Editorial

Domestic violence (physical, sexual, and emotional abuse and controlling and coercive behaviours by current and former intimate partners and family members) has devastating effects on adults and children and is a problem of epidemic proportions. Globally it is estimated that one in three women have experienced domestic violence, with significant implications for mental health (Devries et al., 2013). Longitudinal studies demonstrate evidence for conditions such as depression of a bidirectional causal relationship between mental disorder and domestic violence, while systematic reviews of cross-sectional studies report consistent relationships between domestic violence and mental disorders across the diagnostic spectrum (Trevillion, Oram, Feder, & Howard, 2012). Yet, many mental health service users with experiences of domestic violence report feeling let down by (or put in danger by) inadequate service responses. Asked about mental health service responses to her experiences of domestic violence, one service user told us ‘You’re living in fear until people believe you. You’re left feeling dirty and like you’ve been let down again by the system, ‘cos there is a lack of support and a lack of people believing you’ (Rose et al., 2011, p. 190).

The importance of domestic violence as a determinant of mental health for women and children is increasingly recognized in international and national guidelines and position statements, as is the need for mental health services to do more to identify and respond to this form of abuse. Most recently, the World Health Organization and the National Institute for Health and Care Excellence have issued guidance on preventing and reducing domestic violence, and the World Psychiatric Association have published a position paper on intimate partner violence and sexual violence against women, with an accompanying curriculum for mental health professionals (NICE, 2014; Stewart & Chandra, 2016; World Health Organization, 2013; World Psychiatric Association, 2016). Key principles of safe and appropriate responses are encapsulated by the ‘LIVES’ acronym, which features in both the World Health Organization and World Psychiatric Association guidance: Listen (empathically and non-judgementally); Inquire (about emotional, physical, social, and practical needs and concerns); Validate (by showing victims they are believed and understood); Enhance safety (by discussing how to protect against further harm); and Support (by connecting to services and social support) (Stewart & Chandra, 2016; World Health Organization, 2013). This special issue is a timely opportunity to update readers on developments in our understanding of the relationship between domestic violence and mental health and of approaches to improve the response of mental health services to this issue. We are grateful to the authors and reviewers for their contributions to this issue and thank the editors of the International Review of Psychiatry for inviting its production.

The volume includes reviews of the impact of domestic violence across the life-course, including the impact of children’s exposure to intimate partner violence (McTavish, MacGregor, Wathen, & MacMillan, 2016), of adolescents’ exposure to abuse within intimate relationships (Barter & Stanley, 2016), and of the prevalence and risk of domestic abuse among older adults (Knight & Hester, 2016) and people with dementia (McCausland, Knight, Page, & Trevillion, 2016). Also included are reviews focusing on under-served populations’ experiences of abuse. Mitchell, Wight, Van Heerden, & Rochat (2016) draw attention to the ‘triple epidemic’ of HIV infection, intimate partner violence, and mental health problems in Africa, estimating that these three burdens may affect up to 30% of African women concurrently. Khalifeh, Oram, Osborn, and Johnson (2016) highlight the vulnerability of women with severe mental illness to domestic violence: their systematic review finds that between 15–22% report recent domestic violence. Several years after the authors highlighted the lack of research into gender differences in the violence experiences of people with severe mental illness (Khalifeh & Dean, 2010), evidence on the prevalence of domestic violence among men with severe mental illness is still lacking.

Acknowledging domestic violence as a major determinant of mental distress and psychiatric illness is, however, not enough: mental health professionals and researchers must also recognize their responsibility to reduce its prevalence and impact. This volume, therefore, also seeks to provide readers with an overview of the latest domestic violence health services and intervention research. Opening the volume, Trevillion, Corker, Capron, and Oram (2016) review the evidence on how mental health services currently respond to domestic violence and how these responses could be improved, including the identification, referral, and care of victims and perpetrators, and interventions to improve mental health service responses and outcomes for service users. Key challenges include low levels of direct enquiry and disclosure, inadequate documentation of disclosed and suspected abuse, and a need for further research into interventions for mental health service users who experience domestic violence. Useful components are likely to include psycho-education about the causes and consequences of domestic violence, the development of cognitive and emotional skills to address trauma-related symptoms, a focus on survivors' strengths, and an attention to safety risks. Before-and-after and pilot studies of cognitive behavioural therapies and advocacy interventions have suggested improved psychological outcomes, but require testing in randomized controlled trials. Hegarty, Tarzia, Hooker, and Taft (2016) report similar challenges with regards to primary care responses to domestic violence and highlight a range of potentially promising advocacy, safety planning, and psychological interventions.

Efforts to improve mental health service responses to domestic violence must address the fact that some perpetrators of domestic violence are mental health service users. Previous work has suggested that mental disorder is associated with an increased risk of domestic violence perpetration, although it is unknown whether a causal relationship exists (Oram, Trevillion, Khalifeh, Feder, & Howard, 2014). Yet, and as highlighted by Hegarty et al. (2016) and Trevillion et al. (2016) with regards to primary and secondary care settings, respectively, there is a critical lack of evidence for interventions to reduce domestic violence perpetration (Hegarty et al., 2016; Trevillion et al., 2016). Easton and Crane (2016) take on this issue in the final paper of the volume. They argue that, as multiple factors are associated with the aetiology of domestic violence perpetration, multiple treatments should be considered. Substance use, for example, is consistently noted as one of the strongest correlates of domestic violence and may represent a modifiable risk factor for abuse. Noting that substance abuse often goes unaddressed in standard treatment approaches, Easton and Crane (2016) review several potential treatment models for substance-using perpetrators, including psycho-educational models, cognitive behavioural therapies, integrated care models, couples treatment programmes, parenting programmes, and pharmacotherapy.

Taken together, the articles in this collection highlight that, while there is no doubting the impact of domestic violence on mental health and its importance as a public mental health problem, key evidence gaps remain, and appropriate mental health service provision is often lacking. As highlighted in guidance from the World Health Organization and National Institute for Health and Care Excellence on preventing and reducing domestic violence, there is a critical need for research into interventions for victims and perpetrators of domestic violence (NICE, 2014; World Health Organization, 2013). Few trials have investigated interventions for victims of domestic violence with mental disorders, and to our knowledge no trials have reported on interventions for perpetrators with mental disorders or substance misuse problems. Longitudinal studies of mental disorder and domestic violence are needed to establish causal relationships and potential mechanisms that could be addressed by tailored interventions. We hope, therefore, that this Special Issue serves as a valuable resource to mental health professionals and researchers, and as a call for the prioritization of domestic violence by mental health services and the better integration of domestic violence into epidemiological, health services, and intervention research.

Siân Oram, PhD and Louise M. Howard, PhD MRCP MRCPsych
Section of Women’s Mental Health, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
[email protected]