a) Rationale

As outlined under 1 a) Mental Health Services Perspective:

• neglect of abuse issues in mental health services;
• high prevalence of abuse endured by service users, particularly child sexual abuse;
• potential effects of abuse, notably child sexual abuse, across all presentations, behaviours and diagnoses.

b) Policy detail

The nub of the policy is that, after training, staff should:

• routinely ask about violence and abuse in child and/or adulthood in all mental health assessments (first contact and reviews);
• suitably respond to disclosures, and
• provide ongoing therapeutic support to survivors of abuse through care planning processes.

In addition to staff training (which focuses on child sexual abuse), other key building blocks include:

• insert abuse question in assessment documentation - “Have you experienced physical, sexual or emotional abuse at any time in your life?”;
• embed in clinical audit procedures;
• provide effective staff support and supervision;
• enable staff, who are survivors of abuse, to access confidential counselling;
• establish staff opportunities to develop their clinical practice;
• work in partnership with the voluntary sector.

It’s been part of the DH policy agenda since 2003¹ and further reinforced by revised guidance on the Care Programme Approach² (and therefore applicable to all services that mental health provider trusts deliver). In addition, it is anticipated that routine enquiry will  be incorporated into the National Mental Health Minimum Data Set (MHMDS) in April 2011  ie requirement of trusts to report quarterly on the proportion of staff who are routinely undertaking this enquiry in assessments.

c) Format of the abuse question in mental health assessments

This is the recommended format as outlined in CPA Guidance:

Of course clinicians should express the question in a way that feels most comfortable to them as long as they expressly use the terms ‘physical’, ‘sexual’ and ‘emotional’ and refer to both child and adult abuse.

The specific nature of the recommended format relates to the following:

• A survivor may well choose not to disclose at assessment but, importantly, they were asked. However if they disclose at a later stage, decide to give evidence to prosecute their abuser(s) and ‘no’ has been recorded at assessment - rather than ‘no disclosure’ - the defence barrister may question the veracity of his or her evidence.
• An absence of ambiguity - in terms of whether or not the question was asked - facilitates reliable clinical audits.

A note of caution:

• The abuse question should never be asked as a sole question in any setting including one-to-one formal therapy to protect both clinicians and survivors to any potential allegations of ‘false memory’, particularly in relation to criminal prosecutions of abusers.

d) Survivor perspective

Survivors ‘want to be asked’ routinely, albeit sensitively ^{3 4} , and service users who are not survivors do not object to the question. By asking about abuse, clinicians convey the following positive messages:

• “We recognise that you may have been, or are being, abused and that you’ll feel safer to tell us if we take the lead and ask you the question.”
• “We don’t want you to feel you have to keep ‘holding’ the secret and suffering alone. o “If you are a survivor, it may well be a significant factor in your mental ill health.”
• “It’s important - to us - to know about the potential causes of your mental ill health as well as your symptoms.”
• “We are equipped, as a specialist mental health service, to provide you with the care and support you need.”

Routine enquiry significantly increases the rate of disclosure ⁵.

d) Staff training in child sexual abuse

Why is the course just on child sexual abuse?

This is the form of abuse that staff are least confident about and most reluctant to address – as the majority of clinicians have had little or no relevant training either pre- or post-registration - and it is the most significant cause of survivors long term reliance on mental health services. However, an effect of the course is to increase staff confidence in addressing the broader spectrum of abuse and delivering enhanced care in acute inpatient units.

What does the course cover?

Core elements of the curriculum are as follows:

• Context: Learning outcomes; policy drivers; 
• About child sexual abuse: Historical perspective; definitions and prevalence; issues in mental health services.
• Understanding sexual offending linked to survivor concerns and anxieties: Finkelhor’s Four Factor Model; dispelling the ‘50% of victims become abusers’ myth.
• ‘Telling and ‘not telling’: Why didn’t I tell? or How I silently told … as a child; Why didn’t I tell … as an adult?
• Why has it affected me like this? Impact; long term consequences; effects on relationships; coping mechanisms; diagnoses.
• Issues for staff: Fears and anxieties; addressing diversity issues; attitudes to sex and sexuality; sexual language.
• Asking the question and hearing a disclosure: Why did I eventually tell … as an adult? Asking the question/’trial run’; ‘Dos’ and ‘Don’ts’ of hearing a disclosure; Safeguarding Children and Adults.
• After disclosure: Impact on the family; confronting ‘my abuser’; criminal justice issues; ongoing support for survivors; ongoing support for staff.

The course is designed to be relevant to all services that trusts deliver; where there is a difference in recommended emphasis or approach for a specific client group - eg children and young people; adults with learning disabilities - this is appropriately highlighted.

Who should attend?

All qualified staff - nurses, social workers, occupational therapists, clinical psychologists and psychiatrists - to enable them to implement violence and abuse policy ie conduct routine enquiry; respond appropriately to disclosures; provide effective ongoing support to survivors in their care - and the learning outcomes match these requirements. For clinicians with specific abuse expertise, it is an opportunity for them to share this with other course participants.

It is up to individual trusts whether to open up the training to non-qualified staff from the outset … bearing in mind that healthcare assistants, StR workers, etc are likely to have more ‘patient contact’ than their qualified counterparts and therefore likely to receive disclosures.

1.Gender and Women's Mental Health Implementation Guidance, Section 8, Violence and Abuse (DH 2003) pertaining to all women and men service users.
2. Refocusing the Care Programme Approach Policy and Positive Practice Guidance (DH, 2008).

3. Nelson S (2001), Beyond Trauma: Mental healthcare needs of women who survived child sexual abuse, Edinburgh: Health in Mind.

4. Stafford P (2006), Mental Health Trusts Collaboration Project, Service User Consultation Report. Download a copy

5. Read J & Fraser A (1998), Abuse histories of psychiatric inpatients: To ask or not ask?, Psychiatric Services 49, pp 355-359.

The National Mental Health Development Unit (NMHDU) is the agency charged with supporting the implementation of mental health policy in England by the Department of Health in collaboration with the NHS, Local Authorities and other major stakeholders.