Between 2010 and 2013, Against Violence & Abuse (AVA) delivered the Stella Project Mental Health Initiative (SPMHI) to develop, implement and evaluate a model of integrated partnership working to address the combined issues of domestic and sexual violence, substance use and psychological distress. The NICE guidance on domestic violence and abuse recommends that commissioners of health and social care service should ensure that there are integrated care pathways for identifying, referring and providing interventions to support people who experience domestic violence and abuse, and to manage those who perpetrate it (PH50, recommendation 4). It also recommends ensuring that people who misuse alcohol or drugs or who have mental health problems and are affected by domestic violence and abuse are also referred to the relevant health, social care and domestic violence and abuse service.
Aims and objectives
Services commissioned to support women with mental health problems, problematic substance use and experiences of violence against women often work independently, despite the intersectionality of these issues. Frontline practitioners do not always have the training, assessment tools or referral pathways to address all three issues when they co-occur. Operational and monitoring frameworks do not always make the links between the issues which result in women falling through gaps in service provision.
The aim of the Stella Project Mental Health Initiative (SPMHI) was, therefore, to empower service providers across the three sectors of substance use, mental health and violence against women to develop this work through knowledge transfer, policy development support and promoting strong partnerships and monitoring mechanisms.
There are several components to the SPMHI, encompassing an action research based intervention:
Policy and procedure development, training and partnership working. The SPMHI co-ordinator worked with selected agencies working in the fields of violence against women, substance use and mental health in three regions of the UK to develop an integrated response to survivors of gender based violence and who are experiencing problematic SU and psychological distress. This focused on providing: i) support to agencies to develop their policies and procedures, referral pathways and multi-sector partnerships; ii) training to equip staff with skills and confidence to work with the complex issues and; iii) support to embed issues in local authority and Primary Care Trust strategic policies.
Good practice guidance and online training course. Following completion of the action research, good practice guidance and an e-learning programme were developed and disseminated across the UK through extensive networks. A series of interactive and innovative workshops were held that focused on equipping practitioners with the skills and understanding to implement the good practice guidance.
The Stella Project Toolkit and e-learning are free resources available here.
Reasons for implementing your project
Research illustrates how experiences of violence against women have negative impacts on mental health and are linked to increased substance use. Domestic and sexual violence is a primary cause of depression in women, and also commonly results in self-harm and attempted suicide. Analyses of various studies have found that, on average, women living with domestic violence are 3.8 times more likely to suffer depression and 3.55 times more likely to be suicidal than women who are not. In eleven studies, on average, 64% of abused women have post traumatic stress disorder, significantly more than lifetime prevalence in the general population which is estimated to be 1-12%.
Levels of substance misuse are also higher among women who have experienced abuse than the general population: the Yale trauma study showed that abused women are 15 times more likely to use alcohol and 9 times more likely to use drugs than non-abused women. Importantly, research also clearly indicates that problematic substance use follows experiences of abuse and/or experiences of depression or post traumatic stress disorder.
Services commissioned to support women with mental health problems, problematic substance use and experiences of domestic violence and sexual violence often work independently, despite the intersectionality of these issues. Frontline practitioners do not always have the training, assessment tools or referral pathways to address all three of these issues. Operational and monitoring frameworks do not always make the links between the issues which result in women falling though gaps in service provision. Therefore the aim of the project was to empower service providers across the three sectors of substance use, mental health and violence against women to develop this work through knowledge transfer, policy development and promoting strong partnerships and monitoring mechanisms.
The project selected three sites across England in the summer of 2010: Bristol, Nottinghamshire and the London Borough of Hounslow. Violence against women, substance use and mental health agencies in each area were then invited to submit expressions of interest to participate in the project. A total of 17 agencies providing 20 services across the three sites were selected, based on their capacity and commitment to engage with the work.
1 Barron, 2004
2 Greater London Domestic Violence Project, 2008
3 Golding, 1999
4 Weiss et al, 2003
How did you implement the project
During the project AVA:
- Provided support to agencies to develop their policies and procedures, referral pathways and multi-sector partnerships.
- Trained staff to equip them with skills and confidence to work with complex issues.
- Provide support to embed issues into local authority and Primary Care Trust strategic policies.
- Developed good practice guidance and an e-learning programme.
The project and subsequent evaluation was funded by a three-year grant from the Department of Health.
One of the significant barriers identified by practitioners in all three areas was a lack of engagement from mental health services as a significant ongoing challenge. However, the re-configuration/re-commissioning of services gave opportunities to engage and forge links that would allow them to address all three intersecting issues.
'The newly re-commissioned service is what we are pinning our hopes on (in terms of improvements to the mental health pathway)' We have looked at ways to influence the new service so they'll be met through that route.' (Bristol, Post Intervention Focus Group).
The working partnership formed as a result of the project were instrumental in engaging the commissioners of the new mental health services to meet with the organisations involved with the project to discuss the significance of these intersecting issues.
'One thing that did happen as a result of having a group like this is we got the people who were commissioning the new mental health services to come and talk to us to tell us about how the new service will look and to hear our views on the fact DV should be part of their screening process and people should be able to understand how to refer people etc.' (Bristol, Post-Intervention Focus Group).
In Nottingham, one key strategy in terms of engaging the Mental Health Trust lay in alerting them to the sobering DV homicide statistics for the area. This worked to bring home the urgent need to work in partnership to identify and support women (and perpetrators) with intersecting issues.
An evaluation of the project was undertaken by Middlesex University. Participants' expectations regarding the benefits of their involvement in the project were evaluated through focus groups and were largely met, if not exceeded:
'The [Mental Health] Trust is looking at developing a strategy which feels helpful - it has developed a policy which Stella provided that impetus to actually engage with it.' (Nottingham)
'In terms of working in silos I think that has definitely broken down' We have gone along way from when I came back 2 years ago to where we are now.' (Hounslow)
The post-intervention focus groups in all three areas highlighted the practical benefits of the project in terms of increased staff capacity and confidence to address the needs of women presenting with these intersecting issues, even when the needs of such 'difficult' clients would previously have been regarded as not a 'part of my brief':
'She was able to support this woman [with intersecting needs] effectively whereas before [the training] she would not have been able to.' (Hounslow)
Focus groups from Bristol and Nottingham also discussed increased discussion of violence against women issues amongst their staff members:
"The discussion around sexual abuse, domestic abuse is more part of the conversation now when we are talking about assessments" people aren't afraid to talk about it and say, "this is what has been disclosed, I'm not sure where to go with it". (Nottingham)
An analysis of referrals suggested that women had begun making disclosures about other issues earlier in their engagement with services at the post-intervention stage and that there were shifts in the type and number of agencies referrals were made to between pre- and post-intervention.
Key learning points
The evaluation concluded that practitioners should continue to work together to build a shared understanding of their different professional and practice philosophies, to foster mutual trust and respect, and to build a consensus on how best to integrate services for women with overlapping issues. Agencies should continue to invest in improving the training, confidence and knowledge of their staff, with attention to the following:
- Mental health services were often viewed as 'the weakest link' in the network of services. Attention should be paid to the 'us' and 'them' dynamic between mental health and other services. Focusing on strategies for building institutional empathy may address the dynamic and reduce blame when difficulties arise.
- Clients with intersecting issues continue to be seen as 'difficult' and 'hard to reach'. Post-intervention, participants reported that they felt better able to support, engage and put referral pathways in place for these clients, however the underlying assumptions remained. Engaging clients with intersecting needs as stakeholders is a strategy for challenging them.
Strategies and policies need to develop the ability of services to work together to address the intersectionality of women's needs. Attention should be paid to the ways in which the intersecting issues are viewed by services, the ways in which these issues tend to be 'separated out', and the impact of this on referral practices and pathways.
- The role of GPs in identifying and referring women with intersecting issues was recognized and should continue to be prioritised through the development and implementation of protocols for GPs.
- Drug and alcohol treatment and mental health services are model settings for establishing perpetrator programmes as they often already deliver group-based behaviour change interventions. Given knowledge and links with support services for survivors, staff could be retrained to run programmes for perpetrators.
The project and evaluation was fully funded by a three-year grant from the Department of Health.