Trigger warning: Theme of domestic abuse and violence – no graphic content. One picture of a fictional non-bloody torture scene from TV.
Welcome to the second in a three part series about how we encounter domestic abuse in IAPT Low Intensity work. These have been personally challenging posts to write and I’ve had a lot of support and encouragement to do it, particularly from Sheeva W. (@sheevesb) whose ideas are incorporated into both posts, thanks again Sheeva!
Last week I wrote about some things that we might consider when a person who has experienced domestic abuse comes to IAPT. This week I will share some examples of when the perpetrators of domestic abuse access our service. Domestic abuse is a huge and multi-faceted topic, I can barely scratch the surface in a couple of posts so please do let me know your response, and look after yourself while you read.
Just a reminder that if someone who reports abusive behaviours comes to your clinic it’s important not to offer anger management – see the first post in this series for an explanation. Also important (and hopefully redundant) to add that if the person who you see in your clinic is a danger to others you have a duty to report that.
The open door
IAPT is – obviously – built on the premise that it should be easy for everyone with depression and anxiety to access evidence based talking therapies that have got a good chance of reducing the symptoms of those conditions (remind me to write a post about the medicalised language we use soon!). Because we are all about ‘improving access’ most IAPT teams have little to no screening in place. Most services have a self-referral system which means anyone can get in touch with an IAPT team if they want to. In most places the first person you speak to in an IAPT team will be a Low Intensity Therapist (LIT/PWP).
In principle I applaud this – I like the idea that effective help is available readily to everyone. I think the low intensity training and experience gives us a unique skill set in assessing, engaging and matching people to appropriate treatment and we are well placed to help people to navigate the system. There are times when I wonder if the open door policy could be implemented in a safer way though.
No escape
Last week I acknowledged the prevalence of domestic abuse in the UK. What this means is that most of the people who work in IAPT will either know someone who has experienced domestic abuse; or will have experienced it themselves. Because of the fast paced and demanding nature of our work there often isn’t the flexibility in the system to put things into place that would protect our wellbeing. Whoever walks through the door to see us, we have to just get on with it.
Let’s say a LIT has eight people booked into their clinic in a day – this is usually the minimum number for a qualified Low Intensity Therapist, but some teams require more. There’s no screening in place, so the LIT might have no idea what the topic of the sessions will be (you mostly just cross your fingers and hope like crazy that it’s depression or anxiety). It’s very possible that the first person who comes in could share information that triggers a reliving episode, or that brings up strong and painful emotion. When that happens, we can’t stop to look after ourselves. If we cancel appointments at short notice people who are asking us for help might have to wait weeks or months to get another appointment; so we carry on.
it’s okay not to be okay to work with certain groups, as in this instance. Like, being aware of own bias and also not quashing down feelings of discomfort or anger due to own experience.
@Sheevesb via Twitter
The Chair
I was in a meeting this week with professionals who were describing who they wanted IAPT to see. None of the suggestions were suitable and there was no consideration that IAPT doesn’t have the resources (time amd expert supervision) to support staff to do the work that was being described. The image that came into my head was a scene from the TV show Lost (yes, again, I’m a geek). There was a scene in season 3 episode 7 where someone was strapped into a chair, their eyes were held open while they were forced to watch a screen of images playing in some sort of torture/brainwashing attempt. Its a dramatic image, but being a Low Intensity Therapist (and probably most other health professions) can feel like that. We have to watch whatever is presented to us; there are a number of forces, including our own compassion and work ethic, keeping us strapped in the chair.
It’s important to build our agency; starting with self-awareness and knowing what will be challenging for us to manage, we then have to keep agitating to make sure that our teams put adequate support and systems in place to protect us and the people who come to us for help. Would you want to be the eighth person to have an appointment with a LIT who relived a domestic incident during their first appointment of the day? I wouldn’t.
The Assessment
One very memorable occasion when the limits of our work became clear happened about six years ago, and is probably typical of what might happen in the normal run of IAPT.
I assessed a man who came to us describing anxiety, he also scored very high on the depression measure. Although he was very charming (charm is a red flag for me) alarm bells were ringing at the first appointment; he described that he needed to know where his partner was all of the time, he checked messages on her phone and became very uncomfortable when she went out without him. His focus was on how uncomfortable his “anxiety” made him. If he didn’t know what his partner was doing all of the time, and if she didn’t do what he wanted, he felt very very bad. If he knew where she was and what she was doing, and she did what he wanted, then he had some temporary relief. He was also having problems at work in a care setting because of his irritability. He wanted us to make him feel better and claimed to have an understanding of the principles of CBT from training he had been on at work.
When I’m assessing someone who is badly affected by anxiety I usually do some normalising ‘a lot of people find that their natural anxiety response can become active in ways that get in the way of living how you want to; we’ve got some ideas that people have found helpful that we could support you to try …’ or something along those lines. With him I remember having a blunt conversation instead. I told him that we weren’t going to help him to control the behaviour of another adult and I was worried about the effect of his behaviour on his partner. I gave him a card with the number for local domestic abuse services and explained that what he was describing sounded very difficult for his partner and she might want some support for herself, I asked him to pass the card to his partner and he agreed to this. He said that he just wanted to stop feeling bad.
Personal impact
After that assessment I had supervision and also spoke to the CBT therapist who was managing that particular part of our work with me. I had to explain that I couldn’t continue to work with this person because he had some similar personal mannerisms to a violent abuser who I had known, and was talking about abusive behaviour. I’m very fortunate to never have experienced violence in a relationship, but someone very dear to me nearly died as a result of domestic abuse and I was unable to respond only to what he was telling me in the room, I was responding to my memories of the other situation. Although I acknowledged my bias and distorted perception, I did also flag that the behaviours he was describing were early signs of abuse and could escalate to violence; ‘he isn’t violent, but it feels like he might be soon. It’s going in that direction.’
I worked closely with the CBT therapist on this case, especially when his partner came to us for assessment and treatment for depression a few months later. We both talked to our supervisors about it but at that time there wasn’t enough to report through safeguarding, all we had was our gut instinct (or what I would now call an instinctive synthesis of training and experience), so we carried on with work as usual.
The outcome
The CBT therapist worked with him on depression. We would usually provide empathy and factual reassurance during treatment; with him we both felt that any reassurance would be taken as collusion or permission. The CBT therapist told me ‘I was worried that if I gave him any empathy he would go home and tell her (his partner) that ‘Sarah (name changed) says it’s not my fault I’m like this’ he’d be implying that I said she’d got to put up with it’. His sessions ended; he was not in recovery but there was nothing further that we could offer. While his partner was in treatment with us the situation did escalate to violence and she ended the relationship.
We reflected on it, trying to think of something that we could have done to prevent that escalation. We couldn’t think of anything.
Change
The person in that example did not acknowledge that his behaviour fit a pattern of domestic abuse. He wanted to feel better and since controlling his partner gave him some relief from unwanted feelings he continued to try to control her; using more and more means to achieve this as time went on.
In contrast there have been times when people who perpetrate domestic abuse and violence have come to IAPT and asked us to help them to change these behaviours. My impression of these people has usually been that they genuinely don’t want to hurt their partner and want to be in a healthy relationship, they just don’t know how. When this first happened, about eight years ago, I couldn’t find anything that would help. I rang every local agency, statutory and third sector, who worked in the field of domestic abuse. No one was offering anything that would work with abusive partners to prevent abuse. I found out two weeks ago that we have now got a voluntary domestic violence perpetrator course in my area.
To finish
That’s the second post in the series, and my take home messages are to alert your manager and supervisor if there are people who you can’t work with safely; see if they can figure out a way to support you. Also please do your safeguarding training and know how to spot patterns of abuse. It doesn’t mean that we have to refuse a service, but we need to work in an informed way.
It’s so important to remember that anyone can be a victim or perpetrator of abuse. No group is exempt. That’s the subject of the third post in this series but it needs more thought and I’d like to take a break from the subject for a few weeks so next week will be a surprise topic.
Please let me know what you think, I’m on Twitter @notapwpguru, the facebook page is www.facebook.com/notapwpguru/ and there’s a contact form on this site. If there is ever anything that you want to say about low intensity work and you’d like it to be a post on here then let me know, I swap chocolate for guest posts!
Resources
https://www.reducingtherisk.org.uk/cms/content/perpetrators is a very helpful guide – the whole site is packed with useful resources on domestic abuse and violence.
http://respectphoneline.org.uk/help-information/domestic-violence-prevention-programmes/ has also got a lot of useful information.
If in doubt contact your local domestic abuse services and ask what is available in your area.
Not a Low Intensity Guru 
One thought on “Trapped in the Chair: Domestic Abuse in IAPT (2)”