The effects of domestic violence and sexual abuse on mental health

The Department of Health and National Institute for Mental Health in England have undertaken a programme of research and policy development since spring 2004 in partnership with the Home Office which has important implications for the practice of psychiatry. This article looks at the Victims of Violence and Abuse Prevention Programme (VVAPP) guide ‘Tackling the Health and Mental Health Effects of Domestic and Sexual Violence and Abuse’ launched in 2006, supported by Department of Health and Home Office ministers and national clinical directors.

Prevalence rates for this type of violence and abuse are high and its effects can be lifelong and debilitating (Boxes 2 and 3). The intention behind the VVAPP has been to assist professionals and services to identify and respond to the needs of individuals affected by domestic violence, child sexual abuse, rape and sexual assault, and sexual exploitation in prostitution, pornography and trafficking; involving victims, survivors and abusers, children, adolescents and adults.
The VVAPP was established to develop national service guidelines based on research commissioned, reviewed and conducted under the direction of the VVAPP Director to document what is known about the nature, extent and effects of victimisation, the needs of those victimised, and the treatment and care most appropriate to their needs. The programme has been advised by six panels of 150 multidisciplinary, multiagency, cross-sector expert professionals, service providers and leading academics. Three research projects were designed to provide a triangulation of findings and evidence. A systematic literature review across all areas and groups has covered epidemiology, impact, therapeutic interventions, protection and prevention of mental health-related violence and abuse.
A Delphi expert consultation on the subject was conducted involving 285 individuals completing 586 questionnaires (Taket et al, in press). This included leading academics and professionals from all disciplines, service providers from all sectors and organisations representing mental health service users. The consultation focused on a number of aspects concerning mental health and violence such as service providers' principles, values, core beliefs, theoretical models and therapeutic approaches, as well as prevention, managing safety and risk, training, overcoming obstacles and improving outcomes of treatment.
A violence and abuse care pathway mapping research project has been conducted with victims of extreme and chronic abuse, and organisations providing preventive interventions with abusers. These include individuals with learning and physical disabilities and those from black and minority ethnic communities. Publication of the three research reports (Department of Health; Itzin et al; Trevillion et al; all in press) and the VVAPP guidelines is scheduled for 2008.
The VVAPP has also mapped services and produced a survey and directory of the 180 voluntary and community sector organisations providing counselling and other therapeutic interventions (in mental health) for adult victims of rape and sexual assault, adult survivors of childhood sexual abuse and young people who sexually abuse. The Home Office are using this to establish an interactive website with the potential to support the introduction of a national rape helpline, modelled on the Women's Aid and Refuge online services and national domestic violence helpline. From 2008, the child health, child and adolescent mental health services, and children's services will routinely collect data on child abuse.
A national scoping of therapeutic services for sexually abused children took place in 2007 involving the ZHDANOVA, I. V.,WURTMAN, R. J., LYNCH, H. J., et al (1995) Sleep inducing effects of low doses of melatonin ingested in the evening. Clinical Pharmacology andTherapeutics, 57, 552-558.
Government's Children's Minister, Royal College of Paediatrics and Child Health (RCPCH), the National Society for the Prevention of Cruelty to Children Director, National Clinical Director for children and young people and the full range of stakeholders including: child and adolescent mental health services, mental health trusts, children's services directors, named and designated paediatricians and nurses, therapists, social workers, children's charities, police, inspectorates and local safeguarding children's boards. Its key messages were the need to improve recognition and identification of sexually abused children, assessment and diagnosis of needs, and interventions using the RCPCH guidance to map pathways and establish managed professional networks across sectors and services.
Since 1999, the VVAPP has taken steps to ensure that these issues are included in Department of Health policy such as the Mental Health National Service Framework, National Service Framework for Children, Young People and Maternity, National Suicide Prevention Strategy, Women's Mental Health Strategy, and the Public Health White Paper.
Similar efforts have been made to ensure that the role of health and mental health services has been included in cross-government policy such as the National Sexual Violence and Abuse Action Plan, UK Action Plan on Human Trafficking, National Domestic Violence Delivery Plan, and National Framework for the Development of Services for Young People Who Sexually Abuse.
All of this has been done with a view to improving outcomes for victimised individuals in terms of: 1. reducing the mental illness, self-harm, physical injury and suicide associated with victimisation 2. increasing safety and minimising re-victimisation 3. improving the quality of life of victims and survivors 4. insofar as possible preventing continued and new offending, through early and effective interventions with abusers.
Considering the above, the work of the VVAPP has been widely supported by the Royal Colleges of 'Society as a whole needs to acknowledge and accept the endemic nature of violence and abuse but, in particular, we -as politicians, policy makers and professionals -need to assume our collective responsibility to address it, reduce it's prevalence and ultimately work towards its eradication. I am of the firm belief that theVVAPP will make an important contribution to this process.The ultimate challenge will be the transformation of practice on the ground.'

Home Office Minister, Baroness Scotland
'Domestic and sexual violence results in highlevels of distress and can be the most damaging physically and emotionally. TheVVAPP will help raise awareness and understanding about these terrible crimes and will be instrumental in the development of coordinated community response to domestic and sexual violence that is emerging.'

National Director for Mental Health, Professor Louis Appleby
'Childhood physical, emotional and sexual abuse and neglect, and domestic violence can have long-lasting, devastating effects on the mental health and well-being of those who are victimised. Developing effective preventative and therapeutic interventions is an important part of the mental health modernisation programme.'

National Director of Primary Care, Professor David Colin-Thome
'I know that we general practitioners are not always fully equipped and supported to identify and respond to the needs of domestic abuse, or rape or childhood sexual abuse. This work should help to increase awareness and understanding and improve the care provided.'

National Clinical Director for Children,Young People and Maternity, Dr Sheila Shribman
'It is very important to keep a focus on the health and mental health needs of children who are sexually abused or victims of domestic violence.The findings of the expert consultation will provide a wealth of information which can be used by paediatricians and other child health professionals to address these issues in the wider context of working together to implement the new Safeguarding guidance.' VVAPP,V|ctims of V|olence and Abuse Prevention Programme.

Box 3. Effects of child violence and abuse on health and mental health
Long-term mental health effects of childhood sexual abuse include depression, anxiety, post-traumatic stress disorder, psychosis, substance misuse, eating disorders, self-harm and suicide (Briere & Runtz1988; Polusny & Follette1995;McGee et al, 2002;Spataro et al, 2004).
Adverse health effects of childhood sexual abuse include higher rates of health-risk behaviours such as smoking, alcohol and drug misuse, risky sexual behaviour (including prostitution), sexually transmitted disease and gynaecological problems (Nurse et al, 2005). Child physical abuse -21% of children subjected to physical violence regularly and 7% severe physical abuse (Cawson et al, 2000) Young people who sexually abuse -a third of sexual offenders in contact with the Criminal Justice System annually are adolescents (Whittle et al, 2006) Domestic violence: women -25% in lifetime,10% per annum, two killed in a week, a quarter of all violent crime (Walby & Allen, 2004), 30% starts or escalates during pregnancy (British Medical Association,1998) Rape and sexual assault -7% women, 0.5% men; 54% current or ex-partners, 35% known to their victim,11% strangers (Walby & Allen, 2004) Psychiatrists, Paediatrics and Child Health, Nursing, and Physicians (Faculty of Forensic Medicine), the British Psychological Society and British Psychoanalytical Society, Women's Aid and Refuge, the National Rape Crisis Network, the Survivors Trust, the Association of Chief Police Officers, and Prison, Probation and Youth Justice Services.
The challenge lies in turning guidelines into practice. As part of the VVAPP, a pilot was established in a number of adult mental health trusts to introduce routine clinical enquiry about violence and abuse in assessment and care planning as part of the care programme approach, focused on those with severe mental illness associated with childhood victimisation. The role of psychiatrists in this pilot and its evaluation, and the national implementation to follow, will be instrumental in helping recovery. The question is whether a similar approach in child and adolescent mental health services would produce better outcomes for children and young people. When I qualified in 1987, I was appalled to learn that the vast majority of the on-call forensic medical examiners who examined women subjected to serious sexual assault and rape in the Metropolitan Police area were men. I was subsequently involved in the establishment of an on-call rota of women doctors who were prepared to examine victims of sexual violence. Nowadays, services deliver holistic non-judgemental intervention, particularly in sexual assault centres. These centres are specialist services providing 24-h forensic examinations, other medical and psychological services and aftercare in a secure and sensitive setting (Lovett et al, 2004;Kelly et al, 2008). This model is now being extended.
There was little in my training that covered the mental health effects of abuse and traumatisation, despite it being known that domestic violence, rape and sexual assault, sexual exploitation and childhood physical, emotional and sexual abuse can have life-long effects on the physical and mental health of the victims. Indeed, it was rare that questions about such traumas were even asked. We know, however, that such trauma leads to significant morbidity (Golding, 1999). Golding reported that the weighted mean prevalence of mental health problems among battered women was 47.6% in 18 studies of depression, 17.9% in 13 studies of suicidality, 63.8% in 11 studies of post-traumatic stress disorder, 18.5% in 10 studies of alcohol misuse and 8.9% in 4 studies of drug misuse.
Although many survivors recover spontaneously, treatment of clinically significant psychopathology is essential. The general practitioner has an important role in identifying those requiring formal treatment and ensuring follow-up is carried out. Post-traumatic stress disorder management guidelines (National Collaborating Centre for Mental Health, 2005) indicate that those affected should be offered trauma-focused psychological opinion & debate