Domestic violence could be stopped earlier, says study

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abuse, abusive relationships, Children, coercion, control, coping, danger, domestic abuse, domestic violence, fear, harm, health workers, help, impact, isolation, murder, police, professionals, relationships, risk, serious injury, teenagers, training

Domestic violence could be stopped earlier, says study

Victims of domestic violence are abused for almost three years before they get the help they need, and some are subjected to more than 50 incidents during that time, according to a study of the largest database of domestic violence victims in the UK.

The figures from the domestic abuse charity SafeLives reveal that almost a quarter of “high-risk” victims have been to an A&E with injuries sustained during violent abuse, and some went as many as 15 times before the problem was addressed.

Analysis of the SafeLives database, which has records of more than 35,000 cases of adults experiencing domestic abuse since 2009, found that 85% of victims had been in contact with an average of five professionals in the year before they got “effective” help from an independent domestic violence adviser (IDVA) or another specialist practitioner.

“Time and time again no one spots domestic abuse, even when victims and their children come into contact with many different public agencies. It’s not acceptable that victims should have to try to get help repeatedly. This leaves victims living in fear and danger and risks lifelong harm to their children,” said Diana Barran, the chief executive of SafeLives, which was previously called Co-ordinated Action Against Domestic Abuse (Caada).

Barran said the study was “more shocking evidence” that domestic violence could often be stopped earlier. “Every conversation with a professional represents a missed opportunity to get victims and their children the help they need,” she said.

SafeLives estimates that there are at least 100,000 victims at high risk of murder or serious injury in England and Wales, 94% of them women.

The study found that victims and often their children lived with abuse for an average of 2.7 years. Three-quarters reported abuse to the police, and 23% went to A&E because of violence sustained in abusive relationships.

Frances Wedgwood, a GP in Lambeth who provides training on domestic violence to health workers through the national Iris project, said a challenge for doctors was that many women did not come to them to disclose domestic violence.

“Domestic violence is still a very hidden problem and in my experience women do not disclose if they are not asked,” she said. “We need to get better at asking people directly if they need help.”

The study sheds light on the long-lasting impact of living in a family coping with domestic violence. According to the survey, in about a quarter of cases on the domestic violence database the victim has a child under the age of three. The study estimates that 130,000 children in the UK are living with domestic abuse, and that children are directly harmed in 62% of cases.

Among teenagers who suffered domestic abuse in their own relationships, almost half had grown up in households where violence was commonplace, the study found.

Vera Baird, former solicitor general and the current police and crime commissioner for Northumberland, said professionals needed help and training to have the confidence to deal with domestic violence.

“Domestic abuse is not a one-off violent attack. It is deliberate long-term use of coercion to control every part of the partner’s life. Violence, sexual abuse, financial control, constant criticism, isolating from family and friends are all familiar tools,” she said.

“People in that situation do not find it easy to speak and need those who could help to be alert. The alternative is what these figures suggest: victims and their families locked unnecessarily into cruelty and ill-treatment for years.”

Case study

Rebecca, 34, lived with domestic abuse for eight years before she sought help

One time I was having a nap in the afternoon, the baby had been teething so I’d been awake all night, and I woke up he was standing over me with a mop handle carved into a point, like a spear. He was pushing it into my throat, accusing me of cheating. Then he picked me up and threw me against the wall. I ran downstairs but he followed me, kicking and punching me and split my lip.

I locked myself in the bathroom and called 999. When the doorbell rang I heard chatting, calm talking. There was one young male officer, and my ex-partner was telling him that I was postnatal, that I’d gone mental and he was just defending himself. I started shouting at the officer: ‘Why aren’t you helping me?’ I swore and the officer said people could hear me, and it was a public disturbance so I swore again. He put handcuffs on me. He wouldn’t let me put my shoes on, so I wouldn’t move, and he lifted me up by the handcuffs and put me in the back of the car.

I was in a cell for hours asking for a solicitor. The duty sergeant finally came and when he opened the hatch he could see I’d been attacked. He got the officer to come and apologise to me and asked me if I wanted to file a complaint, or if I wanted to press charges against my partner. But I said no. I was exhausted and my baby was at home with my partner, who’d been drinking since the morning. It got worse after that. He was sort of smug, saying he could do what he wanted. I know there’s more training for police now, but that put me off calling the police for years.

By 2003/4 the abuse was worse. We had two girls by that time. I was hospitalised with concussion after he’d kicked me in the head wearing steel-toe-capped boots. The police and the paramedics came and I was patched up and sent home. They asked me if I wanted to press charges but I didn’t want to go through all that, I thought it would make it worse. I didn’t know where the support would come from, where I could get help.

Another time I went to the hospital walk-in. I had a black eye and it wasn’t getting better. A doctor asked me what had happened and I said I’d been punched in the face. He repeated what I said: ‘You were punched in the face.’ I didn’t know what he wanted me to say. I was ashamed, I didn’t want to say my husband did this to me. If he had asked, I’d have told him. But he didn’t.

Social services got in touch because of the paramedics’ reports; he got put on an anger management course. But Christmas Day night he’d been drinking. He grabbed me by the throat and I stumbled and fell; he kept kicking me over and over again. My teeth went through my lip, my nose was bleeding, I couldn’t see. He picked me up and carried me to the bathroom saying: ‘Look what you made me do. Why did you do that?’ I crawled to the living room and phoned the police before he ripped it out of the wall.

I did press charges that time. He was sentenced to four months for ABH. He served two. We were separated, but we got back together. Why? I had such low self-esteem and he was always there, always pestering me, grinding me down. He’d be so nice, helping with the children and I was exhausted, I needed the help. I thought it might be OK.

It was OK for a while. The kids had been on the at-risk register because a couple of incidents had been reported, but they came off that and social services were visiting less. His behaviour just went back to the way it had been before, and that’s when I decided to leave.

I remember the exact moment when I saw the sticker for the Women’s Aid helpline: it was on the back of the toilet door in Asda. It took me a couple of months to call but when I did they offered me refuge. I didn’t even know that existed. They organised transport when he was out. It was quite surreal, but it was such a relief.

Women’s Aid were so helpful, they gave us so much support including counselling. My eldest daughter was seven when we left, her sister was three and their brother was nine months. That was the main reason I left, I was terrified for my kids.

I do think professionals should offer support. If they can’t support victims themselves, they just need to know who can. I think if I’d had that information I would have left earlier.

I was 16 when we got together; he was 23. By the time I was 17 we had a daughter. I thought it was a good relationship, he helped with the parenting and around the house, but about a year later, in 1999, slowly controlling behaviour crept in. He wouldn’t like certain friends, or me going out without him, wearing certain clothes or makeup. It was quite subtle at first, but then when we argued there was pushing, then hair-pulling – each time it was a little worse than before.

Soon it was normal to have slapping, kicking, punching, throwing things. At first I didn’t tell anyone; my self-esteem was very low. I just tried to pretend it wasn’t happening, I didn’t know anything about domestic abuse.

Exporting trauma: can the talking cure do more harm than good?

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civil war, community, coping strategies, counsellors, crisis, cultural insight, cultural practices, culturally sensitive, culture, Depression, Genocide, group therapy, interventions, mental health issues, NGOs, post traumatic stress disorder, psychological therapy, psychosocial, PTSD, rape, talking therapy, traditional, trauma, treatment, tsunami, well-being, western

Exporting trauma: can the talking cure do more harm than good?

A few years ago Andrew Solomon had to get into a wedding bed with a ram. An entire village, taking a day off from farming, danced around the unlikely couple to a pounding drumbeat, draping them both in cloth until Solomon began to think he was going to faint. At this point the ram was slaughtered along with two cockerels, and Solomon’s naked body was drenched in the animals’ blood, before being washed clean by the village women spitting water onto him.

Solomon had been taking part in a traditional Senegalese ceremony to exorcise depression as research for his book The Noonday Demon. “I discovered that depression exists universally, but the ways that it’s understood, treated, conceptualised or even experienced can vary a great deal from culture to culture,” he says now. He describes being the subject of the ceremony as “one of the most fascinating experiences of my life”.

When in Rwanda, interviewing women raising children born of rape for another book, Solomon mentioned his experience in Senegal to a Rwandan man who ran an organisation helping these women. The Rwandan told Solomon they had similar ceremonies in his country and that the disconnect between the western and traditional approaches to treating mental health had caused problems in the immediate aftermath of the genocide. “Westerners were optimistically hoping they could heal what had gone wrong,” says Solomon. “But people who hadn’t been through the genocide couldn’t understand how bad it was and their attempts to reframe everything were somewhere between offensive and ludicrous. The Rwandan felt that the aid workers were intrusive and re-traumatising people by dragging them back through their stories.”

As the Rwandan, paraphrased by Solomon, puts it: “Their practice did not involve being outside in the sun where you begin to feel better. There was no music or drumming to get your blood flowing again. There was no sense that everyone had taken the day off so that the entire community could come together to try to lift you up and bring you back to joy. Instead they would take people one at a time into these dingy little rooms and have them sit around for an hour or so and talk about bad things that had happened to them. We had to ask them to leave.”

The best way to improve mental health after a crisis is something NGOs working in Ebola-hit countries are currently considering. International Medical Corps (IMC) recently released a report assessing the psychological needs of communities affected by the disease. IMC’s mental health adviser Inka Weissbecker is aware that they must avoid previous mistakes by international NGOs. “Whenever there is a humanitarian crisis agencies flood in,” she says. “Though with good intentions, counsellors turn up from the UK [for example] and often create more problems … It’s a very foreign concept in many countries to sit down with a stranger and talk about your most intimate problems.”

During the recovery from Haiti’s earthquake five years ago mental health researcher Guerda Nicolas was even stronger in her message to American counsellors who wanted to ease the trauma of survivors. “Please stay away – unless you’ve really, really done the homework,” she said. “Psychological issues don’t transcend around the globe.”

The fact is that different cultures have different views of the mind, says Ethan Watters, the author of Crazy Like Us: The Globalization of the American Psyche. “In the west a soldier coming home might be troubled by their battlefield trauma. They think of the PTSD [post-traumatic stress disorder] as a sickness in their mind and they take time away from responsibilities to heal. That makes sense to us and it’s neither wrong nor right but conforms to our beliefs about PTSD. For a Sri Lankan, to take time away from their social group makes no sense because it is through their place in that group that they find their deepest sense of themselves.”

While researching his book Watters spoke to anthropologists who had in-depth knowledge of Sri Lanka’s culture and history. They said that western approaches after the tsunami had done real damage in the country where there were certain ways to talk about violence due to the long-running civil war. He says: “Into that very delicate balance came western trauma counsellors with this idea that the real way to heal was truth-telling, where you talked about the violence and emotionally relived it. That’s a western idea, it makes sense here, but it does not make sense in these villages. It had potential to spark cycles of revenge violence.”

International NGOs describe dealing with the mental health of a community after a disaster as the “psychosocial” response – meaning caring for individual and collective psychological wellbeing. The UN advertises dozens of jobs under this keyword and the American Red Cross says that since the 2004 Boxing Day tsunami there has been “increasing recognition of the need for psychosocial responses”. It also says – perhaps implicitly acknowledging that mistakes have been made in the past – “we are still in the process of identifying and documenting good practices”.

As awareness has grown that the western talking cure is not always the answer, global organisations have tried to find better ways to help. In 2007 WHO issued guidelines to advise humanitarians on their work to improve mental health and psychosocial wellbeing in emergencies. Coordination between the organisations working in the post-disaster zone as a key recommendation. Weissbecker says that this is crucial. “We reach out to organisations who might not know about the guidelines to coordinate,” she says. “It’s part of every agency’s job to watch out for other organisations doing this kind of work.”

The guidelines also stress learning local cultural practices. IMC now always start with an initial assessment that looks at the understanding and treatment of mental health that exists in that country before putting any programmes in place. “We usually don’t provide direct mental health services to the affected population because we feel that most of the time that’s not culturally appropriate and not sustainable,” says Weissbecker. In many communities, she has been impressed with indigenous coping strategies. “In Ethiopia people say depression is related to loss,” she says. “So the community takes up a collection and they all give them something. This is very positive.” IMC meets with traditional healers and builds up relationships with them.

Many argue that for some mental illnesses western expertise can be genuinely helpful. In Ethiopia Weissbecker’s team discovered a man with schizophrenia who had been tied up in a goat shed for seven years. “Once this family was connected to our services he started taking medication was unchained and participating in family life,” she says. “The father held up the chains to the community and said, ‘look I used these chains on my son and now he’s part of the family again’. People will throw stones because they are understandably frightened [of people with severe conditions].”

The Rwandan that Solomon met questioned whether talking therapy helped survivors of the Rwandan genocide. “His point of view was that a lot of what made sense in the west didn’t make any sense to him,” says Solomon. But Survivors Fund, a British NGO that works in Rwanda, has found that western-style group therapy sessions have really helped women who were raped. “It’s 20 years since then but many of the women our groups have never told their story before,” says Dr Jemma Hogwood who runs counselling programmes for the charity. “A lot of women say it’s a big relief to talk,” she says.

Hogwood has been working in Rwanda for four years but hasn’t heard of traditional ceremonies like the one described by Solomon. The group therapy sessions incorporate local practices such as praying before and after, as this is something the women wanted to do. Weissbecker adds that one-on-one therapy with expats can help people who have experienced extreme violence, rape or torture. “Some of them want to talk to foreigners because they don’t trust people in their communities,” she says. “So then it’s also important for them to have that one-on-one option.”

Some feel that aid should be focussed on food, medicines, shelter, and stay away from mental health. International relations academic Vanessa Pupavac has researched the effect of the war in former Yugoslavia, and has argued that “trauma is displacing hunger in western coverage of wars and disasters … Trauma counselling, or what is known as psychosocial intervention, has become an integral part of the humanitarian response in wars.” The problem with this, she believes, is that blanket-defining a whole population as traumatised becomes “a reinforcing factor that inhibits people from recovery”. Her recent work with Croatian veterans found that the PTSD label stops them from moving on with their lives and contributing to society.

“There are more Croatian veterans on post-traumatic stress disorder pensions now than there were ten years ago,” she tells me. “The international-PTSD-framing of people’s experiences has not only inhibited recovery but has also created social, economic and political problems for postwar Croatia.” She believes NGOs should stop psychosocial programmes altogether because they disrupt communities’ own coping strategies.

But this point of view is rejected by Weissbecker and her colleagues, who don’t accept “the romantic idea that without intervention everything will be fine”. The response to mental illness in many countries is often harmful, she says: “Psychotic patients are chained. Children with developmental disorders are at risk of abuse. Mothers with depression have a higher risk of malnourished children. People with anxiety are often given benzodiazepines which can be very addictive.” The solution, Weissbecker says, is to bring together global and local expertise.

The best experts to bridge the gap between international and local experience are those who might not have a health or psychology background, but have deep knowledge about cultural differences: anthropologists. Since the Ebola outbreak there is a growing recognition of this discipline’s role in emergencies. The American Anthropological Association has asked its members to become more involved in the west African countries hit by the disease. It argues that if anthropologists had been more involved from the start of the outbreak more people wouldn’t have caught the disease due to misunderstandings over traditional burials and conspiracy theories about westerners spreading the illness.

Médecins Sans Frontières (MSF) has employed anthropologists to inform their work for years but one of them, Beverley Stringer, says there’s been a “surge” in interest in what they can offer humanitarian work. “I was at a seminar at the Royal Anthropology Institute recently where they said ‘finally the humanitarian world is interested in our perspective’,” she says. “They’re quite excited about that.”

But Stringer warns that getting anthropologists to work for NGOs should not just be a case of parachuting in an expert; aid workers and volunteers on the ground need to recognise that their own experience gives them insight. “If mums aren’t coming to get their kids vaccinated you don’t need to be an anthropologist to work out why,” she says. “My work is to encourage curiosity and to equip teams with the skills to be able to understand.”

Whether it’s through working more with locals and anthropologists – or ideally both – there is recognition that cultural insight is essential for preventing aid workers from causing damage when they are trying to do good.

“I think enlisting the anthropologists in this process – people who truly know about how to go into other countries and be culturally sensitive – is very important,” says Watters.

“One anthropologist asked me to imagine the scenario reversed. Imagine that after 9/11 or Katrina these healers come from Mozambique to knock on the doors of family members of the deceased to say ‘we need to help you through this ritual to sever your relationship with the dead’. That would make no sense to us. But we seem to have no problem doing the reverse.”