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Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study

  • Diana Rose (a1), Kylee Trevillion (a2), Anna Woodall (a2), Craig Morgan (a1), Gene Feder (a3) and Louise Howard (a4)...
Abstract
Background

Mental health service users are at high risk of domestic violence but this is often not detected by mental health services.

Aims

To explore the facilitators and barriers to disclosure of domestic violence from a service user and professional perspective.

Method

A qualitative study in a socioeconomically deprived south London borough, UK, with 18 mental health service users and 20 mental health professionals. Purposive sampling of community mental health service users and mental healthcare professionals was used to recruit participants for individual interviews. Thematic analysis was used to determine dominant and subthemes. These were transformed into conceptual maps with accompanying illustrative quotations.

Results

Service users described barriers to disclosure of domestic violence to professionals including: fear of the consequences, including fear of Social Services involvement and consequent child protection proceedings, fear that disclosure would not be believed, and fear that disclosure would lead to further violence; the hidden nature of the violence; actions of the perpetrator; and feelings of shame. The main themes for professionals concerned role boundaries, competency and confidence. Service users and professionals reported that the medical diagnostic and treatment model with its emphasis on symptoms could act as a barrier to enquiry and disclosure. Both groups reported that enquiry and disclosure were facilitated by a supportive and trusting relationship between the individual and professional.

Conclusions

Mental health services are not currently conducive to the disclosure of domestic violence. Training of professionals in how to address domestic violence to increase their confidence and expertise is recommended.

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Copyright
Corresponding author
Louise Howard, Section of Women's Mental Health, Health Service and Population Research Department, PO31 Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK. Email: l.howard@iop.kcl.ac.uk
Footnotes
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See editorial, pp. 169–170, this issue.

This paper reports independent research commissioned by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) Programme. The views expressed by the authors are not necessarily those of the NHS, the NIHR, or the Department of Health.

Declaration of interest

None.

Footnotes
References
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Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study

  • Diana Rose (a1), Kylee Trevillion (a2), Anna Woodall (a2), Craig Morgan (a1), Gene Feder (a3) and Louise Howard (a4)...
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eLetters

DISCLOSURE OF DOMESTIC VIOLENCE BY MENTAL HEALTH SERVICE USERS

ANURAG JHANJEE, Senior Resident (Psychiatry)
23 June 2011

DISCLOSURE OF DOMESTIC VIOLENCE BY MENTAL HEALTH SERVICE USERSThe article by Rose et al1 is an interesting article that attempts to throw light over the practical problems faced by the victims as well as the mental health professionals during assessment of domestic violence.The study showed that fear of Social Services involvement, fear that disclosure will lead to family disruption and further violence and that disclosure will not be believed are among the chief barriers to disclosure by the victims of domestic violence. The mental health professionals when dealing with cases of domestic violence are confronted with various problems including dilemma regarding role boundaries, issues related to competency and confidence. In the backdrop of the above mentioned factors, there is an overbearing need to integrate mental health services with social services to ensure effective management of domestic violence cases.We would like to suggest a relook at our existing curriculum for M.B.B.S course with the aim to make provisions for specialized and dedicated training techniques for dealing with cases of domestic violence. The reason for priming the medical students towards dealing with domestic violence so early in their career is that the victims of domestic violence are not exclusively confined to psychiatry clinics and they may be seen utilizing services of other departments.

Domestic violence is an important etiological factor of various psychiatric disorders and because of this reason, it deserves due mention in the currently used classificatory systems of Psychiatric disorders. It is sincerely hoped that with extensive research in the near future, we may be better equipped in dealing with the menace of domestic violence.

References:1.Rose D; Trevillion K; Woodall A; Morgan C; Feder G, and Howard L: Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. The British Journal of Psychiatry (2011), 198, 189-194.
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Conflict of interest: None Declared

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Domestic Violence - Why the abysmal rates of service uptake

MANJULA OCONNOR, Consultant Psychiatrist, Senior Research Fellow
12 April 2011



More than a decade has passed since public education campaigns against Domestic Violence (DV) commenced in Australia. Yet, their impact on service utilization rates has been minor. Only one third of DV victims seek and obtain right assistance. DV is a significant preventable source of much mental, physical illness, including suicide andgynaecological problems. So why as a medical profession and as Psychiatrists we are not making efforts to target DV as a priority remainsunanswered.One obvious symptom of lack of medical interest in DV is that DV Services are stand alone services, away from main stream medical establishments, with minimal engagement with medical profession includingPsychiatry , thus giving an impression that Domestic Violence(DV) is not amedical problem. The result is that medical profession plays a peripheral role in detection and management of Domestic Violence.Many victims suffering from Major Depressive Illness, Anxiety Disorders, PTSD etc are left untreated for their mental disorders. Their management is primarily social and legal.Victims visiting their general practitioners do not share DV with their doctors. If the patients can disclose serious stigmatizing illness like HIV, why not DV. Perhaps the victims do not believe DV to be the prerogative of the family doctor.

Another consequence has been the neglect of serious examination of perpetrators. This leads to continuation of cycle of violence in a large number of cases.While the emphasis of the authors Rose et al is laudable i.e. the medical profession must bring DV as a core topic into the training and education of medical students, as well as General practitioners , Obstetricians and Gynaecologists alongside Psychiatry trainees. It calls for the psychiatry profession to work with political and social structures to make an impact and a contribution to the current systems of service delivery and influence priorities in research funding .
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Domestic violence: we need changes in the ICD and at the start of training

Virginia A Davies, Child and adolescent psychiatrist
30 March 2011

In order to enhance rates of disclosure of domestic violence by service users, Rose et al(1) argue for additional specialist training for mental health professionals. I would argue that this is the wrong level atwhich to pitch training. I would also suggest that to precipitate any realshift in health workers’ attitudes, and therefore practice, we need to seechanges in the International Classification of Disease, version 11 (ICD-11).

With ICD-11 still in its pre-production stages, Rose et al’s excellent paper should be mandatory reading for the Revision Steering Group. If, as the WHO maintain, the ICD-11 aims to serve ‘not only … as a classification system but also as a building block for health’(2), the Revision Steering Group would do well to reflect on the comments captured within this research. Medicine’s ambivalence about accepting domestic violence as a key determinant of health is amply highlighted by the absence in our current ICD of any code for domestic violence. Whereas abuse of children can be recorded with a range of different Z codes, the abuse of adults remains non-existent in terms of axis V coding. This position surely validates both those in this study who do not see domesticviolence as their business, but also goes some way towards promulgating the idea that this is a condition beyond the realms of ordinary practitioners’ experience and therefore competence.

Training about domestic violence needs to happen at university level.Domestic violence is not just something that affects mental health serviceusers, and it is something that medical students can be trained to ask about, think about and feel comfortable enough to approach. I base my comments upon training I co-deliver with a service user to fifth year medical students. The training takes place in the context of practising interviewing skills.

During the course of providing the history, the service user mentions“being in a very violent relationship”. Medical students often freeze at this point, or say something like “I am very sorry”, before moving swiftlyon to another topic. At the end of the interview slot, the service user talks with the student group about how important it is to be able to ask about and listen to this kind of material, and how the student’s desire tomove away from the topic leaves her feeling this is something bad / dirty /unmentionable. She tells them how liberating it has been for her to be able to talk about this experience with others, and we both remind them ofhow common domestic violence is in our society, regardless of class or race or religion. Our work has not been evaluated in terms of whether the students who pass through our module go on to be better at facilitating discussion about domestic violence, but this would perhaps be a useful area of study for medical schools or other professional training centres.

1. Rose D; Trevillion K; Woodall A; Morgan C; Feder G, and Howard L:Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. The British Journal of Psychiatry(2011), 198, 189-194.

2. http://www.who.int/classifications/icd/ICDRevision.pdf
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