Intimate partner violence (IPV) causes mortality and mental and physical health problems. Particularly affected are women, who experience IPV as victims more commonly than men, and children, whose development and wellbeing can be negatively impacted by growing up in a home where IPV is occurring (Milligan, 2022; Oram et al., 2022).
Interventions to support the wellbeing of women and children exposed to IPV can reduce the mental health impact of IPV, but interventions are also needed to support the perpetrator (which is the word I will use to describe the person causing the harmful behaviour we refer to as IPV) to reduce their abusive behaviour.
In some areas, especially in high income settings, perpetrators of IPV can be referred to behavioural interventions. These are sometimes referred to as “perpetrator programmes”; in forensic and occasionally general psychiatry settings, we often work with patients who have previously gone through a behaviour change programme, such as Building Better Relationships (Teasdale, Sorbie & Elliott, 2023). However, more evidence is needed on how to improve the effectiveness and reach of these interventions.
One route to improving evidence could be to consider the role of mental ill health and substance use problems in causing and maintaining IPV perpetration behaviours. We have recently found that IPV perpetrators in England are more commonly using health services for mental illness compared to the general population, and there is a strong relationship between alcohol and substance use and IPV perpetration (Bhavsar et al., 2023; Sri, 2020). Given the high prevalence of mental health problems (not just formal diagnoses) among perpetrators of IPV, it is possible that interventions which are developed specifically for IPV perpetrators with mental health and substance use problems could be beneficial.
This recent systematic review, by Sousa and colleagues (2024), reviewed the literature on interventions for IPV perpetrators, focusing on perpetrators with substance use and mental health problems.
It is important to identify and support victims of intimate partner violence, but what do we know about interventions designed for perpetrators?
Methods
The authors included peer-reviewed studies which tested interventions for male and female perpetrators of IPV with mental health or substance use disorders, in English, Spanish, or Portuguese. They used broad search terms to capture IPV perpetrators, substance use and mental ill health and didn’t search for specific search terms e.g. for specific drugs of abuse or specific psychiatric disorders, such as ‘personality disorders’. They also searched reference lists of several key reviews which had already been published.
They extracted information on the study from each paper and evaluated it’s quality using an existing tool, the mixed methods appraisal tool (MMAT) (Hong et al., 2018).
Results
A total of 23 articles were included in the review. Among these, 14 were randomised controlled trials. Just 7 of the studies scored either 4 or 5 out of 5 in terms of quality criteria. Studies were published between 2015 and 2021, with the majority (n=15) conducted in the United States. Studies investigated between 23 and 303 perpetrators of IPV who were predominantly male and between the ages of 30 and 44 years.
The 23 included papers examined 13 separate interventions. Seven were based on cognitive behavioural therapy (CBT) alone, three combined CBT with motivational interviewing, and the remaining interventions employed motivational interviewing alone, behavioural therapy, or a combination of motivational, cognitive and dialectical behavioural therapy. Interventions were implemented in groups only, individual sessions only, or in a mixture of group and individual sessions.
Around half of included papers examined participants who were referred by a court, and the other half participants who were already receiving treatment (i.e. non-IPV perpetrator specific treatment for mental health or substance use problems). Most interventions were delivered in community settings rather than in inpatient or in prison settings.
Interventions integrating intimate partner violence and substance use
The reviewers divided IPV and substance use interventions into specific and non-specific interventions. One specific intervention developed in the US jointly aimed at IPV and substance use was evaluated by three studies with different comparators. They found no impact (in comparisons) on attendance or frequency of violence at follow up. However, this intervention performed better than the twelve steps programme on number of days abstinent from alcohol, and violent behaviour, though the differences were not sustained at follow-up.
Three other specific interventions, evaluated in two studies each, were aimed primarily at addressing substance use, with IPV perpetration as a secondary outcome. These programmes produced significant reductions in recidivism of IPV, however impact on violence was not statistically significant.
Four specific interventions which were aimed at substance use primarily were evaluated by one study each. The findings of these studies were mixed, with some significant findings. For example, a behaviour change programme for men using alcohol and perpetrating IPV found reduced IPV severity in the intervention group.
The review identified four studies examining a non-specific behavioural intervention for IPV perpetrators with alcohol problems in Spain, finding a reduction in alcohol consumption, recidivism, depressive symptoms, sexist attitudes, and improvement of social integration. There was evidence that the programme increased cognitive flexibility.
Interventions integrating intimate partner violence and mental health
Two studies examined interventions for mental health problems and IPV perpetration. A 2021 study found that both CBT and mindful stress reduction reduced symptoms in both groups of IPV perpetrators. A 2009 study of IPV perpetrators found that mental health treatment had limited impact on re-assault, or on participation/completion of IPV behaviour change programmes.
Thirteen interventions for intimate partner violence perpetrators were examined in this review, most combining CBT and motivational interview techniques.
Conclusions
The review identified 23 papers reporting 13 eligible interventions primarily developed in the US. Included studies demonstrated reductions in alcohol and drug use, violent behaviour, and the occurrence of IPV recidivism. However, the quality of the included studies overall was moderate.
The authors conclude the blending of motivational techniques with CBT might be beneficial, however this is slightly speculative, because the evidence overall was weak.
This review of interventions to help perpetrators of violence, suggests that blending CBT with motivational techniques might be beneficial, however this is slightly speculative, because the evidence overall was weak.
Strengths and limitations
This is a useful review on an important area of mental health practice, given that we need interventions for perpetrators of IPV with mental ill health. The small number of interventions and limited evidence of effectiveness are unsurprising, and reduce the confidence in the findings. The search terms were broad, and didn’t for example include specific diagnostic categories such as ‘personality disorder’, which is a common diagnosis among IPV perpetrators (Tunmore, 2021; Yu et al., 2019).
I think some important areas/challenges for the evidence base were left out, e.g.
- How are victim/survivors supported while perpetrators are receiving interventions for mental health / substance misuse?
- To what extent are interventions developed in collaboration with perpetrators of IPV or with victim/survivors?
- How are interventions tailored to social/demographic characteristics (e.g. ethnic/cultural diversity, socioeconomic status) of perpetrators?
To what extent are interventions developed in collaboration with intimate partner violence victims / survivors?
Implications for practice
IPV is highly prevalent, reported by 1 in 3 women and 1 in 4 men worldwide (Garcia-Moreno et al., 2006). Effective prevention programmes aimed at reducing the incidence of IPV perpetration (stopping people becoming perpetrators) are likely to be more relevant than treatment programmes for the much smaller number of perpetrators who reach interventions via criminal justice/the courts. But the scale and reach of IPV perpetrator intervention programmes is a problem for this field, because to get onto programmes, usually perpetrators need to have gone through the courts system and we know that the majority of perpetrators of IPV do not reach the attention of authorities (Hester et al., 2020). There is also regional variation in the availability of perpetrator programmes.
The acceptability and impact of behaviour change programmes might be improved by incorporating a stronger focus on mental health. Arguably, given the widespread distribution of mental ill health e.g. in men perpetrating IPV who are in contact with the criminal justice system, all perpetrator interventions received by this group should be designed with mental health in mind.
This review shows that evidence to support IPV programmes tailored to mental illness and substance use is limited. More interventions should be developed and evaluated for this group to strengthen the evidence base. Helpful knowledge in this area could support the training of health professionals in providing brief interventions.
We need both high quality accessible interventions and effective prevention. Indeed, fathers perpetrating IPV receiving perpetrator interventions are likely to reduce the exposure of children to IPV, including boys who are more likely to perpetrate IPV in adulthood if they are exposed during childhood. Developing interventions for delivery in secure/inpatient settings might be of benefit for the literature. Much more intervention knowledge is needed on women perpetrators of IPV, who we know experience higher rates of IPV and other victimisation compared to men, and might need tailored support on this basis.
To reduce intimate partner violence (IPV) we need a combination of high-quality interventions as well as effective prevention strategies, which aim to IPV perpetration before it starts.
Statement of interests
I am a psychiatrist working in forensic psychiatry and parental mental health. I am also currently funded by NIHR to carry out research on perpetrators of domestic abuse, including perpetrators of IPV.
Links
Primary paper
Sousa M, Andrade J, de Castro Rodrigues A, Caridade S, Cunha O. (2024) The effectiveness of intervention programs for perpetrators of intimate partner violence with substance abuse and/or mental disorders: a systematic review. Trauma, Violence, & Abuse. 2024:15248380241270063.
Other references
Bhavsar V, McManus S, Saunders K, Howard LMJBo. Intimate partner violence perpetration and mental health service use in England: analysis of nationally representative survey data. 2023;9(3):e64.
Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH, Health WHOM-cSoWs, et al. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet. 2006;368(9543):1260-9.
Hester M, Feder G, Westmarland N, Burrell S, Gilchrist G, Gadd D, et al. A Domestic Abuse Perpetrator Strategy for England And Wales. DRIVE project; 2020.
Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for information. 2018;34(4):285-91.
Milligan, R. The Lancet Psychiatry Commission on Intimate Partner Violence and Mental Health #IPVmentalhealth. The Mental Elf, July 2022.
Oram S, Fisher HL, Minnis H, Seedat S, Walby S, Hegarty K, et al. The Lancet Psychiatry Commission on intimate partner violence and mental health: advancing mental health services, research, and policy. The Lancet Psychiatry. 2022;9(6):487-524.
Sri, A. Mental disorders and intimate partner violence perpetrated by men towards women. The Mental Elf, March 2020.
Teasdale J, Sorbie A, Elliott I. Evaluating the Building Better Relationships (BBR) Programme: Feasibility Study for an Impact Evaluation of Proven Reoffending. Ministry of Justice Analytical Series. 2023.
Tunmore, J. Borderline personality disorder and intimate partner violence. The Mental Elf, March 2021.
Yu R, Nevado-Holgado AJ, Molero Y, D’Onofrio BM, Larsson H, Howard LM, et al. Mental disorders and intimate partner violence perpetrated by men towards women: A Swedish population-based longitudinal study. PLOS Medicine. 2019;16(12):e1002995.
