Help‐seeking amongst women survivors of domestic violence: a qualitative study of pathways towards formal and informal support

Abstract

Background

Informal and formal support for women experiencing domestic violence and abuse (DVA) can improve safety and health outcomes. There has been little qualitative work on the role of both pathways to support and women's experiences of disclosing their experience of DVA in different contexts.

Objective and study design

This qualitative study used repeat interviews with women survivors of DVA to explore their pathways to support and their experiences of barriers and facilitators to disclosure and help‐seeking.

Setting and participants

Thirty‐one women seeking help from specialist DVA agencies in the UK were interviewed twice over 5 months.

Results

Women recounted long journeys of ambivalence, often only disclosing abuse after leaving the perpetrator. Access to specialist support rarely came via general practitioners, despite high levels of consulting for anxious and depressed feelings, and was more often facilitated by police or housing agencies following a crisis such as assault. Informal disclosure only led to specialist help if the family member or friend themselves had experience or knowledge of DVA.

Discussion and conclusions

Women experiencing DVA need earlier access to specialized DVA services. Many women needed an ‘enabler’ to facilitate access, but once this contact was made, disclosure to other professionals or to family and friends was legitimized in the eyes of the women. Safely accessible publicity about DVA services and an appropriate response from social and health‐care professionals should be promoted, including support for women disclosing DVA to take action on the information they receive about services.

Background

Informal and formal support for women experiencing domestic violence and abuse (DVA) can play a vital role in improving safety, physical and mental health outcomes.1, 2, 3 Over three quarters of women experiencing DVA disclose the abuse at some point,4, 5, 6 but disclosure may be limited and come after a long period using private strategies, such as placating or reframing their experiences, to cope within the abusive relationship.7, 8 Women experiencing abuse tend to have small networks with weak interconnections, partly as a result of coercion from the abusive partner, giving limited opportunities for disclosure.5, 9, 10 Specialist DVA services providing advocacy and safe housing can result in improvement in functioning and resilience and a decrease in abuse,8 but women experience many barriers to accessing these services, such as feelings of shame or denial, lack of trust in others or fear of repercussions such as the perpetrator finding out or family members seeking revenge.11, 12 Other barriers to disclosure include a past history of abuse in the family and poor previous experiences of help‐seeking.11

Women experiencing DVA have physical and psychological health problems leading to high levels of consultation with health professionals13, 14, 15 who are therefore well placed to identify abuse and sign‐post women to specialist services.15, 16 However, UK studies show that doctors and nurses rarely ask about abuse, often fail to identify signs of DVA in their patients and may not know how to respond to a disclosure of abuse.17, 18 Referral for psychological counselling without a DVA focus does not necessarily meet the needs of these women.16 Women often lack confidence that their primary care doctor or general practitioner (GP) can offer help, but those who do disclose abuse value the empathetic communication, validation of their situation and referral for additional help that may follow.17, 18, 19 However, disclosure without appropriate referral may leave women vulnerable20, 21 and a major trial showed that GPs, to identify abuse, need both dedicated training and a clear referral pathway to specialist advocacy.22 Little is known about the part played by health professionals in women's overall help‐seeking strategies.

Studies of help‐seeking have mostly been conducted in North America, many limited to cross‐sectional data from retrospective surveys, often using a priori response categories and no follow‐up of respondents.5, 23 Further understanding of the process of disclosure and help‐seeking comes from a few qualitative studies which highlight the complexity of the notion of support and the mistrust on the part of survivors that leads to ‘cautious relating’.1, 24 There is a need for more studies of women's experiences of help‐seeking over time, their motivations, expectations and outcomes of disclosing in different contexts. Studies show that both formal and lay supporters may at times facilitate and at times inhibit the process of breaking free of abuse.25 Helpful responses to disclosure include emotional support, allowing women to talk about the abuse and offering tangible practical help. Unhelpful responses include victim blaming or pressure to act in a certain way such as leaving the relationship.19, 26 Such reactions can hinder access to resources and make it more difficult for women to escape an abusive relationship.4, 27

Previous studies tend to focus on either formal or informal support, although Rose and Collins found that disclosure to a friend or family member may act as a precursor to formal help‐seeking.1 In this article, we report a UK qualitative study looking at patterns of both informal and formal help‐seeking amongst women receiving help from specialist DVA agencies. We aimed to explore women's pathways to specialist support, identify factors that facilitate access to DVA agencies and to articulate the part played by health professionals. The findings are interpreted in the light of models of change and help‐seeking.28, 29, 30, 31 The study is timely as commissioning of specialist DVA services is now within the scope of health‐care providers in the UK.32 It is the first qualitative study to explore disclosure and help‐seeking amongst women survivors of DVA outside North America.

Methods

A purposive sample of women was recruited from participants in the Psychological Advocacy Towards Healing (PATH) trial33 at two DVA agencies in the south‐west of the UK that offer safe housing in a refuge and outreach in the community. The sample included women with a range of age, ethnicity, socio‐economic background, employment status and type of support received (Table 1). Consent was in two stages: consent to contact followed by informed consent before the interview. Initial interviews took place shortly after arrival at the DVA agency, with a follow‐up after 5 months when most women had moved on from the agency and were able to reflect on the experience and outcomes of their help‐seeking.

Table 1.

Characteristics of sample

Qualifications		Employment status		Age		Children		Ethnicity		Length of time in abusive relationship		Previous experience of abuse
Women in a refuge		n = 14
GCSE	4	Employed	3	Mean age	35 years	Yes	11	White British	11	Mean	7.3 years	Previous partner	5
NVQ	4	Looking after children	2	Range	20–65 years	None	3	Iraqi	1	Range	1.5–30 years	Childhood	1
A Level	1	Unemployed	5					Spanish	1			Both	2
Degree	2	Long‐term sick	3					Mixed White and Black Caribbean	1			None	6
Other	1	Retired	1
None	1	Full‐time education	0
Not given	1
Women in the community		n = 17
GCSE	6	Employed	5	Mean age	36 years	Yes	15	White British	15	Mean	8.5 years	Previous partner	2
NVQ	4	Looking after children	6	Range	22–60 years	None	2	Black Caribbean	1	Range	2– 30 years	Childhood	2
A Level	1	Unemployed	3					Mixed White and Black Caribbean	1			Both	2
Degree	3	Long‐term sick	1									None	11
Other	1	Retired	1
None	2	Full‐time education	1
Not given	0

Interviews took the form of a guided conversation based on a topic guide enabling issues of importance to participants to be followed up. Extracts from the topic guides, excluding questions concerning the trial, are given in Box 1. Interviews were conducted and audio‐recorded by a female researcher (ME) at safe locations, including the participant's home, a refuge, the DVA offices, a room at a community or health centre. Data were collected and analysed from an interpretivist perspective seeking to explore how people interpret and make sense of their experiences by attaching meanings to objects and events.34 Interviews were transcribed verbatim and ME led a narrative thematic analysis, coding data and identifying emerging themes and narratives. GF and other colleagues double‐coded a sample of transcripts and verified the emerging interpretation.

Box 1. Sections of topic guides related to help‐seeking (outlines).

Initial interview

Background

• Age, number of children, location of friends and family, employment

Contact with DVA agency

• Timing, reason and experience of making contact

• Expectations of agency

• Experience of agency: positive, negative

Experience of other services

• Contact with any other services to do with DVA, health or family concerns, why, when

• Experiences of other services: positive, negative

Health History

• Physical and emotional health history

• Experience of disclosure/non‐disclosure of DVA to GP or other professional and outcome

Support and safety

• Main avenue of support

• Disclosure of DVA to family and friends, reactions and outcomes

• Experience and meaning of ‘safety’

• Effects of DVA on mood and quality of life

• Any support that is missing

Attitude towards change

• What are the most important changes you would like to make? Who might be able to help you?

• Do you feel ready to make changes to your situation? In what ways?

Follow‐up interviews

Introduction: Update on circumstances

• Living situation, employment, access to services

Health

• Update on mental and physical health and quality of life

Support from DVA agency

• Positive and negative experiences

• Relationship with support worker

Attitude towards change

• What are the most important changes that have happened since the last interview

• What changes would you would still like to make?

• Who might be able to help you?

Support and safety

• Changes in main avenues of support

• Experiences of formal and informal disclosure of DVA, changes, outcomes

• Any support that is missing

Ethics approval was obtained from the National Research Ethics Service South‐West committee.

Results

Thirty‐one women were recruited, fourteen in a refuge and seventeen in the community, either in their own home or with family or friends. Four additional women gave consent for contact but could not subsequently be reached. All the women had been in a long‐term relationship (average 8 years) with an abusive partner (Table 1). Twenty‐two women received a follow‐up interview after 5 months. Nine could not be contacted at follow‐up.

The data give insights into women's experiences of disclosure and help‐seeking from professional agencies and informal networks, the barriers they experienced, and the outcomes of their disclosure. At follow‐up, women were able to describe changes in support over time and also to reflect back on their help‐seeking trajectory, adding to and clarifying issues raised in their initial interview. Verbatim quotations are used to illustrate findings, (INT = Interviewer, RES = Respondent). Respondent's age, location of support and length of abusive relationship are given. Based on themes emerging from the data, the analytic strategy included a comparison between women in refuge and in the community, and a focus on the role of health professionals in women's pathways to specialized support.

Five themes were identified and are explored below. The first theme is ‘Motivations for help‐seeking at a DVA agency’. The second theme describes ‘Barriers to disclosure’ including ‘women's self‐perception’, ‘past relationship experiences’ and ‘fear of repercussions of disclosure’. The third theme is ‘Trajectories to specialist services’ including the role of professional agencies, informal support and self or third‐party referral. The fourth theme focuses on the role of health professionals including GP responses to DVA disclosure. The final theme is ‘Disclosure and help‐seeking over time’.

Motivations for help‐seeking at a DVA agency

Women were motivated by a desire to make changes in their circumstances and the recognition that they were unable to do so without help. They wanted to protect children and family members from further abuse, reduce their own social isolation and increase their understanding of DVA to avoid it in future. Women had witnessed their children being bullied by peers, some receiving death threats on Facebook, truanting from school, developing psychological disorders and manifesting violent behaviour. They also reported violent assaults on family members or a new partner. Contacting the DVA agency was a major step in acknowledging abuse both to themselves and to others. They were hoping for rehousing in a safe location and someone to talk to about DVA who was outside their network of family and friends and could give them non‐judgemental advice. The final trigger to contacting a DVA agency was usually a crisis such as rape, physical assault or being rendered homeless. Leading up to that, women recounted a long journey characterized by ambivalence, weighing up the pros and cons of disclosure.

Baring your soul is a two‐edged sword… painful…but better in the long run [Age 42, community, 20 yrs]

Barriers to disclosure

Only in retrospect, having broken free of their abusive relationship and obtained help were women able to clearly identify what had held them back from seeking help over many years. A significant finding was how little women disclosed about DVA, formally or informally, while they were with the perpetrator, and the mostly negative reaction they received when they did disclose. For most women, disclosure to others only began after leaving the relationship. Many justified not seeking help or leaving their partner sooner by prioritising their role as a mother who needed to keep the family together.

INT: What do you think stopped you trying to get help?

RES: Just thinking perhaps it was me that was the problem and I am the mother and the wife and I am supposed to keep things together and really I should have got help actually and got the kids away from it because they might not have been as they are, you know what they have gone through and I feel guilty about that now, but I was trying to do the best I could for everybody. [Age 49, community, 30 yrs]

Three themes were identified that help explain women's psychological, social and emotional barriers to disclosure.

Women's self‐perception

Self‐blame was a recurrent theme, women believing that their partner's behaviour was their fault. Socially isolated, they lost sight of what was ‘normal’, making it difficult to recognize their partner's behaviour as abusive, to talk about it to others or to justify help‐seeking. This was compounded by women's experience of depression and low self‐esteem. They did not want to burden or ‘bore’ family members or friends and tended to downplay their personal troubles compared to those of others. Some women felt that their role in the family or friendship network was to support others. To express their own needs would upset this equilibrium, and bring shame and embarrassment. Women feared a judgmental response or advice to leave the perpetrator before they felt ready.

It was quite difficult to communicate really when you were in the thick of it… because of him. There's always excuses and stuff you know, he was always watching what I was doing, so I didn't get much time to sort of you know associate with family really. He tried to cause an argument so like my kids wouldn't speak to me, so it's pretty hard. [Age 48, refuge, 3 yrs]

Past relationship experience

Disclosure was particularly difficult where abusive behaviour formed part of family or cultural norms and the woman had experienced abusive relationships throughout her life, including childhood. When family members were in prison or children were in care, as a consequence of abuse, women had little expectation that help would be forthcoming. They found it hard to imagine a life without violence, which deterred them from beginning the process of seeking help.

I've never been in a relationship that wasn't abusive you know so I just assumed that's how it was… my mum was in an abusive relationship… my sister was in an abusive relationship, we just like, you know, it was just normal, it was completely normal. [Age 29, community, 9 yrs]

Women in long‐term marriages with several children also had particular difficulty in disclosing abuse. They were fearful of change and did not expect others to take them seriously, after having remained in the relationship for so long. Women talked about ‘living a lie’, putting on a brave face for the world and insisting that their lives were fine.

Women like me just paint on a face a lot of the time. [Age 25, community, 6 yrs]

Nobody could really hear what I was saying. In fact for a long time I felt that, you know the three monkeys? See no evil … hear no evil … speak no evil. [Age 48, community, 30 yrs]

Previous experiences of unhelpful disclosure to a GP or unhelpful counselling without a focus on DVA acted as a disincentive to disclose to professionals.

Fear of repercussions of disclosure

Women feared that disclosure, particularly to family or friends, would precipitate further abuse or trigger revenge violence against the perpetrator from family members, with implications for their own safety and that of others. Some experienced emotional blackmail, particularly those in long‐term partnerships, when the perpetrator threatened to kill himself or harm the children if she left. Fear was compounded by guilt if the perpetrator suffered from anxiety or depression. Disclosure to professionals in statutory agencies such as police or doctors was inhibited by women's lack of trust, with fears around confidentiality and the potential misuse of personal information. Some expressed anxiety about repercussions of formal disclosure for their partner or children, such as children being taken into care.

Trajectories to specialist services

Disclosure of abuse, whether to a professional or an informal contact, rarely led to accessing DVA agencies in a simple or immediate way. Three different pathways to specialist DVA support were identified.

Role of professional agencies

Contact with the DVA agency often followed a crisis via a series of links that might include a housing department, the police, victim support, the national DVA helpline, a solicitor, probation department, health professional or a hostel for homeless people. Agencies offered information about DVA services, but women did not generally take action until months or years later, often after many such incidents. On rare occasions, a police officer escorted a woman directly to the agency or a GP phoned on the patients’ behalf, resulting in swifter access to DVA services. Professional agencies had a greater role for women entering a refuge, who were less well resourced financially and socially than women remaining in the community.

Role of informal support

Women were more likely to disclose fully to friends than to family. Friends offered emotional support while family more often provided instrumental support for example a place to stay, childcare or financial help. Disclosure to family was often ‘partial’, with little detail given. Some employed women made a partial disclosure to colleagues. For women in the community, informal network members did sometimes play a part in facilitating access to DVA services, but only if the contact had personal experience of DVA, knew a family member or friend who had, or worked in an allied field. As with women entering a refuge, women in the community sometimes waited for up to 2 years before acting on information received. Swift access was achieved in one case when a friend phoned the DVA agency herself in the presence of the survivor.

Self or third‐party referral

Three women self‐referred to the DVA agency, having prior knowledge of the agency through work or personal experience. Once again, delay over several years was evident, owing to the potential stigma arising from disclosing DVA to work colleagues. In a minority of cases, contact with the DVA agency was ‘forced’ by a third party, such as a neighbour or a school counsellor acting out of concern for the welfare of the children and making contact with the social services department which led to a chain of referrals. Despite initial reservations, women were relieved that the decision to access DVA services had been taken out of their hands.

When you are in those kind of problems you really need someone to turn round and go, YOU need this NOW. When you're in a domestic violence situation… sometimes you do need someone to almost parent you … especially when you are under that much stress, I'm pretty sure it's like it for every woman who goes through this kind of stuff… You don't know who to ask, there isn't anyone to ask. Unless someone says, this is what you need to do, the doors are closed. I've always had closed doors, nobody helps. [Age 31, refuge, 5 yrs]

The role of health professionals

Two women were sign‐posted to the DVA agency while in hospital following a serious assault. In primary care, although GPs featured in the chain of referral for some women, their role in accessing specialist DVA support was not considered significant. Women had low expectations of getting help and felt that GPs lacked the skills for asking and talking about DVA. They reported doctors missing signs of abuse such as a ‘stress rash’ and marks on the throat from strangling. Women felt particularly inhibited when the GP was male or was unknown to them. Lack of continuity with a specific GP, either within a practice or following a house move to a different area, acted as a disincentive to disclosing abuse. Some women had returned to their parental home to consult with a well‐known and trusted GP.

INT: What was it like talking to your GP in that way? RES: Um, it opened up a bit of a floodgate… Err, which… she's great, the GP because it's one particular doctor that if I had to see any other doctor in the surgery I wouldn't have done it. But because she knows me from the past a little bit, she recognised there was some marital problems as far back as last July [Age 48, community, 30 yrs]

Twenty‐seven women had consulted their GP, mainly for help with anxious and depressed feelings. Sixteen disclosed abuse, although five only did so after they had left the abusive relationship and were receiving DVA agency support. For them, contacting the DVA agency legitimized further disclosure and also triggered support from the GP.

If you say [Name of DVA agency] they (doctors) automatically know well that's to do with domestic violence and they soften, you can see their face soften, their attitude softens… [DVA agency] itself is a powerful word. If I go to the doctors on my own, when I was going to the doctors before I had [DVA agency] and go in and say about my problems they were like right, okay, fair enough, we will patch you up, on your way but it's not like that, I go to my doctors and I say I am feeling bad, and they sit me down and they listen…. there's a massive difference in how I am treated, massive difference [Age 31, refuge, 5 yrs]

None of the women consulted their GP with the intention of talking about domestic abuse, and they described breaking down into tears and talking about it. Disclosure was patient‐led rather than a response to enquiry about DVA from the doctor.

GP response to disclosure of DVA

All but four of the disclosing women (n = 16) said their doctor listened and was empathetic, but in most cases prescribed antidepressants and took no further action. Women did not find this supportive and few of them took the medication. This experience set up a cycle of disillusion where further consultation was not considered helpful and disclosing abuse seen as a waste of time.

I've got huge stress and anxiety. I have medication for it but, um, I don't take it because I don't like medicines. I just think my anxiety is caused through the situation I'm in…. I try and pick myself back up. I don't want to end up, you know, a mother that's full of pills and doesn't know what day it is…. I just think they're addictive and they mask the problem…. he's [GP] a man and I don't think unless you've been through it you can never really understand. [Age 37, community, 6 yrs]

Helpful interventions, recounted by a minority of women, were suggestions for self‐help strategies such as taking time out for themselves and referrals for counselling. Four women who disclosed abuse were referred for counselling, but only one had actually received any at follow‐up owing to long waiting lists or difficulty contacting the counsellor. Only two women were referred to a DVA agency. One was given contact details which she followed up herself after a considerable delay. In the second case, the GP telephoned the DVA agency in the woman's presence, an action that was perceived as helpful and supportive.

Disclosure and help‐seeking trajectories over time

Repeat interviews (n = 22) enabled us to track changes in women's perception of support over time. At follow‐up, most women were living independently in social housing or privately rented accommodation, having moved on from either a refuge, the home shared with the perpetrator or temporary accommodation with family or friends. In three cases, the perpetrator left the shared home, enabling the woman to remain. Many women described ongoing harassment. Three women were in new non‐abusive relationships.

At first interview, the most frequently cited source of support was the agency, followed by children or a new boyfriend. There was evidence of social isolation in that few women perceived family or friends as their main source of support, except for key individuals who had personal experience or knowledge of DVA or had provided long‐term support, such as a survivor’ s mother. Many said they had no support at all and had to rely on themselves. They all felt the lack of someone to talk to about DVA outside the agency without fear of a judgemental response.

A significant finding was the limited nature of informal disclosure by women while they were with the abusive partner, and their negative experiences of this disclosure. Women described not being taken seriously or their experiences being ‘normalized’.

My friends don't understand ‘cos they have arguments and disagreements with their blokes but they don't understand what it's like to go through domestic violence. [Age 31, community, 3 yrs]

Friends or family sometimes ‘sided’ with the abusive partner or urged the woman to leave the relationship before she was ready. Some families or social groups such as a church community or the perpetrator's family closed ranks against the woman following disclosure.

At follow‐up, the pattern of perceived support had changed. There was less reliance on the DVA agency, but several women continued to receive multi‐agency support for themselves or their children. Some women were disappointed by the limited help they received from the DVA agency and some felt isolated once agency support ended.

RES: I don't get really support from anyone.

INT: Uh‐huh, and how does that feel?

RES: Erm, sometimes feels lonely.

INT: How about your son, what's your relationship like with your son?

RES: Oh we fell out in August, I haven't seen him since. But then again err, he's in an abusive relationship… his… his partner is really bad to him. [Age 47, refuge, 10 yrs]

Others, however, felt empowered to move on and make new connections such as joining a new church community or a college course.

I'm a carer. When I spoke to you last I was doing my course, I was on an access to nursing course. [Age 30, community, 3 yrs]

Late in the day they were finally able to talk to their GP about abuse. A minority of women had a long‐term thread of enduring support from their mother, a new partner, adult children or close friends. There was a noticeable shift in perception of family and friends. Many women described increased connection and improved relationships since contacting the DVA agency, while a few still had troubled and difficult relationships, particularly in the two cases where women had returned to the perpetrator. Another shift was the number of women citing the workplace and colleagues as a source of support. The move towards independence had enabled many women to return to work. This provided social and financial support as well as boosting self‐esteem. Individual friends or family members with experience of DVA were still an important support at follow‐up. Fourteen women described an improvement in their emotional well‐being over time and a gradual return of self‐esteem. The other eight women who were interviewed felt they had not moved on psychologically, were experiencing fluctuating moods and confidence levels. Some were still socially isolated and unsupported, having lost confidence to form new friendships and preferring to rely on themselves, a pet or e‐friends.

Discussion

This study shows that women remained in abusive, controlling relationships for many years with little access to support. Access to services was more likely to occur following a crisis such as assault or homelessness, while women who were better resourced in terms of accommodation and informal contacts often found it harder to access specialist support.

Strengths and limitations

Data from repeat interviews enabled a fuller understanding of the process of disclosure and help‐seeking for women surviving DVA, enhanced by a trusting relationship with the researcher over time and the opportunity to reflect on current and past experiences.

The sample may not be representative of women receiving help at a DVA agency as they were participants in a trial. The sample also included few women from minority ethnic groups who may have particular needs that warrant further study.

The study provides corroboration and further understanding of barriers to disclosure and help‐seeking previously identified.1, 5, 6, 11, 24, 35, 36 All the women in the study were eventually ‘successful’ help‐seekers in terms of accessing specialist DVA services and we can learn from their trajectories. Women's narratives of help‐seeking need to be heard by policy makers and health‐care funders, to inform interventions that facilitate earlier access to services, as highlighted in a recent longitudinal study from the USA reporting a ‘drastic improvement in functioning and resilience and decrease in abuse for all women’ who connected with DVA services.8 Our study shows that only after connecting with a DVA agency did many women feel that disclosure of abuse and help‐seeking via other formal or informal avenues was legitimized. It is notable that only two women had returned to the perpetrator at follow‐up which highlights the role of agency support in keeping women safe.

Previous studies suggest that women's disclosure of abuse and help‐seeking represents empowered, planned and strategic actions,2, 5 but this study shows it is not always so. Many women in the study held information about DVA resources for months or years before acting. Help‐seeking was often reactive to a crisis or to a serendipitous encounter with a significant individual who acted as an enabler.

Explanatory models of help‐seeking for women experiencing DVA explore the interaction between a woman's ‘inner’ processes, such as how she defines and appraises her experience, and the contextual influences in her life, such as the availability of information, social support and financial resources.2 Our study helps broaden our understanding of survivor's needs and experiences. While we have focussed on contextual factors, this is in recognition of the interplay of multiple influences on women's ability to move away from an abusive relationship. The legitimization of help‐seeking that followed contact with a DVA agency in our sample was the outward expression of women's inner process of acknowledging and accepting that they were being abused.

A woman's recognition or acknowledgement of abuse is seen as a crucial stage in her journey away from abuse. Only then can she contemplate what action to take. Explanations of women's trajectories away from abuse have emerged from the transtheoretical model of change (TTMC), adapted from its roots in addiction behaviour.2, 28, 29, 30, 31 The model describes a series of changes from pre‐contemplation through contemplation and preparation leading to action and finally maintenance of safety. While the model has proved useful in the context of counselling,31 there are limitations: in reality, the stages are nonlinear, women's freedom of action is restricted by the abusive relationship, and women take multiple pathways to improving their safety. Many women in our study only really accepted the abuse after contacting the DVA agency and internalizing the label, having previously been held back by self‐blame and low self‐esteem.

Women's accounts reveal the significance of other agencies, serendipitous encounters with individuals or the intervention of others that triggered or enabled help‐seeking. Further developments of the TTMC have stressed the importance of these ‘turning points’ in women's lives that trigger a psychological shift, or provide external support to taking action.29, 30 The concept of turning points is part of the ‘psychosocial readiness model’ describing the dynamic interplay of internal factors and external interpersonal and situational factors that affect women's movements towards or away from change.30 Our study provides support for this model, with examples of diverse factors affecting help‐seeking such as increasing severity of abuse, recognition of the impact of abuse on other family members, particularly children, or an encounter with another survivor of DVA. Making contact with a DVA agency enabled women to reframe their experiences and reach out to others.

Domestic violence and abuse requires a multi‐agency response which is sensitive to the needs of women at different points in their trajectory, a response that goes beyond sign‐posting because many women lack the confidence to act on the information provided. Help may need to be sensitively offered by third parties, be they formal or informal contacts, and not necessarily in response to a direct request from the survivor.

Our study confirms previous findings that disclosure of abuse does not always have a positive outcome for women.24, 37 Women used strategies of ‘partial disclosure’ to avoid a negative outcome. In contrast to previous studies, we did not find that informal disclosure often led to formal support, except in situations when an informal contact had personal experience or knowledge of DVA.

An important finding was the reluctance of women to disclose abuse to their GP, despite the fact that the majority were receiving treatment for anxiety or depression. In line with previous work, the GP or family physician did not play an important role in helping abused women to resolve their problems, but an empathetic consulting style was valued.18 To encourage disclosure, women in our study wanted greater continuity with a known GP and individually tailored support, in line with the results of a synthesis of qualitative studies of the experiences and expectations of DVA survivors with regard to doctors.19

Safe advertising of DVA resources and increased awareness of the need for a compassionate but strong response should be promoted in agencies that women experiencing DVA are likely to contact. Help to take action on the information received should be offered. Access to support from other women surviving DVA could be improved such as online peer support or the development of resources such as buddying between survivors or non‐professional mentoring.38

Source of funding

NHS National Institute for Health Research Programme grant RP‐PG‐0108‐10084, London, UK

Conflicts of Interest

None.