Don’t Empty the Bucket: Domestic Abuse in Low Intensity Work (1)

Trigger warning: Theme of domestic abuse and violence with some examples given (nothing explicit or graphic).

While this isn’t a true guest blog this post wouldn’t have been written without the support and contribution of Sheeva W. (@sheevsb). Sheeva is, in her own words: ‘a Low Intensity therapist, an activist and queer intersectional feminist who can oft be found at a climbing wall, feeling angry about the state of the world, or absolutely entranced by some dreadful reality TV show (which definitely sums up the state of the world, but hey girl’s gotta catch a break)’. Thanks again for your support Sheeva.

October is domestic abuse awareness month. I wanted to write about domestic abuse and how it intersects with Low Intensity work anyway, this is the moment. Let me know what you think, and if this is a sensitive subject for you please take care while you read. The links to external sites and resources in this post are particularly worth a click.

https://wellbeing.bitc.org.uk/all-resources/toolkits/domestic-abuse-toolkit

The office of national statistics estimates that 2 million people in England and Wales experience domestic abuse every year. The BBC reported that there were 173 domestic abuse related murders last year. There is a growing awareness that domestic abuse is not just about violence but about coercive control; this was highlighted in a powerful speech delivered in the House of Commons by Rosie Duffield MP and is reflected in recent legislation. It’s rare to find anyone who hasn’t been affected by at least one abusive relationship; either through direct experience, or caring about someone who has been in an abusive relationship and seeing the consequences. Anyone can experience abuse – you can be the partner, sibling, cousin, aunt, uncle, parent, child, in-law or housemate of an abuser.

I’ve occasionally heard comments that someone who is experiencing abuse and violence should just leave the situation. It is never that straightforward; there are a lot of reasons why people stay in their domestic situation (otherwise known as their home and family), even when that is unhealthy or dangerous. Even reporting abuse can seem to cause more problems than it solves, for some people it can genuinely appear that there is no way to escape from the situation.

What does this mean for Low Intensity therapists in IAPT? That’s a long answer so this will be a three part series:

1. This week is about when we’re working with someone who has experienced domestic abuse
2. Next week I’ll talk about when we’re working with the abuser.
3. I think something needs to be said about matters of diversity and culture around domestic abuse; at some point I will post that blog, I might not be the best person to write it though, I’ll ponder on it.

Although we can’t cure or treat domestic abuse I have seen a lot of people over the years whose domestic situation, either current or past, is the trigger and maintaining factor of depression and anxiety. This is yet another area where there are no easy answers or simple guidelines. Whatever the situation of the person who you are talking to, you have to remember that safeguarding children is always the top priority. Always take details and check the safety of any children who are witness to abuse, and follow your safeguarding procedures.

Domestic violence and abuse is not anger

I want to put this at the top because I think a lot of people in IAPT aren’t clear about this. Domestic abuse and violence in intimate relationships aren’t an anger management problem. Domestic abuse and violence in intimate relationships are about power and control. If you send a perpetrator of domestic abuse on an anger management course you risk turning them into a more effective abuser. Don’t offer anger management techniques to a perpetrator of domestic abuse. Likewise don’t offer couples therapy when the relationship is abusive in any way, you risk enabling the abuser.

The LIT role in prevention

I’ve been told by managers and supervisors that domestic abuse is a social work concern and has nothing to do with low intensity work. I disagree. All low intensity therapists should understand patterns and warning signs of abuse and know the red flags that indicate a situation is dangerous. Training is provided in most NHS Trusts, and local authorities sometimes provide it too. This informs your risk assessment but also equips you to make the best use of your position. You might be the first health and social care professional to realise that something is wrong.

I can remember two occasions off the top of my head when people reported early signs of controlling behaviour in a relationship that later escalated to violence. If you can equip someone with good information at an early stage you can be a key part of preventing harm and enabling informed decisions, and you can do it comfortably within the scope of your role and in-line with your organisation’s safeguarding policy and procedures.

The Equality wheel from the Duluth Domestic Abuse Intervention Program https://www.theduluthmodel.org/wheels/

The Duluth wheels are really excellent for this. I once worked with a person who had left a long term relationship to be with a new partner. They were intensely attracted to the new partner and said that they were happy; they were seeing IAPT because of stress. After a couple of appointments the person described that their new partner was trying to tell them what to wear and had threatened to hit a child in the house if my patient didn’t do what the partner asked them to. I showed the person two of the Duluth wheels – one describing a healthy relationship and the other was the power and control wheel. My patient looked at them and asked for copies – the healthy relationship wheel described the relationship they had ended, and the power and control wheel described the new relationship. It was only a few minutes in the session, we didn’t base an intervention on it, I didn’t tell them what they should do (apart from emphasising that I would have to share information to keep the child safe), it was enough that the person could make an informed decision.  

I did get told off by my manager for using the wheels; they are a social care model, not CBT based, and I had overstepped my competencies. I’d do it again though.

The Power and Control wheel from the Duluth Domestic Abuse Intervention Program https://www.theduluthmodel.org/wheels/

Trauma

I once worked out that through IAPT and my pre-IAPT low intensity work I’ve seen more than 3,000 people. Starting with my first assessment as a trainee a shockingly high proportion of those people exhibit signs of a post traumatic response. Before IAPT Post Traumatic Stress Disorder (PTSD) was a bit of a mystery; I thought it was rare, I thought only soldiers got it. Overwhelmingly most of the people who I have met with signs of PTSD are victims of domestic abuse, both male and female.

Whether or not you think that someone has got PTSD if you are offering an IAPT treatment to someone who has experienced domestic abuse there are a few things you need to check out.

1. Is the abuse ongoing?

 If it is then don’t go any further with treatment at that time. Support the person to contact the police if they want to report it, put them in touch with local domestic abuse services. Do a really good risk assessment. I described in an earlier post how domestic abuse led one person to contemplate suicide; people can feel utterly trapped in their domestic situation and suicide can feel like the only way out. Don’t treat anxiety and depression when someone is living with, or in a relationship with, an abuser.

I had a hearbreaking conversation with someone a couple of months ago. They described how they had been in an abusive relationship for years. While they lived with the abuser they had seen a counsellor at their GP surgery for about 18 months. This person sincerely believed that the counselling prolonged the abuse they had suffered. ‘I went to counselling every week and emptied the bucket so that I could go home and have it filled up again. Why didn’t they do something to help me instead of making it possible for me to endure it?’    

2. Is the perpetrator still around?

Even if the abuse is not ongoing treating anxiety when the person who perpetrated the abuse is sitting behind your patient in their classroom, or living one street over and hanging out at the local shops, is complex. Although there might be no more danger (that would be part of your risk assessment) there will still be a lot of threat. You’d have to check if the person is OK to continue with general work on depression and anxiety, or if they need to work with a domestic violence specialist service. In IAPT a slower assessment and personalised formulation in CBT would probably be more helpful than low intensity interventions. Make sure the person has all of the options and make good use of supervision and your Trust’s safeguarding advisors.

3. Is there still danger?

This is similar to the last point but makes a difference in how we might approach treatment for anxiety. When abuse is over and there is no further danger there can still be a sense of threat, things can happen that bring back vivid memories of dangerous events that spark a physiological reaction. That’s different to when there is still real danger of harm.

We saw a lady who had recently left an abusive situation. She had made a police report and the abuser was under a court injunction to stay away from her and her children. Even then he would go to her house at night and try to open the doors and windows. She wanted us to treat the anxiety that was stopping her from sleeping but the threat was real – a dangerous person was trying to get access to her house at night, she needed to be alert. Anxiety is a survival response. We advised her to talk to the police and her solicitor urgently, helped with a referral to domestic abuse services, and did not offer treatment for anxiety.

Complex or simple trauma?

You probably wont pick this apart in a Step 2 assessment, this is about knowing when and were to step. Provision for the treatment of PTSD is different everywhere. NICE updated their guidelines recently to differentiate between treatment for complex and simple trauma. We used to talk about single or multiple incidents. Domestic abuse and violence in intimate relationships is likely to involve more than one incident. Safelives.org.uk say that people will endure about 50 incidents of abuse before they leave a situation. If PTSD is the result of domestic abuse we are usually seeing multiple incident trauma, but that doesn’t necessarily mean it’s complex PTSD. It’s worth having the conversation in your service about how much assessment is expected to take place at Step 2 before someone has an assessment with a CBT therapist who has got training in trauma informed work. Would you, as a low intensity therapist, be expected to decide if further assessment takes place in IAPT or in a specialist service? Do your local specialist services understand how IAPT works and understand the role of the Low Intensity Therapist? Would the accept a referral directly from you or require a Step 3 assessment first? If you don’t feel trained and equipped to do what is expected of you then request (firmly) further training and better supervision.

In closing

Domestic abuse affects hundreds of thousands of people in our country. People from every socio-economic, cultural and professional background are affected. For Low Intensity therapists this requires us to be informed and alert for distorted patterns of power and control in relationships, and confident to speak to that in an assertive, sensitive and compassionate manner. As a LIT we can be a key person in empowering people with the time and information that will enable them to make informed decisions, and we will often facilitate access to support from other teams. Domestic abuse isn’t what we “do” but it is part of our work and our lives, and will affect our clinical decision making.

Next week I’ll write about times when we have worked with people who perpetrate domestic abuse. If this is a topic or area that you’re interested in and you’d like to contribute a post or support me to write mine then I would love to hear from you!