Family and domestic violence

A coroner’s inquest in Victoria (2021-22) triggered a recommendation that all psychiatrists undertake at least four hours of education, every two years in mental health aspects of family violence (FV)/Intimate partner violence (IPV). 

In Australia, in 2022, 1 in 4 women and 1 in 8 men experienced violence by an intimate partner or family member or a current or previous partner. In New Zealand 1 in 3 (35%) ever-partnered women report having experienced physical and/or sexual IPV in their lifetime. When psychological/emotional abuse is included, 55% report having experienced IPV in their lifetime. (NZ Clearing House 2017).

1 in 6 women witnessed parental violence during childhood (16%), 1in 9 men witnessed parental violence during childhood (11%). Children who witness FV are vulnerable to increased risk of internalising and externalising mental health issues, learning difficulties, and behavioural problems. (Campo M.2015).  On average, 1 woman a week is murdered by her current/former partner. [Australian Bureau of Statistics (2021-22)]. 

Family domestic violence (FV) Is a socially determined crime. Abuse of power and control is considered central to the perpetration of violence. Coercive control over time is an essential pattern of FV. 

Coercive control is a red flag for future intimate partner homicide. The NSW Domestic Violence Death Review Team report (2019-2021) found that intimate partner homicide in NSW is typically preceded by coercive control often without any recorded physical violence. The NSW Government has legislated to criminalise coercive control. It is a pattern of abuse that has the cumulative effect of denying victim-survivors their decision-making capacity. They are watched, judged, lose autonomy, and subjected to isolation from support networks and independence. (Stark 2007) 

FV is associated with serious mental and physical health consequences and puts an enormous financial burden on the country, with KPMG estimating it at approximately $22 Billion annually.

The role of psychiatry in family violence

The role of psychiatry in FV is increasingly being highlighted. There are however barriers to women and men disclosing FV in psychiatric practice. (Rose et al 2011) Strong associations between FV and post-traumatic stress disorder, panic attacks, depressive illness, chronic substance use, risky sexual behaviours, eating disorders, and suicidality are found. Women are three times more likely to be affected. (Howard, Trevillion et al. 2010); Trevillion K, et al 2012)

Pre-existing mental illness and disability are associated with a higher risk of being victimised by carers and intimate partners. Serious mental illness such as psychotic disorders is associated with two to eight times greater experience of domestic violence. The experience of domestic violence in turn exacerbates pre-existing mental illness, suicide attempts, and substance abuse. (Khalifeh, Moran et al. 2015)  

The role of mental illness in perpetrators is being increasingly accepted as an important contributor to domestic violence. A recent big data study of reports on 492,393 police callouts to FV events shows an extensive association of mental illness in FV in alleged perpetrators. In 15.51% of events, mental illness was mentioned, and almost three-quarters concerned the alleged perpetrator. “Mood disorders” (e.g. bipolar disorder, depression) had the highest number of mentions, followed by “attention deficit hyperactivity disorders,” and “conduct disorders”. (Karystianis, Simpson et al. 2020)

Case example

On 21 August Mr X attended his psychiatrist. He was severely depressed but reported that he was not a risk to himself. Dr Z queried whether Mr X may have been experiencing thoughts of self-harm that he did not wish to disclose. There was no further disclosure of self-harm.

During this appointment, Mr X also disclosed that Ms Y, his intimate partner didn’t ‘want’ him anymore and that this meant that he ‘had nothing to live for’. Mr X also spoke of concerns regarding his ability to maintain employment, his dire financial situation, and his lack of sleep.

His partner Ms Y, who had told him to vacate her house, attended the consultation with him. Dr Z had earlier warned her of the risk of being financially manipulated by Mr X. 

Later the same day Ms Y’s children contacted emergency services. Police and paramedics confirmed that both Mr X and Ms Y were deceased and appeared to have suffered fatal gunshot injuries. It was murder-suicide perpetrated by Mr X.

His past history of serious domestic violence and intervention orders protecting his ex-wife was revealed at the coroner’s inquest. It was known to Dr Z. 

Ms Y’s children reported evidence of dominating and controlling behaviours towards Ms Y at the coroner’s inquest. Victoria Police stated that in November 2014, they received information that Mr X was illegally in the possession of 8 firearms and conducted a search of his residence. They found 6 out of 8 guns but were not able to find two missing firearms, and the trail went cold. It appears he hid the two guns, that he used later.  The full details of the case (reference COR 2017 4175) are published Findings | Coroners Court of Victoria

Enhancing the safety of our patients 

As psychiatrists, we assess risk in every patient. The information gathering and assessment of the risks need to be completed in three domains: 

• risk to oneself
• risk to others
• risk from others

and included in the final formulation. 

Information may be shared with other key service providers overriding privacy concerns in Victora according to MARAMS framework legislation. 

Practice tips

Separation is the most dangerous time for the victim. The separating or divorced women have five times the risk of intimate femicide compared to other women.  (Brownridge 2006), (Karystianis, Simpson et al. 2020). The role of past history of domestic violence, and owning a gun are significant factors in perpetration. (Cherie Toivonen and Corina Backhouse, 2018). It is essential to make a Safety Plan with the separating survivor.  

Combined consultations with the abusive partner should be avoided. It provides opportunities to the perpetrator for further coercive control and violence.   

Further learning

A duty to care: Mental health service responses to family violence. Including diverse populations experiencing family violence. A webinar, presented by Family Violence Psychiatry Network RANZCP, and Safer Families Program by University of Melbourne, Department of General Practice.

There are a number of webinars and podcasts on family violence and mental health are available on the RANZCP education portal.

References

Adj. Professor Manjula O’Connor - Member, Committee of Continuing Professional Development and Chair, Family Violence Psychiatry Network

Australian Bureau of Statistics (2021-22), Personal Safety, Australia, ABS Website, accessed 24 April 2023.

Brownridge, D. A. (2006). "Violence against women post-separation." Aggression and violent behaviour 11(5): 514-530.

Campo M. Children's exposure to domestic and family violence: Key issues and responses (CFCA Paper No. 36). Melbourne, VIC: Australian Institute of Family Studies; 2015:1-24

Cherie Toivonen and Corina Backhouse (2018.) Australia’s National Research Organisation for Women’s Safety, for the Commonwealth Department of Social Services ANROWS

Howard, L. M., et al. (2010). "Domestic violence and severe psychiatric disorders: prevalence and interventions." Psychol Med 40(6): 881-893.

Karystianis, G., et al. (2020). "Prevalence of Mental Illnesses in Domestic Violence Police Records: Text Mining Study." J Med Internet Res 22(12): e23725.

Khalifeh, H., et al. (2015). "Domestic and sexual violence against patients with severe mental illness." Psychol Med 45(4): 875-886.

New Zealand Family Violence Clearing House. 2017. 

NSW Domestic Violence Death Review Team. Report 2019-2021.

RANZCP position statement Family violence and mental health, May 2021.Position statement 102)   

Rose, D., Trevillion, K., Woodall, A., Morgan, C., Feder, G., & Howard, L. (2011). Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. 

The British journal of psychiatry: the journal of mental science, 198(3), 189–194. 

Stark. Evan. 2007. Coercive Control. Oxford University Press.

Trevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis.