Social Psychiatry and Psychiatric Epidemiology
https://doi.org/10.1007/s00127-023-02431-1
EDITORIAL
Interpersonal violence and mental health: new findings
and paradigms for enduring problems
Louise Michele Howard1
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany 2023
It is well established that violence and abuse, both in child-
hood and/or adulthood, have profound impacts on mental
and physical health, and that the commonest form—domes-
tic violence and abuse (DVA)—is experienced dispropor-
tionately by women, particularly young women. For exam-
ple, in England and Wales, the 2019 Crime Survey [1], a
self-report random household survey, found that 26% of
women versus 15% of men reported at least one incident of
DVA in adulthood; in the previous year alone, 7.5% women
(1.6 million) and 3.8% men (786,000) had experienced DVA.
There is also a larger sex difference for severe and repeated
abuse—in 75% of DVA-related crimes the victim is female,
and between March 2016—March 2018, 74% of victims of
domestic homicide in England and Wales were female [2].
Children are also victims of DVA—a recent UK study esti-
mated that 3.3% of children aged < 11 years had witnessed
at least one incident of domestic violence or threatening
behaviour in their household in the preceding year, as had
2.9% of young people aged 11–17 years [3]. A total of 12%
of children aged < 11 years and 18.4% of young people aged
11–17 years had witnessed at least one incident of domestic
violence or threatening behaviour in their childhood. Similar
data are found in other high-income countries—for exam-
ple, the US National Survey of Children’s Exposure to Vio-
lence reported that approximately one-sixth of children had
witnessed an assault between parental partners, and that 6%
had witnessed an assault between parental partners in the
past year [4]. Yet until recently, the impact of DVA was not
a focus in the training of health professionals and was not
included as a priority for mental health research.
As a result, in 2019 a group of cross-disciplinary academ-
ics, practitioners, third-sector partners and survivors were
* Louise Michele Howard
louise.howard@kcl.ac.uk
1
Section of Women’s Mental Health, Institute of Psychiatry,
Psychology and Neuroscience, King’s College London, De
Crespigny Park, London SE5 8AF, UK
funded by UK Research and Innovation to develop a mental
health network focused on DVA. The central aim was to
develop a better understanding of the relationship between
DVA and women’s mental health including the mediators
and moderators of this relationship, and as a result develop
better interventions. The funding included support for a
Commission [5] that brought together academics, practition-
ers and people with lived experience of abuse and mental
health problems to carry out an evidence review and make
recommendations. The research recommendations included
ensuring DVA is measured in new population-based cohorts
(in men, women and nonbinary people, with analyses strati-
fied by sex and gender), to include DVA as a potential mod-
erator of treatment response in intervention studies and to
improve coordination and cooperation across sectors regard-
ing both data collection and core indicators/outcomes to
assess interventions to reduce DVA, reflecting priorities of
survivors. It was also noted that there is less understand-
ing of how DVA impacts occur across the whole of the life
course and what research findings mean for service delivery
implementation.
Mental health research in general has tended not to sys-
tematically examine sex differences [5, 6] and even where it
has done so it has rarely considered gender self-identifica-
tion so the research discussed here is focused on sex differ-
ences. Future research on all gender categories is very much
needed to further our understanding. However this series
includes rich and methodologically innovative ­researcha
which attempts to address many of the limitations of the
current evidence base by: ensuring quantitative data is disag-
gregated and analysed by sex, using datasets large enough to
have the statistical power to examine sex differences [7–9];
considering carefully the measurement of abuse—for exam-
ple, including technology-enabled abuse [9]; similarly, re-
evaluating measurement of outcomes by carrying out longer
follow-ups and including several domains important to sur-
vivors of abuse; and taking a life course approach [10], for
example, on how childhood sexual abuse may impact on
13
Vol.:(0123456789)

the experience of assessments for psychotherapy [11] and
the 1-year outcomes in adolescents following sexual assault
[10].
Our understanding of the results of these studies is
enhanced by invited commentaries by people with lived
experience and/or working in relevant NGOs. Authors
commented on how DVA research in low to middle-income
settings has traditionally been marginalised, the potential
impact of racism in cumulative trauma and the need for cul-
turally appropriate services which could facilitate access and
appropriate service responses [12, 13]. In addition, several
authors and commentators highlight the problems associated
with some of the concepts and terminology in this field.
[12, 14–16]. The term survivor suggests an empowered
individual but also may make the person feel defined by
the abuse. Miller [14] reflects on terminology and voice in
her commentary, and suggests that the term survivor may
not accurately describe researchers with lived experience
in the context of their research, as it implies they have had
to survive an ordeal (the process under investigation); she,
therefore, suggests, instead of describing “survivor research-
ers”, reframing them as “researchers having experience of
the process under investigation”. D’Cruz and Chandra sug-
gest that another paradigm shift is needed so that there is
collective responsibility for outcomes which emphasises
that recovery and outcomes are a function of not only the
"survivor " but also their social systems [16]. The data in the
study of adolescents from a Sexual Assault Referral Cen-
tre illustrates this well, with the response of the school, and
social relationships at home and with peers, being key in
determining outcomes [10].
The papers commissioned here have novel and signifi-
cant findings, with important implications for services. Yapp
et al.[8] used a latent class analysis to examine the sex differ-
ences in experiences of multiple traumas and mental health
problems using data from a very large (UK biobank) cohort
of 157,358 participants. The researchers aimed to identify
groups of individuals who report exposure to diverse combi-
nations of traumatic experiences. The study establishes that
males compared with females in this UK Biobank cohort
experience different patterns of trauma and adversity over
their lifetime with females more likely to experience mul-
tiple types of trauma. Participants reporting multiple types
of trauma and sexual violence and abuse were more likely
to report symptoms of current and recent mental health
problems. This study has important implications for mental
health services as it highlights the need to identify not only
experiences of childhood sexual abuse and DVA (which are
highlighted in many international policies) but also experi-
ences of multiple victimisations and sexual violence in both
male and female mental health service users.
It is also important to examine specific traumatic
experiences at specific points in the life course to inform
13
Social Psychiatry and Psychiatric Epidemiology
interventions. There has been little longitudinal research on
adolescent survivors of sexual violence despite our knowl-
edge about a key developmental stage when many adoles-
cents experience such severe trauma. The effects of such
trauma in adolescents include brain development, mental
and physical health, emotion regulation, self-esteem, and
relationships so it is timely to include a prospective mixed-
methods cohort study of adolescents experiencing sexual
assault attending a specialist sexual assault referral centre
in London. Clarke et al.[10] recruited 141 adolescents (134
female, 6 male and one transgender woman) and followed
them up at 13 to 15 months post assault. Very high pro-
portions of participants (many of whom had experienced
multiple disadvantages before the index assault) were expe-
riencing symptoms of anxiety disorder, PTSD, or depres-
sion (60%, 72% and 54%, respectively) and/or self-harmed
(51%) at this follow-up. Depressingly, 14% had experienced
revictimization by the study end and the proportion in foster
care had nearly doubled to 32%, as had a persistent absence
from school (in 47%). Qualitative data highlighted that in
addition to court hearings and other appointments, symp-
toms of mental ill-health impacted attendance at school—
and importantly, participants reported how teachers were
unable to support them post-assault and that few allowances
were made for its effects on academic work. Implications,
therefore, include robust implementation of relevant poli-
cies for schools relating to sexual violence, and multi-modal
multi-agency packages of support.
Similarly, it is important to investigate more recent forms
of DVA. In this series, threatening or obscene messaging
in unwanted texts, emails and other forms of messaging
is examined by analysis of responses of 7058 participants
in the Adult Psychiatric Morbidity Survey [9]. Responses
were obtained using computer-assisted interviewing such
that information considered more sensitive was collected
by self-completion for increased privacy with participants
keying their responses directly into a laptop. The researchers
found that one in 15 people in England experienced threaten-
ing or obscene messaging from current or previous partners
(this is the first prevalence estimate of such messaging in
England), and that those experiencing such messaging are
more likely to be young, female and living in poverty. People
who received threatening or obscene messages in the past
year were more likely to have symptoms of anxiety, depres-
sion, suicidality and to self-harm, even after adjusting for
confounding for poverty and exposure to other types of vio-
lence and abuse. This study was based on a single question
about threatening or obscene messaging and further research
should investigate the impact of other technology-facilitated
abuse. However, the study does demonstrate that healthcare
professionals, during assessments and provision of care,
should include questions about online and offline messages,
and communications from previous and current partners, and
Social Psychiatry and Psychiatric Epidemiology
establish whether or not survivors still have ongoing contact
and the nature of any communication.
Healthcare professionals are often involved in assessment
processes of various kinds including assessment for mental
health care. Faulkner et al.[11] contribute to the very lim-
ited research to date on trauma survivors’ experiences of
psychotherapy assessments. Most researchers carrying out
this qualitative study had experienced psychotherapy assess-
ments themselves and this guided the whole research process
from formulating the research questions to drawing conclu-
sions. The research team saw participants’ experiences as a
journey leading to the assessment and its aftermath. Most
participants had experienced severe abuse or neglect lead-
ing to anxiety and anticipation regarding the assessment,
fearing being judged and yet needing to prove themselves
worthy of help. This could lead to people being retrauma-
tised by the assessment process so that the assessment could
present a formidable hurdle or a potential opportunity. Par-
ticipants appreciated authenticity and compassion and there
was a complex dynamic around the sharing or withholding
of experiences and feelings. There are clear implications
for those carrying out psychotherapy assessments here and
Miller [14] suggests that the next step could be to examine
the views of those who conduct assessments alongside those
who experience them.
While the majority of individuals experiencing mental
health problems are at risk of being a victim of DVA rather
than perpetrating it, there is an association between mental
health problems and intimate partner violence perpetration
[5, 17], though with low absolute rates. Saunders et al.used
an individual participant data (IPD) meta-mediation analysis
to examine the relationship between depression and the per-
petration of intimate partner violence (IPV), examining sex
differences and potential confounders, and exploring mecha-
nisms by examining the effects of potential mediators [7].
The authors confirmed that depression is associated with
recent physical IPV perpetration and that this association
persists after controlling for a range of confounders. The
study also confirms the higher levels of IPV perpetration
reported by women compared with men. The analyses were
unable to take into account of severity, frequency or context
of these violent acts, and the authors rightly highlight the
discrepancy between these findings and the analyses that
have shown that the majority of high-frequency and severe
IPV is predominantly experienced by women. No associa-
tion was found for alcohol misuse being a mediator of this
relationship and this is likely to be due to insufficient data
harmonisation. However, IPV victimisation did explain a
significant portion of the effect of depression on IPV per-
petration among women which may reflect bidirectional
violence. The lack of data on mental health problems other
than depression, the context of violence and the lack of lon-
gitudinal analyses are some of the limitations of this study
but the study is an important first step in the use of advanced
statistical methods in meta-analyses examining the relation-
ship between IPV perpetration and mental health problems.
Finally, Keynejad et al.describe the results of a qualitative
survey to identify research, education and capacity-building
priorities for gender-based violence and mental health in low
to middle-income countries. Three quarters of respondents
were from Sub-Saharan African countries but there were
also respondents from Asia, Latin America and the Middle
East (though nearly half of all respondents were based or
employed in high-income countries) and while many were
researchers there were also respondents from the third sec-
tor. Participants identified many barriers to research in this
area including lack of funding, high workforce turnover,
cultural sensitivities and stigma, normalisation of gender-
based violence and a lack of political will. Survey partici-
pants wanted open collaborative structures to bring experts
from both the Global South and North together to strengthen
research capacity, training and the production of interven-
tions with survivors. Kienzler in her commentary [15] points
to the often unspoken legacy of colonialism which manifests
itself in a number of ways, perpetuating western modes of
thinking, learning and acting. She challenges all of us to pay
attention to the internal power inequalities which exist in
international networks and urges us to create ethical spaces
within which people from the Global South and North can
engage in substantive, reflexive, and deep dialogue with col-
leagues to ensure that diverse knowledge, epistemologies
and languages impact on global mental health [15].
Thus, this collection of papers contributes to our under-
standing of the relationship between DVA and mental health.
Next steps for research includes carrying out studies with
boys and men, non-binary and genderqueer people to under-
stand abuse further. There are also intersections with a dis-
ability, ethnicity and other areas of potential disadvantage
which need further examination. As this series demonstrates
it is essential to carry out this research in different contexts
(e.g. low to middle-income countries) while consider-
ing internal power inequalities, using adequately powered
population data sets and appropriate advanced methodo-
logical techniques and including the voice of people with
lived experience of abuse and mental health problems from
the conception of research questions to the interpretation
of results and their implications. There is now considerable
experience among many international research groups, many
of whom are represented in this collection, on how to safely
interview people about violence and mental health so, as
long as safeguards are in place, it may be unethical not to do
this vital research, [18] and it should continue to be a prior-
ity area for research funding. Finally, authors here and else-
where [5] highlight that while there are many opportunities
to prevent abuse during the life course, addressing societal
inequalities [5] including syndemic intersections [13] is a
13

political imperative that will reduce not only violence and
abuse but also ultimately improve population mental health.
Data availability There are no data involved in this editorial so there
are no data to make available.
Declarations
Declaration of interests The author was a grant holder for the UK
Research and Innovation Mental Health Network on violence, abuse
and mental health and is also a co-author on some of the papers in this
series discussed in this editorial.
References
1. Office for National Statistics. Crime in England and Wales: year
ending September 2019 (2020) https://​www.​ons.​gov.​uk/​peopl​
epopu​latio​nandc​ommun​ity/​crime​andju​stice/​bulle​tins/​crime​ineng​
landa​ndwal​es/​yeare​nding​septe​mber2​019
2. Office for National Statistics. Domestic abuse victim characteris-
tics, England and Wales: year ending March 2019 (2019) https://​
www.​ons.​gov.​uk/​peopl​epopu​latio​nandc​ommun​ity/​crime​andju​
stice/​artic​les/​domes​ticab​usevi​ctimc​harac​teris​ticse​nglan​dandw​
ales/​yeare​nding​march​2019
3. Radford L, Corral S, Bradley C, Fisher H, Bassett C, Howat N
et al (2011) The maltreatment and victimisation of children in the
UK: NSPCC report on a national survey of young peoples’, young
adults’ and caregivers’ experiences. NSPCC, London
4. Finkelhor D, Turner HA, Shattuck A, Hamby SL (2013) Violence,
crime, and abuse exposure in a national sample of children and
youth: an update. JAMA Pediatr 167(7):614–621. https://​doi.​org/​
10.​1001/​jamap​ediat​rics.​2013.​42
5. Oram S, Fisher HL, Minnis H, Seedat S, Walby S, Hegarty K et al
(2022) The Lancet Psychiatry Commission on intimate partner
violence and mental health: advancing mental health services,
research, and policy. Lancet Psychiatry 9(6):487–524. https://​doi.​
org/​10.​1016/​S2215-​0366(22)​00008-6
6. Howard LM, Ehrlich AM, Gamlen F, Oram S (2017) Gender-
neutral mental health research is sex and gender biased. Lancet
Psychiatry 4(1):9–11. https://​doi.​org/​10.​1016/​s2215-​0366(16)​
30209-7
7. Saunders KRK, Landau S, Howard LM, Fisher HL, Arseneault
L, McLeod GFH et al (2021) Past-year intimate partner vio-
lence perpetration among people with and without depression:
an individual participant data (IPD) meta-mediation analysis.
Soc Psychiatry Psychiatr Epidemiol. https://​doi.​org/​10.​1007/​
s00127-​021-​02183-w
13
Social Psychiatry and Psychiatric Epidemiology
8. Yapp E, Booth T, Davis K, Coleman J, Howard LM, Breen G et al
(2021) Sex differences in experiences of multiple traumas and
mental health problems in the UK Biobank cohort. Soc Psychiatry
Psychiatr Epidemiol. https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00127-0​ 21-0​ 2092-y
9. McManus S, Bebbington PE, Tanczer L, Scott S, Howard LM
(2021) Receiving threatening or obscene messages from a part-
ner and mental health, self-harm and suicidality: results from the
Adult Psychiatric Morbidity Survey. Soc Psychiatry Psychiatr
Epidemiol. https://​doi.​org/​10.​1007/​s00127-​021-​02113-w
10. Clarke V, Goddard A, Wellings K, Hirve R, Casanovas M, Bewley
S et al (2021) Medium-term health and social outcomes in ado-
lescents following sexual assault: a prospective mixed-methods
cohort study. Soc Psychiatry Psychiatr Epidemiol. https://​doi.​org/​
10.​1007/​s00127-​021-​02127-4
11. Faulkner A, Kelly K, Gibson S, Gillard S, Samuels L, Sweeney
A (2021) Respect for the journey: a survivor-led investigation of
undergoing psychotherapy assessment. Soc Psychiatry Psychiatr
Epidemiol. https://​doi.​org/​10.​1007/​s00127-​020-​02017-1
12. McTavish JR, MacMillan HL (2022) The need for meaningful
support following exposure to sexual assault. Soc Psychiatry Psy-
chiatr Epidemiol. https://​doi.​org/​10.​1007/​s00127-​022-​02232-y
13. Keynejad RC, Bentley A, Bhatia U, Nalwadda O, Mekonnen
FD, Ali PA et al (2021) Research, education and capacity build-
ing priorities for violence, abuse and mental health in low- and
middle-income countries: an international qualitative survey.
Soc Psychiatry Psychiatr Epidemiol. https://​doi.​org/​10.​1007/​
s00127-​021-​02061-5
14. Miller P (2021) Invited commentary. Soc Psychiatry Psychiatr
Epidemiol. https://​doi.​org/​10.​1007/​s00127-​021-​02134-5
15. Kienzler H (2022) Ethical spaces in imperfect global health col-
laborations. A commentary on Keynejad’s research, education and
capacity building initiative to address gender-based violence in the
Global South. Soc Psychiatry Psychiatric Epidemiol. https://​doi.​
org/​10.​1007/​s00127-​021-​02213-7
16. D’cruz MM, Chandra PD (2022) Invited commentary on
“Medium-term health and social outcomes in adolescents follow-
ing sexual assault: a prospective mixed-methods cohort study” by
Clare and colleagues. Soc Psychiatry Psychiatr Epidemiol. https://​
doi.​org/​10.​1007/​s00127-​021-​02205-7
17. Yu R, Nevado-Holgado AJ, Molero Y, D’Onofrio BM, Larsson
H, Howard LM et al (2019) Mental disorders and intimate partner
violence perpetrated by men towards women: a Swedish popu-
lation-based longitudinal study. PLOS Med 16(12):e1002995.
https://​doi.​org/​10.​1371/​journ​al.​pmed.​10029​95
18. Cook E, Markham S, Parker J, John A, Barnicot K, McManus
S (2022) Risk, responsibility, and choice in research ethics. The
Lancet Psychiatry 9(1):5–6. https://​d oi.​o rg/​1 0.​1 016/​S 2215-​
0366(21)​00434-X