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

7 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

8 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

9 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).

10 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).

11 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

12 Hostages at home: Post-Traumatic Stress A normal reaction to an abnormal event 3 characteristics: Intrusive Events Avoidance Arousal

13 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

14 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

15 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

16 More on substance use: Stella project: vlets/doc/ vlets/doc/961

17 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

18 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

19 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)

20 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)

21 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)

22 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?

23 Self-esteem (altered self-perception) Its my fault; I failed I can’t help it Whatever you want I’ll never be the same I cant believe I did that I’m going crazy I should have got over it Self-acceptance Self-responsibility Living purposefully Self-assertiveness Personal integrity Living consciously Brandon, 1994

24 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

25 Altered relation with perpetrator The Stockholm Syndrome ‘traumatic bonding’ ‘omnipresence’ Not as simple as ‘but she loves him’ ‘she always goes back’

26 Common concerns altering relationship with you Questions about violence Anxiety and arousal Numbing and avoidance Fear for safetyDepressionAnger Intrusive memories Sleeping difficulties Difficulties in assertion Unusual signsLack of self- esteem Grief and loss Parenting issues Loss physical self-esteem Making sense of it all

27 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

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

29 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

30 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

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

32 As witnesses to domestic violence We can Know the trauma will somehow be replayed Explore the effects on our attitudes/beliefs Look after ourselves

33 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

34 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

35 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


37 How do you take care of you? Physically Psychologically Emotionally Spiritually Professionally Eat; Exercise Focus - achievements Get angry Nature; faith; action Supervision; Pacing

38 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 safety Ask how to make meetings feel safer Model taking care of your own safety

39 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)

40 Endorse strengths- hers and yours Counteract abuse criticism blame Recognisestrength courage creativity perseverance Who was the cause of the problem? Reattribute causes of distress or problems to domestic violence Hold abuser accountable

41 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

42 Discuss goals Goals should berealistic achievable chosen by woman Our role should beexplicit defined by limits empowering to recognise progress

43 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

44 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

45 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

46 Dr. Roxane Agnew-Davies Mental Health Advisor, Greater London Domestic Violence Project Senior Research Fellow, London South Bank University RoxaneDavies @ 0797 495 2313 0208 399 4504

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