Title: Improving the response of mental health services to domestic abuse perpetration(DAP)
Funder: Department of Health and Social Care

Abstract: Aim: to generate evidence on three unanswered research questions(RQ1a-c) and integrate this evidence to support future intervention to reduce violence: RQ1a. How, why and in what circumstances is DAP identified and assessed by mental health practitioners? RQ1b. How prepared are mental health professionals to identify and assess DAP? RQ1c. What is the performance of violence risk assessment in mental health services when DAP is identified, and can it be improved using a prediction model? Background: Domestic abuse(DA) is perpetration of violence or abuse towards an adult partner, ex-partner, or family member. The preventable mortality, suffering, and morbidity caused by DA remains a critical policy challenge and has increased during the pandemic. Psychiatric morbidity attributable to DA causes burden to mental health services. This chiefly harms women, especially women from ethnic minority groups, reinforcing gender and ethnic inequality.Evidence, expertise and experience shows that addressing DAP is an effective violence prevention measure. Yet, mental health services research has overlooked this, focusing instead on improving management of DA victims. Preparatory reviews and involvement of policymakers, patients, carers, and charities suggests that while strengthening responses of mental health services to DAP could be important, new evidence is urgently needed: -New UK legislation and statutory guidance now requires some individuals convicted of DAP to access mental health services, calling for rapid development of evidence-based interventions. -Pandemic restrictions have exacerbated existing uncertainty in identifying and assessing DAP, due to a reduction in face-to-face clinical encounters.Methods Workstream (WS) 1a. thematically analyse patient records from two NHS trusts to develop a framework for the identification and assessment of DAP by mental health professionals, informed by text analytics, lived experience, and cross-disciplinary expertise (4/22-3/23). WS1b. Conceptualise and measure professional preparedness to identify and assess DAP in mental health services, using focus groups(n=30), cognitive interviewing, and psychometric analysis of survey data(n=150, 4/23-3/24) WS1c. Examine performance of violence risk assessment for DAP in mental health services by: -Estimating current predictive performance of violence risk assessments for later violent incidents, analysing electronic health records and police data on violence arrests/charges(minimum n=23228) -Assessing if a collaboratively-produced prediction model integrating electronic health records data improves upon current performance according to statistical best practice principles(minimum n=23228, 4/24-3/25). WS2. Use WS1a-c findings to co-produce an evidence-informed theory of change(ToC) for improved mental health services response to DAP (4/25-3/26). The final ToC will describe how a complex intervention informed by WS1 could improve mental health professional responses to DAP by: A. increasing professional preparedness to respond to DAP, B. reducing violence, C. improving wellbeing of carers/family members, Involving relevant stakeholder communities of practice(NHS Violence Reduction, London DA Clinical Reference Group, RCPsych Forensic Faculty) will ensure future interventions I develop (e.g a practitioner/services toolkit) are contextually appropriate, relevant and useable, improving buy-in and ensuring knowledge uptake and impact. Patient safety research will be improved through scalable/reproducible methods to evaluate violence risk assessment I will develop with service user research collaborators.Dissemination will include public events demonstrating how collaborative understanding of patient records can improve safety.

Lay abstract: Aim My research will strengthen how mental health professionals respond to domestic abuse perpetration, collaborating throughout with patients, professionals, and researchers/experts in women's mental health and forensic psychiatry. Background and PPI Domestic abuse is abusive behaviour towards a partner, ex-partner or family member. Domestic abuse affects around 30% of women and 10% of men, causes significant mortality, and is driving increasing health and social care need in the UK. We need better solutions to domestic abuse. Most research focuses on victims of domestic abuse, with less attention paid to perpetrators, who are the people responsible for domestic abuse. Perpetrators of domestic abuse are often referred to mental health services, according to Oram's review (2014) and my PPI with charities and victims/survivors. PPI with policymakers suggests new UK law will increase these referrals. Therefore, mental health services urgently need to improve how they identify and assess perpetration of domestic abuse. I propose that this is a window of opportunity to help mental health services carry out their role more effectively and to reduce violence. My carer PPI, supported by the charity Hundred Families, supports better use of electronic health records to tackle domestic abuse perpetration. This could ensure the right information is available to professionals at the right time, and that risks are safely assessed. This is especially urgent because developing safe telephone/video-based care is a priority as mental health services adapt to and recover from the pandemic. My work will complement colleagues' research on perspectives of both domestic abuse perpetrators, and victims/survivors who have shaped my project. Methods Workstream 1a extends my previous work using text mining software, which detects specific words/phrases in patient records. I will use this to gather text data to examine how professionals currently identify and assess domestic abuse perpetration, using thematic analysis. Thematic analysis is a method by which data is examined to see what patterns, topics, and ideas emerge. This will help get detailed understanding of professional responses to domestic abuse perpetration. I will collaborate with someone with lived experience and discuss findings regularly with an advisory committee of patients, professionals, and researchers to address any ethical challenges. This knowledge will help me develop a questionnaire for mental health professionals (nurses, doctors, social workers) about how prepared they are to identify and assess domestic abuse perpetration (workstream 1b). I will use statistical testing to arrive at a consistent and reliable questionnaire. This will be the first evidence on how prepared mental health professionals and services are to respond to this critical problem. Using this understanding of how mental health professionals identify/assess domestic abuse perpetration, I will study how professionals determine which patients present risk of harm ('violence risk assessment'). I will investigate how well violence risk assessments work when domestic abuse perpetration is encountered, and whether future practice can be improved by combining these assessments with prediction methods, which estimate risk using patient data (workstream 1c). Workstream 2 will involve workshops with patients, carers, professionals, charities and wide-ranging experts about domestic abuse perpetration encountered by mental health services - what they want to know, what they think is important, and what ideas they have for improving responses to domestic abuse perpetration. This evidence will allow me to spread knowledge among practitioners/services, e.g.using a toolkit for better responses to domestic abuse perpetration, produced with stakeholders. Sharing findings I will share findings with participants, stakeholders, and the public using online events/workshops, co-produced summaries, and an interesting website that will allow interaction with my methods/results. Links with domestic abuse charities (SafeLives, Respect, Drive), and policymakers (NHS Violence Reduction, RCPsych Forensic Faculty) will support policy impact.

Research activity codes: 4.3 INFLUENCES AND IMPACT;7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH;DISPUTED AETIOLOGY AND OTHER