Disclosure of domestic violence in mental health settings: A qualitative meta-synthesis

Figures & data

Fig. 1. Flow diagram of screened and included studies.

Table 1. Characteristics and quality scores of included studies.

Study characteristics						Participant characteristics				Appraisal
Source	Study aims	Study country/type of mental health setting	Method	Theories used	Analytical methods	Sample (sex, age range)	Ethnicity	Abuse type	Contact with mental health professionals	Appraisal scores
Barron (2004)	To explore abused women's experiences of statutory and voluntary services, with particular focus on healthcare services	UK Type of mental health setting not specified	Individual in-depth interviews and focus group interviews	Not specified	Thematic analysis	30 female victims of domestic violence (aged 19–64 years)	Data not collected	Physical, sexual, psychological or financial violence that takes place in an intimate or family-type relationship	17 women reported contact with psychiatrists, 9 with a community psychiatric nurse, 20 with a counsellor	Total score: 24/86
Bates (2001)	To explore abused women's experiences of health services response to domestic violence	Australia Outpatient and inpatient mental health services	Focus group interviews	Feminist position, focused on concerns for health equity and social justice	Thematic analysis	65 female victims of domestic violence (aged 18–60 + years)	72% Anglo-Australian 27% Aboriginal or Torres Strait Islander	Not specified (participants were referred by domestic violence support worker)	One woman reported contact with a psychiatric nurse	Total score: 57/86
Bradbury-Jones (2011)	To explore abused women's experiences of health services response to domestic violence	UK Community mental health service	Individual in-depth interviews	Ecological framework and feminist positions	Framework analysis	17 female victims of domestic violence (aged 23–46 years)	Data not collected	Physical, sexual, psychological or financial violence by a current or former intimate partner/family member	One woman reported contact with a community psychiatric nurse	Total score: 71/86
Hager (2001)	To explore abused women's desired responses to domestic violence by healthcare professionals	New Zealand Mental health outpatient clinics, community mental health services and non-governmental mental health services	Individual and group in-depth interviews	Feminist position	Phenomen-ological analysis	10 female victims of domestic violence (aged 20–63 years)	100% Pakeha	Psychological, physical, sexual, financial and emotional abuse by a current or former intimate partner	5 women reported contact with mental health professionals	Total score: 65/86
Laing (2010)	To explore abused women's experiences of domestic violence and mental health services	Australia A range of mental health contacts (e.g. inpatient psychiatric units, community mental health teams and private psychiatrists/ psychologists)	Individual in-depth interviews	Feminist position	Thematic analysis	33 female victims of domestic violence (aged 18–65 years)	15% Aboriginal 24% ethnic minorities 3% British 3% American 55% Anglo-Australian	Violent and intimidating behaviour by an intimate partner	All women had contact with a range of mental health professionals	Total score: 64/86
Prosman (2013)	To gain insight into the pattern of help-seeking behaviour of (undisclosed) abused women in family practice.	Netherlands General practice settings	Individual in-depth interviews	Not specified	Thematic analysis	14 female victims of domestic violence (age range not specified)	57% Dutch 43% ‘migrant’	Physical abuse, emotional abuse, harassment, severe combined abuse	One woman reported contact with a psychologist	Total score: 45/86
Rose (2011)	To explore the facilitators and barriers to disclosure of domestic violence by community mental health service users	UK Community mental health services	Individual in-depth interviews	Not specified	Thematic analysis	16 female and 2 male victims of domestic violence (aged 19–59 years)	50% White British 6% European 17% Black Caribbean 5% Black British 6% Black African 6% Asian 5% Mixed race 5% Latin American	Psychological, physical, sexual, financial and emotional abuse by a current or former intimate partner/family member	All 18 male and female participants reported contact with community mental health professionals	Total score: 64/86
Ruddle (1997)	To explore women's experiences of receiving support from services for domestic violence	Ireland Community mental health and outpatient psychiatric services	Individual in-depth interviews	Not specified	Content analysis	41 female victims of domestic violence (age range not specified)	No data provided	Not specified	5 female participants reported contact with psychiatrists and 5 with psychologists	Total score: 54/86
Spangaro (2011)	To understand the conditions that lead women to disclose domestic violence in response to routine screening and their constructions of the impact of routine screening	Australia Community mental health settings	Individual in-depth interviews	Construct-ionist and realist traditions	Inductive analytical techniques	20 female victims of domestic violence (aged 17–50 years)	65% Anglo-Australian, 10% indigenous, 5% South Pacific Islanders, 10% South American, 10% South Asian	Physical, sexual and emotional violence and controlling behaviour by a current or former partner	Two women reported contact with community mental health professionals	Total score: 67/ 86
Tower (2008)	To explore facilitators and constraints of healthcare delivery among women experiencing domestic violence	Australia Community mental health setting and private therapy delivered by a psychiatrist	Individual in-depth interviews	Postmodern and feminist positions	Narrative analysis	9 female victims of domestic violence (aged 29–45 years)	Data not collected	Physical, mental, social and sexual violence by a current or former intimate partner	2 women reported contact with psychiatrists	Total score: 70/86
Trevillion (2012a)	To explore the acceptability of routine enquiry and experiences of responding to violence from mental health service user and professional perspectives	UK Community mental health service	Individual in-depth interviews	Not specified	Thematic analysis	16 female and 2 male victims of domestic violence (aged 19–59 years)	50% White British, 6% European 17% Black Caribbean 5% Black British 6% Black African 6% Asian 5% Mixed race 5% Latin American	Psychological, physical, sexual, financial and emotional abuse by a current or former intimate partner/family member	All 18 male and female participants reported contact with community mental health professionals	Total score: 63/86
Women's National Commission (2010)	To explore abused women's experiences and desired responses of health services identification and response to domestic violence	UK Type of mental health setting not specified	Focus group interviews	Not specified	Not specified	211 female victims of gender-based violence (3 focus groups were conducted with women experiencing domestic violence; no exact numbers given)	48% White British 44% Black, Asian or ethnic minority 4% mixed race	Physical, sexual, psychological violence	7 women reported contact with mental health professionals	Total score: 2/86

Table 2. First-order constructs.

Construct name	Construct description
Identification of domestic violence
Fear of disclosure	MHSUs reported fear of the potential consequences of disclosure, for example, Social Services involvement, further violence, labelling, confidentiality constraints and not being believed. They also reported uncertainty about the benefits of disclosure and not wanting to be a burden to service providers
Recognizing abuse	MHSUs described how they struggled to identify themselves as victims of abuse due to their mental state. In these situations they wanted mental health professionals to help them identify and label the violence
Language and cultural barriers	MHSUs described language and cultural barriers in accessing mental health services and exploring experiences of abuse
Failure to identify abuse	MHSUs were critical of mental health professionals’ failure to identify their abuse. Overall, they were accepting of direct enquiry about domestic violence
Training	MHSUs recommended mental health professionals receive training in recognizing the signs of abuse and its impact on mental ill health, and in improving their skills of enquiry
Acknowledgement of disclosures
Stigma	MHSUs reported not being believed and being treated disrespectfully owing to their mental health diagnosis
Blame	MHSUs gave examples of being blamed for the abuse they had experienced
Facilitating discussions of abuse	MHSUs described how they lacked opportunities to talk about the abuse and to work through issues at their own therapeutic pace
Lack of acknowledgement	MHSUs felt mental health professionals were not interested in their experience of abuse and did not acknowledge the impact of abuse on their mental health
Attributes and behaviour of mental health professionals	MHSUs described the importance of mental health professionals showing respect and compassion, undertaking an assessment of their safety, and being non-judgemental and trustworthy
Immediate responses to disclosures
Limitations of the biomedical model	MHSUs felt mental health services were too focused on prescribing medications. They were dissatisfied that they did not seek to address the underlying causes of their symptoms
Autonomy	MHSUs reported a lack of choice over their care plan and described some mental health professionals as controlling
Medication	MHSUs reported uncertainty about the benefits of taking medication for their symptoms and concern about possible side effects
Working with perpetrators	MHSUs valued a response from mental health professionals that sought to challenge their abusers’ behaviour as this reassured them that they were not to blame. Some MHSUs wanted mental health professionals to provide independent support and referrals for abusive partners
Safety assessment
Risk of harm	MHSUs expressed concern that some of the actions of mental health professionals increased their risk of experiencing further abuse
Safety of inpatient mental health services*	MHSUs stressed the importance of mental health services being safe and recommended single sex wards
Referral
Group support	MHSUs discussed the value of meeting others who had similar concerns and experiences of violence. Group meetings were described positively
Coordinated service delivery	MHSUs described the stress associated with re-telling their story to different providers. They recommended better communication between domestic violence and mental health services
Dissatisfaction with counselling*	MHSUs were dissatisfied with their access to counselling services. They described how problems escalated while they were waiting to access services and how problems were insufficiently addressed within the time-limited number of sessions provided

MHSUs, mental health service users.

*Represents constructs confined to lower quality studies.

Table 3. Second-order constructs.

Construct name	Construct description
Facilitation of disclosures of domestic violence
Enquire about violence and abuse	Create a supportive environment that can facilitate disclosures Implement routine enquiry for domestic violence in all mental health settings Discuss confidentiality constraints and implications of disclosures with service users
Attributes and behaviour	Use verbal and nonverbal cues to build rapport and establish trust Be non-judgemental
Identification of domestic violence
Identifying abuse	Be able to identify and respond to signs of abuse Provide information on available services whenever abuse is suspected Conduct joint visits with domestic violence services where abuse is suspected
Language and cultural barriers	Use trained interpreters with service users who have difficulties with English Be aware of how cultural beliefs and practices may impact on service users responses to domestic violence
Training	Attend regular and ongoing training on domestic violence in order to improve confidence identify signs of abuse, facilitate disclosures understand the mental health effects of domestic violence
Acknowledgement of disclosures
Stigma of mental health	Take service users and their disclosures of abuse seriously
Blame	Reassure service users that they are not to blame for the violence
Reassurance	Reassure service users that disclosures will be taken seriously
Facilitating discussions of abuse	Support women in addressing issues at their own therapeutic pace
Immediate responses to disclosures
Autonomy	Involve service users in decisions about their treatment and care
Social model of mental illness	Explore underlying causes for mental ill health as well as treating symptoms Offer a range of treatment options beyond medication
Working with perpetrators	Follow good practice guidelines when working with perpetrators Be aware of partners using mental health diagnosis to entrap women Be aware of partners interfering with mental health treatment
Safety assessment
Preventing further abuse	Prioritize service users safety
Perceived safety of mental health services	Make women aware of mechanisms available for them to raise concerns about safety
Referral
Coordinated service delivery	Be aware of services available for abused women Different sectors need to communicate with each other to improve continuity of care
Group support	Give service users an opportunity to join support groups with other survivors of domestic violence
Access to domestic violence services	Be proactive in signposting women to other services
Role of third sector	Work in partnership with third sector services who support people experiencing domestic violence

MHSUs, mental health service users.

Table 4. Intra- and inter-study contradictions.

Apparent contradiction number	Apparent contradiction description	Second-order construct resolved	Third-order construct resolved	Resolution
1.	MHSUs found it acceptable or unacceptable to be asked about domestic violence	Yes	*	Views on acceptability are related to service users’ feelings of safety. Mental health professionals need to recognize the importance of service users’ feelings of shame, autonomy, and physical safety when asking about domestic violence
2.	MHSUs were satisfied or dissatisfied with the treatment received	Yes	*	Interventions should facilitate discussions of abuse, challenge the actions of abusers and develop individually tailored care plans to meet the needs of service users
3.	Marital therapy plays or does not play an important role in the response to domestic violence	No	Yes	Service providers need to determine the type of abusive relationship experienced by service users and assess their risk of harm before considering the suitability of marital therapy

MHSUs: mental health service users.

*Second-order constructs resolved this contradiction; therefore a third-order construct is not required.

Table 5. Third-order constructs shown as recommendations to mental health service providers.

Third-order construct	Recommendation to service provider
Before disclosure or questioning	Attend training on domestic violence Be able to refer to relevant services Be alert to indicators of abuse Accept the credibility of service user disclosures of abuse Create opportunities for service users to disclose abuse Discuss confidentiality issues and implications
Immediate responses following disclosure	Reassure service users that they are not to blame Be non-judgemental and supportive Reassure service users that their disclosures will be taken seriously Assess level of risk Acknowledge abuse as an underlying cause of mental ill health Provide information on referral and support options Involve service users in developing appropriate care and safety plans Explain rationale for clinical actions
Ongoing responses	Ensure continuity of care Explain rationale for clinical actions Connect service users with other survivors Offer individually tailored support and interventions to meet the specific needs of service users

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