ADVANCE Programme – Summary of findings

The ADVANCE team have written a summary of the programme findings:

The ADVANCE study:
ADVANCE is a 60-month programme with 5 workstreams to describe the role of substance use in intimate partner violence (IPV) perpetration by men in substance use treatment and develop and test a perpetrator programme for this group. ADVANCE is led by King’s College London, together with colleagues from the University of Worcester, University of Manchester, University of Bristol, University of York, RESPECT, South London and the Maudsley NHS Foundation Trust and Rochester Institute of Technology.

Background:
• IPV includes physical harm, sexual abuse, psychological harm, controlling behaviour and financial abuse between an intimate couple.1
• In the UK, 8% of women and 4% of men experienced past year IPV2 compared to 57% of women attending substance use treatment.3,4 40% of men receiving substance use treatment have perpetrated past year physical or sexual IPV rates four times higher than men in the general population.5-9
• No single factor explains why some people perpetrate IPV but alcohol, cocaine and methamphetamine are strongly and consistently associated with IPV perpetration.9-11
• Around 23-63% of IPV incidents involve alcohol as a contributing factor,1 “approximately equal to other contributing causes such as gender roles, anger and marital functioning”.11
• Physical violence is also more severe on days when heavy drinking has occurred and when one or both partners have been drinking.12

Our previous research found:
• 77% of men in substance use treatment in England had perpetrated IPV, only 25% had been arrested for it, and even fewer had received support13
• Substance use treatment staff have concerns about role boundaries, competency and confidence in asking service users about IPV perpetration. Staff highlighted a lack of care pathways including perpetrator programmes.14
• A systematic review was conducted to determine the efficacy of interventions to reduce IPV by men who use substances. Limited evidence that IPV interventions targeting substance-using men reduce IPV. Individual trials report short-term improvements in IPV and substance use outcomes. Integrated IPV and substance interventions showed no difference IPV outcomes compared to usual treatment.15

Gaps in knowledge
• There remains an urgent need to explain and address the high prevalence of IPV amongst men receiving substance use treatment and to develop evidenced based, integrated interventions for IPV perpetrators who use substances.
Findings to date from ADVANCE:
Two studies were conducted to explore how substance use featured in survivors’ and perpetrators’ accounts of IPV to inform the development of the ADVANCE intervention to reduce IPV perpetration by men receiving substance use treatment:

1. A systematic review of 26 qualitative studies 16
Whilst perpetrators depicted their violence as typically motivated and moderated, the studies exposed assaults that were uncontrolled and brutal, the repetition of which survivors anticipated. The review found that substance use and IPV were linked in the following complex ways:

Intoxication: Survivors and perpetrators both explained IPV perpetration in terms of a change or disinhibition in self when under the influence of alcohol or stimulant drugs.
Withdrawal: There was an increased risk of IPV perpetration when men were in withdrawal or craving alcohol, heroin and stimulant drugs due to irritability and frustration or because they needed money to obtain substances. Failure or refusal of a partner to procure money for drugs increased the likelihood of violence.
Impact of substance use on relationship: Perpetrators who used substances were more likely to blame their violence on intoxication or their partner’s behaviour. The substance user’s lifestyle further created environments experienced as emotionally unstable and unpredictable. Survivors reported hypervigilance in anticipation of their partner’s abusive behaviours and bore the burden of an unequal share of childcare, domestic duties and economic finances to support the family.
Power and control: Survivors often depicted their partner’s intoxication and withdrawal as part of a wider pattern of behaviour, including controlling tendencies and emotional unpredictability. Male perpetrators’ controlling behaviours were exacerbated by intoxication
Psychological vulnerabilities: Childhood trauma, mental health and emotional instability were further linked to substance use and IPV perpetration.

2. A qualitative study of 14 male IPV perpetrators in substance use treatment in England and their current or former female partners17,18
The majority of men used heroin, crack, cocaine and/or alcohol. Four female partners were current heroin and/or crack users, and two had previously used substances. Eight men reported they had been arrested for IPV and 6 men reported having received a custodial sentence. Eleven men and 8 women disclosed mental health problems. At least three couples reported that their children had been taken into local authority care.

Overall men minimised and/or denied their violence. Some men viewed it as a one-off incident and/or context specific, whereas women reported violence as part of an ongoing pattern of abuse and controlling behaviour. Men were more likely to describe violence as bi-directional. Women’s accounts of hypervigilance (being constantly aware and assessing the environment for signs that violence may occur) featured. Women who used substances often fought back. Perpetrators considered their behaviour to be protecting their partners against other men or the woman’s escalating drug use however survivors experienced the man’s behaviour as controlling and stifling. Both partners brought histories of adversity, psychological disorders, childhood abuse and IPV in previous relationships with them.

Overall a complex interplay between the psycho-pharmacological effects of intoxication, withdrawal and craving, gendered power relations and controlling behaviours were found.

Intoxication was found to exacerbate IPV within the context of anger, aggression and sexual jealousy and could be the tipping point into violence, although other contributory factors were involved. Whilst both partners blamed intoxication for the violence, men viewed their violence as a one-off incident in isolation while often blaming their partner in some way for their violence. Women however were more likely to report IPV as part of a long-standing pattern of abusive and controlling behaviours.
Withdrawal, craving and ‘coming down’ from substances presented conflict situations due to the psychopharmacological impact of the drug making them irritable or frustrated. In addition, when the need for procuring funds to support dependent substance use became the focus, some men coerced their partners into sex work or other criminal activity, threatening them to provide money or using the family finances to support their habits. Exerting financial control over the women sometimes involved threats of and actual physical violence. In relationships where both partners used substances disputes around unequal shares of substances or procuring funds to support substances could spill over to physical violence or jealousy over sex working. Women who use substances are made particularly vulnerable by their substance dependence often keeping them in abusive relationships. Secretive substance use, whether due to relapse or otherwise was also an area for conflict where the woman was unaware of their partner’s use/relapse, sometimes intensifying a situation in which IPV could occur.

Recommendations:
• Perpetrator programmes need to address the multifaceted complex interplay between substance use and IPV.
• The findings should be used as robust and scientific evidence to help support the funding and commissioning of services within central Government and locally, which target both the substance use and IPV within substance use services.

Next steps:
• These findings have informed the development of the ADVANCE group intervention which is currently being tested among 108 male perpetrators in substance use treatment settings in England. Findings will be reported by the end of 2019.

Financial implications:
In England, the costs associated with alcohol and illicit drug use, are estimated at over £32 billion in terms of economic, social, health and crime.19 In England and Wales, domestic violence costs around £16 billion including costs of (largely public) services to those who experience domestic violence; the value of lost economic output; and the associated human and emotional costs.20 The estimated cost of social services supporting and caring for children where there has been domestic violence are £283 million.20 Investing in interventions which tackle the behaviours that result in such financial costs to society and the tax payer would help to reduce those costs potentially representing substantial savings.

Acknowledgements
ADVANCE https://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/advance.aspx is funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG-1214-20009). The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

About the National Institute for Health Research
The National Institute for Health Research (NIHR): improving the health and wealth of the nation through research. Established by the Department of Health and Social Care, the NIHR:

• funds high quality research to improve health
• trains and supports health researchers
• provides world-class research facilities
• works with the life sciences industry and charities to benefit all
• involves patients and the public at every step
• For further information, visit the NIHR website www.nihr.ac.uk

References
1 World Health Organization (2012) Understanding and Addressing Violence Against Women. Geneva: WHO.
2 Office for National Statistics (2016) Compendium Intimate personal violence and partner abuse. Results from the Crime Survey for England and Wales 2015.
3 Tirado-Muñoz, J., et al. (2018) Psychiatric comorbidity and intimate partner violence among women who inject drugs in Europe: a cross-sectional study. Arch Women Mental Health, 21:259–269.
4 Gilchrist, G., Blazquez, A., Torrens, M. (2012) Exploring the relationship between intimate partner violence, childhood abuse and psychiatric disorders among female drug users. Adv Dual Diagnosis, 5(2):46-58.
5 Gilchrist G, et al. (2015) Factors associated with physical or sexual intimate partner violence perpetration by men attending substance misuse treatment in Catalunya: A mixed methods study. Crim Behav Mental Health, 25(4): 239-257.
6 Smith, P.H., et al. (2012) Intimate partner violence and specific substance use disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Psych Addict Behav, 26:236–245.
7 Fleming, P.J., et al. (2015) Risk factors for men’s lifetime perpetration of physical violence against intimate partners: Results from the International Men and Gender Equality Survey (IMAGES) in eight countries. PLoS One, 10(3), E0118639.
8 Chermack, S.T., et al. (2008) Partner aggression among men and women in substance use disorder treatment: correlates of psychological and physical aggression and injury. Drug Alc Depend, 98:35–44.
9 Choenni, V., et al. (2017) Association Between Substance Use and the Perpetration of Family Violence in Industrialized Countries. A systematic review. Trauma Viol Abuse, 18(1):37-50.
10 Cafferky, B., et al. (2018) Substance use and intimate partner violence: A meta-analytic review. Psych Viol, 8(1):110-131.
11 Leonard, K.E., Quigley, B.M. (2017) Thirty years of research show alcohol to be a cause of intimate partner violence: future research needs to identify who to treat and how to treat them. Drug Alcohol Rev, 36:7–9.
12 Graham, K., et al. (2011) Alcohol may not cause partner violence but it seems to make it worse: a cross national comparison of the relationship between alcohol and severity of partner violence. J Interpers Viol, 26(8):1503-1523.
13 Gilchrist, G., et al. (2017) The prevalence and factors associated with ever perpetrating intimate partner violence by men receiving substance use treatment in Brazil and England: a cross-cultural comparison. Drug Alcohol Rev, 31(1):34-51.
14 Hughes, L., Fitzgerald, C., Radcliffe, P., Gilchrist, G. (2015) A framework for working effectively and safely with men who perpetrate intimate partner violence in substance use treatment settings. London: King’s College
15 Stephens-Lewis, D., et al. Interventions to Reduce Intimate Partner Violence Perpetration by Men who use Substances: A Systematic Review and Meta-Analysis of Efficacy. Trauma Viol Abuse (under review)
16 Gilchrist, G., et al. (2019) The interplay between substance use and intimate partner violence perpetration: A meta-ethnography. Int J Drug Policy, 65:8-23.
17 Gadd, D., et al. The Dynamics of Intimate Partner Violence Perpetrated by Substance Using Men. Br J Crim (under review)
18 Radcliffe, P., et al. How do men and women explain Intimate Partner Violence and what is the role of substance use in this? (in preparation)
19 Public Health England (2018) Alcohol and drug prevention, treatment and recovery: Why invest?
20 Walby, S. (2009) The Cost of Domestic Violence: An Update, 2009. Lancaster University, Lancaster.

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