Addressing Violence and Abuse in Mental Health: A Workshop

1. Why ask about violence and abuse in the context of mental health? A one hour introduction workshop for teams and groups

2. How common is violence and abuse amongst people using mental health services? At least half of women and over a quarter of men using statutory mental health services will have been sexually abused in childhood.1 Over a third of women using mental health services will have suffered severe domestic violence at some point in their lives.2 Abuse features in the backgrounds of those experiencing severe as well as more commonplace mental health difficulties.3 1. Sweeney (2016) 2. Howard LM, et al (2010) 3. Goodman, L. A., et al (2001)

3. Abuse Impacts Mental Health

4. There is lots of evidence of the mental health impacts of violence and abuse.1 • Anxiety / fear • Anger / aggression • Unhappiness / depression • Lack of confidence / self-esteem • Feeling dirty / damaged / guilty • Difficulties in all types of relationships • Sleep disturbance • Intrusive memories • Inability to trust others • Problems with sex This includes but is not limited to: 1. Fisher et al, 2017; Mc Grath et al, 2018; Kmett & Eack, 2018

5. So…. • Abuse is part of the ‘core work’ of mental health services • But despite the evidence and a decade of policy drivers, mental health services still don’t always see abuse as significant1 • As a result mental health services are places where patients’ needs are often not fully understood and they are at risk of re-traumatisation, and re-victimisation2 1. Read et al, 2018;2. Agenda, 2018; Sweeney et al, 2016; Sweeney et al, 2018; Care Quality Commission, 2018

6. Why should asking be a normal part of assessment? • Survivors want to be asked1 • It gives people permission to speak about their experiences • It creates the possibility of people getting more appropriate and helpful support • It makes clear that these types of experiences are relevant to their distress • If the question is not asked at assessment it tends not to be asked later 1. Nelson & Hampson, 2008; REVA (Briefings 3) 2014; REVA (Briefings 4) 2014; 1 Scott et al, 2014b

7. Asking is a policy requirement Routine exploration of violence and abuse in Adult Mental Health Services is Department of Health policy It links with the Gender Equality Duty 2007 It is consistent with ‘New Ways of Working’ 2007 It is required under CPA Guidance 2008 Brooker et al, 2018; Howard, 2018

8. CPA guidance states that… “Questions should be asked by suitably trained staff at assessment about the experience of physical, sexual or emotional abuse at any time in the service user’s life. The response, with brief details, should be recorded in case records/care plans. If the specific question is not asked, the reason(s) for not doing so should be recorded.” Refocusing the Care Programme Approach, Policy and Positive Practice Guidance, Section 4, March 2008

9. What gets in the way of asking? In Mental Health Services1: Some staff still avoiddiscussing the subject Many are worried aboutsaying the wrong thing Staff often have no training on the impacts of violence and abuse or how to respond appropriately to a disclosure Sexual abuse is still seen as an issue only to be dealt with by specialists 1. Hepworth & McGowen 2013

10. How are we doing in this service? • Do we ask routinely? • Is asking supported by our paperwork? • Is it supported by management? • Is it supported in supervision? • Are we confident about how we respond? • Are we less likely to ask some people rather than others? • Are we able to discuss good practice examples and where we could do better?

11. How should we ask about violence and abuse? At the start of an assessment: • Acknowledge that they may find some questions difficult and some may not be relevant to them • Make the boundaries of confidentiality clear…‘What we talk about is confidential unless you tell me about any serious risk of harm to yourself or other people’

12. How should we ask about violence and abuse? Keep it simple and straightforward: “Have you experienced physical, sexual or emotional abuse at any time in your life?” Or: “Have you suffered any kind of abuse or violence – recently or in the past?” Further questions may include: “Has anyone hurt you, made you feel uncomfortable, made you scared?”

13. Hearing a disclosure – Part one/two • Re-assure the client that it was okay/a good thing to tell • Have they told anyone before? How did that go? • Do not try to gather all the details • Is it an issue that they need help with? • Is this the right time to deal with it? • At the end of the assessment ask them how they are feeling • Check they can access any immediate support they need

14. Hearing a disclosure – Part two/two Don’t assume: • You know what they feel or think about their experience • They no longer have a relationship with their abuser • Any children are currently being protected • The abuser was a man • They were abused by just one person

15. Support for survivors Guided self-help, support from non-specialist staff, helplines etc Self-help, friends & family support Survivor support groups, counselling Longer-termpsychotherapy

16. What next • Deal with any immediate concerns raised by the person • If there is a current safeguarding issue for them or for any children consult your safeguarding lead • Record information to reflect on and minimise the number of times a person has to repeat their story (inappropriately) • Have self-help materials available in your service and signpost to other self-help materials • Know what the local options are for support

17. In summary • The case for asking people using mental health services whether they have experienced violence or abuse is overwhelming • It is important to recognise what gets in the way of staff asking • Then carry on or start asking…