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Survivors deserve to be heard: 

The reality of the barriers to mental health support 

A Safe Blog by Lizzie McCarthy and Jenny Birchall, Women’s Aid

6th December 2021: Today, Women’s Aid has published two reports as part of our Deserve To Be Heard campaign. This campaign aims to highlight the devastating impact of domestic abuse on the mental health of women and their children. Through our campaign, we will ensure that the mental health needs of women, who are all too often not listened to and not believed, are heard and responded to effectively.

In this blog we highlight some key findings from these reports on the barriers facing domestic abuse survivors in accessing appropriate and timely mental health support. The reports linked to above look at these barriers in more detail, as well as exploring the impact of domestic abuse on survivors’ mental health and the work of specialist domestic services in meeting mental health needs. The references for all this evidence can be found in the reports.

The mental health trauma caused by domestic abuse 

The evidence is clear; being subjected to domestic abuse can have devastating and long-term consequences for mental wellbeing and the perpetration of domestic abuse is a key driver of women’s mental ill health. One study referenced in Mental health and domestic abuse: A review of the literature describes the impact of domestic abuse as having “…psychological parallels with the trauma of being taken hostage and subjected to torture” (Howard et al., 2010).

However, survivors face a range of barriers in accessing appropriate mental health support, and all of these barriers are heightened for survivors from minoritised or marginalised groups. We highlight some of the main barriers discussed in the reports below.

Survivor disclosure and help-seeking 

Putting the burden on the survivor herself to disclose abuse or seek out mental health support (rather than services reaching out to survivors or healthcare professionals safely and sensitively enquiring) is problematic. The impact of domestic abuse often includes lowered self-esteem and feelings of shame, meaning that survivors do not feel able to seek out support. Expecting them to do so is therefore often unrealistic. Survivors also often fear that they will not be believed or taken seriously if they talk about abuse and/or mental health concerns (sometimes because of negative experiences in the past).

There is sadly still considerable stigma around being diagnosed as mentally ill, which is often used by perpetrators to discredit survivors. Perpetrators may also use a survivor’s insecure immigration status (or lack of clarity about immigration status) as the basis of threats that prevent survivors talking to domestic abuse or healthcare services. In addition, survivors with children are often fearful that accessing mental health or domestic abuse support may mean that social services will get involved and they will be judged as “failing to protect” their children from abuse; or it will be used against them in any child contact or child protection legal proceedings.

Unhelpful professional responses 

Unfortunately, when survivors do talk to healthcare professionals about domestic abuse and mental ill health, the response is not always helpful. Victim-blaming, disbelieving attitudes and inappropriate responses are significant barriers to accessing support. It is also important to understand the context of oppression (including multiple intersecting forms of inequality and discrimination) in which survivors are experiencing domestic abuse, and the barriers that structural sexism, racism and other forms of inequality create in accessing mental health support. In Thiara and Harrison’s report (published by Women’s Aid today) the authors note that access to mental health support is lowest amongst the most marginalised groups. They state that:

“The ways in which racism perpetuates health inequalities is evident in how Black and minoritised groups access, or are deterred from accessing, forms of help and support, especially through statutory/mainstream mental health services…”

The issue of survivors not being asked about possible domestic abuse by healthcare professionals (including GPs and mental healthcare specialists) is a key theme in the literature on mental health and domestic abuse. There is evidence of some healthcare professionals not feeling confident in addressing domestic abuse and sometimes treating survivors’ mental health concerns as completely separate from their experiences of abuse. This leads healthcare professionals to focus solely on physical injuries or narrowly view a survivor’s mental ill health as a medical problem or condition, rather than understanding it as the result of being subjected to violence and abuse.

There are examples of good practice in the literature too, though, including healthcare services working in partnership with domestic abuse services and healthcare professionals receiving the tools and training they need to safely and sensitively enquire about domestic abuse.

Inaccessible and re-traumatising services

Mental health information and services are not always accessible to all and this creates another barrier to survivors accessing support. These inaccessibility barriers include communication barriers, cultural awareness barriers, and practical access barriers (e.g. where a venue is not wheelchair accessible). In addition, survivors who are denied recourse to public funds because of their immigration status do not have access to many publicly funded services, or fear accessing them due to hostile immigration policies.

Attempting to engage with some mental health services can even worsen survivors’ mental health issues and create further trauma; for example if services

  • Are not working with an understanding of the impact of domestic abuse on women’s lives.
  • Do not provide safe opportunities and spaces for survivors to tell their own stories.
  • Do not understand the impact of intersecting forms of oppression (such as racism and sexism) or are themselves discriminatory.
  • Or fail to keep survivors safe from sexual harassment or violence from other patients.

Some studies also raise concerns that survivors are being medicated or referred directly to inappropriate mental health services which are not trauma-informed, without any exploration of the abuse they are experiencing or referral to specialist domestic abuse support.

Overstretched services 

When survivors do disclose mental health problems and are taken seriously, there are long waiting lists for mental health support. Mental health services are usually over-stretched and often can only offer short-term support. These waiting times have only been exacerbated by a surge in demand during the Covid-19 pandemic. The Royal College of Psychiatrists raised concerns in September 2021 about the backlog of patients waiting for mental health support, with an estimated figure of 1.6 million people waiting for treatment from mental health services (and the actual number is likely to be greater).

Specialist domestic abuse services are well-placed to meet many of the mental health needs of survivors, sometimes working in partnership with health services and healthcare professionals. Specialist domestic abuse services – including ‘by and for’ services for Black and minoritised women, LGBT+, and disabled survivors – work in a holistic way that addresses many survivor needs, including mental wellbeing. These are services that understand the impact of intersecting inequalities, build trusting and empowering relationships with survivors, and recognise the extent of the trauma caused by domestic abuse.

Despite facing high demand and many funding challenges, specialist domestic abuse services are doing important work in meeting survivors’ mental health needs. In her book on the experiences of survivors living in refuges, Hilary Abrahams (2007) sums up the importance of adequately resourcing the work of specialist domestic abuse services:

“The value of this complex and demanding work needs to be fully appreciated and properly funded, taking into account its one-to-one nature and the requirement for extended support within the community. Combining practical and emotional assistance in this way enhances the prospect of a successful transition to a new life for the woman and may also lessen future demands on health and social care provision and possible expensive crisis interventions.”

Opportunities for change 

The reforms proposed in the Health and Care Bill and the forthcoming Women’s Health Strategy are key opportunities to recognise and take action on the mental health consequences of domestic abuse. In response to the evidence found in the reports published today, Women Aid’s Deserve To Be Heard campaign is calling for the following:

  • Tackling domestic abuse must be explicitly recognised as a public health priority, with greater emphasis on the mental health impacts of domestic abuse in healthcare policy and funding.
  • Services and professionals responding to survivors’ mental health must work in a trauma-informed way. Greater partnership work between health services and specialist domestic abuse services and specialist training of healthcare professionals are key ways of achieving this aim.
  • The intersecting forms of structural oppression that survivors face must be considered in any policy or strategy relating to women’s health.
  • Investment in mental health services is important and must be accompanied by investment in specialist domestic abuse support services, including ring-fenced funding for specialist services led by and for Black and minoritised women, Deaf and disabled women and LGBTQ+ survivors.
  • Medical students and professionals responding to domestic abuse (including healthcare professionals, police, legal professionals) need specialist domestic abuse training that strengthens their understanding of perpetrator tactics in weaponising mental ill health.

Domestic abuse survivors deserve to be heard by healthcare professionals, they deserve to be heard in healthcare policy-making, and they deserve to be heard in healthcare decision-making structures. Campaign with us to make this happen!

For more information about the Deserve To Be Heard campaign and how you can get involved, please click the button below.

Thank you to all the survivors whose expertise and stories have informed the literature reviewed in the reports published today. 

For information and support, please go to: https://www.womensaid.org.uk/information-support/  

Thank you to Ravi Thiara and Christine Harrison for their important contribution to the evidence base for this campaign.  

Thank you to the Gamesys Foundation for funding the Deserve To Be Heard campaign. 

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