Intimate partner violence (IPV) is a public mental health issue that requires collective societal change to tackle it effectively, according to a Lancet Psychiatry Commission published today.
The authors, a group of internationally renowned experts in IPV and mental health, including those with personal experience, have said that the relationship between IPV and mental health problems is an issue that has been marginalised by society and by clinicians in mental health services. They suggest that reducing levels of IPV in society experienced by women and witnessed by their children could go a long way to bringing down the number of people, who experience illnesses like depression, anxiety, and post-traumatic stress disorder (PTSD).
Professor Soraya Seedat, Executive Head of the Department of Psychiatry at Stellenbosch University's Faculty of Medicine and Health Sciences is one of the senior authors of the Lancet Psychiatry Commission that can be accessed here.
A gendered problem
While the relationship between IPV and mental illness is a complex issue, the authors are clear that it is women and girls who overwhelmingly bear the burden of these experiences. More than one in four women and girls over the age of 15 (27%) have experienced either physical or sexual IPV.
A root cause of this is gender inequality, something that manifests itself at all levels of society. Women and girls living in societies that are most unequal in terms of gender relations are at the highest risk of experiencing IPV, especially where violence against women is an accepted norm.
The authors suggest that a key issue that needs to be addressed are societal norms that promote violence. Men's endorsement of sexist, superior, or sexually hostile attitudes can all be predictors of someone who is likely to commit IPV, while women might be expected to tolerate violence against them.
However, the Commission suggests that challenging these beliefs early on can be an effective means of ensuring they do not take hold later in life. They identify schools as particularly important here. The creation and promotion of an ethos that models gender equality and respectful relationships would educate both boys and girls from an early age that people are to be respected.
Policies and legislation are also important including the UK Domestic Abuse Act (2021) which highlights the impact of IPV on children, and the need for adequate funding for specialist services in the third sector. The gendered impact of the COVID-19 pandemic highlights how societal changes such as lockdowns are associated with increases in IPV.
Professor Louise Howard, the Commission's lead author and a professor in Women's Mental Health at King's College London UK's Institute of Psychiatry, Psychology & Neuroscience (IoPPN) said: “Our findings reinforce the need for mental health services to follow the NICE Public Health 2014 guidance which recommended mental health professionals routinely ask about IPV as it is so common an experience of people using mental health services."
A mental health system in need of reform
People experiencing mental health problems often require the help of professional services to deal with their illness. While this can be the first step towards recovery for many, the Commission finds that many survivors of IPV find interacting with these services to be harmful and retraumatising.
The prevalence of IPV experience among mental health service users is high. Previous research reported that around 2/3 of women and 1/3 of men in contact with mental health services had experienced domestic abuse – figures that are considerably higher than found in the general population. In the year before they were interviewed, a quarter of women and just over 10% of men had experienced domestic abuse – a rate that was more than double that of the general population. However, the Commission finds that the design of these services mean that that they too often concentrate on symptoms that users have, rather than establishing what happened to them and how they can be best supported.
The Commission suggests a number of ways to address this issue. Trauma-informed care that has been co-produced by people with direct experience of IPV would help to provide more targeted treatments to those in need, and awareness training would help to educate clinicians further.
Finally, they suggest that asking about IPV by practitioners trained in how to ask and respond safely and who work within a clear referral network should be a standard part of mental health assessments.
Professor Louise Howard said: “There is a distinct lack of training offered to mental health professionals like myself. I am a practising psychiatrist. As a medical student, a trainee, and even when I started practising in general adult psychiatry, I was never taught about the effects of domestic violence.
“Given how prevalent this is among service users, this represents a desperate oversight that urgently needs to be addressed."
A societal response
The Commission's authors acknowledge that the gendered inequalities that underpin IPV are present in all social systems and institutions, but is much more likely to affect those that come from disadvantaged backgrounds. Challenging IPV needs to be prioritised at all levels in all systems, and the authors are calling for a collective societal effort to face this challenge, with the health, criminal justice, security, faith, education, and civil society systems all needing to act cooperatively.
While the authors recognise that there are problems, they also suggest that there are solutions. Stable housing, high quality education, and employment opportunities can all help to reduce levels of gendered violence.
Professor Helen Fisher, Professor of Developmental Psychopathology at King's IoPPN said: “Collective momentum must be matched with real world actions. In recent years we have seen the funding for specialist IPV services reduced, including in services designed specifically to aid women from racial minority backgrounds which were already severely underfunded."
This Commission was supported by funding from the UK Research and Innovation through the Violence, Abuse and Mental Health Network (https://www.vamhn.co.uk/).
Photo caption: Prof Soraya Seedat
Photo credit: Stefan Els