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Transcript — Programme 126: Domestic Violence and Chronic Pain

Exam­in­ing the links between domes­tic vio­lence and chron­ic pain, par­tic­u­lar­ly dur­ing the Covid-19 lockdown 

To lis­ten to this pro­gramme, please click here.

This edi­tion of Air­ing Pain has been fund­ed by the Women’s Fund for Scot­land.

The Coro­n­avirus pan­dem­ic has been long and iso­lat­ing for every­one, but par­tic­u­lar­ly for those who expe­ri­ence abuse. The pan­dem­ic and sub­se­quent lock­downs have seen an increase in the lev­el and sever­i­ty of domes­tic abuse.

In this episode of Air­ing Pain, our host Paul Evans dis­cuss­es the iso­lat­ing effects of Covid-19, trau­ma and how this can con­tribute to the devel­op­ment of debil­i­tat­ing chron­ic ill­ness­es, such as fibromyal­gia and chron­ic fatigue syn­drome. Through­out the episode Paul speaks can­did­ly with Kath Twigg, senior lec­tur­er in social work, train­er, men­tor, writer and domes­tic abuse sur­vivor, about her expe­ri­ence of abuse and pain.

An arti­cle by Kath Twigg will accom­pa­ny this extend­ed episode of Air­ing Pain, and her book, The Hall of Mir­rors, How to Change Life Pat­terns and Avoid Tox­ic Rela­tion­ships, is avail­able in Kin­dle and paper­back ver­sions on Amazon.

Issues cov­ered in this pro­gramme include: Abuse, chron­ic fatigue syn­drome, covid-19, domes­tic vio­lence, fibromyal­gia, ner­vous sys­tem, peer sup­port, psy­cho­log­i­cal pain, PTSD, social iso­la­tion, stress and wom­en’s pain.

Paul Evans: This is Air­ing Pain; a pro­gramme brought to you by Pain Con­cern. The UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and for those who care for us. I’m Paul Evans, and this extend­ed edi­tion of Air­ing Pain has been fund­ed by the Wom­en’s fund for Scotland.

Joht Singh Chan­dan: If we think even in a pre-Covid world, domes­tic abuse is unfor­tu­nate­ly an expe­ri­ence which affects one in three women glob­al­ly. In the UK we’re think­ing about one in four women, but there’s always a hid­den bur­den of domes­tic abuse which is not being report­ed to ser­vices or through sur­veys. So, if any­thing, the num­ber could be much higher.

Car­o­line Brad­bury-Jones: When we went into lock­down in the spring of 2020 there was spec­u­la­tion about how lock­down and iso­la­tion would impact on the num­bers of domes­tic vio­lence inci­dents that were tak­ing place. There’s very clear evi­dence that it’s increased dramatically.

Evans: As we record this edi­tion of Air­ing Pain in the week lead­ing up to Christ­mas 2020. [Due to] the dis­cov­ery of a new vari­ant of the COVID-19 virus along with a sharp increase in infec­tions, The UK’s devolved gov­ern­ments have imposed new stricter social iso­la­tion lock­down rules to try and stem infec­tion rates whilst we wait upon a full vac­cine roll­out. For women, because it is most­ly women, lock­downs and social iso­la­tion height­en the lev­el and sever­i­ty of domes­tic abuse. A 2019 study by the Uni­ver­si­ty of Birm­ing­ham showed that UK domes­tic abuse vic­tims are three times more like­ly to devel­op severe men­tal ill­ness­es. A fur­ther study by the Uni­ver­si­ty of Birm­ing­ham at War­wick found a link between women who are sub­ject­ed to domes­tic abuse and the long-term con­di­tions fibromyal­gia and chron­ic fatigue syn­drome. Dr Car­o­line Brad­bury-Jones is pro­fes­sor in Gen­der Based Vio­lence and Health at the Uni­ver­si­ty of Birm­ing­ham. She is a co-author of the study.

Brad­bury-Jones: What the study found was that there was an asso­ci­a­tion between fibromyal­gia and chron­ic pain amongst women who had had domes­tic vio­lence expe­ri­ences. We found in sep­a­rate stud­ies, asso­ci­a­tions with poor men­tal health [and] den­tal issues. Also, in oth­er work that I’ve under­tak­en, and more recent­ly inter­views with women who’ve expe­ri­enced domes­tic vio­lence, the nar­ra­tive about the expe­ri­ence of pain is a real­ly strong one. So, when you’re hear­ing about sur­vivors talk­ing about their expe­ri­ences, they talk about pain.

Kath Twigg: I was con­stant­ly in pain all the time.

Evans: This is Kath Twigg. She’s a sur­vivor of two abu­sive mar­riages. In her book, The Hall of Mir­rors How to Change Life Pat­terns and Avoid Tox­ic Rela­tion­ships, she chron­i­cles her abuse and the path­way through it. We’ll be hear­ing her sto­ry through­out this edi­tion of Air­ing Pain.

Twigg: I remem­ber just before I left my long-term job, I’d been in it for 26 years, I was doing quite a senior role and asked to go down to Lon­don one day, to Bris­tol the next day, up to the north­east anoth­er day lit­er­al­ly. And I remem­ber, on one occa­sion, going on a train up to Durham from the Peak Dis­trict, where I live, and not being able to sit down on the train, I was in so much pain. I had to stand up and move around as much as I could, I was in so much pain. And on anoth­er occa­sion, I remem­ber com­ing back from Lon­don, and I’ve got to go some­where else the next morn­ing and leave about six o’clock, and all I could do was go and lie on the bed. I was in so much pain, it was awful, and this did­n’t get much bet­ter. I had all kinds of ail­ments and ill­ness­es and rash­es and all sorts of odd things [for] about two years after I left that job, and I think it was because of the push­ing and push­ing and push­ing. I had bac­te­r­i­al menin­gi­tis and very near­ly died. My fam­i­ly were told that I had no high­er brain func­tion and the life sup­port machines would need to be turned off, and it was just mirac­u­lous that I came out of that. And I put that down to an accu­mu­la­tion of pain and stress, psy­cho­log­i­cal pain as well as phys­i­cal pain.

Evans: Kath Twigg. Dr Joht Singh Chan­dan is a spe­cial­ist Reg­is­trar in Pub­lic Health, and he’s an aca­d­e­m­ic Clin­i­cal Lec­tur­er at the Uni­ver­si­ty of Birm­ing­ham, and he too is co-author of that study show­ing the rela­tion­ship between domes­tic abuse and chron­ic pain.

Singh Chan­dan: When you sort of expe­ri­ence abuse or mal­treat­ment or trau­mat­ic expe­ri­ences on a reg­u­lar basis. There’s a huge body of research which is show­ing that actu­al­ly these expe­ri­ences can result in a dys­reg­u­la­tion of the hypo­thal­a­m­ic pitu­itary adren­al axis. In sim­ple terms, that axis, that sys­tem that I’m refer­ring to there, is our cen­tral stress response sys­tem. When we see that dis­rup­tion of that sys­tem, we can actu­al­ly see that these effects alter our nor­mal func­tion­ing of the immune sys­tem, of our meta­bol­ic sys­tem, neu­roen­docrine sys­tem, and actu­al­ly quite a few bod­i­ly sys­tems. So, the knock-on effect of hav­ing alter­ation in these areas can lead to our bod­ies sort of being in a height­ened state of, what I described as, a very inflamed state. And actu­al­ly, that’s very vis­i­ble even if we just sort of do blood sam­pling from sur­vivors of abuse and trau­ma. There are a few blood tests that we use in hos­pi­tal, for exam­ple, which check for inflam­ma­tion. We nor­mal­ly use them in cas­es of infec­tion or if some­body comes into hos­pi­tal acute­ly unwell, but we also see in sur­vivors of abuse is some of these lev­els are just raised at base­line. So, there’s some­thing going on, an inflam­ma­to­ry process being proven, actu­al­ly from expe­ri­enc­ing abuse. So that’s just one ele­ment to it. That’s one rea­son why there could be an asso­ci­a­tion with ill health and domes­tic abuse.

Evans: Dr Kate Gillan is a Clin­i­cal Psy­chol­o­gist with­in the Acute Psy­chol­o­gy Ser­vice, and work­ing in the NHS Greater Glas­gow and Clyde Pain Ser­vice. She has a par­tic­u­lar inter­est in the rela­tion­ship between trau­ma and pain.

Kate Gillan: There’s a mul­ti­tude of pre­dis­pos­ing fac­tors that are linked to chron­ic pain, but we like to look at a term called ‘cen­tral sen­si­ti­za­tion’. What we like to see it as is a sort of per­sis­tent alarm sys­tem that’s going off in the ner­vous sys­tem. We think about it in terms of two main char­ac­ter­is­tics: this height­ened sen­si­tiv­i­ty to pain and the sen­sa­tion of touch, so you would get peo­ple who might say that there’s pain even though some­body is touch­ing them light­ly; or they have a sort of per­sis­tent state of height­ened reac­tiv­i­ty. So, the brain isn’t pro­duc­ing a mild sen­sa­tion as it should, but it’s more of this kind of hyper-sen­si­tised ner­vous sys­tem. It’s more like this sort of high reac­tiv­i­ty, that the ner­vous sys­tem is in this per­sis­tent state of pain being amplified.

Evans: A pain that should­n’t nec­es­sar­i­ly be painful is turned up.

Gillan: That’s exact­ly it, the alarm sys­tem is going off but it’s not nec­es­sary. It’s some­thing that you don’t need to actu­al­ly act on, but the alarm sys­tem is telling you that there is some­thing wrong. So, it’s a dif­fer­ent part of your ner­vous sys­tem that’s being acti­vat­ed with chron­ic pain.

Evans: Now, here’s the big ques­tion: What does acti­vate it?

Gillan: There’s a lot inter­linked: the bio­log­i­cal, the psy­cho­log­i­cal and envi­ron­men­tal pre­dis­pos­ing fac­tors. A lot of what, as a psy­chol­o­gist, we’re inter­est­ed in is the stress response; what are the links to do with pre-exist­ing anx­i­ety or some­thing that has pre­dis­posed some­body to have this height­ened state of their ner­vous system.

When we see peo­ple in the clin­ic, we usu­al­ly have two ses­sions that are focus­ing on assess­ment and for­mu­la­tion. For­mu­la­tion, from psy­cho­log­i­cal point of view, is pulling togeth­er the infor­ma­tion, the patient sto­ry, that has been dis­cussed in those two ses­sions and hypoth­e­sis­ing about what is keep­ing dif­fi­cul­ties going for some­body, and form­ing the basis for a treat­ment plan.

Twigg: When I was a young teenag­er, rela­tion­ships, par­tic­u­lar­ly with my father, became soured, hav­ing been very, very spe­cial and close when I was lit­tle. And I got stuck in some­thing I would call a ‘trau­mat­ic bond’, which means that you keep try­ing to put rela­tion­ships right when you can’t any­more. And I tried to do that with my father, and he would­n’t lis­ten to me, and then we lost each oth­er. He died ear­ly and I became preg­nant when I was a teenag­er, and got mar­ried very ear­ly, which was a great dis­ap­point­ment to him. So, I felt I’d lost him many times dur­ing my life, and I’d let him down. That was kind of the pat­tern so that my first mar­riage was not good, that was char­ac­terised some­times by vio­lent rela­tion­ships, and [I] thought that I’d escaped and got mar­ried again in my late thir­ties, and that turned out to be dis­as­trous. That was a real­ly, real­ly dam­ag­ing rela­tion­ship, which had all the hall­marks of coer­cive con­trol and some vio­lence as well, and was deeply hurt­ful. I, again, got stuck for 12 years in that rela­tion­ship, and instead of walk­ing away, which I should have had the capac­i­ty to do as some­one who knew about these things, I still tried to put it right. So that’s been my pat­tern; instead of recog­nis­ing when some­thing is wrong, and is nev­er going to go back to the vision you had of that rela­tion­ship in the first place, like many peo­ple I know would do, they would walk away. But in terms of my pat­tern and the way that I habit­u­al­ly dealt with dam­ag­ing rela­tion­ships, I tried to stay, and I tried to argue my case, and I tried to put things right. So, that meant that for most of my adult life, until my late 40s, I’d been in a real­ly dam­ag­ing pat­tern of relationships.

Gillan: So, we would real­ly want to pull togeth­er this devel­op­men­tal his­to­ry right through to what’s a typ­i­cal day like for you so that we can find out, obvi­ous­ly it’s cru­cial to find out, is some­body expe­ri­enc­ing ongo­ing trau­ma, and are there safe­ty con­cerns that you would need to work with that per­son on alert­ing them to that and to seek safety.

Evans: But you can’t take away those ear­li­er experiences.

Gillan: But we can help peo­ple reframe what’s hap­pened to them. There’s a huge sense of shame that’s attached to com­plex trau­ma. If you think about some­body com­ing in and prob­a­bly feel­ing high­ly vul­ner­a­ble in a clin­i­cal sit­u­a­tion. You’re refram­ing things to not what is wrong with you, but what’s hap­pened to you? That can have a huge impact on some­body’s well-being and abil­i­ty to adhere to oth­er aspects of the pain service.

Evans: I haven’t count­ed them, but there’s an awful lot of use of the word shame in your writ­ing. Explain to me, and oth­ers, who might not under­stand why you should be ashamed of domes­tic abuse.

Twigg: Peo­ple who get stuck, like I do, tend to have quite a lot of bag­gage and dam­age in their rela­tion­ships right back from child­hood. What I found myself doing is com­par­ing myself to oth­er peo­ple. I come from a fam­i­ly of sta­ble rela­tion­ships, where peo­ple have been togeth­er for a long, long time. My friends had long-term sta­ble rela­tion­ships, and I had this feel­ing of being inside a gold­fish bowl and look­ing at the world and every­one else had shin­ing lives and per­fect rela­tion­ships, and that was­n’t the case for me. So, I felt like I could­n’t tell peo­ple because that would expose the fact that I did­n’t, and it would make me feel even more wretched.

Evans: Kath Twigg. ACE, the Adverse Child­hood Expe­ri­ences study, was a research pro­gramme in Cal­i­for­nia in the 1990s, in which thou­sands of peo­ple received a phys­i­cal exam­i­na­tion, and com­plet­ed con­fi­den­tial sur­veys about their child­hood expe­ri­ences to do with phys­i­cal abuse, neglect, wit­ness­ing domes­tic abuse and oth­er social fac­tors. These, the researchers found, were pre­dic­tive of health prob­lems in lat­er life. Kate Gillan.

Gillan: The study was quite piv­otal because it showed that almost two thirds of par­tic­i­pants report­ed at least one ACE. Now we’re con­tin­u­ing to gain insight into how that impacts peo­ple lat­er in life. With­in the pain clin­ic, the psy­chol­o­gy team are very involved in assess­ing peo­ple for a type two PTSD. So, we have type one PTSD, which peo­ple are famil­iar with, but there’s a dif­fer­ent pre­sen­ta­tion when you have a type two PTSD, and we kind of link that to the cen­tral sen­si­ti­za­tion, the pro­longed stress relat­ed to adverse events.

Evans: PTSD is post-trau­mat­ic stress dis­or­der. Now, I asso­ciate that with mil­i­tary vet­er­ans, or peo­ple who’ve been through ter­ri­ble things like that. I assume that is what you’re talk­ing about with type one PTSD. So, what is type two?

Gillan: You’re right mil­i­tary vet­er­ans, we some­times have peo­ple that we would refer to organ­i­sa­tions such as com­bat stress to receive trau­ma ther­a­py, but com­plex trau­ma, there are mil­i­tary vet­er­ans that would expe­ri­ence com­plex trau­ma as well. It’s very much about, you know, if you think about trau­mat­ic events like a phys­i­cal or sex­u­al assault, a road traf­fic acci­dent, a nat­ur­al dis­as­ter. Trau­mat­ic events expe­ri­enced is high­ly dis­tress­ing, leav­ing us feel­ing out of con­trol, over­whelmed, leav­ing us with this emo­tion­al shock or psy­cho­log­i­cal trau­ma. And the symp­toms are this kind of tri­ad of unwant­ed mem­o­ries, flash­backs, night­mares, avoid­ing any reminders of event, feel­ing unusu­al­ly tense, irri­ta­ble, on edge. These are kind of key indi­ca­tors that we would be look­ing out for, for active type one PTSD.

There’s some­thing dif­fer­ent with com­plex trau­ma, and com­plex PTSD. You would have the same pre­sen­ta­tion as type one, but you would have addi­tion­al dif­fi­cul­ties. The rea­son for that is that with com­plex trau­ma, it’s cumu­la­tive expe­ri­ence of mul­ti­ple trau­mas over long peri­ods of time. Often, they can start in child­hood, not always, we might have peo­ple who have expe­ri­enced these events lat­er in life, but it’s this mul­ti­ple trau­mat­ic impact that they’ve had. So, if you think about child phys­i­cal, sex­u­al, emo­tion­al abuse, child neglect, domes­tic abuse, tor­ture. These events can be espe­cial­ly dif­fi­cult because they’re all of that inter­per­son­al nature. If you think about where some of the sit­u­a­tions that I’ve talked about that are linked to com­plex trau­ma, they’re par­tic­u­lar­ly dif­fi­cult because they might be by peo­ple that we should have been able to trust. There’s that kind of pow­er and con­trol dynam­ic. If peo­ple have expe­ri­enced these events, they are like­ly to have dif­fi­cul­ties with con­trol­ling over­whelm­ing feel­ings, dif­fi­cul­ties in rela­tion­ships, dif­fi­cul­ties with sense of self and needs that we all have, as chil­dren. We’ve got basic needs, and as adults, basic psy­cho­log­i­cal needs: to feel safe; to feel sup­port­ed; to have rou­tine and struc­ture; to feel loved and accept­ed. If we don’t get that we have a chal­leng­ing upbring­ing or chal­leng­ing adult­hood, then we’re more like­ly to devel­op safe­ty strate­gies in order to sur­vive. All this is linked to this ‘cen­tral sen­si­ti­za­tion’. In the pain clin­ic we know that if some­body has PTSD, research has shown that there can be about 80% of peo­ple with PTSD are like­ly to have phys­i­cal health dif­fi­cul­ties as well, such as chron­ic pain. We know in the pain clin­ic that if some­body is pre­sent­ing, par­tic­u­lar­ly with things such as wide­spread pain, or a pain that you’re think­ing ‘why is this per­son expe­ri­enc­ing this per­sis­tent unex­plained pain?’, we do want to check out for a his­to­ry of com­plex trau­ma. And we know that you’re more like­ly to have that pre­sen­ta­tion in a clin­i­cal set­ting with chron­ic pain than in a non-clin­i­cal set­ting with chron­ic pain because obvi­ous­ly, we know that chron­ic pain is com­mon in the gen­er­al population.

Evans: Kate Gillan. Of course, domes­tic abuse is not car­ried out in the clin­ic, it’s car­ried out behind the closed doors of a fam­i­ly home. Dr Car­o­line Bradbury-Jones’s prea­ca­d­e­m­ic expe­ri­ence was as a Nurse, Mid­wife and a Health Visitor.

Brad­bury-Jones: The health vis­it­ing role in par­tic­u­lar takes you into peo­ple’s homes. Going into peo­ple’s homes in any role is real­ly very inter­est­ing, because you then assume the role of a pro­fes­sion­al vis­i­tor, if you like, and the health vis­it­ing also is a ser­vice where­by you have quite a lot of reg­u­lar con­tact with fam­i­lies and with peo­ple. That gives the oppor­tu­ni­ty to build up trust. So, what I was see­ing as a health vis­i­tor was women dis­clos­ing to me about their expe­ri­ences of domes­tic vio­lence, but more fre­quent­ly me being con­cerned about them in some way and gen­tly ask­ing them, were they okay?

Evans: It occurs to me that going into a home like that, a woman isn’t going to open up straight­away and say ‘I am expe­ri­enc­ing vio­lence from my hus­band’, you have to work out what is going on.

Brad­bury-Jones: Absolute­ly right, for most women in most cir­cum­stances. So, through under­stand­ing this prob­lem of domes­tic vio­lence, and through my con­tact with women and fam­i­lies over the years, and all of the evi­dence, I’ve read from, real­ly good research on the sub­ject, it’s high­ly unlike­ly that women will present at a clin­i­cal encounter, whether it’s in the home or whether it’s not, very rare that they would say in an ini­tial con­tact, ‘I’m expe­ri­enc­ing domes­tic vio­lence’. That’s why that repeat­ed con­tact with women, the rela­tion­ship build­ing that I talked about before, is so cru­cial. They need that in order to feel safe to dis­close what’s hap­pen­ing to them. They need that in order to know, or to hope, that when they do dis­close that they’re not going to be dis­be­lieved, that they’re not going to be crit­i­cised in some way, that they’re not going to be trau­ma­tised by what’s going to hap­pen to them. Because women who’ve expe­ri­enced domes­tic vio­lence have lived through being con­trolled, through being coerced, through being told that if they ever tell any­body about what’s hap­pen­ing to them the con­se­quences are going to be such that they may have their chil­dren removed, that they’re not going to be believed any­way, that they’re going to be made home­less, they’re going to be judged as being a real­ly bad moth­er. So, they don’t dis­close because of real­ly sound ratio­nal judg­ments and they don’t dis­close because of those mis­be­liefs and mis­in­for­ma­tion that they’ve been giv­en over a peri­od of time, kind of ‘gaslight­ing’ as it’s referred to. Under­stand­ably, they would very rarely present, or say to some­body who’s going into their home on a one-off encounter, ‘I’m expe­ri­enc­ing domes­tic vio­lence’. It often takes many, many attempts, and they often try it out. You know, when we’re dis­clos­ing any­thing in life, we test out, we drop lit­tle hints so that we can get a sense of how this per­son is going to react, and it’s no dif­fer­ent domes­tic violence,

Evans: I sup­pose also going into some­body’s home, you’re also going into the home of the per­pe­tra­tor of vio­lence, who may even be sit­ting in the next room, or even in the same room.

Brad­bury-Jones: Absolute­ly, because part of the abil­i­ty to be a per­pe­tra­tor is based on that coer­cion and con­trol and the very tight con­trol, phys­i­cal­ly, of a per­son­’s space. And so, with­in that home a per­pe­tra­tor will often be there, delib­er­ate­ly so, so that they can hear what’s going on. So, they can make sure that that woman is not going to dis­close. They pro­hib­it it through their very pres­ence. So, for the women who’ve ever dis­closed to me, they wait­ed till the per­pe­tra­tor was out. That’s very impor­tant thing for health pro­fes­sion­als to under­stand, and I think most do when they’re deal­ing with domes­tic vio­lence. That you would nev­er broach the sub­ject with any­body if there was a risk that the per­pe­tra­tor could know that you’ve had that con­ver­sa­tion, if you have a sense that some­body might be expe­ri­enc­ing domes­tic vio­lence, and that can be real­ly tricky. For exam­ple, in mater­ni­ty care and mid­wifery prac­tice where there is an encour­age­ment to ask all women who are com­ing into con­tact with mater­ni­ty ser­vices, they are to ask a ques­tion about domes­tic vio­lence, and to doc­u­ment that you’ve asked that ques­tion. It can be real­ly tricky when you have anoth­er per­son there, and to try and get that woman alone. So, mid­wives will often say to a part­ner, ‘would it be okay if I just, I’m going to do a bit of a per­son­al exam­i­na­tion now. I just need just need to have this dis­cus­sion in pri­va­cy.’ And then while that per­pe­tra­tor is out of the way to then qui­et­ly ask the woman ‘is every­thing okay with you? Are you feel­ing safe at home?’ Those kinds of ques­tions, just with that minute of the win­dow of oppor­tu­ni­ty to ask about it.

Evans: I would assume that the process of get­ting some­body to open out in some­thing as per­son­al as that may take many consultations.

Brad­bury-Jones: Absolute­ly, and that’s why it’s so help­ful if you are for­tu­nate enough as a health care prac­ti­tion­er to have an oppor­tu­ni­ty to see the same woman on repeat­ed occa­sions, because it takes that incre­men­tal test­ing out of the woman to see what the reac­tion is going to be. And it also takes the oppor­tu­ni­ty for the health care prac­ti­tion­er to be able to gen­tly probe to be able to say ‘I’m going to come and see you next week’, or to devel­op strate­gies to have time for that woman to feel safe to dis­close. And then, of course, because dis­clo­sure does not nec­es­sar­i­ly mean leav­ing, in fact it often does­n’t, women will say that they’re expe­ri­enc­ing domes­tic vio­lence and have no inten­tion of leav­ing the per­pe­tra­tor, again, for myr­i­ad rea­sons. But they want to tell, and they want to hear about what their options are, it’s a process. Just ear­li­er on I was talk­ing about the fact that women would rarely dis­close a kind of one-off event. The only time when that’s like­ly to hap­pen is in the most extreme sit­u­a­tions, where they are lit­er­al­ly fear­ing for their life, or fear­ing for the life of their chil­dren. It’s on those occa­sions, an absolute cri­sis sit­u­a­tion where they would present as a kind of one-off. I refer to it, and have writ­ten about it as being a cri­sis event. Where women have often expe­ri­enced, in those cas­es, seri­ous phys­i­cal abuse and are lit­er­al­ly fear­ing for their lives.

Twigg: On one occa­sion, my hus­band threw me onto the bed and put his hands around my throat and was bang­ing my head against the pil­low. And there were many times when I was afraid to push too far because I knew that he might have just snapped.

Evans: The men­tal abuse and the phys­i­cal abuse, which was the worse?

Twigg: Oh, the men­tal abuse, def­i­nite­ly. That was dev­as­tat­ing. Even when I left that rela­tion­ship, even­tu­al­ly when it end­ed, I told myself ‘Whoop­ie I’m out of it. I am okay now, and I’m hap­py and all the rest of it’. But again, I did­n’t stop and give myself time to heal. There were signs that I was becom­ing very depressed. It could have been Post Trau­mat­ic Stress Dis­or­der as well, I think. I would­n’t open let­ters for instance, I would­n’t open bills or I would­n’t be able to cope with day-to-day things prop­er­ly and at work. I was late for every­thing, just not func­tion­ing prop­er­ly, but dri­ving myself for­ward think­ing I must be okay now, but not hav­ing that space to stand back and think I’m prob­a­bly not okay, and I need to get myself some help.

Evans: Dr Lene For­rester is a Con­sul­tant Clin­i­cal Psy­chol­o­gist at Albyn Hos­pi­tal in Aberdeen. She, along with a phys­io­ther­a­pist, cre­at­ed the pain man­age­ment pro­gramme for Grampian Pain Ser­vice and a peer sup­port group in Aberdeen for peo­ple with pain. She has a par­tic­u­lar inter­est in inter­per­son­al vio­lence, and the link between post-trau­mat­ic stress dis­or­der, that’s PTSD, and chron­ic pain.

Lene For­rester: Inter­per­son­al vio­lence is a par­tic­u­lar type of trau­ma, it’s very inti­mate, it’s very pre­dom­i­nant­ly female, it’s about 80/20. The psy­cho­log­i­cal trau­ma of that, you know, pain is pro­duced by the brain, it’s in the brain. It does­n’t mean that we’re mak­ing it up, it just means that we have sus­cep­tion, we have sig­nals to the brain, and the brain makes sense of it and sends the sig­nals back to pro­duce pain. And that process in the brain is incred­i­bly com­plex, you know, it’s affect­ed by mem­o­ry and mood and atten­tion and per­son­al­i­ty. So, the trau­ma is rel­e­vant in that part, but also oth­er­wise, and in terms of the psy­cho­log­i­cal aspects of trau­ma. So, there are more phys­i­cal trau­ma that’ll have a psy­cho­log­i­cal com­po­nent in terms of help­less­ness, like if you have a car acci­dent, say. Of course, there’s psy­cho­log­i­cal aspects of that run help­less­ness and lack of con­trol, when an acci­dent is an acci­dent. And then you have more delib­er­ate forms of trau­ma inflict­ed upon you, like peo­ple who have been vic­tims of ter­ror­ist attacks or par­tic­u­lar­ly vicious attacks in war, or whether it’s delib­er­ate intent to hurt you, which adds anoth­er psy­cho­log­i­cal com­po­nent to it. And then you have inter­per­son­al vio­lence, where the one per­son who’s the clos­est to you in your life, and is meant to pro­vide you with a safe space as an adult, is the per­son who’s the most dan­ger­ous to you.

Evans: Did you have fore­warn­ing, if you like, before you mar­ried this per­son that he was like that?

Twigg: Yeah, I ratio­nalised it away. You know, there was jeal­ousy, there was crit­i­cism, cold­ness, very typ­i­cal things that you get from some­one who might be described as a nar­cis­sist, I think in the field of domes­tic abuse. Very lit­tle emo­tion­al warmth, just want­i­ng to con­trol me and change me into some­one I was­n’t, and did­n’t want to be. But because of this feel­ing I’ve had that I could­n’t be alone, and I did­n’t know myself and I could­n’t respect myself enough, I felt that I had to be with some­one else.

For­rester: I’m using the lan­guage ‘domes­tic vio­lence’ today but often I use ‘domes­tic abuse’, because ‘vio­lence’ has con­no­ta­tions of being phys­i­cal, and that’s real­ly unhelp­ful because a lot of it is not. So, when we look at the imagery around domes­tic vio­lence, it’s often show­ing women with black eyes, and yet that is just an unhelp­ful image because a lot of domes­tic vio­lence is not phys­i­cal in nature, but emo­tion­al, finan­cial, sex­u­al, coer­cive, con­trol­ling. All domes­tic vio­lence is under­pinned by coer­cion and con­trol — all of it, and most of it is emo­tion­al in nature. Those dif­fer­ent forms of domes­tic vio­lence often inter­sect, so a woman would expe­ri­ence a num­ber of them. So that’s not to say for one minute that phys­i­cal vio­lence does­n’t exist, because it absolute­ly does, but there’s so many women who don’t expe­ri­ence phys­i­cal vio­lence and there­fore are left won­der­ing whether their expe­ri­ences are real­ly domes­tic vio­lence. ‘He’s only telling me that I’m not good look­ing.’ ‘He’s only stopped me from hav­ing mon­ey.’ ‘That’s not real­ly domes­tic vio­lence, is it? Because what I’ve seen about domes­tic vio­lence is women with black eyes. So that can’t real­ly be domes­tic vio­lence that I’m expe­ri­enc­ing.’ But all domes­tic vio­lence is based on coer­cion and control.

Twigg: Crit­i­cism, jeal­ousy, not lik­ing my friends or my fam­i­ly, crit­i­cis­ing my job and my career which was deeply hurt­ful because that real­ly kept me going. Not want­i­ng me to say much about myself when friends were around, not want­i­ng me to have phone calls with peo­ple, becom­ing aggres­sive when I was on the phone so that I then did­n’t answer the phone at home. Did­n’t speak to any­one any­more, moved away from my fam­i­ly incre­men­tal­ly and felt very lone­ly. This per­son incre­men­tal­ly took away every­thing that made my life worth living.

For­rester: Women report that the psy­cho­log­i­cal abuse is worse because it tar­gets your­self and who you are. But, also, it does­n’t have a begin­ning and an end, and the unpre­dictabil­i­ty of it is very rel­e­vant in terms of devel­op­ment of chron­ic pain. I’ve seen women who’ve been abused in a very pre­dictable man­ner, like some­body whose hus­band, every time his foot­ball team lost, he would get drunk and he would come home and he would abuse her. Of course, that was ter­ri­ble, it was pre­dictable, and she found him pathet­ic. She could see that it had to do with him and his behav­iour, noth­ing to do with her, and so it did­n’t affect her in the same psy­cho­log­i­cal man­ner. Whilst oth­er women and men, if it’s a real unpre­dictabil­i­ty around it you nev­er know what’s going to set them off, you nev­er know what will spi­ral, you nev­er know what’s wrong or what’s right. You’re always on guard, you’re always walk­ing on eggshells, and always tense. And if you live like that, always tens­ing your mus­cles, of course some­thing’s going to hap­pen. In fact, I saw a woman many years ago and she told me: ‘of course I devel­oped fibromyal­gia, because I lived like this. I was always tens­ing my body, wait­ing for the next blow.’

Evans: A friend of yours said ‘he would only have to hit me once, and I’d be gone.’ Why did you stay?

Twigg: It goes back to this phrase ‘trau­mat­ic bond­ing’, the way that you get trapped by dis­tort­ed think­ing, by telling your­self that you can have a decent rela­tion­ship with this per­son, you can go back to what you thought you had in the first place. And peo­ple like me, with that pat­tern of rela­tion­ships into which they get a meshed, tend not to think log­i­cal­ly in that way. So ‘trau­mat­ic bond­ing’ is where you have this dis­tort­ed lit­tle bub­ble around your­self that makes you see the world slight­ly dif­fer­ent­ly than oth­er peo­ple. And you don’t always see the dan­ger with the per­spec­tive that oth­er peo­ple have. The friend who said it to me very def­i­nite­ly would not have stayed, and I have many friends who I know would not have stayed, but I also know a lot of peo­ple who have stayed and do stay. And when I talk to peo­ple who are in sit­u­a­tions that I was in, there is kind of a glaze that comes over peo­ple. When you talk about, you know, how they could remove them­selves and make them­selves safe. You know when the shut­ters have come down and they can’t take in what you’re say­ing. It’s very hard for peo­ple who’ve not expe­ri­enced this kind of syn­drome to under­stand how that works.

Evans: Kath Twigg. The NICE guide­lines for trau­ma and PTSD rec­om­mend either cog­ni­tive behav­iour­al ther­a­py, that is CBT, pro­longed expo­sure, or eye-move­ment desen­si­ti­sa­tion and repro­cess­ing (EMDR), or a com­bi­na­tion of the two. Lene Forrester.

For­rester: The CBT pro­longed expo­sure is a very ver­bal way of pro­cess­ing trau­ma. So, what hap­pens in trau­ma is that some­thing hap­pens that is too awful, real­ly, for the brain to let it in, and maybe because of high amyg­dala involve­ment, a lot of stress. So, it’s stored in the rear sort of left part of the brain, may be the less ver­bal part, and it stays there because you try to push it away and not inte­grate it. And that’s why it leads to flash­backs, or come back in your night­mares, or affect you in oth­er more phys­i­o­log­i­cal ways, like in pain. The CBT pro­longed expo­sure is a ver­bal way of recount­ing, clos­ing your eyes, record­ing it and recount­ing the events and lis­ten­ing back to them every day, which can be quite har­row­ing of course. Which helps with pro­cess­ing in the brain and per­spec­tive, I sup­pose, maybe we can be a bit more com­pas­sion­ate for the per­son on the tape than we are to ourselves.

Whilst EMDR is a much more phys­i­cal and vis­cer­al emo­tion­al kind of pro­cess­ing and less ver­bal. So, it involves that the per­son brings to mind and a trau­mat­ic event and the feel­ings asso­ci­at­ed with that and cog­ni­tions that they have. And they hold that in mind and body whilst they fol­low your fin­ger back and forth with their eyes real­ly fast. Hence the name, which is to do with alter­nat­ing stim­u­la­tion of the left and right brain hemi­sphere. It helps the brain to process trau­ma. So, you can see on func­tion­al MRIs that the activ­i­ty goes from the rear right to the high­er func­tion­ing. From the sort of rep­til­ian part to the basic part, the pri­mal part to the high­er func­tion­ing left pre­frontal cor­tex, the ver­bal parts. So, it’s inte­grat­ed as a nor­mal mem­o­ry, rather than bad mem­o­ry, but still a nor­mal memory.

Evans: Clin­i­cal psy­chol­o­gist Dr Lene For­rester. As always, I’ll remind you that whilst we in Pain Con­cern believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you and your cir­cum­stances, and there­fore the appro­pri­ate action to take on your behalf.

Now, it’s par­tic­u­lar­ly impor­tant to reit­er­ate that this edi­tion of Air­ing Pain is being record­ed just a few days before Christ­mas 2020. Please bear in mind that between then and when­ev­er you’re lis­ten­ing to this pro­gramme, pub­lic guid­ance for deal­ing with COVID-19 may have changed. So, do keep up with the cur­rent NHS and gov­ern­ment advice. How­ev­er, the con­tent of this pro­gramme is rel­e­vant regard­less of the cur­rent cri­sis. Dr Car­o­line Bradbury-Jones.

Brad­bury-Jones: When we went into lock­down in the spring of 2020, there was spec­u­la­tion. I spec­u­lat­ed myself about how domes­tic vio­lence would be exac­er­bat­ed or how lock­down and iso­la­tion would impact on the num­bers of domes­tic vio­lence inci­dents that were tak­ing place. And since that time, and it’s a rel­a­tive­ly short time, there’s very clear evi­dence that it’s increased dramatically.

When it comes to domes­tic vio­lence ser­vices, they have respond­ed very well to the cur­rent sit­u­a­tion, and have devel­oped safe ways of engag­ing with women in a way that is remote and is over the tele­phone or using Zoom, Skype, etc. So, face to face con­tact with­in the domes­tic vio­lence sec­tor is remote. Sim­i­lar­ly, con­sul­ta­tions between GPs, between health vis­i­tors, mid­wives, those kinds of clin­i­cians who typ­i­cal­ly have face to face con­tact with women are no longer the case. And obvi­ous­ly that’s prob­lem­at­ic, because there were oppor­tu­ni­ties for find­ing that phys­i­cal space, find­ing the close­ness are miss­ing, and now that is real­ly very impor­tant. When it comes to hav­ing a screen, there’s so much about human inter­ac­tion that you can’t cap­ture. So, for health prac­ti­tion­ers who would nor­mal­ly pick up on lit­tle cues about some­thing that would be unchar­ac­ter­is­tic for a woman, are very dif­fi­cult in this sit­u­a­tion. So, when it comes to offer­ing a ser­vice or offer­ing sup­port, the cur­rent work­ing from a dis­tance or prac­tis­ing vir­tu­al­ly is an addi­tion­al lay­er of com­plex­i­ty, and real­ly extends the iso­la­tion that a lot of sur­vivors and vic­tims of domes­tic vio­lence feel.

Evans: Over the tele­phone or over a Zoom link or a video link, you have no idea who is sit­ting with­in a cou­ple of feet of the per­son you’re deal­ing with, or tap­ping into the con­ver­sa­tion. You have no idea who’s there.

Brad­bury-Jones: No, absolute­ly, no,you have no idea.

Gillan: The impact of lock­down has not caused the domes­tic abuse, only the peo­ple who abuse are respon­si­ble for their actions, but we do know that things have esca­lat­ed. But, you know, pri­or to this year we’ve had sit­u­a­tions where peo­ple, you know, we’ve just actu­al­ly had to try and sign­post them to seek refuge or to con­tact the police, social ser­vices. There are sit­u­a­tions that you think ‘this is not the job of the pain clin­ic’, all we can do is direct that per­son because if some­body is in quite a dan­ger­ous sit­u­a­tion, cer­tain­ly in terms of a trau­mat­ic frame­work, we will look at what we call a win­dow of tol­er­ance. This opti­mal zone where some­body is able to tol­er­ate emo­tions and inte­grate infor­ma­tion. They’re curi­ous, they’re able to take on board new learn­ing. When peo­ple have a trau­ma­tised his­to­ry, they can present with quite a nar­row win­dow, so they might be quite like­ly to go up into the, what we call the, hyper arousal zone, this fight or flight response, very emo­tion­al­ly reac­tive, hyper vig­i­lant, all the PTSD symp­toms that we’re talk­ing about in the most extreme sense. Or they might be called a hypo arousal zone. So, you’ve got the red zone and the blue zone and they might quite quick­ly go back and forth, and in this blue zone you might have peo­ple that are very qui­et, there’s a kind of numb­ing of emo­tions, reduced phys­i­cal move­ment. And I think in our clin­ic sit­u­a­tion, if you think about going into a busy out­pa­tient ser­vice, this kind of over reac­tiv­i­ty or under reac­tiv­i­ty, peo­ple need to be aware of that. As health pro­fes­sion­als, we need to be aware of that. And, you know, if you’re run­ning late for an appoint­ment, you need to be able to go and tell that per­son ‘look, I’m run­ning five min­utes late. Are you able to wait?’ You need to be aware that this win­dow of tol­er­ance could result in some­body leaving.

Brad­bury-Jones: In GP prac­tices in the UK, there is a won­der­ful inter­ven­tion called IRIS (the Iden­ti­fi­ca­tion and Refer­ral to Improve Safe­ty). It is like a nation­al pro­gram, it is research-based. For a woman who presents to a GP and dis­clos­es domes­tic vio­lence there is a real­ly clear path­way for refer­ral. So, that GP or the mem­ber of the prac­tice staff would know exact­ly what to do and would know exact­ly where to refer that woman to for help.They would have, as part of their surgery, a named expert called an ‘advo­cate’ who can help that woman. That is not in place right the way across the UK, GP prac­tis­es sign up for it. The ben­e­fits being they receive train­ing, all the prac­tise staff get train­ing in how to iden­ti­fy domes­tic vio­lence, how to ask about it and they have that named per­son, that named expert, as a point of refer­ral. Which the prac­tise staff, main­ly GPs I would say, a real­ly good ground­ing in what they are look­ing for and what they deal­ing and how to deal with it and then it gives that impor­tant point of refer­ral. So, they, in some ways, they are not the one who are then hav­ing to deal with the sit­u­a­tion or find­ing that sup­port. That is very dif­fer­ent to oth­er areas where they don’t have this par­tic­u­lar inter­ven­tion. Where the per­son ask­ing about the domes­tic vio­lence or the dis­clo­sure sit­u­a­tion is then, I’ve heard it being referred to ‘open­ing a can of worms’ because prac­ti­tion­ers are left hold­ing that sit­u­a­tion, respon­si­ble for it. Often, with very lit­tle idea of where to go for help and how to sup­port that woman. Often, quite frankly, not hav­ing the con­fi­dence or the knowl­edge on how to deal with it in a help­ful way. From lis­ten­ing to women talk­ing about their expe­ri­ences over the years that I have, report­ing that health pro­fes­sion­als often get it wrong. Unwit­ting­ly, most health pro­fes­sion­als want to help that why they’re in that busi­ness, but they just do not have the resources inter­nal­ly and pro­fes­sion­al­ly to be able to deal with it and they often don’t have the resources phys­i­cal­ly to refer to, because resources as regards ser­vices for domes­tic vio­lence sur­vivors are under resourced and there were not enough of them.

Evans: That was Dr Car­o­line Brad­bury-Jones, Pro­fes­sor in Gen­der Based Vio­lence and Health at the Uni­ver­si­ty of Birm­ing­ham. Dr Joht Singh Chan­dan, Spe­cial­ist Reg­is­trar in Pub­lic Health and aca­d­e­m­ic Clin­i­cal Lec­tur­er, also at the Uni­ver­si­ty at Birmingham.

Singh Chan­dan: What we’ve seen in the pan­dem­ic is, it was even described by the Unit­ed Nations as, a shad­ow pan­dem­ic of vio­lence against women and chil­dren. So that is refer­ring to things like domes­tic abuse. It’s very like­ly that fol­low­ing the pan­dem­ic, due to the men­tal health con­se­quences of the pan­dem­ic [and] due to the prob­lems of iso­la­tion, there will very like­ly be an increase of fibromyal­gia [and] more demand for ser­vices. So, what we’ve got is the per­fect storm here brew­ing away because of the pan­dem­ic. We’ve got more peo­ple who might be exposed to domes­tic abuse, hence we’ve also got a greater bur­den of indi­vid­u­als who may go on to expe­ri­ence symp­toms relat­ing to pain or fatigue and dys­func­tion. As a pub­lic health doc­tor, we are quite wor­ried about the pub­lic health bur­den. What does this mean to greater soci­ety? What does this mean to the bur­den on our ser­vices as well? How can we actu­al­ly plan and restruc­ture ser­vices to con­sid­er this? This going to be the real chal­lenge for 2021 and beyond. It is very clear in my mind, actu­al­ly, how do we solve a com­plex prob­lem such as this? And the only real way to do it is to take a pub­lic health approach. It is not some­thing we’ve done before it is some­thing we’ve been cam­paign­ing for a very long time but it is very clear that now is the time to do some­thing about it.

What does a pub­lic health approach to abuse or mal­treat­ment look like? Well it’s very sim­ple, there are 4 steps to it. A lot of this is being pre-doc­u­ment­ed by the World Health Organ­i­sa­tion, but it is not an approach that we nec­es­sar­i­ly take in the UK or with­in Europe. The first ele­ment being improv­ing sur­veil­lance. That real­ly means defin­ing the vio­lence prob­lem that we have, the abuse prob­lem that we have, through sys­tem­at­ic data col­lec­tion on the preva­lence of abuse, how com­mon it is. These fig­ures are not very reli­able. Who does it affect? We don’t real­ly have very reli­able sta­tis­tics on this because we have issues in the way that data is col­lect­ed around this top­ic. We’ve shown our­selves in a lot of research we’ve done, health­care data real­ly only cap­tures the tip of the ice­berg, police data only cap­tures those who encounter police ser­vices and char­i­ty data only cap­tures those who are will­ing to go and engaged with these ser­vices, or were aware of them. So, we’ve got a huge prob­lem with under record­ing. There is a sec­ondary prob­lem with that, which is if we don’t the bur­den it is hard to plan ser­vices going for­ward, and sec­ond­ly, it’s hard to under­stand the risk and pro­tec­tive fac­tors for domes­tic abuse, unless we’ve got a good pop­u­la­tion or a good under­stand­ing of who’s being affect­ed we can’t real­ly get to the bot­tom of why they are being affect­ed. Is domes­tic abuse dur­ing the pan­dem­ic affect­ing cer­tain sub­groups of peo­ple? Is it women between a cer­tain ages or dif­fer­ent eth­nic groups? An area we real­ly don’t under­stand is what does domes­tic abuse look like in dif­fer­ent eth­nic groups, and that’s some­thing which wor­ries me quite a lot.

So, the Covid-19 pan­dem­ic has been dis­pro­por­tion­ate in the way that is affect­ing peo­ple, par­tic­u­lar­ly dif­fer­ent eth­nic­i­ties. We have no under­stand­ing of what that’s meant dif­fer­ent eth­nic­i­ties in term of rates of domes­tic abuse dur­ing this peri­od. So, unless we improve sur­veil­lance we won’t get to the sec­ond step of under­stand­ing risk and pro­tec­tive fac­tors very well.

Also, when it comes to under­stand­ing risk and pro­tec­tive fac­tors, because we don’t real­ly have many mech­a­nisms of cap­tur­ing all this infor­ma­tion on peo­ple, it is actu­al­ly very hard to under­take risk assess­ments. There is a lot of research say­ing that actu­al­ly clin­i­cians, even police offi­cers, you know, these pro­fes­sions have the best will in the world, they only real­ly ever want to help peo­ple, but this is a very tricky top­ic to bring up. It is a very dif­fi­cult con­ver­sa­tion to have with some­one when we sus­pect them to be at risk. Can we improve the train­ing in these areas to make sure peo­ple feel con­fi­dent to do so? A lot of research has been pub­lished and peo­ple don’t nec­es­sar­i­ly feel con­fi­dent in ask­ing these ques­tions because they don’t real­ly know what to do next. So, there is clear­ly some­thing about improv­ing the way we have refer­ral path­ways. Then actu­al­ly the third step real­ly comes into its own which is, can we devel­op and eval­u­ate inter­ven­tions that work dur­ing this peri­od where we appar­ent­ly in a state where face-to-face inter­ven­tions are not being sup­port­ed in the same way that they would have been? What oth­er sort of ser­vices do we have. There is a vast area for remote ser­vices that are avail­able, but a lot of these have not been cre­at­ed or devel­oped in con­junc­tion with sur­vivors of domes­tic abuse, and very few of them have been eval­u­at­ed. So, to be com­plete­ly hon­est, we are a bit stuck in what pop­u­la­tion-based remote mea­sures we can imple­ment dur­ing this time and that’s some­thing which we real­ly need to get to the bot­tom of. We need more research very urgent­ly. The bit that wor­ries me the most is that we are essen­tial­ly in month 9 of the pan­dem­ic and we still haven’t tak­en these actions for­ward. Unless we get good inter­ven­tions very soon, I think all that we are doing is basi­cal­ly say­ing that we are not sup­port­ing the sur­vivors in the way that they real­ly need. The final step of any good pub­lic health approach is, once you iden­ti­fy­ing and eval­u­ate some of these good inter­ven­tions, we need to scale them up in pol­i­cy and to man­date cer­tain actions to hap­pen in areas. But we are very far from that because char­i­ties, health­care ser­vices, admin­is­tra­tive ser­vices, pub­lic sec­tor ser­vices are def­i­nite­ly doing the best they can but equal­ly there is still a long way to go until we real­ly nail this area, and real­ly just sup­port the sur­vivors the best way possible.

Evans: Did you con­fide with friends at all?

Twigg: Not for a very long time. I kept to every­thing to myself. I was ashamed because I’d gone through one mar­riage that end­ed. I did not want to be seen as a fail­ure. I got a pro­fes­sion­al job so I need­ed to put on a per­sona and go out and do that. It just didn’t feel right to tell any­one. It took a very long time and the help of some spe­cial peo­ple before I realise, I need­ed to do that. Even then it was still hard to go. It is hard to leave what you work for; it is hard to leave your home. Also, the dis­tort­ed think­ing still draws you back and makes you think that some­how, I could put things right and I could take it back to what I thought I had in the first place, which was nev­er real.

Evans: What sort of advice would you give to some­body who feels their friend or fam­i­ly mem­ber is under­go­ing vio­lence at home. How can they get involved? What should they do?

Brad­bury-Jones: They can do some prac­ti­cal things and they can do some emo­tion­al sup­port things. From the prac­ti­cal point of view, they can find out and get details of resources and points of refer­ral, there is a domes­tic vio­lence helpline for exam­ple, get the details of that and right it down, have some­thing phys­i­cal. The most they can do is ask when it’s safe. We’ve talked about safe­ty and we’ve talked about the lin­ger­ing pres­ence of per­pe­tra­tors, but they not around for ever, you know, per­pe­tra­tors go to the toi­let. Find­ing the oppor­tu­ni­ty to ask, that’s just such a cru­cial thing, and it doesn’t actu­al­ly mat­ter if you get the word­ing wrong. It doesn’t real­ly mat­ter if you feel you might have said the wrong thing. The point of ask­ing qui­et­ly, gen­tly and in a sup­port­ive way is a key to show­ing that mem­ber of the fam­i­ly, [or] show­ing your sis­ter or your friend that you’re con­cerned about them and that you’re brave enough to ask. Even though the answer might be ‘of course I am fine. No, no, no I am absolute­ly fine’, open­ing up the oppor­tu­ni­ty to have that dis­cus­sion again and show­ing that per­son that you are there to lis­ten to them and there to help should they need it.

Evans: It is so easy to be judg­men­tal or ‘he’s doing this to you, this that or the oth­er’ You are under his thumb. ‘I told her to get it sort­ed, she wouldn’t do it, there we are, leave it there.’

Brad­bury-Jones: That’s right. Again, refer­ring to some of the women that I’ve spo­ken to recent­ly, a num­ber told me that after they’d dis­closed, after they got help and after they left that rela­tion­ship that friends and fam­i­ly would say ‘you know I am so glad that you are not with him any­more because we always thought that some­thing going on’, but nev­er, ever men­tioned it. Women are angry about that, because they think they have been in the pres­ence of mem­bers of their fam­i­ly and their friends who they thought cared for them and yet they couldn’t find the words, and couldn’t find the where­with­al to actu­al­ly ask them. That, for a lot of women, they find very upsetting.

Evans: It is easy to judg­men­tal and to say ‘what I would do in these circumstances.’

Brad­bury-Jones: It is easy to be judg­men­tal and sur­vivors talk about that. They talk about the unhelp­ful advice they get, often by well-mean­ing peo­ple. Well-mean­ing friends and fam­i­ly, but also well-mean­ing pro­fes­sion­als as well. Those judg­men­tal ele­ments are hard to con­tain, and a lot of well-mean­ing helpers would say that ‘you need to get out of this sit­u­a­tion, you need to leave now.’ Which seems like a ratio­nal piece of advice, but as I’ve said before a lot of women who dis­close domes­tic vio­lence don’t want to get out there and then. They often do even­tu­al­ly but it takes time and that’s not always the help­ful action, and it is not what they want to hear and in some sense that’s why they don’t talk about it or say what is hap­pen­ing to them. They pre-empt that judg­men­tal stance of the per­son who’s there, but health pro­fes­sion­als have the same response as well. I am think­ing of one par­tic­u­lar study that we con­duct­ed a few years ago: health pro­fes­sion­als expose a real frus­tra­tion some­times, when women are remain­ing in a rela­tion­ship they don’t under­stand it, they don’t get it. You know, ‘you are expe­ri­enc­ing domes­tic vio­lence, get out, leave.’ It’s not that sim­ple, we know it’s not that sim­ple. Frus­tra­tion, when we know that some­body close to us is endur­ing some­thing that’s so ter­ri­ble and yet they’re still there. ‘Why are you still there?’ Is a com­mon ques­tion, but it’s not a sen­si­ble one. We can talk about the help­ful things that one can do, the prac­ti­cal and the emo­tion­al sup­port, but we can also talk about the things not to do. The ‘not to do’ are real­ly about not ask­ing when there is any risk that the per­pe­tra­tor can find out that you’ve asked. Also, with­hold­ing more of the advice that you would want to give and just take more of the hear­ing, lis­ten­ing stance than an advi­so­ry one.

For­rester: It is very impor­tant to seek pro­fes­sion­al help, psy­cho­log­i­cal help, for what you’ve been through. This is a mas­sive event or series of events. You’re not going to be okay imme­di­ate­ly, in a psy­cho­log­i­cal way, more often than not. Maybe some peo­ple are, but most peo­ple are not. To strug­gle on with that because there are oth­er pri­or­i­ties, you don’t val­ue your­selves enough to do some­thing about it, or you think that you can leave it behind and that it won’t affect you, is a dan­ger­ous prospect. You do deserve help for your trau­ma and pre­vent­ing sec­ondary ill­ness­es to evolve.

Evans: Clin­i­cal Psy­chol­o­gist Dr Lene For­rester. There is a list of pro­fes­sion­als and third sec­tor resources on Pain Concern’s web­site, which is

I’d just like to high­light some impor­tant organ­i­sa­tions for imme­di­ate help. One is Refuge, at and the 24-hour Nation­al Domes­tic Abuse Helpline phone num­ber is 0808 2000 247 and Woman Aid office 24/7 Domes­tic Abuse and Forced Mar­riage sup­port. Each of the UK nations has its own web­site with spe­cif­ic infor­ma­tion in Scot­land is

Kath Twigg whose accounts of abuse we’ve been hear­ing through­out this pro­gram runs ther­a­peu­tic writ­ing cours­es for sur­vivors of domes­tic abuse, and work­shops for those who wish to escape destruc­tive life pat­terns and abu­sive rela­tion­ships. Vis­it her web­site at for more details of her work and her book The Hall of Mir­rors, How to Change Life Pat­terns and Avoid Tox­ic Rela­tion­ships. Kath is spelled with a ‘k’ and Twigg ends in dou­ble ‘g’. She’ll have the last words.

Twigg: You have to find a way of lov­ing your­self. Remem­ber the per­son that you lost along the way, because in all of this pat­tern and fluff that you lived through; you for­get who you are. So, I mar­ried the wrong people.

Evans: Are you in a rela­tion­ship now?

Twigg: Yes, yes, I am with an old, old friend who I’ve known for 37 years. He was always on my wave­length, who is my soul mate.

Evans: Do you argue or is every­thing lovey-dovey and sweet and nobody says any­thing bad about each other.

Twigg: We argue, yes. We have dif­fer­ent point of view about things, we get on each other’s nerves. It’s nor­mal, that’s what nor­mal rela­tion­ships do. Peo­ple don’t have, you know, a kind of going off into the sun­set. We have a nor­mal, up and down rela­tion­ship, and we’re very happy.


  • Kath Twigg, Senior Lec­tur­er in social work, train­er, men­tor, writer, and domes­tic abuse survivor
  • Dr Lene For­rester, Clin­i­cal Psy­chol­o­gist at Albyn Hos­pi­tal, Aberdeen
  • Dr Joht Singh Chan­dan, Aca­d­e­m­ic Clin­i­cal Lec­tur­er at the Mur­ray Learn­ing Cen­tre, Uni­ver­si­ty of Birmingham
  • Dr Kate Gillan, Clin­i­cal Psy­chol­o­gist for NHS Greater Glas­gow and Clyde
  • Prof Car­o­line Brad­bury-Jones, Head of Gen­der-Based Vio­lence and Health at the Uni­ver­si­ty of Birmingham.

More Infor­ma­tion:

Tran­scrip­tion by Oliane New­man-Savey & Jen­nifer Bowey