from RANZP website: https://www.ranzcp.org/
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.
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.
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.
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. The most extreme outcome of FV is death with 200 domestic homicides recorded in Australia between 2012-14. In New Zealand, there were 194 deaths related to FV between 2009 and 2015.
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. This compares with 6.1 per cent of men in Australia. 1 in 3 women have experienced violence in their lifetime when sexual harassment, emotional and physical violence figures are combined. 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. 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.
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.
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.
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.
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.
Though not present in all cases, high rates of mental health conditions are present among men arrested for domestic violence, particularly PTSD and depression. 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. 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. Evidence shows that childhood education programmes around gender norms and attitudes can help prevent FV before these attitudes become entrenched.
Significant proportions of perpetrators of FV, particularly those who offend against an intimate partner or a previous partner, are likely to reoffend. 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. 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. 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.
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.
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. 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. 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. 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.
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. 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. Rather whānau (family) violence is entangled in a history of colonisation, socioeconomic deprivation, and trauma that persists into contemporary times. 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. 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.
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.
Psychiatrists can play an important role in clinical leadership as well as identification, risk assessment and referral, and treatment including perpetrators of FV. 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. 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.
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. 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.
1 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.
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.