The big issue: Behind closed doors
Therapy Today, April 2021

‘I was in a relationship for seven years; there was abuse on every level including sexual, emotional, financial, and coercive control,’ says Nadia.* ‘I managed to end the relationship when I realised that the alternative was suicide. But nothing prepared me for the aftermath. I was at sea, with no direction; I had lost my whole self. However, I knew I had to repair and recover. I recognised that I was traumatised so I looked for a therapist who was experienced in that area. Eventually, I found someone who was qualified. At that point, I trusted no one, but I felt able to talk to her. Complex trauma is hard to unravel but for me, it is a long-term investment.’

In April last year, the World Health Organisation (WHO) announced a ‘shadow pandemic’¹ – violence against women and girls. Not all of this may have been domestic violence – violence within the home – and not all domestic violence is exclusively perpetrated against women, but the startling rise in levels and/or severity of domestic violence under the COVID-19 pandemic has shocked many people. What is the breakdown of the situation and where do therapists and counsellors fit in?

The increase since early 2020 is partly in numbers and partly in degree. The Office for National Statistics (ONS) reports an increase in demand for domestic abuse services during the pandemic, particularly affecting helplines as lockdown measures eased. However, as the ONS report says, this does not necessarily indicate an increase in the number of people who are experiencing abuse, but ‘perhaps an increase in the severity of abuse being experienced, and a lack of available coping mechanisms such as the ability to leave the home to escape the abuse, or attend counselling’.²

Sociologists Dr Katrin Hohl (City, University of London) and Dr Kelly Johnson (Durham University) have also looked at the reported rise, comparing the data from the start of lockdown with data from the previous couple of years.³ They found that police-recorded domestic abuse has been steadily rising – it is a long-term trend – but that a number of perpetrators are using the lockdown rules to intensify and/or conceal abuse, and that lockdown has made it much harder for abuse survivors to leave the home.

What counsellors working on the ground report is that their services have been put severely under pressure. Calls to helplines certainly went up dramatically, and Women’s Aid’s network of refuges anticipates a continuing spike in demand. ‘We run one of the biggest advice lines, and we received an increasing number of calls from women as lockdown approached,’ says Asalet Tulaz, counselling service manager with Solace Women’s Aid. Another record surge in calls came at the beginning of May last year, when lockdown started to ease and, presumably, survivors could get a little more privacy to call.

That surge at the end of May demonstrates a point flagged up in the ONS figures – the total number of highest-risk cases being discussed by professionals actually decreased between April and June 2020, very probably because people experiencing abuse were unable to contact the police. ‘One thing that has made it very hard during lockdown is that the things that were helping make life bearable for many women have been closed down. Meeting a friend, going to work, going to a yoga class, being involved in school, having relatively easy access to other services or activities that give you some kind of support or self-esteem – those aren’t there,’ says Helen Hayes, a trustee of the specialist mental health charity Woman’s Trust. ‘It’s also been difficult for women who recently left an abusive situation but don’t have new support structures yet. We’re seeing higher levels of complex distress. And the kind of abuse they’re experiencing if they’ve left is increasing, in the form of abusive messages from perpetrators with more time on their hands.’

Mental health connection

Successive studies have shown, to nobody’s surprise, that domestic abuse inflicts considerable mental and psychological damage. In fact, a lot of abuse doesn’t take the form of a fist in the face; it is the manipulation and/or gaslighting that accompanies or even replaces the physical abuse. ‘Coercive or controlling behaviour’ is now recognised as a criminal offence, but in practice it is still often going unrecognised.

‘I think it’s such a complex dynamic that it trickles down into every aspect of life,’ says Birmingham-based counsellor Kiran Mahboob. ‘A lot of the time, people tend to end up blaming themselves, because the abuser’s behaviours don’t make a lot of rational sense. Abusers tend to repeat and repeat, until you think maybe they have a point. It’s just a downward spiral again, where you feel that you’re the one who is the problem.’

A number of dedicated agencies supporting domestic abuse survivors approach this using a trauma model and, like other forms of trauma, the impact lasts long after the damage is inflicted. ‘It often affects how people conduct their relationships in the future – and very often there are children involved, so that means ongoing contact with the abuser,’ says Catherine Mulcaster, an integrative coach-therapist who works with Living Your Life, a Bedfordshire-based not-for-profit service for people affected by trauma. ‘It’s not the case that someone is helped to leave and then all is well. The picture is so much more complicated,’ adds Hayes. ‘Abuse affects people in many and complex ways and the impact is long-term anxiety and depression, low self-esteem and other complex trauma responses.’

There are links with mental health in other ways. Researchers from the Institute of Psychiatry, King’s College London have reviewed successive studies that find that people who are already experiencing mental health problems are more likely to be abused,⁴ and there’s also evidence that people who perpetrate domestic violence may have mental health problems.⁵ None of this is surprising, but it all adds up to a quite complex picture. It also means that a number of people may be seeking counselling as a result of abuse in their past, even if they don’t recognise it as having been abuse. Others may have current unrecognised abuse that has left them feeling that there is something profoundly wrong with them or how they perceive the world and themselves.

Race and disability

Overall, more than half (53%) of the respondents surveyed for Women’s Aid on the effect of the pandemic said that their mental health had been affected.6 Solace reports that anxiety has increased ‘massively’, along with alcohol and eating disorders. Women in some social groups have been particularly badly affected.

Domestic abuse isn’t limited to socioeconomic or racial groups (in fact, it is arguably identified less in white middle-class families, especially when it is more psychological than physical) but it is also the case that black, Asian and minority ethnic women often face particular barriers to getting abuse recognised or finding support.

Ashiana Network provides support to women from ethnic minority communities, including three refuges and a counselling service. ‘It started in 1989, mainly with women from the South Asian community, and then broadened out to support other minority communities,’ says clinical lead Molleka Simms. ‘If women go to a generic service, they may not feel their background, traditions and culture are being heard. We wanted to provide something where women felt that their own experiences and cultures were being reflected and understood, so that they could express themselves and have their needs met. And our counsellors are able to offer Bengali, Hindi and Urdu at the moment, so we can support women who don’t have English as a first language, and may be even more isolated as a result.’ Both Ashiana and the charity Imkaan, which also focuses on violence against black and ethnic minority women and girls, report a dramatic increase in referrals since lockdown.

A report from the disabled women’s collective Sisters of Frida describes how the pandemic and lockdown have also disproportionately affected disabled women – often because they cannot go outside the house, either because of mobility issues or because they are more vulnerable.⁷ And, statistically, disabled women and women with long-term illnesses are far more likely to be subjected to domestic abuse. ‘I think lockdown gave an excuse to perpetrators to control even more, and control using health as an excuse not to leave the house and not to communicate with friends as well,’ says Asalet Tulaz from Solace.

The other group that is, of course, hugely affected by domestic abuse is children. There have in fact been fewer referrals for medical help – but again, this is probably because children have not been able to talk to a trusted adult in private.⁸ The #SortItOut campaign, of which BACP is a member, is calling for immediate action to reduce the damaging impact of parental conflict on children.

Dr Jo Casebourne is Chief Executive of the Early Intervention Foundation, a charity that champions and supports the use of effective early intervention to improve the lives of children and young people. ‘Witnessing domestic abuse has similar effects to being the target,’ she says. ‘It has a big impact on children’s mental health, putting them at greater risk of being involved in substance abuse, antisocial behaviour, difficulties forming relationships and so on. The statistics show that 15,000 children in the UK are at risk of domestic abuse in any two-week period, and obviously we think the numbers will be increased under lockdown; the financial pressures, the stress and home schooling all raise the pressure and make conflict and abuse more likely.’

Remote working

The shift to delivering remotely has been problematic in some ways. ‘We’ve had to be more flexible about times and availability and to be able to cancel sessions at short notice, both because of alleged perpetrators and because children may be around,’ says Simms. ‘A lot of the tangible things we can suggest to clients aren’t available – going to the gym or visiting a friend, for instance – so we’ve had to focus more on the mental and emotional work. And for women who have left the danger but are now increasingly isolated within their homes, the reduced contact with their support network has made them much more prone to flashbacks of abuse and their mental health worsening.’

On the other hand, Tulaz points out that ‘it has increased some levels of access to our service, especially for women who have escaped that situation but still have travel issues. A phone or video call at home is so much easier. In that sense it did increase some access.’ This very much bears out the broader findings of Women’s Aid.

However, another team of researchers from the Institute of Psychiatry has pointed out that mental health services more widely are often missing the opportunity to identify domestic abuse in the clients they’re seeing.⁹ ‘Often it’s missed, and people can present to services with depression and anxiety, but what’s actually going on is not picked up,’ says Hayes. So what are the implications for practitioners working in ‘mainstream’ therapy?

The past and the present

Sometimes it’s possible to work out from things that clients say that abuse may be a factor in the way they see themselves and the world. Clues may be seen in ‘patterns of conflict or difficulty which seem very one-sided, where you’re getting a sense of abuse of power or abuse of control, or arguments where somehow she has to change her ways,’ Hayes suggests. But, she points out, the effects of the abuse can also present in different ways. ‘Many women are in a state of constant low-level trauma. They may be a bit unreliable, or a bit vague or give stories that don’t add up or be unreliable about turning up on time. Therapists get quite concerned about this kind of thing and often can decide the client has serious issues and isn’t committed to the therapy. It’s actually about trauma, and a dissociative process and a level of anxiety and distress.’

Mahboob recommends work on maintaining an emotionally safe relationship for the client, so they can be vulnerable. ‘If they fear judgment, people may not be honest about what is happening to them. But if the client is comfortable enough with you challenging them, in a very gentle way, they may be able to explore the unhealthiness of the relationship and maybe the lack of boundaries that are there, without making them deal with something they’re not ready for. If it’s done very gently and kindly, it can enable them to explore it and talk it through.’

Where this isn’t appropriate is in couples therapy. ‘The abused person can’t speak openly, and if they even hint at it they’ll pay for it when they get home. Abusers can present a perfectly reasonable account and be very charming, so the therapist is drawn into the whole dynamic,’ says Hayes. And she also cautions against just encouraging someone to leave, pointing out that the risk of serious harm – including being killed – is often at the point of leaving. ‘Leaving may not be the answer for some, and for others it’s only the beginning. It’s a process, not a beginning. There’s a whole practical process to be handled, and a whole psychological, emotional and relational process to manage. How do you deal with the immediate and the wider fallout of leaving?’

On the other hand, Hayes and others feel that if therapists do suspect that abuse is happening, it is within the therapist’s remit to help by referring clients to agencies that are skilled in this work, which may well involve doing some basic research themselves into what help is available locally. ‘If you have any suspicions, please ask if everything is OK at home,’ says Tulaz. ‘And please feel ready to give out numbers. It’s usually seen as something happening behind doors, and by not asking questions we’re actually increasing what is happening behind doors. It’s everyone’s responsibility.’

* Client’s name and identifiable details have been changed.