It doesn’t hurt to ask: why healthcare professionals need to – and can – ask about experiences of violence and abuse with patients

New research by Truth director, Carol McNaughton Nicholls

How would you feel if someone asked you if you had experienced sexual abuse or domestic violence? Have you? Most of us feel fairly uncomfortable thinking about, never mind talking, seriously and personally, about these issues. We only need to check the news to know this happens, and professionals like myself can become inured to speaking about sensitive issues as part of their day to day work. But this in often in an abstract sense – the reality is these issues remain taboo and difficult to speak about to individuals even in professional settings – the type of conversation that can bring out the awkward scrunch in the solar plexus that you have overstepped the conventional norms; and that require real ‘emotional work’ to navigate empathetically. Mental ill health is another issue that, despite concerted efforts to address the stigma and discrimination associated with it, there can be deep-rooted fears regarding how to talk about and respond on a personal level. Both difficult subjects then – but also vitally important to talk about and help support people affected by them. 

Recent research I was involved in delivering, for the Department of Health Policy Research Programme (and numerous other studies) has found mental ill health and interpersonal abuse and violence are strongly related. For example, our research found that people with extensive experience of interpersonal violence and abuse are five times more likely to suffer from mental health problems such as depression than the general population.

Which brings me to why it is so important that people who are experiencing mental health issues are asked about whether they have experienced abuse or violence – not only to ensure they are currently safe, though that is vitally important, but also so that effective support and care can be provided that incorporates this experience and the impact it is having. This may seem obvious but we only need to think of very recent, very raw scandals, such as Operation YewTree[1], to remember not only are people not asked about such experiences, there can be a reaction of disbelief and lack of action, even when disclosures are made.

Thankfully, in recognition of the need to ask, ‘routine enquiry’ has been Department of Health policy since 2003 - routine enquiry is the process of asking adult service users about prior experience of violence and abuse in mental health assessments. The research that I was involved in (a major study that involved interviewing over 120 health care professionals and survivors of abuse and published this week) explicitly examined how the policy of routine enquiry is being implemented. The research found that it is inconsistently applied and that, whilst for some it has become routine, other healthcare professionals lack confidence in asking people about experiences of violence and abuse or responding to disclosures.

But I am not sure this is entirely surprising. Health care professionals are humans too – and asking about such experience remains fairly taboo. Interestingly some professionals felt particularly uncomfortable or that it would be inappropriate to ask certain people  - often that were different to them or did not fit stereotypes of ‘victims’ – those that were older, younger, of a different gender or ethnicity to them[2]. Again this highlights the strong influence of cultural assumptions – and the taboo nature – of the issue, and the very real impact this can have on who gets asked. Even though it is policy to ask everyone in assessments, staff are assessing, during a busy, over worked schedule whether it is ‘culturally appropriate’ to ask about such a personal issue or not. And sometimes the decision is to not ask.

Why does this matter? Well we found from people who have experienced abuse that they welcome being asked: perpetrators rely on victims silence and often encourage it through threats or cajoling – and they are protected by cultural norms not to talk about the issue. People who have experienced abuse can then be silenced again by a ‘system’ that refuses to ask or listen to their experiences. This system may in part be due to busy staff members just feeling they cannot overstep into that taboo area – because they are not resourced or equipped to deal with an affirmative response. But for survivors of abuse this is bewildering, and it continues to support the cultural norm that we shouldn’t talk about this issue - which only acts to obscure it. So we need to talk about abuse if we are to be able to identify, address and tackle it[3]. The people we interviewed welcomed being asked because it opened up to them the possibility of being able to talk, when they had been silenced, and to be listened to, when they had felt ignored – all of which could compound their mental health issues further.

So it is also about culture change.  In large institutions such as the NHS there are specific mechanisms that can support culture change. These mechanisms are embedded in effective implementation of routine enquiry – it is not about just asking, but staff being trained and supported, systemically to feel comfortable asking everyone, and to respond empathetically. This is the heart of routine enquiry – and of being able to talk about abuse – being comfortable subverting the norm, knowing that it is not only ok, but important, to ask.

Some of the health care professionals we interviewed did recognise the importance of routine enquiry – of asking the question – and often had structural support from within their Trust that enabled this. But as we flagged, others struggled. I can’t help but see this for a broader metaphor for all of us – busy, trying to do our best, but perhaps taking the easier path to do so – and in doing so inadvertency silencing those in need and maintaining the status quo. So perhaps we can turn this metaphor around and if we can overcome our own taboos and discomfort to face the reality that people who have been abused and who have mental health issues need empathetic support and responses, within a culture of talking, not of silence, then similar shifts in institutional cultures will more easily follow.