Title: Advancing theory and treatment approaches for males in substance misuse treatment who perpetrate intimate partner violence (Programme ADVANCE)
Funder: Department of Health and Social Care

Abstract: Aims/objectives ADVANCE is a 60-month multi-methods programme with 5 consecutive workstreams(WS) that generate evidence to develop and test an intervention to reduce intimate partner violence(IPV) by men attending substance use treatment and improve depressive symptoms among for their ex/current-partners as a result. Background/rationale 40% of men receiving substance use treatment have been physically or sexually violent towards their partner in the past year rising to 70% for psychological abuse, rates far higher than the general population. Despite this, few studies have been conducted to examine the effectiveness of perpetrator interventions for male substance users. Integrated interventions that address IPV and substance use concurrently show promising results, but there remains a need for further research. Distinct perpetrators types have been described, but the role of substance use within these is poorly understood. Research plan WS1:Understanding IPV perpetrator typologies(months 1-12) A meta-ethnography(synthesis of qualitative literature) will be undertaken to better understand substance users perceptions of the role that substance use may play in IPV perpetration. In-depth qualitative interviews with 45 male IPV perpetrators attending substance use treatment in London and West Midlands (and their ex/current-partners) will be conducted to describe what contributes to IPV and ascertain their relationship/support needs. The Free Association Narrative Interview Method will be used for analysis. A new IPV perpetrator typology will be generated that evidences the relevance of intoxication and substance use to inform intervention development(WS3). WS2:Determining the efficacy of interventions to reduce IPV perpetration(months 1-12) A systematic review will compare and determine the efficacy of different treatment approaches. A narrative review will describe trials that addressed substance use or reported substance use outcomes. Effective interventions will be sourced for review in WS3. WS3:Developing the intervention and training package(months 6-18) An executive group will have overall responsibility for content. Two development groups(expert group and a PPI group) will meet 5 times to agree intervention and training package content. WS4: Feasibility and acceptability study(months 19-30) Approximately 108 male perpetrators receiving substance use treatment will be randomly allocated to the integrated group intervention developed in WS3 or treatment-as-usual(TAU) to inform the parameters required for planning an efficacy trial(WS5). Integrated women s support services will be offered to perpetrators ex/current partners(survivors). 76 survivors(includes 38 whose ex/current partners are allocated to the group intervention) will be recruited. Outcomes will be assessed at baseline and 3 months post-randomisation. The feasibility of obtaining outcome measures from survivors and perpetrators will be assessed. The following outcomes will be considered survivors depressive symptoms, perpetrator and survivor reports of IPV perpetration, respectful communication; awareness of the impact of IPV; substance use; quality of life; mental health; service use and criminal justice involvement. Survivors will also be asked about feeling safe. Various parameters needed to judge the feasibility of an efficacy trial will be estimated. A formative evaluation of the intervention s implementation will be conducted. A staging report(with stop/go criteria) will consider whether progression to full trial is warranted. WS5: Randomised controlled trial(RCT) of an evidence-based intervention developed in WS3 compared to TAU to reduce IPV perpetration among men attending substance use treatment(months 31-57) Trial design, primary and secondary outcomes for the efficacy trial will be the same as described for WS4. Outcomes will be assessed at baseline and 3, 6 and 12 months post-randomisation. It is estimated that to detect an improvement of 3 points in survivors Patient Health Questionnaire(PHQ-9) (measures depressive symptoms) scores using a two-tailed t-test at the 5% significance level to compare mean PHQ-9 between the trial arms with 90% power, 346 survivors(173 per trial arm) are required. In order to recruit 346 survivors, around 480 perpetrators need to be recruited from substance use treatment in West Midlands, Bristol and London. Perpetrators will be randomly allocated to receive the integrated group intervention or TAU. Intention to treat analysis will be conducted. Linear mixed modelling will be used to assess the effect of the intervention. Secondary continuous and count outcomes would be analysed following a similar generalized linear mixed modelling approach. A nested process evaluation will provide an understanding of mechanisms of action, how context affects implementation, or why those delivering or receiving the intervention do or do not engage as planned. Incremental cost-effectiveness and cost-utility analysis of the intervention over and above usual practice will be undertaken alongside the trial. Projected outputs/dissemination Local Learning Alliance(LA) of key stakeholders in the West Midlands and London will meet 15 times to develop local cross-sector solutions to this complex problem, building on knowledge transferred from ADVANCE into practice. The intervention and training package will be disseminated via the project website and 6 dissemination events. Research findings will be disseminated in open-access publications and conferences. Benefits to patients/NHS IPV costs &pound;5.5bn annually, impacting negatively on survivors mental and physical health. Responding to IPV by those most likely to perpetrate it could reduce this economic and social burden.

Lay abstract: Background/Aims Domestic violence (DV) includes physical, sexual and psychological harm by a current/ex-partner. In the UK, 30% of women have experienced DV. DV impacts negatively on survivors health, costing the NHS &pound;5.5 billion annually. Reducing DV and improving survivors mental health is a public health priority. Men in substance misuse treatment are more likely than men in the general population to perpetrate DV. This research will develop and test a group therapy to reduce DV by men receiving substance misuse treatment, that we anticipate will improve current/ex-partners depression. The research has 5 Workstreams: Workstream 1 We will interview male DV perpetrators and their current/ex-partners about their relationships and treatment/support needs to understand what kinds of treatment might be helpful. Existing literature will be summarised to establish how substance misuse may play a role in DV. Workstream 2 While therapies for perpetrators exist, few target men in substance misuse treatment. We will review other studies to determine what type of treatment reduces DV and for whom treatment works. Workstream 3 A group of experts and lay people (including survivors and perpetrators) will use findings from earlier Workstreams to develop a staff training package and group therapy for men in substance misuse treatment. Workstream 4 The group therapy developed will be tested with men in substance misuse treatment in three services to demonstrate whether it is possible to recruit men and their current/ex partners, and deliver a group therapy to male perpetrators in substance misuse treatment. We will assess whether they find the therapy acceptable, attend the sessions, can be retained in the research and are willing to be followed-up. We will offer support to their current/ex-partners and evaluate whether they take up this offer of support. We will describe how the group therapy is delivered in practice before we undertake a large experimental study (trial). Workstream 5 If it proves possible to deliver the therapy in substance misuse treatment, we will conduct a large trial in more services to evaluate whether the group therapy results in improved mental health for ex/current partners of the men receiving the group therapy, and is better value for money, than usual care (fortnightly individual therapy session with a key worker). We anticipate that if DV reduces, ex/current partners depressive symptoms will improve. Support will be offered to all current/ex-partners, irrespective of perpetrator s treatment. Depressive symptoms, frequency of DV, quality of life and feeling safe (survivors only) will be assessed after one year among perpetrators and victims to measure any changes. Dissemination Key stakeholders (including survivors and perpetrators, voluntary sector/practitioners from DV/substance misuse sectors, researchers) will be involved in meetings throughout the research to ensure that findings are disseminated and translated into policy and practice.

Research activity codes: 5.6 PSYCHOLOGICAL AND BEHAVIOURAL;6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH