Someone presents to their GP with depression. They're exhausted, struggling to sleep, increasingly anxious and finding everyday decisions difficult. They might be prescribed antidepressants, referred for psychological therapy or, if things have deteriorated significantly, assessed by a mental health team. There may be a history of previous episodes of depression, perhaps some suicidal thoughts, and the clinical focus understandably settles on managing their symptoms and helping them function.
But what happens if nobody has explored their relationship? What if the person they're going home to is controlling their finances, monitoring their communications, undermining their confidence and making their life so unpredictable that they're constantly trying to anticipate what might happen next?
The treatment may be entirely appropriate. The diagnosis may be accurate. Yet something fundamental about the person's circumstances remains unexplored, and they continue returning to an environment that may be contributing substantially to their distress.
I've spent over 30 years working across mental health, domestic abuse, safeguarding and services supporting people with complex needs, and one of the things that continues to concern me is how readily we can concentrate on the psychological consequences of someone's experiences without properly understanding those experiences in the first place.
Understanding the psychological impact
Coercive control can have a profound effect on psychological functioning, particularly when it continues over months or years. The cumulative impact of criticism, intimidation, isolation, humiliation, threats and restrictions on everyday choices can gradually change the way someone thinks about themselves and the world around them.
I've worked with people who were once confident, independent and perfectly capable of managing complicated lives, but who had become frightened of making even relatively minor decisions. They would second-guess themselves constantly, apologise for things that required no apology and look for reassurance before expressing an opinion. Some had become so accustomed to monitoring another person's mood that they struggled to relax even when that person was absent.
These behaviours can appear puzzling when viewed without context. Someone may seem excessively anxious, dependent, indecisive or emotionally unstable. They may struggle with concentration, memory, sleep or emotional regulation. Others experience dissociation, persistent low mood, panic attacks or symptoms associated with post-traumatic stress.
There may also be an existing mental health condition, sometimes predating the relationship by many years. That matters because abuse and mental illness can coexist, and professionals need to be able to recognise both without assuming that one explains away the other.
A person who has spent years being told that their judgement is unreliable may understandably find decision-making difficult. Someone whose movements are monitored and whose mistakes are punished may develop considerable anxiety about ordinary activities. These responses make far more sense when we understand what the person has been living with.
When the diagnosis shapes everything else
Clinical diagnoses have an important place in mental healthcare. They can help practitioners understand symptoms, plan treatment and provide access to appropriate support. Difficulties arise when a diagnosis begins to dominate how everything else about a person is interpreted.
Consider someone with a longstanding diagnosis of depression whose partner accompanies them to appointments. The partner appears concerned, explains that the person has always struggled emotionally and describes how much support they provide at home. They might answer questions on their behalf, correct their recollection of events or explain away their reluctance to speak.
None of those behaviours, considered individually, necessarily indicates abuse. However, if that partner also controls the household money, monitors communications, discourages contact with friends and repeatedly tells the person that they cannot cope independently, the clinical picture becomes considerably more complicated.
I have seen how effectively abusive individuals can present themselves as the reasonable, long-suffering partner, particularly when the person experiencing abuse has an established psychiatric history. The language of concern can be remarkably useful to someone who wants to retain control.
Diagnostic overshadowing provides one way of understanding what can happen here. Symptoms, behaviours or concerns may be attributed to an existing diagnosis without adequate consideration of other explanations. Someone reporting that they feel watched or monitored may have their concerns interpreted through a psychiatric framework before anyone has established whether monitoring is actually taking place.
A person who becomes visibly distressed in the presence of their partner might be described as emotionally dysregulated. Reluctance to engage with services could be understood as avoidance or poor motivation, without consideration of whether attending appointments or speaking openly carries consequences at home.
Of course, clinical interpretations sometimes prove entirely correct. The point is that we need enough information to make those judgements, and that includes understanding the person's relationships, their opportunities to exercise autonomy and any behaviour by others that may be contributing to their distress.
Credibility, disclosure and professional assumptions
One of the more disturbing features of coercive control involves the deliberate use of someone's mental health against them. A history of depression, anxiety, self-harm or psychiatric admission can become another means of undermining their credibility.
People may be repeatedly told that they're imagining things, remembering events incorrectly or overreacting. Their distress can then be presented to family members, friends and professionals as evidence that they are unreliable or incapable of managing independently.
Over time, some begin to doubt their own perceptions. Others become reluctant to disclose what has been happening because they anticipate being dismissed, particularly if previous attempts to seek help have gone badly.
Professionals also need to recognise how difficult disclosure can be when someone has very little privacy. Their phone may be checked, their movements questioned and their appointments monitored. They may fear retaliation, losing contact with their children, becoming homeless or facing financial hardship. For some, the risks associated with disclosure feel greater than those associated with remaining silent.
I've encountered people who could describe years of intimidation and restriction but still struggled to identify their experiences as domestic abuse. They had become so accustomed to accommodating another person's demands that they regarded the resulting anxiety and exhaustion as personal failings.
This presents a genuine challenge for assessment. Asking about domestic abuse during an appointment may be useful, but we also need to consider whether the person can answer safely, whether someone else is influencing the conversation and what might happen if the disclosure becomes known.
There are circumstances in which attempting to explore abuse without adequate privacy may increase risk. Professionals need to understand those circumstances and work within appropriate safeguarding and domestic abuse procedures.
Coercive control and suicidal distress
The relationship between domestic abuse and suicide deserves considerably more attention within mental health and safeguarding services.
Research examining domestic abuse-related deaths has identified coercive control in a substantial proportion of cases involving suicide. A Home Office analysis of domestic abuse-related death reviews found that coercive control was recorded as an aggravating factor in 88% of the 26 suicide deaths examined. This was a small and specific group of reviewed deaths, so the finding cannot be generalised to all suicides, but it raises important questions about the circumstances professionals consider when assessing risk.
Suicide involves multiple and often interacting factors, including mental health, previous experiences, social circumstances and access to support. However, the experience of being trapped in an abusive relationship can contribute to profound hopelessness, fear and despair.
Someone may feel unable to remain in the relationship but equally unable to leave. They may have no independent income, nowhere safe to live and genuine concerns about what will happen to their children or pets. Threats of violence, exposure, humiliation or further abuse may make the consequences of leaving seem unbearable.
For some, separation brings additional difficulties. Stalking, harassment, financial abuse and the use of children or legal proceedings to maintain control can continue long after the relationship has ended.
These circumstances matter when someone presents with suicidal thoughts. An assessment that concentrates primarily on psychiatric history, current symptoms and immediate intent may overlook significant ongoing risks within the person's environment.
I have always been concerned about the tendency to locate risk entirely within the individual. We assess their thinking, their behaviour, their protective factors and their willingness to engage with treatment, all of which have an important place. Yet we may devote considerably less attention to the behaviour of someone who is actively contributing to their distress.
That creates the possibility of providing appropriate clinical care while leaving a serious safeguarding concern unidentified.
I've explored the evidence around domestic abuse-related suicide in greater detail in Prevalence of Domestic Abuse and Coercive Control Related Suicide in the UK.
What this means for assessment and safeguarding
Recognising coercive control within mental health presentations requires practitioners to consider the person's circumstances alongside their symptoms. It also requires sufficient confidence to explore difficult subjects without making assumptions about what may be happening.
There are several areas where I think professional practice deserves particular attention.
The first concerns how we gather information. A partner who appears helpful and concerned may genuinely be providing valuable support. Equally, their involvement may restrict what the person feels able to disclose. Professionals need opportunities to hear directly from the individual, privately and safely, and to consider whether there are patterns of restriction, intimidation or interference with their independence.
The second concerns how we interpret behaviour. Someone who misses appointments, appears inconsistent, struggles to make decisions or repeatedly returns to an abusive relationship may be described in ways that obscure the difficulties they're facing. Terms such as 'non-compliant', 'dependent' or 'difficult to engage' can become shorthand for behaviour that has never been properly explored.
There may be many reasons for these difficulties, including mental illness, practical barriers and previous experiences with services. Coercive control needs to remain among the possibilities considered, particularly where other information raises concerns.
The third concerns the quality of risk assessment. Professionals should consider whether suicidal distress or deteriorating mental health may be associated with threats, intimidation, isolation, escalating abuse or fears about separation. Where abuse is identified, specialist advice and appropriate safeguarding responses may be necessary alongside mental health intervention.
Documentation also matters. Recording what someone has reported, what has been observed and how professional conclusions were reached helps others understand the basis for decisions. However, the possibility that an abusive partner may access correspondence, records or appointment information must be considered when planning communication and information sharing.
Multi-agency working can be particularly important. Mental health services may know about suicidal thoughts, while domestic abuse practitioners know about threats or stalking, and children's services hold information about safeguarding concerns. No single professional necessarily has a complete understanding of the circumstances.
Information sharing must be lawful and proportionate, but organisational boundaries should not prevent practitioners from recognising when concerns require a coordinated response.
The responsibility of organisations
We often talk about professional curiosity as though it were simply a personal quality that practitioners either possess or lack. In reality, the conditions in which people work have a considerable influence on their ability to assess complex situations.
Someone managing a heavy caseload, working with limited appointment times and responding to repeated crises may struggle to explore competing explanations for a person's presentation. If supervision concentrates largely on throughput, documentation and immediate risk management, there may be little opportunity to consider whether important information has been missed.
Reflective supervision provides space to examine assumptions, explore uncertainty and consider how a person's wider circumstances might affect their presentation. It can help practitioners recognise when an established formulation no longer adequately explains what they are seeing.
But organisations also need clear procedures, access to specialist domestic abuse advice, effective safeguarding arrangements and opportunities for staff to develop their knowledge. Responsibility cannot simply be placed on individual practitioners without considering whether they have the resources and support to respond appropriately.
In safeguarding reviews, we frequently encounter situations where different professionals held information that, when considered together, might have prompted a different understanding of risk. The challenge is to improve how that information is recognised, interpreted and acted upon before serious harm occurs.
Looking beyond the presenting problem
I am certainly not suggesting that depression, anxiety, PTSD or other mental health conditions should be attributed to coercive control without careful assessment. That would be as unhelpful as overlooking abuse because someone already has a psychiatric diagnosis.
People can experience serious mental illness independently of abusive relationships. They can also experience coercive control alongside existing mental health difficulties, with each potentially affecting the other.
Medication, psychological therapy and other mental health interventions may be entirely appropriate and beneficial. Identifying abuse may mean that additional support is needed, including specialist domestic abuse services, safeguarding intervention, housing assistance or legal advice.
What concerns me is the possibility that we continue treating someone for years while remaining unaware of circumstances that are contributing to their deterioration.
I've worked with people who believed they were incapable of coping, whose confidence had been gradually eroded and who had come to accept another person's description of them as unstable or inadequate. Understanding what had happened to them could be an important part of their recovery, although recognition alone rarely resolves the practical and psychological difficulties involved.
Mental health assessment requires clinical knowledge and judgement, but it also requires an understanding of people's lives beyond the consultation room.
We need to be willing to question our formulations, recognise the influence of other people on someone's wellbeing and remain alert to the possibility that a presentation we have understood in one way may have another important dimension.
For those experiencing coercive control, that understanding can make a considerable difference to the support they receive, the risks that are recognised and the choices available to them.
And for professionals, it provides a more complete basis on which to make difficult decisions.
Specialist online training for professionals
Reflect Training & Consultancy offers specialist live online training in Coercive Control and Mental Health: Recognising Abuse Behind the Symptoms.
Developed for mental health practitioners, safeguarding professionals, social workers, domestic abuse services and other frontline teams, the programme explores the psychological effects of coercive control, diagnostic overshadowing, suicide risk, professional assessment and safeguarding responses.
The training draws on clinical and forensic psychology, domestic abuse practice and learning from safeguarding and domestic abuse-related death reviews, with an emphasis on applying the learning to complex situations encountered in practice.
Contact Reflect Training & Consultancy to discuss online training for your organisation.
Related reading
• Prevalence of Domestic Abuse and Coercive Control Related Suicide in the UK
• How Coercive Control Impacts Mental Health and Suicide Risk
References and professional guidance
• Home Office. Controlling or Coercive Behaviour: Statutory Guidance Framework.
• Home Office. Domestic Homicide Review Reports and Analysis.
• National Institute for Health and Care Excellence. Domestic Violence and Abuse: Multi-agency Working (PH50).
• National Institute for Health and Care Excellence. Self-harm: Assessment, Management and Preventing Recurrence (NG225).
About the author
Fiona Palmer is Director of Reflect Training & Consultancy and has over 30 years' experience across clinical and forensic psychology, domestic abuse, safeguarding, mental health, substance use and complex needs. She is a Home Office registered Accredited Domestic Homicide Review and Domestic Abuse Related Death Review Chair and provides specialist training, consultancy and reflective practice to organisations across the UK.
Questions About Coercive Control and Mental Health: When the Symptoms Are Treated but the Abuse Is Missed
Diagnostic overshadowing occurs when a person's distress, behaviours, or emotional instability are attributed entirely to an existing or presumed psychiatric diagnosis (such as depression, anxiety, or emotional dysregulation) without exploring whether their symptoms are actually a response to ongoing psychological abuse, surveillance, or intimidation at home.
