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CHAPTER EIGHT: PHYSICAL ABUSE AND DOMESTIC ABUSE

Introduction

8.1 This chapter defines physical abuse and domestic abuse, considers the potential signs or indicators to be aware of, and explores the available protection and support for adults "at risk. This chapter does not differentiate between domestic abuse of vulnerable adults and domestic abuse of adults with capacity. In reality it is very difficult to differentiate between such behaviours and in the United States viewing elder mistreatment as a form of domestic violence has become an increasingly popular approach (Pillemer, 1993).

Definition

8.2 The ' No Secrets' guidance (DoH, 2000a) defines physical abuse as:

"…hitting, slapping, pushing, kicking, misuse of medication, restraint, or inappropriate sanctions." (DoH, 2000a: 2.7).

8.3 The Scottish Executive published the ' National Strategy to Address Domestic Abuse in Scotland' in 2000 ²⁵. This Strategy states that

"Domestic abuse is most commonly perpetrated by men against women and takes a number of specific and identifiable forms. The existence of violence against men is not denied, nor is the existence of violence in same sex relationships, nor other forms of abuse, but domestic abuse requires a response which takes account of the gender specific elements and the broader gender inequalities which women face. In this context, the definition adopted is as follows:

Domestic abuse (as gender-based abuse), can be perpetrated by partners or ex-partners and can include physical abuse (assault and physical attack involving a range of behaviour), sexual abuse (acts which degrade and humiliate women and are perpetrated against their will, including rape) and mental and emotional abuse (such as threats, verbal abuse, racial abuse, withholding money and other types of controlling behaviour such as isolation from family or friends)." (Scottish Executive, 2000).

Domestic abuse is often considered separately to the abuse of vulnerable adults, although certain legislative provisions relating to domestic abuse may be applicable to vulnerable adults. Nonetheless, vulnerable adults are potential victims of domestic abuse.

8.4 The domestic abuse literature is also clear that men are victims of domestic abuse and may require different prevention and intervention strategies from women; for example, men are more likely to receive less severe physical injuries due to domestic abuse and consequently require less health interventions. Conversely male victims are less likely, for reasons of shame or embarrassment, to impart the true seriousness of assaults by women (Gadd et al., 2002; Mirlees-Black, 1999) ²⁶.

8.5 Research undertaken by the Scottish Executive, "Domestic Abuse Against Men In Scotland" (Gadd, Farrall, Dallimore, and Lombard, Department of Criminology, Keele University) set out that "Relative to female victims of domestic abuse, male victims in general were less likely to have been repeat victims of assault, to have been seriously injured, and to report feeling fearful in their own homes." It also concluded:

"Neither abused men's nor service providers' responses suggested that there is presently a need for an agency whose specific remit is to support male victims of domestic abuse in Scotland. Neither does there currently appear to be a need for refuges for abused men, although some male victims would benefit from support and advice regarding housing and welfare. Men who are trying to separate from abusive partners may benefit from the provision of alternative accommodation (for themselves and their children) and better legal and financial support. However, there is some evidence to indicate that abused men are not making full use of the pre-existing support services available to them, perhaps suggesting that some service providers need to publicise their remit more widely²⁷." (Gadd et al., 2002: vii).

Characteristics of physical abuse

8.6 Physical abuse of a vulnerable adult is one of the easiest forms of abuse to identify, due to the physical combination of injuries (bruising, injury, burn-marks). It is often found as an element of multiple forms of abuse (usually together with psychological, financial, or sexual forms of abuse). It may be considered as a crime (for example, physical assault) with specific legislation in place to protect individuals relating to Offences Against the Person Act (1861) ²⁸ (Brown, 2003; NHS Tayside, 2005).

8.7 Alleged criminal offences differ from all other non-criminal forms of abuse in that the responsibility for initiating action almost invariably rests with the state (private prosecutions are possible in theory but extremely rare in practice). When complaints about alleged abuse suggest or indicate that a criminal offence may have been committed it is essential that reference should be made to the police as a matter of urgency. Normally, criminal investigation by the police should take priority over all other lines of inquiry (DoH, 1993).

8.8 Physical abuse can occur across a range of care settings. Relevant agencies and authorities may intervene and the perception of 'duty of care' may result in an investigation taking place. There will normally be an assessment and decision about the alleged abuse (or assault) and how best to protect the individual involved. Issues of capacity are important: individuals who retain capacity (for instance, an older person with vulnerabilities relating to physical health) may determine that no course of action is required in relation to a specific situation. Such individuals retain the right to refuse interventions to stop or prevent the abuse. In such circumstances a follow-up and monitoring plan must be developed by the agencies involved.

Support and protection for adults "at risk" of physical abuse

Primary intervention

8.9 Primary intervention is the development of a political, welfare, and legal structure that acknowledges the damage caused by domestic abuse. The social policy response within England and Wales has been to offer interventions at the secondary care interface (mainly health and social care agencies). The majority of interventions are provided by the voluntary sector. Health and welfare services are mainly charged with interventions when adult victims are caring for younger children. The health sector has not developed an appropriate prevention strategy for domestic violence; however, the issue is beginning to appear on the health radar ²⁹.

8.10 Whilst the health sector has yet to clarify its role in any primary prevention strategy for domestic abuse, there is evidence of progress in addressing the health and healthcare implications of this issue, for example the inclusion of domestic abuse in key strategic developments in mental health and maternal and child health, and the development of detailed 'guidance on domestic abuse' for health staff highlighting the pivotal role of the NHS in identifying and responding to women experiencing abuse. The recent issue of guidance to health boards in relation to developing 'Gender Equality Schemes' firmly located this abuse within the domain of gender equality, and placed significant responsibility on boards to respond accordingly.

8.11 Education and improved public awareness appear to be the most effective forms of primary intervention. Several high profile campaigns have been launched and evaluated with impressive outcomes; for example, the 'Zero Tolerance' campaign in Edinburgh in 1992 ³⁰, and the Scottish Executive domestic abuse publicity campaign that has been developed since 1999. This latter campaign has been evaluated every year and has proved to be very successful, with an average reach of around 70%. The 'Respect' campaigns run by East Ayrshire Zero Tolerance Group (1998 to date ³¹) have had a positive impact on the pupils participating with many pupils reporting a positive shift in attitude towards how people should talk and listen to each other, what boys and girls should be like, and how people should treat each other. Such educational campaigns have taken place in other countries (for example Sweden) and have been positively evaluated (Leander, 2002; Roberts et al., 1997) ³².

Secondary intervention

8.12 Secondary intervention primarily involves screening and risk assessment of vulnerable individuals to identify and establish a suitable degree of ongoing monitoring. This subsequently should lead to clear guidelines and processes to distinguish and recognise physical abuse in all its manifestations.

8.13 Accident and emergency departments have recently started to address domestic violence with screening questions at triage (Bullock, 1997; Cobin, 2002; Cole, 2000; Gerard, 2000; Tommie, 1999). McLeer and Anwar (1989) reviewed the case studies of 359 females before introducing a screening protocol, and found 5.6% had been victims of abuse. After the protocol, a prospective analysis found 30% of a sample of 412 women to be victims of abuse. However, the main focus has been on screening possible female victims of abuse who are not considered vulnerable adults. Awareness education is necessary to assist accident and emergency staff to recognise that other individuals (people with learning disabilities, physical disabilities, frail older people, people with mental health challenges, etc.) may also be victims of domestic abuse.

8.14 Other health practitioners are beginning to understand their role in detecting and responding to domestic abuse in the population as a whole; for example, surgeons noting physical injuries that might be caused by domestic violence (Guth and Pachter, 2000); family physicians and general practitioners asking questions related to relationships in the case of anxiety and depression (Rodriguez et al., 2001; Wasson et al., 2000; Wilson et al., 2001); obstetricians being aware of the high risk of domestic abuse in pregnancy (Abbasi, 1998); and dentists noting and questioning individuals with facial and tooth damage that might be caused by domestic violence (Littel, 2004). Nonetheless, it is also important to be aware of the potential for abuse in vulnerable populations.

8.15 Domestic abuse services provide advice, guidance, and potential assistance for individuals within communities, but these services may not be easily accessed by vulnerable adults. Domestic abuse services are ill equipped to work with individuals who have complex needs; for example, people with learning disabilities or older people who are physically frail. Help the Aged (Blood, 2004) outlined reasons why older women make limited use of such provision:

• Awareness is generally low
• Refuges are not aware of levels of demand
• Refuges may be noisy and chaotic or lack facilities for those with disabilities, reduced mobility, or complex health problems
• Leaving home often disrupts family and other relationships
• Some women may care for older male children or teenagers, who can't usually be accommodated by refuges
• Refuges may not be able to provide the intensive emotional and practical support needed by some women
• Refuges can't afford to provide accommodation for women who don't receive full housing benefit, and most survivors are unlikely to have a high enough income to pay for a refuge place themselves
• Women are likely to be a main carer and therefore may feel guilty about leaving home
• Older survivors who have been abused by their sons and daughters may need intensive counselling, which refuges cannot provide
• Many survivors have lived in the same area (or house) for many years. It is difficult for them to access new social networks and facilities, and refuge workers may not be equipped to advise on housing needs

8.16 One refuge for young women with disabilities in London has however been successfully evaluated. Most women were positive about being in the refuge and the majority of women also appreciated the safety provided by the refuge and that the refuge was a women only environment (McCarthy, 2000). This service predominantly serves young women with intellectual disabilities, but has a small provision for women with physical impairments or complex needs.

8.17 Dumfriesshire and Stewartry Women's Aid ³³ has appointed a full-time support worker to provide support, counselling, and advice to older women. One of the organization's refuges is designated for women over the age of 50 years. The project worker runs drop-in sessions, giving women an opportunity to make friends and try new activities, and provides services on an outreach basis (including home visits). Women are encouraged to pursue educational opportunities and the project worker continues to support women after they have been resettled ³⁴.

8.18 Tayside Domestic Abuse and Substance Misuse Project ³⁵ works with women experiencing domestic abuse who also have substance misuse issues, and children and young people affected by domestic abuse and their mother's substance misuse issues. The project aims to identify and address the needs and barriers to service provision faced by women (and their children, if any) who experience domestic abuse and substance misuse issues. There is a lot of anecdotal information on their needs, barriers to service provision, service pathways and patterns of referral but the project aims to verify the validity of this anecdotal information through research and then build on this research to identify priorities for action and subsequently implement a number of activities.

8.19 Within care settings, physical abuse has raised issues surrounding the needs of vulnerable individuals with intellectual disabilities and other cognitive impairments who display challenging behaviour, which may at times relate to extreme forms of physical aggression and violence. The management of these needs for both the individuals concerned, and for others who may be vulnerable to potential assault, is of paramount importance. Policies and procedures concerning abuse need to be supplemented by relevant policies relating to risk assessment, risk management, and the management of challenging behaviour. The responsibility for investigating physical abuse within care settings ultimately rests with the agencies charged with regulation and inspection.

8.20 Contact between vulnerable adults and social care or primary health care professionals may occur on a regular basis, and risk assessments should examine the nature of relationships, the physical safety and degrees of risk involved for the individual, as well as any risk factors for abuse. This should be a role for all health and welfare practitioners; however, specific advice may be sought from adult protection teams. This would include advice in terms of risk assessment judgements for individuals who may be experiencing abuse, advice on financial safeguards, etc.

8.21 Secondary intervention also concentrates on responding to allegations of potential abuse at an appropriate level and within an adequate time frame. A thorough assessment of the situation will be required. This may take time to achieve because of the sensitivity regarding the situation, especially surrounding disclosure. The individual's perceptions and aspirations related to outcomes and the handling of the investigation are vital. This is likely to cause some concern when the vulnerable individual either retains decision-making capacity (and perhaps wishes to remain with an abusive partner) or wishes to remain autonomous in a relationship with an abusive partner, when they have lost capacity.

8.22 In responding to allegations of abuse, the foremost concern should be to safeguard the individual(s) involved in order to prevent further abuse occurring, particularly whilst the assessment is taking place. This may include the suspension of an alleged perpetrator who is working in a care setting.

8.23 The most effective investigations will generally involve other agencies and authorities. In relation to physical abuse this may require the involvement of the police and forensic medical practitioners at as early a stage as possible.

8.24 Individuals who express concern or make a complaint or allegation about potential abuse to any agency (whether they are staff, service users, carers, or members of the general public) should be reassured that their concerns will be taken seriously, that their statements will be treated sensitively, that they will be treated equitably and fairly, and kept informed about action taken. If the person is a service user they should be given protection from intimidation and retribution (especially if the concern relates to a care setting). If the person is a member of staff they should be offered support, assistance and protection if necessary, within the terms of the Public Interest Disclosure Act (1998). It is good practice to obtain consent before sharing information, but confidentiality is never absolute. There may be circumstances, specifically in cases where there is risk of actual or imminent harm against one or more individuals, where consent may not be possible to secure.

8.25 Advocacy services should be made available to victims of domestic abuse, irrespective of their capacity ³⁶. The benefits of advocacy include:

• Empowerment through expressing individual concerns and experiences
• Expressing concerns and experiences through a third party, providing anonymity
• Provision of information, professional support, complaint procedures, and services
• Information regarding availability of other services, such as local community services, self-help groups, and other support networks
• Information explained by the advocate
• Assistance from advocates in making an informed choice

The Scottish Executive document 'Independent Advocacy: A Guide for Commissioners' can be found at www.scotland.gov.uk/library3/health/iagc-00.asp .

Tertiary intervention

8.26 Tertiary intervention focuses on moderating the harmful effects of abuse on an adult. Appropriate arrangements to ensure the safety of the adult as far as possible, and to prevent similar incidents occurring in the future, need to be activated wherever possible. This includes prevention of future abuse by the same perpetrator, of the same or other potential victims; for example within a care setting.

8.27 Potential actions that may be taken are influenced by the nature of the abuse, the degree of severity, and the characteristics of the perpetrator. In the case of a care worker, to prevent the perpetrator making contact with vulnerable adults in the future in any formal role, the perpetrator may be prosecuted, removed from their respective professional register, placed on the protection of vulnerable adults ( POVA) list, or banned from owning or managing a care home by the Commission for Social Care Inspection or Care Commission in Scotland.

Conclusions

8.28 Physical abuse is one of the most frequent forms of abuse to occur in terms of prevalence data, mainly due to the observable nature of injuries. Physical abuse appears to affect a range of service users although, arguably, the needs of individuals with cognitive impairments need to be considered paramount, especially for those individuals who may not be able to report the situations that are occurring.

8.29 Developing appropriate contacts with individuals who are vulnerable may help to ensure that these individuals are able to access those services when necessary. Existing literature recommends risk assessments for vulnerable individuals (McCreadie, 2001). In addition to the development of appropriate systems of inter-agency communication and co-operation, the provision of assistance deriving from support groups (Pritchard, 2003) and telephone help-lines (Scottish Executive, 2004) for abused individuals is also effective; see 4.25.

8.30 Whilst the literature suggests that there has been an increased professional awareness concerning abuse in recent years, public awareness remains low. At the same time, specific and evaluated interventions in relation to adults who experience physical abuse are also lacking.

8.31 The most important issue for the next five years will be to mainstream services that exist for younger victims of abuse for all age groups and for individuals deemed "at risk" of abuse; for example, individuals who have learning disabilities, frailty, or lack capacity.

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