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Family violence and mental health

Position statement Last updated: May 2021 Published in Australia Reference: PS #102

This position statement describes the role of psychiatrists in supporting the mental health of people who have experienced family violence.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises the significant and pervasive impacts of family violence1. This position statement describes the role of psychiatrists in supporting the mental health of those who have experienced, or who are experiencing, family violence and those who perpetrate family violence. 

Key messages

  • Family violence is a significant global public health, social and human rights issue which affects all countries, communities, cultures, religions and socioeconomic groups throughout the lifespan.
  • There is a strong and complex association between family violence and mental health, recognising that people living with and leaving family violence will need psychological as well as physical safety. 
  • Mental health and addiction services have a significant role to play in identifying family violence, responding to those who disclose abuse and to those who abuse, assessing needs and risks, providing support and interventions, as well as referring to specialist agencies.
  • Psychiatrists are essential in multidisciplinary teams, both in public and private practice, in caring for people who are experiencing mental health issues as a result of exposure to family violence and to those who are referred for treatment for perpetrating family violence. Inquiry into current or past history of family violence must be part of a comprehensive psychiatric assessment. 
  • Care for people who are exposed to family violence must be evidence-based, culturally competent and safe, and appropriately targeted to those who are experiencing or perpetrating family violence   
  • Causal factors of family violence are multiple, and complex. It is recognised as a social problem rooted in gender inequality and power imbalance, one that results in significant mental health burden. 
  • Psychiatrists with appropriate training also have a role to play in advocacy and broad-based prevention, using a public health and prevention-based approach, such as by building community awareness and networking with local services.  

Definitions

For the purposes of this position statement, family violence will be defined as a pattern of gendered violent or coercive behaviour being used against those with whom there is a familial or intimate relationship. Such behaviour applies to physical, sexual, reproductive, psychological, verbal, social, spiritual, financial, technological abuse or coercive control which takes place in a current or previous relationship. 

Family violence encompasses intimate partner violence, child abuse and neglect and intrafamilial violence. It occurs within a range of relationships including: intimate partners, children and infants by parents, between siblings, child to parent, towards older people, between other members of a broader family or kinship network, within family like relationships such as carers. Examples of family violence include: abuse perpetrated by intimate partners or ex intimate partners, abuse of older people, forced marriage, pregnancy coercion, children witnessing abuse against a parent, dowry-related abuse, restricting access to or withholding money, online stalking or distributing intimate photographs online without consent. This definition draws from the Family Court of Australia, Australian Institute of Health and Welfare (AIHW) and the Family Violence Act 2018 in New Zealand.[1-3] 

The unequal distribution of power, resources and opportunity, in which there is a different value afforded to men and women, has its historical roots in societal gender norms, laws, and policies, creating the social context in which violence against women occurs. The factors are targets of change and prevention of violence against women and their children.[4]

Background

Family violence (FV) is a significant public health issue which affects all countries, communities, cultures, religions and socioeconomic groups. As a social and human rights issue, it is insidious and destructive, negatively impacting all aspects of health and wellbeing. FV can take many forms including physical, emotional, sexual, spiritual and financial.[5] The most extreme outcome of FV is death with 200 domestic homicides recorded in Australia between 2012-14.[6] In New Zealand, there were 194 deaths related to FV between 2009 and 2015.[7] 

Though FV is experienced by people of all genders, current statistics indicate a much higher prevalence in women, making FV a gendered issue. In Australia, 17 per cent of women report having experienced physical or sexual violence from a current or previous partner.[2] This compares with 6.1 per cent of men in Australia.[2] 1 in 3 women have experienced violence in their lifetime when sexual harassment, emotional and physical violence figures are combined.[8] In New Zealand, 35 per cent of women report having experienced physical or sexual FV, which rises to 55 per cent when emotional abuse is included.[9] Abuse of older people, usually those 65 years and older, is also reported more by females.[10, 11] In addition, FV prevalence increases during times of disasters and other times of community stress.[12] 

It is commonly acknowledged that the physical impacts of FV can be severe, however, it is important to recognise the long term and pervasive impacts of FV on mental health. Individuals who have experienced FV can suffer from a variety of long-term, chronic conditions such as post-traumatic stress disorder, major depressive illness, eating disorders, problematic substance use, chronic pain, generalised anxiety disorders and panic disorder.[13, 14] There is a growing evidence base of the short and long-term physical, mental, sexual, and reproductive health outcomes from experiencing FV across one’s life span.[15]

Violence and abuse are harmful to mental health at any stage of development. Children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are more likely to develop emotional, social, and health-related complications as adults, with the potential to replicate trauma within future families.[7] 

More also needs to be understood about how individual and collective ‘health burdens’ are shaped and compounded by poor organisational responses and the embeddedness of structural inequities, for example, why victims who receive negative responses to their help-seeking are more likely to receive a diagnosis of a mental health disorder and why Māori whanau seeking help continue to experience institutional racism.[16,17]
Subsequently, FV must be understood as a complex, nuanced phenomenon which is not always easily recognised as it occurs across and within a cross-section of relationships such as that within families/whānau or between intimate (or ex) partners. 

Evidence

People living with and leaving FV need psychological as well as physical safety as FV has long term and far reaching negative impacts on mental health. Trauma informed practice, based on the principles of safety, trustworthiness, collaboration and empowerment supports recovery.[13,18] 

Though there are many complexities and variables involved, mental health plays an important role in many areas of FV. Women with pre-existing depression or major mental health disorders are more vulnerable to experiencing intimate partner violence victimisation and re-victimisation.[19] 

Though not present in all cases, high rates of mental health conditions are present among men arrested for domestic violence, particularly PTSD and depression.[20] While prevalence data in some studies varies, it found that in perpetrators of domestic and family violence homicides there was a history of mental health issues (33.3%), problematic substance use (50.4%), suicidal ideation (17.1%) and suicide attempts (13%).[21, 22] 

Though more research on the mental health of perpetrators is needed, mental health services still play an important role in assisting perpetrators of FV in areas such as treatment of co-morbid mental disorders. Substance use services may also play a role in providing treatment to perpetrators of FV.[23] Though never an excuse to use violence and coercion, perpetrators of FV may have experienced FV at some point in their lives, adding a layer of complexity to the issue which must be addressed within the entire spectrum of mental health interventions starting with prevention and early intervention.[22] Evidence shows that childhood education programmes around gender norms and attitudes can help prevent FV before these attitudes become entrenched.[24]

Significant proportions of perpetrators of FV, particularly those who offend against an intimate partner or a previous partner, are likely to reoffend.[21] More research is needed into culturally aware, evidence-based programs which aim to change violent and controlling behaviour into behaviour and communication which supports healthy relationships.[25] Currently there is a dearth of prevention and intervention services for perpetrators in Australia and New Zealand which must be addressed. Psychiatrists may identify and collaborate with existing successful social and justice programmes where possible.

When dealing with perpetrators, safety of the person experiencing FV should always remain the first priority including children and infants (even if the violence has not been aimed at them directly). The introduction of legislation in New Zealand works towards prioritising supporting people who are survivors of FV. However, in Australia, further work is required by the courts to better safeguard the mental health of adults, children and families involved in proceedings, to provide consistent, safe outcomes for survivors of FV.[26] Perpetrators may also use court proceedings to continue their abuse including utilising the court system to further deplete the financial resources available to their previous partner or family member.[27]

Vulnerable populations

While FV is a significant concern across all populations, there are several populations who are more vulnerable to experiencing FV including: children and infants, people with disability, older people, people from culturally and linguistically diverse backgrounds, LGBTIQ+, people in rural and remote areas, Aboriginal and Torres Strait Islander people and Māori.[2, 28] Pregnant women or women in the postnatal period are also vulnerable as FV can begin or worsen during these times.[24]

Multiple factors in these populations increase vulnerability to experiencing FV and can also act as a significant barrier to seeking and being able to obtain support.[29] Power imbalances can help perpetrators use abuse and coercion against those who may require their support such as the case of caring for a disabled family member who requires care, threats to ‘out’ a partner as LGTBIQ+ to family or those who rely on a family member for residency status.[30-32] 

The intergenerational impact of exposure to FV, even when not directed at a child or infant, can result in high levels of anxiety and post-traumatic stress.[33] Children who have grown up in environments with FV may not have accurate reference points for how healthy relationships function. 

FV amongst people from culturally and linguistically diverse backgrounds is multifactorial.[34] In addition, migration-related factors play a role in enhancing vulnerability to FV. It remains poorly understood due to lack of evidence and underreporting, however, it is clear there is a need for more culturally responsive services.[22]

Aboriginal and Torres Strait Islander people and Māori are more likely to experience FV then a non-Indigenous person.[2, 7] The impacts of colonisation is understood to be a fundamental cause of the fragmentation of traditional culture, discrimination and racism effecting Aboriginal and Torres Strait Islander people and Māori. Aboriginal and Torres Strait Islander people are 32 times more likely to be hospitalised due to FV, then non Aboriginal and Torres Strait Islander people.[2] Due to continued impacts of colonisation, support from FV may often be provided informally through family or friends rather than services. FV is a continuing legacy of colonisation discrimination and destruction which have forced fragmentation in traditional Māori culture and did not exist in pre-colonial times.[35, 36] It is more than just an issue of coercive control commonly associated with FV affecting the majority of the population.[37] Rather whānau (family) violence is entangled in a history of colonisation, socioeconomic deprivation, and trauma that persists into contemporary times.[38] It extends beyond just intimate partners and children to include wider whānau members (such as siblings, grandparents, aunties, uncles, and cousins).  

Older people often rely on others to assist them in daily living or have conditions which make them vulnerable to experiencing FV (such as dementia). It may be intergenerational, with adult children perpetuating violence, abuse or neglect against a parent, such as forcing a parent to hand over money or assets.[39] Abuse of older people is a serious health problem with more than 10,900 calls made to a hotline for older people experiencing abuse across Australia in 2017-18 (except the Northern Territory), though, like many forms of FV, it is often underreported.[2]

The role of mental health services in responding to family violence

Due to the association between mental health conditions and FV, mental health services have a significant role to play in the identification of those consumers of mental health services who are at risk of experiencing, or who are experiencing FV, as well as those perpetrating FV.  To better ensure a positive outcome, the involvement of mental health services may also need to be part of a cross-agency interventional approach utilising trauma and violence-informed practice to address needs which should include recognising the cumulative impact of current and past trauma. Strengthening how hospitals and health services interact with other sectors, creating a holistic FV system would help support people who have experienced, or are experiencing FV.[40] 

Psychiatrists can play an important role in clinical leadership as well as identification, risk assessment and referral, and treatment including perpetrators of FV.[41]  As medical professionals are often the first point of contact, they are uniquely situated to identifying and responding to FV for those experiencing, those perpetrating FV and those who have experienced FV in the past. This includes being aware of factors or signs which may make a person more vulnerable to experiencing FV, for example, an older person with dementia experiencing coercion and abuse from a support person or family member. 

As such, it is important that mental health professionals have training in FV including how to enquire about exposure to FV, the nature and intersectionality of FV and how best to provide support.[42] Responding to disclosure in a way that safely engages the individual in a comprehensive assessment with collaborative development, with the consumer, of an individualised care plan to address needs, including risk is essential to supporting people who are experiencing FV. 

There is some evidence of positive outcomes for a range of therapeutic interventions in the context of FV such as psychological therapies, psychotropic medications, and supportive networks.[43]

Acknowledgement of the complexities around the relationship held between the person experiencing violence and the perpetrator is also necessary. Psychiatrists also work with perpetrators of FV in assessing risk and providing treatment and referrals where appropriate. 

Partnering with local, safety services and resources, particularly those in the FV services sector, is important to building safe places for people seeking practical help.[28] This includes ensuring appropriate confidentiality, safety and privacy principles are maintained to protect people who are experiencing or have experienced FV from further harm from perpetrators and other people.[28] 

Further reading

The issue, Our Watch
Position Statement 100: Trauma-informed practice, RANZCP

Recommendations

Policy

  • Develop and implement policies by government to prevent FV, with clarity on how sectors such as health, disability, homelessness, family violence, immigration, multicultural, Aboriginal and Torres Strait Islander and Kaupapa Maori and Pasifika services, can work together to address FV.
  • Develop public policy initiatives and legislative reform to protect victims and rehabilitate perpetrators and partnering with other organisations committed to decreasing FV.
  • Ensure policy is developed which prioritises safety and acknowledges FV is a largely gendered issue.

Governments

  • Ensure funding is provided for mental health support and treatment for people who have experienced FV.[40]
  • Establish a national mechanism for funding FV counselling and therapeutic services by medical professionals.[40]
  • Provide more funding for women’s refuge accommodation services so ensure safe housing is available for women and children including ensuring access to addiction services. 
  • Establish a method of collecting data nationally which can be used to calculate the need and cost of FV.[40] 
  • Resource health services to implement a multidisciplinary model for responding to FV, drawing on evaluated approaches.[40]

Health services

  • Increase access to mental health assessment, treatment and support for perpetrators of FV.
  • Ensure policies and procedures are available which incorporate trauma and violence-informed practice based assessment, risk and treatment of those who have identified as experiencing (or who have experienced) FV including supervision for staff in responding to disclosure.[28, 44] Further information about Trauma-informed Practice can be found on the RANZCP’s Position Statement 100: Trauma-informed Practice.
  • Identify networks and referral pathways for local services which can assist people seeking help including FV services, police, disability, aged care, homelessness and social services, for services which cannot use multidisciplinary teams.
  • Display culturally appropriate posters and brochures to advise to patients and visitors that the service is safe place to seek help for all types of FV.[28]

Education and training

  • Fund ongoing education programs for health, medical, disability and aged care professionals to better identify, understand and respond to FV which align to standards of best practice.[40] The RANZCP and individual psychiatrists have a responsibility to continually improve training and practice for assessing and treating people with lived experience of FV and those who perpetrate FV.
  • Enhance community awareness of FV and gender inequality by contributing to multi-agency education programs in community services, schools and health services using culturally appropriate approaches.[24]

Research and programs

  • Fund evidenced-based programs for recognition, treatment and rehabilitation of perpetrators involved in FV, including programs which focus on prevention.
  • Fund research to build an evidence-base into the psychiatric impacts of FV, intergenerational trauma and prevention of FV, to improve mental health and addiction responsivity to FV.[45] 

The RANZCP recognises the differing terminology used between jurisdictions for family violence, including domestic violence. Family violence has been used for the purposes of this position statement as this is the preferred term in New Zealand and several other Australian jurisdictions and broadens the scope to include all forms of family-based violence, not only that perpetrated in an intimate partner relationship. It also reflects the wording used for the RANZCP’s Family Violence Psychiatry Network.

References

1.    New Zealand Ministry of Justice. A new Family Violence Act 2018 [Available from: https://www.justice.govt.nz/justice-sector-policy/key-initiatives/reducing-family-and-sexual-violence/a-new-family-violence-act/].
2.    Australian Institute of Health and Welfare. Family, domestic and sexual violence in Australia: continuing the national story. Canberra; 2019.
3. Family Court of Australia. What is family violence? : Family Court of Australia; n.d [Available from: http://www.familycourt.gov.au/wps/wcm/connect/fcoaweb/family-law-matters/family-violence/what-is-family-violence].
4.    Our Watch, Australia's National Research Organisation for Women's Safety, VicHealth. Change the story: A shared framework for the primary prevention of violence against women and their children in Australia. Melbourne, Australia: Our Watch; 2015.
5. Royal College of Psychiatrists. Domestic violence and abuse – the impact on children and adolescents n.d [Available from: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/domestic-violence-and-abuse-effects-on-children].
6.    Australian Institute of Criminology. AIC reports, Statistical report 02, Homicide in Australia 2012-13 to 2013-2014: National Homicide Monitoring Program report. 2017.
7.    Family Violence Death Review Committee. Fifth report data: January 2009 to December 2015, New Zealand. Wellington, NZ: Family Violence Death Review Committee; 2017.
8.    Australian Bureau of Statistics. Personal Safety Survey 2016. ABS2016.
9.    New Zealand Family Violence Clearinghouse. Data summary: Violence against women (Data summary 2, June 2017). 2017.
10.    Kaspiew R, Carson R, Rhoades H. Elder abuse in Australia. Family Matters. 2016(98):64-73.
11.    Glasgow K, Fanslow J. Family Violence Intervention Guidelines: Elder abuse and neglect. In: Health NMo, editor. Wellington, NZ2006.
12.    Health Equity Research and Development Unit. Rapid Evidence Review: Domestic Violence and COVID-19. 2020 8 April 2020.
13.    Braaf R, Barrett Meyering I. Fast facts: Domestic violence and Mental Health. Australian Domestic & Family Violence Clearinghouse. 2013.
14.    Royal Australian and New Zealand College of Psychiatrists VB. Victorian Royal Commission on Family Violence, RANZCP Victorian Branch Submission. Royal Australian and New Zealand College of Psychiatrists; 2017.
15.    Webster K. A preventable burden: Measuring and addressing the prevalence and health impacts of intimate partner violence in Australian women. ANROWS Compass (07/2016 ed.). . Sydney, Australia: ANROWS; 2016.
16.    Richardson C, Wade A. Islands of safety: Restoring dignity in violence-prevention work with indigenous families. First Peoples Child and Family Review. 2010;5:137-45.
17.    Inquiry into Mental Health and Addiction. Oranga Tangata, Oranga Whanau: A Kaupapa Maori Analysis of Consultation with Maori for the Government Inquiry into Mental Health and Addiction. Wellinton, NZ; 2019.
18.    Isobel S. Trauma informed care: a radical shift or basic good practice? Australasian Psychiatry. 2016;24(9):589-291.
19.    Khalifeh H, Moran P, Borschmann R, al e. Domestic and sexual violence against patients with severe mental illness. Psychological Medicine. 2015;45:875-86.
20.    Shorey R, Febres J, Brasfield H, Stuart G. The prevalence of mental health problems in men arrested for domestic violence. Journal of Family Violence. 2012;27(8):741-8.
21.    Australian Institute of Criminology. Trends  & issues in crime and criminal justice: Domestic violence offenders, prior offending and reoffending in Australia. Australian Government; 2019.
22.    Queensland Government. Domestic and Family Violence Death Review and Advisory Board, 2017-18 Annual Report. Brisbane, Queensland: Domestic and Family Violence Death Review and Advisory Board; 2018.
23.    Morgan A, Chadwick H. Key issues in domestic violence. 2009 December 2009.
24.    World Health Organisation. Promoting gender equality to prevent violence against women. Switzerland: WHO; 2009.
25.    Council of Australian Governments. National Plan to Reduce Violence against Women and their Children. 2015.
26.    Parliament of Australia. Parliamentary inquiry into a better family law system to support and protect those affected by family vioence: 3. Challenges of current system: Parliament of Australia; 2017 [Available from: https://www.aph.gov.au/Parliamentary_Business/Committees/House/Social_Policy_and_Legal_Affairs/FVlawreform/Report/section?id=committees%2Freportrep%2F024109%2F25161.
27.    Douglas H. Legal systems abuse and coercive control. Criminology and Criminal Justice. 2017;18(1):84-99.
28.    Fanslow J, Kelly P, Ministry of Health. Family violence assessment and intervention guideline: Child abuse and intimate partner violence (2nd ed). Wellington, New Zealand: Ministry of Health; 2016.
29.    Australian Institute of Family Studies, Child Family Community Australia. Intimate partner violence in Australian refugee communities: Scoping review of issues and service responses. 2018.
30.    People with Disability and Domestic Violence NSW. Women with Disability and Domestic and Family Violence: A Guide for Policy and Practice 2015 [Available from: http://dvnsw.org.au/pwd_doc1.pdf.
31. Community Law. Family violence, vulnerable migrants and other special visa policies: Family/domestic violence n.d [Available from: https://communitylaw.org.nz/community-law-manual/chapter-28-immigration/family-violence-vulnerable-migrants-and-other-special-visa-policies/].
32. Campo M, Tayton S. Intimate partner violence in lesbian, gay, bisexual, trans, intersex and queer communities, Key issues: Australian Institute of Family Studies; 2015 [Available from: https://aifs.gov.au/cfca/publications/intimate-partner-violence-lgbtiq-communities].
33.    Gerrard J. Every 4 minutes: A discussion paper on preventing family violence in New Zealand. 2018 6 November 2018.
34.    O'Connor M, Colucci E. Exploring domestic violence and social distress in Australian-Indian migrants through community theater. Transcultural Psychiatry. 2015;53(1):24-44.
35.    Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice: Australian Government Department of the Premier and Cabinet; 2014.
36.    Committee FVDR. Fifth Report Data: January 2009 to December 2015. Wellington: Family Violence Death Review Committee; 2017.
37.    Johnson M, Leone J, Xu Y. Intimate terrorism and situational couple violence in general surveys: Ex-spouses required. Violence against Women. 2014;20(2):186-207.
38.    Wilson D. Journal of Indigenous Wellbeing. Transforming the normalisation and intergenerational whānau (family) violence;1(2).
39.    Senior Rights Victoria. Elder abuse as family violence. n.d.
40.    Victorian Royal Commission in Family Violence. Summary and recommendations. 2016 March 2016.
41.    Braff R, Barrett-Meyering I. Domestic Violence and Mental Health: Fast Facts 10. Australiand Domestic and Family Violence Clearinghouse; 2013 May 2013.
42.    Victorian Department of Health and Human Services. Chief Psychiatrist's guideline and practice resource: family violence. Victoria: Victoria Department of Health and Human Services; 2017.
43.    Hameed M, O'Doherty L, Gilchrist G, Tirado-Munoz J, Taft A, Chondros P, et al. Psychological therapies for women who experience intimate partner violence. Cochrane Database of Systematic Reviews. 2020(7).
44.    Spangaro J, Ruane J. Health interventions for family and domestic violence: a literature review for NSW Kids and Families. University of New South Wales; 2014.
45.    Short J, Cram F, Roguski M, R S, J K-M. Thinking differently: Re-framing family violence responsiveness in the mental health and addictions health care context. . International Journal of Mental Health Nursing 2019;28:1209-19.

Footnote reference: https://aifs.gov.au/cfca/publications/domestic-and-family-violence-pregnancy-and-early-parenthood 

Responsible committee: Family Violence Psychiatry Network Committee (FVPN) 

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.