A thought exercise and invitation to the sector to collaborate.
In a recent conversation with a regional Domestic Abuse (DA) service commissioner, I was told, "the evidence for short term (10-12 week) interventions is strong and so we invested in that".
I was fascinated to hear this, as I meet so many clients who have had short term support - often at the point of crisis or after extensive waiting periods, who report that they are left without answers, with high shame and regret and/or confusion about they past and how to approach their futures.
As a clinician it strikes me as obvious that a complex trauma experience, that often went on for years, cannot be healed with a 12 week group programme - as in almost all mental health approaches recommended by NICE, 12 weeks would be considered a low-intensity intervention unless delivered by a highly trained clinician in a 1 to 1 setting. Unpacking, repacking and healing from what might be a decade of domestic abuse is not going to be met adequately in 12 weeks, unless I missed the invention of a therapy approach recently.
If c-PTSD is well supported, UK NICE guidelines recommend 8-12 sessions. But we have to consider domestic abuse as trauma, plus grooming, plus trauma bonding (addiction), plus learned helplessness, plus dissociation... including potential physical injury... multiplied by the 1000s of experiences of abuse over the duration of the relationship. Recovery needs to be framed as requiring time and resource, to support victims in being able to embrace the scale of the experience and their needs.
Speaking as a former DA victim and service user on the very same pathway this commissioner was referring to, I wondered if I had been considered a good outcome when I eventually quit on the service waiting list and closed doors to therapy, and sought my own recovery approach.
I know service evaluation well - not coming back, is often interpreted as 'cured'.
In my work since, developing GOGL, and trying to understand how to measure outcome... I've come to realise, it is tricky to say the least.
Recovery from abusive relationships
It's fair to summarise that recovering from abusive relationships is a difficult journey that can take years of hard work and dedication. Survivors of abuse face many obstacles as they work towards healing and services face the challenge of measuring the success of what they offer.
While measuring success is important for funding recovery approaches, there are several problems with trying to measure good outcomes for people in recovery from abusive relationships. These are perhaps evidenced by the lack of consistency in the sector and published papers that detail what good outcomes look like, in a way that can steer solutions at scale.
Firstly, some of the challenges:
Subjective Nature of Recovery
One of the main challenges of measuring outcomes for domestic abuse survivors is the subjective nature of the recovery process. Domestic abuse can have a profound impact on a person's mental, emotional, and physical wellbeing, and recovery can be a deeply personal and individual process. What may be a positive outcome for one person may not be the same for another.
For example, one person may see leaving their abuser as a major success, while another person may view simply being able to hold it together at work, as their primary need and goal.
Difficulty in Assessing Progress
Another challenge in measuring outcomes for those in recovery from domestic abuse is the difficulty in accurately assessing progress. While traditional measures such as length of time since the last abusive incident or frequency of counseling sessions may provide some information, they may not paint a complete picture of an individual's progress. Recovery from domestic abuse is often a nonlinear process, with ups and downs along the way. A person may make significant strides forward in their recovery, only to experience setbacks that appear to undo all of their progress.
I've seen the use of boundary setting assessments and self-esteem assessments, without much case made for how these integrate in the idea of a successful future life. I most often hear domestic abuse clients refer to regret, shame, guilt, fear, a sense of failed duty and a fear that they are a burden to others... none of which feature well in the validated measures I most witness used in this space.
Stigma and Shame
The stigma associated with domestic abuse can also make it difficult to measure good outcomes. Shame and embarrassment often prevent survivors from sharing their experiences or seeking help, which can make it challenging to track their progress. Additionally, social expectations can lead to survivors feeling pressure to present a certain image of their recovery process, which may not accurately reflect their true experience.
This is felt not just at the point of measurement, but often at the point of disclosure and assessment. Shame and guilt are deeply entrenched in the experience of abuse, but so are dissociation and cognitive dissonance. It can be incredibly difficult to assess one's own state at the point of escape, as one's own state has likely been denied for such a long time - in service of the abuser. Confusion is most commonly talked about and a deep sense of regret. Most measures of single constructs (such as esteem, mood etc) are not validated to such an extent that they consider the user lacks any trust in their ability to perceive reality or to know their own state. Both of which I've heard in clients, repeatedly... and recall in my own journey.
Lastly, it's important to acknowledge that measuring outcomes for people in recovery from domestic abuse can be a triggering experience. The process of discussing past traumatic events, revisiting feelings of fear and helplessness, and confronting the lingering effects of abuse can be overwhelming and potentially retraumatising. This can make it difficult for survivors to engage in the measurement process and may even discourage them from seeking help altogether.
It can be easier to ice over a question rather than dig deep to find the answer, risking further trauma. This is potentially more likely if the intervention assessed was itself icing over the issue, which is a valid risk when short term therapies are provided to people with long term complex trauma. It is communicated, potentially, within the model that the need is not so great as the solution was not so large. To name further need, after receiving support - would seem out of sync with what most victims have come to expect, which is to put their needs last and to put the needs of others first.
A different approach?
How do we measure the recovery of a wounded heart? We have to start by ditching all assumptions and listening.
In our work with the GOGL programme, which provides long-term support to people (6-9 months), we are collecting stories, expectations, hopes and fears. Qualitatively. The words used and the stories told.
Through an analytical lens that invites meaning from these encounters, we are developing an assessment tool that explores the starting point, journey points and outcomes for people that is framed around shared aspirations, rather than shared starting points (which are disperate, to say the least).
Hopes to resolve:
Hopes to understand the relationship, the past and how it came to be.
Hopes to achieve:
Trust in self and others
Self-love / esteem
The work has just started, but this perhaps gives a sense of the goal. Recognising that domestic abuse is a love story gone bad, and for most people - the outcome they seek is a story made good. It's not an easy sell to commissioners, but it could make all the difference when we come to design pathways and interventions in the future world, of commissioning.
It's a tall order - we are hoping to invite collaborators. GOGL is the first long-term support platform in this sector that can both digitally support and track the impact with people it empowers. We hope to support 100,000 people in the coming years (as a starter) and to learn from them. We're not wedded to any outcome, we are being led by our users.
Contact us if you'd like to join in.