Mental health & addiction services urged to improve family violence responsiveness

Mon 09 Sep 2019

A new article urges mental health and addiction services to reframe the way they understand and respond to family violence.

The article, Thinking differently: Re‐framing family violence responsiveness in the mental health and addictions health care context (Short, Cram, Roguski, Smith & Koziol-McLain, 2019) is published by the International Journal of Mental Health Nursing. Written by Family Violence Death Review Committee members and staff, it draws on 28 in-depth New Zealand family violence death reviews carried out between 2011 and 2018.

Co-author Dr Jacqueline Short says there is a strong association between family violence and mental health and addiction issues in Aotearoa New Zealand, and that people who experience and use violence within their whānau are often in contact with mental health and addiction services.

The paper notes that responses to family violence within health care settings remains limited because it is treated and resourced as a marginal health issue, and because responses are modelled on addressing a simple problem, rather than a "complex social problem that requires a comprehensive and equitable health system response." (p.8)

The paper uses a composite story to illustrate current practice issues in mental health and addictions services, and discuss alternative responses that could create safer lives for people and families.

It emphasises the importance of understanding intimate partner violence as social entrapment (Ptacek, 1999) characterised by: social isolation, fear, and destruction created by her partner’s coercive controlling behaviours; lack of responsiveness of powerful institutions to help-seeking and suffering; and exacerbation of the abuse by structural inequities (for example colonisation, racism, sexism, poverty, heteronormativity, and disability).

The authors state mental health and addiction services need to work in partnership with statutory and community based specialist family violence services, and contribute to local family violence multi‐agency review processes.

The paper notes the importance of trauma-informed approaches, which do not ask "what is wrong with you" but rather "what has happened to you?" However, it also notes that trauma can also result from "what did not happen for you", for example, when systems fail to respond to family violence and structural inequities, meaning victims suffer additional harmful health burdens and social consequences. (p.7)

The authors call for a shift from trauma-informed to trauma- and violence-informed (TVI) practice:

"Importantly, this brings an explicit focus to structural inequities to avoid seeing trauma as happening only ‘in people’s minds’ but also in their social context; ongoing violence, as for many people violence is intergenerational and connected to the violence of colonization; and the responsibility of organizations to change as systems perpetuate harm (i.e. institutional racism)."

They also emphasise:

"In Aotearoa New Zealand the development of TVI approaches must be informed by Maori-specific approaches that stem from the distinctive Maori and Indigenous collective experiences of historical and intergenerational trauma." (p.8)

The paper calls for health services to develop practice with men who use violence, noting that there are currently no formal organisational approaches to support mental health and addictions practitioners with this. Consequently, many of the service contacts with these men did not address their use of violence in ways that increased safety for child and adult victims; instead they may minimise violence or misunderstand it as symptomatic of their alcohol and drug problems, hence missing potential risk.

The authors have included two sets of questions to help mental health and addictions practitioners reflect and reshape their practice. The first set focus on effectively responding to clients experiencing and using violence (see Box 6):

"Have I assessed the risks of her partner’s coercive and controlling behaviours towards her and the children?
How do his coercive and controlling behaviours constrict her and her children’s lives and her ability to do what she wants to do, including her ability to formulate and engage in any MH&A care plans?
What do I know about what safety strategies she previously tried, how these worked, if services were helpful, her partner’s reactions, and what if any access she has to financial, family and whānau, social and cultural supports?
Are she and her family and whānau experiencing systemic barriers, such as a lack of stable housing, limited access to money and transport, poverty, and dismissive racist responses from services? How is this impacting her, her children and whānau and family’s safety and wellbeing?
What are her biggest fears for her and her children?
Who is working with her partner? What strategies are in place to support him and address his use of violence?
Comprehending all of this, what actions can I take as a ‘safety ally’, as part of my treatment plan?
How and with who will I review whether what we are doing is supporting creating safety for her, the children and her family and whānau?
What local Māori and Tauiwi (New Zealand non‐Māori) family violence organizations and networks could we develop relationships, and work in partnership with?"

The second set focus on the wider perspectives of the practitioner that influence their responses, such power and privilege, perceptions of trauma and violence, cultural responsiveness and more (see Box 8):

"What kinds of power and privilege do I have? How do these shape my life and world view?
What kinds of power and privilege do we hold as an organization? How can we use our privileges and power for social justice?
Have I considered how experiencing trauma and violence may have contributed to the development of the presenting complaint/reason for referral?
Am I using a culturally responsive, trauma and violence‐informed practice approach to address the presenting complaint/reason for referral?
How do I support the provision of health care to Māori to be culturally responsive, including respect for and application of te reo (language) and tikanga (protocols) (Ministry of Health, 2014)?
Do I use assessment tools such as the Meihana Model to infuse culture into clinical assessments that provide a broad picture of patients’ health and well‐being (Pitama, Huria, & Lacey, 2014)?
What do the patterns of patients’ journeys tell us about the level of responsiveness (including cultural) our organization provides to MH&A patients who are experiencing IPV?
How does our organization monitor equity and other health improvement targets to ensure that whānau Māori who are experiencing family violence have access to culturally responsive MH&A services (Ministry of Health, 2014)?"

Related research and resources

For more information see our NZFVC reading list on mental health, addiction, trauma, violence and abuse (2018).

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