View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by London Met Repository October 2015 Violence, abuse and mental health in England Population patterns Responding effectively to violence and abuse (REVA project) Briefing 1 Summary • New analysis of national survey data shows that a quarter of the population have had experience of violence and abuse. • This research highlights strong links between different types of violence and abuse and a range of mental disorders. • These experiences are major and under-acknowledged factors shaping people’s service needs. • Services must address both mental health and violence and abuse if they are to respond effectively to service users’ needs. Introduction and key findings In 2006 the Department of Health introduced routine enquiry about peoples’ experience of violence and abuse as part of adult mental health assessments. This was in response to evidence that such experience was a significant aspect of the histories and difficulties of many service users. This research extends the evidence base by showing how mental illness is linked with experience of abuse and violence. It is based on a representative community-based sample rather than a patient population and examines experiences of both women and men across the life course. Key findings • Experiences of violence and abuse are strongly related to subsequent mental health and the services people need and use. • Six distinct groups in the population were identified through analysis of data from the Adult Psychiatric Morbidity Survey (APMS) on reported experiences of violence and abuse in childhood and adulthood. • Three quarters of the population have little experience of violence or abuse, but the remaining quarter consisted of people with five distinct profiles of violence and abuse. Each group differed in terms of their socioeconomic circumstances, health, mental health and use of treatment and services. Poverty, disability, poor health and health risk behaviours were much more common in those groups characterised by extensive violence and abuse. • One of the groups, representing 1 in 25 of the population (around 1.5 million adults) had experienced extensive forms of both physical and sexual violence, with an abuse history extending back to childhood. Nearly everyone in this group had, at some point in their life, been pinned down, kicked or hit by a partner. Half had been threatened with death. Most had been sexually abused as a child and some severely beaten by a parent or carer. Many had also been raped as an adult. Over half the members of this group had a common mental disorder such as clinical depression or anxiety. However, only 10% were in receipt of counselling or a talking therapy when they were interviewed. • A further group – representing 1 in 50 of the population - were characterised by their experience of extensive physical violence and coercive control by a partner (but not by other kinds of abuse). They also had very high levels of common mental disorder. Our analysis shows an extremely strong relationship between partner violence and mental health which has previously received little attention. 01 Relevance for service provision Mental health professionals Public health People who have experienced extensive physical and sexual violence are far more likely than those with little experience of violence or abuse to have a common mental disorder, psychosis, PTSD or an eating disorder. Effectively supporting survivors of violence and abuse should be ‘core business’ for mental health services. Sexual and domestic violence are major public health issues. Violence and abuse are experienced in all socioeconomic groups but those with the most extensive experience are more likely to also have to cope with disability, low-income and the challenges of poorer health, housing and neighbourhoods. The evidence clearly links the experience of extensive physical and sexual abuse with alcohol dependency, smoking, and obesity. Health care commissioning Despite being 15 times more likely to have multiple mental disorders, people with extensive experience of physical and sexual violence were just four times more likely to discuss their mental health with a GP and only three times more likely to access community mental health services. Only 10% were receiving any kind of talking therapy. However, they were 12 times more likely to have spent time as an in-patient on a mental health unit. Crisis and emergency services Suicide attempts are 15 times more likely among people who have experienced extensive physical and sexual abuse. They are also 5 times more likely ever to have self-harmed than those with little experience of abuse. A&E staff, paramedics, police and fire officers are likely to encounter survivors of violence and abuse at their most distressed. 3 02 The research The findings presented here were part of wider research into effective mental health service responses to the long-term consequences of violence and abuse, conducted by researchers from NatCen Social Research, DMSS Research, and the Child and Women Abuse Studies Unit at London Metropolitan University. The analysis presented here uses data from the Department of Health funded Adult Psychiatric Morbidity Survey (APMS). This is the only representative, national, community-based data source to use mental assessments to generate rates of treated and untreated mental illness and risk factors in England. APMS 2007 included long interviews with 7,400 adult men and women of all ages from across England. They were asked about their: • Experience of a range of types of violence and abuse • Current mental health • Current social and economic circumstances • Use of health and community mental health services. We used latent class analysis, a statistical approach which divides the population into non-overlapping groups of people with similar profiles, in order to increase our understanding of how people with different histories of violence and abuse go on to have different mental health outcomes and service needs. 4 03 Lifetime experience of abuse and violence: the six groups The population can be divided into six different profiles based on lifetime experience of a wide range of different types of abuse and violence. 5 03 Life time experience of abuse and violence: the six groups Group 1 Group 5 Relatively little experience of violence or abuse Three quarters (76%) of the population belonged to this group and had relatively little experience of any of the types of abusive experience asked about. However, even in this group, 3% had been prevented by a partner from seeing friends and family, and 2% had household finances withheld. 14% reported some experience of having been bullied. Sexual violence as an adult (and sometimes also in childhood) Group 2 Physical violence from a partner One in ten (10%) belonged to this group. 81% of whom had been ‘pinned down, slapped, pushed’ by a partner, and 61% had been ‘kicked, bit, hit’. There was some evidence of coercive control. For example, a third (33%) had been prevented from seeing friends/ family and 39% were threatened with hurt. However, sexual abuse and the more ‘severe’ types of physical abuse (choking, use of weapon, threatening to kill) were rarely reported by members of this group. Group 3: Extensive physical violence from a partner 3% of the population was in this group. The abusive experiences that defined this group were almost entirely sexual. Virtually all (99%) had experienced non-consensual sexual touching as an adult, and almost a third had non-consensual intercourse in adulthood (30%). Childhood sexual abuse was also evident in this group: half had been ‘talked to in a sexual way’ and 40% had been touched sexually as a child. Group 6 Extensive physical and sexual violence as adult and child One in twenty-five (4%) of the population was in this group. Almost all had been ‘pinned down, slapped, pushed’, as well as ‘kicked, bit, hit’ by a partner, and had experienced high levels of coercive control. In addition, they had suffered very high levels of severe sexual violence: 38% had non-consensual sex in adulthood and 23% had experienced this as a child. One in fifty (2%) were assigned to this group. 81% of people in this group had been threatened with death and 53% had weapons used against them. Almost all had been ‘pinned down, slapped, pushed’ and ‘kicked, bit, hit’ by a partner, and two-thirds (65%) had also been choked. They had experienced high levels of coercive control. However, members of this group had experienced very little sexual violence. Group 4 Sexual violence as a child (not in adulthood) One in twenty (5%) belonged to this group. 85% had been ‘talked to in a sexual way’ and 66% had been touched sexually as a child. 13% had experienced non-consensual sex in childhood. 13% of people in this group had been beaten by a parent. Although almost half had experienced non-consensual sexual talk in adulthood, few had experienced abusive sexual contact as an adult. 6 04 Profiles of the six groups Proportion of each violence and abuse group who are female 84 80 73 67 60 46 % Little violence/abuse Physical from partner Extensive Sexual: only as physical/coercion, child partner Sexual: adult, sometimes child Extensive physical, sexual as child/adult Sex, age and ethnicity Women were more likely than men to be in every abuse group, especially those groups where such experiences were most extensive. 84% of those in the ‘extensive physical and sexual violence’ group were women. However, men were present in every group. The people most likely to be in a group characterised by violence and abuse were divorced women aged 35 to 54. group. The low prevalence of older people in the groups characterised by violence and abuse may be partly due to under reporting of violence by this age group. In terms of ethnicity, white people were overrepresented in one of the two physical violence only groups, and black people were overrepresented in the ‘extensive physical and sexual violence’ group. Divorced and separated people were overrepresented in groups characterised by extensive violence and abuse, and older people (and the widowed) were overrepresented in the ‘little violence or abuse’ 7 04 Profiles of the six groups Socioeconomic profile Extensive experience of violence and abuse was more common among; people with a lower household income, a low level of educational qualification (GCSE or equivalent) and living in rented households, in the most deprived neighbourhoods. However, this pattern did not hold for all groups characterized by violence and abuse. Having a degree, for example, was associated with being in one of the two sexual violence only groups. While there were associations between socioeconomic factors and abuse and violence, what was even more pronounced was the fact that violence and abuse are experienced in all socioeconomic groups. 29% of people with extensive experience of physical and sexual abuse live in households with an income in the highest tertile. Proportion of each violence and abuse group living in a household in the lowest income tertile 48 42 31 32 27 23 % Little violence/abuse Physical from partner Extensive physical/coercion, partner Sexual: only as child Sexual: adult, sometimes child Extensive physical, sexual as child/adult Health, wellbeing and disability Violence and abuse were strongly and consistently associated with poor health and disability. People in the two groups characterized by extensive violence and abuse were most likely to describe their health as ‘fair’ or ‘poor’. People in all the violence and abuse groups were less likely to regard themselves as ‘happy’ compared with people in the ‘little violence or abuse’ group. Most violence and abuse groups were associated with people having difficulty with one or more ‘activities of daily living’. (ADLs provide an indication of disability). People in the five groups characterized by experience of abuse and violence were also more likely to be providing care for someone else due to the other person’s ill-health or disability. 8 04 Profiles of the six groups Proportion of each violence and abuse group that needs help with multiple activities of daily living (2+ ADLs) 52 % 17 Little violence/abuse 20 Physical from partner 23 22 16 Extensive Sexual: only as physical/coercion, child partner Sexual: adult, sometimes child Extensive physical, sexual as child/adult Common mental disorders Violence and abuse are strongly associated with common mental disorders (CMD) such as anxiety or depression. People in the ‘extensive physical and sexual’ violence group were five times more likely than those with little experience of violence to have a CMD. More than half of this group met the threshold for a CMD. This same pattern held true for individual disorders (such as phobias, depressive disorder and generalized anxiety disorder). Phobias were present in 10% of people in the extensive physical violence group and 14% of people in the extensive physical and sexual group. This compared with a prevalence of 1% among people with few such experiences. Other mental disorders Violence and abuse are not just predictive of common mental disorders. A wide range of different mental disorders, including screening positive for psychosis, post-traumatic stress disorder (PTSD) and eating disorders, showed strong and consistent associations with such experiences. There was also a strong link with having more than one disorder. People in the ‘extensive physical and sexual’ group were about 15 times more likely than those with little experience of violence and abuse to have three or more disorders present at the time of interview. 9 04 Profiles of the six groups Proportion of each violence and abuse group with 3 or more mental disorders 17 14 10 % 5 5 1 Little violence/abuse Physical from partner Extensive Sexual: only as physical/coercion, child partner Sexual: adult, sometimes child Extensive physical, sexual as child/adult Suicide and self-harm There is a strong association between experience of violence and abuse and suicidal behavior. People in all the groups characterised by violence and abuse were at least five times more likely than those with little experience to have attempted to take their own life. People in the ‘extensive physical and sexual group’ were fifteen times more likely to have done so, and 4% had made an attempt in the last year. 56% of people in this group had self-harmed at some time – compared to 10% of those with little experience of violence and abuse. Proportion of each violence and abuse group who have attempted suicide 29 % 10 12 10 10 2 Little violence/abuse Physical from partner Extensive Sexual: only as physical/coercion, child partner Sexual: adult, Extensive sometimes child physical, sexual as child/adult Mental health treatment and service use Use of community mental health services was not as common as might be expected given the rates of poor mental health in the violence and abuse groups. Only 10% of people in the ‘extensive physical and sexual’ group were currently in receipt of a talking therapy, despite more than half this group having a CMD and 16% screening positive for posttraumatic stress disorder. However, 12% of people in the extensive physical and sexual group had been admitted to a unit specialising in mental health. Such high rates of use of secondary health care services may indicate a failure of primary and community care providers to meet the needs of people with experience of violence and abuse. 10 04 Profiles of the six groups Proportion of each violence and abuse group admitted to a ward specialising in mental health 12 % 4 4 3 3 1 Little violence/abuse Physical from partner Extensive Sexual: only as physical/coercion, child partner Sexual: adult, Extensive sometimes child physical, sexual as child/adult Health risk behaviours Violence and abuse are strongly associated with a range of health risk behaviours. People in the two groups characterized by extensive violence and abuse were more than twice as likely to be dependent on illegal drugs and to be smokers as those with little such experience. Alcohol dependence was also more common among people in the two ‘extensive violence’ groups. 38% of people in the ‘extensive physical and sexual’ group had a problematic pattern of alcohol consumption. Proportion of each violence and abuse group who are regular smokers 48 45 29 % 24 20 Little violence/abuse 19 Physical from partner Extensive Sexual: only as physical/coercion, child partner Sexual: adult, Extensive sometimes child physical, sexual as child/adult Experience in the early years and parenting People in the two groups characterised by extensive violence and abuse were less likely to have lived with both natural parents to the age of 16. They were more likely to have spent time in an institution or local authority care. We do not know whether the childhood experiences of violence and abuse preceded going into care or happened while they were in care. People in the groups characterised by physical violence were more likely to have children of their own (compared with those with little experience or in a group characterised by sexual violence only). For full tables of results and details of the methodology used, see the full report of the statistical analysis: www.natcen.ac.uk/REVAstrand1report 11 This is the first of five briefings based on the REVA study: • Violence, abuse and mental health in England (REVA Briefing 1) www.natcen.ac.uk/revabriefing1 • Guidance for Trust managers: Implementing and sustaining routine enquiryabout violence and abuse in mental health services (REVA Briefing 2) www.natcen.ac.uk/revabriefing2 • A briefing for mental health professionals: Why asking about abuse matters to service users (REVA Briefing 3) www.natcen.ac.uk/revabriefing3 • A briefing for commissioners: What survivors of violence and abuse say about mental health services (REVA Briefing 4). www.natcen.ac.uk/revabriefing4 • A briefing for service providers and commissioners: Measuring outcomes for survivors of violence and abuse (REVA Briefing 5). www.natcen.ac.uk/revabriefing5 This briefing reports independent research commissioned and funded by the Department of Health Policy Research Programme (Effective Responses to Long-Term Consequences of Violence, Trauma and Abuse, 115/0005). The views expressed in this briefing are those of the author(s) and not necessarily those of the Department of Health. 12 The REVA research was conducted by the following team: Dr Sara Scott and Dr Jennie Williams DMSS Research Dr Carol McNaughton Nicholls Truth Consulting Sally McManus, Ashley Brown and Shannon Harvey NatCen Prof Liz Kelly and Joanne Lovett CWASU, London Metropolitan University