Each of the steps of intervention development is described below.
3.1.1 Step 1: Define the problem
There is a lack of targeted effective interventions to reduce or stop IPA among male perpetrators receiving treatment for substance use. Perpetrator interventions do not address the complex role that substance use plays in IPA perpetration. The target population was men attending community services for drug and/or alcohol use in England.
Stephens-Lewis et al. (2019) conducted a systematic review and meta-analysis of the effectiveness of perpetrator programmes for men who use substances. The review identified few trials (n=9) and, of these, the five trials of integrated IPA and substance use programmes. The meta-analysis within this review, showed no difference in substance use (three trials) or IPA outcomes (four trials) compared to substance use treatment as usual. However, the small number of studies along with the heterogeneity of these mean that it is premature to conclude that integrated interventions do not work. these trials results do prompt further questions though including: (1) the theory, content, mode of delivery, and duration and intensity of interventions; (2) the characteristics of the individuals requiring treatment, including the types of substances used, the type of abuse perpetrated, and the nature of the relationship between substance use and IPA perpetration; and (3) what outcomes are assessed, where information is sourced, and the duration of follow-up.
Gilchrist et al. (2019) conducted a meta-ethnography of qualitative studies to explore how substance use features in survivors’ and perpetrators’ accounts of IPA. The themes identified related to the complex interplay between substance use and IPA in the context of intoxication, withdrawal and addiction, the impact on relationships, wider dynamics of power and control, and psychological vulnerabilities. Survivors were more likely to see substance-related IPA as part of a pattern of abusive behaviour, whereas perpetrators tended to describe a causal relationship between intoxication and discrete incidents of IPA perpetration. Irritability and frustration during withdrawal from or craving alcohol, heroin and stimulants, and/or a partner’s refusal or failure to obtain money for substances increased the likelihood of violence. Survivors were more likely to identify abuse being related to substance use, and to focus on how substances impacted their relationship and dynamics of power and control. The conclusion was that behaviour change interventions must address the meanings behind divergent narratives about IPA perpetration and substance use.
Building on this, interviews were conducted with intimate partner (current and/or ex) dyads, where men were receiving treatment for substance use and who reported IPA perpetration (Gadd et al., 2019; Radcliffe & Gilchrist, 2016). They concluded that withdrawal and substance acquisition are key contexts in which controlling behaviours proliferate, conflicts escalate, and seemingly erratic behaviours are commonplace, sometimes anticipating the perpetration of potentially lethal acts of IPA. More specifically, substances can be independently implicated in the perpetration of coercive control, in that perpetrators may control their partners by increasing their substance dependency and restricting access to substances. This may continue to entrap women within an abusive relationship. Hence, there is a complex relationship between substance use and IPA, with an interplay between intoxication, acquiring substances, craving, withdrawal, gender power relations, and control, all of which should be considered when designing perpetrator programmes.
To summarise, the research resulted in several factors and inferences. There is limited evidence of effective interventions targeting substance using men who perpetrate IPA. There is also a need to recognise a number of factors that correlate with substance use and IPA (such as negative childhood experiences and poor mental health, suggesting a trauma-informed approach might be beneficial). There is a need for tailored interventions that address the complex ways that substance use and IPA perpetration intersect in relation to social, psychological, and environmental factors. While power and control are implicit in understanding IPA perpetration, interventions for those men within substance use treatment should also address key risk areas, including intoxication, anger, trauma, grief and dependency (Gadd et al., 2019) and the presence of mental health issues such as anxiety and depression (Leonard & Quigley, 2017). Interventions need to focus on individuals' specificities. an approach that seeks to personalise goals may facilitate application for individuals. Although some trials report short-term improvement in outcomes, this is not replicated when follow up assessment of ongoing change are undertaken. As such, there is a need to consider mechanism to maintain treatment gains. While motivational interviewing and cognitive behavioural therapy seem promising, recent research identifies gender and control as important variables. Approaches should be blended to address the range of needs and engage participants. Interventions need to address the intricate interdependencies within substance using relationships and include not only intoxication but also craving, withdrawal, acquisition and the substance using lifestyle, the gendered power dynamics underpinning substance use and IPA, and individual need.
3.1.2 Step 2: Select the target behaviour
Many factors are associated with the perpetration of IPA (Fulu et al., 2013) with consensus that there is no single factor that explains why some men may perpetrate IPA and not others. These factors impact at individual, community, and systemic levels (Smith Slep et al., 2014). Table 1 provides a summary.
Substance use alone, however, cannot explain all IPA and it is clear that some perpetrators will perpetrate with or without substance use (Fernández-Montalvo et al., 2012). One helpful approach in understanding this heterogeneity comes from the multiple thresholds model (Gilchrist et al., 2014). This model suggests that while for some substance use has no bearing on the occurrence of IPA, for others IPA will only occur in the presence of substance use. It goes on to suggest a further group where substance use may affect the type of behaviour, and nature of risk including the level of violence and severity of injury and imminence, including predicting when abuse would occur, but that it is not the sole causal factor. A multiple thresholds model suggests that abuse occurs when the instigation to abuse outweigh the inhibition from abuse, and posits that drugs or alcohol could affect both (Leonard & Quigley, 2017).
A review of cognitions associated with IPA, indicated that this group is characterised by skewed thinking, with a number of studies highlighting the prevalence of offence supportive beliefs in IPA offenders (Gilchrist, 2009). The types of implicit theories found in IPA populations include: general violence supportive beliefs, a sense of entitlement to control women, jealousy, a need to police womens’ sexuality, a right to have one’s needs met, that violence is normal and necessary, and that women are untrustworthy or in need of monitoring (Weldon & Gilchrist, 2012). These beliefs militate against the formation and maintenance of respectful, egalitarian relationships.
Many studies have identified that men who perpetrate abuse have poor emotional regulation, poor stress-coping, avoidant coping, and poor conflict resolution (Hardesty & Ogolsky, 2020). The primary research undertaken within this programme of work indicated an inability in the men interviewed to deal effectively with raised emotions, set and achieve clear positive goals in relation to personal, relationship and domestic issues (e.g., enacting a healthy lifestyle, maintaining positive familial relationships, managing finances, employment and housing) or to manage stressors or conflict without recourse to substances. Stabilising mood and emotions are likely to reduce the likelihood of aggression and violence and improve relationship satisfaction which is protective against IPA (Halmos et al., 2018).
Our research identified a lack of understanding by perpetrators of the range of ways that substance use could impact on their behaviour, and a reluctance to acknowledge the impact of their poor behaviour on others. Our research also identified that there was a simplistic understanding of the impact of substances on them, often linked to simple intoxication and discussion of pharmacological effects rather than an acknowledgement of the impact of lifestyle, withdrawal, need or intoxication and beliefs around the right to control partners (Gadd et al., 2019; Radcliffe & Gilchrist, 2016). Therefore, reducing, or quitting substance use is important, but in pursuit of this conveying a nuanced understanding of the complex role of substance use on IPA is vital. Participants in the intervention require a fuller understanding of the rationale for changing substance use and the positive impact on their relationship of doing so, consequently their motivation to change will be enhanced. Positive impacts on other aspects of life are likely from reducing substance use, including improved physical and mental health, financial benefits, and fewer life crises.
In summary, ADVANCE targets the following three areas for men in substance use treatment who perpetrate IPA: 1) promote respectful egalitarian behaviours, 2) promote alternatives to violent and aggressive behaviour, 3) reduce substance use.
3.1.3 Step 3: Specify the target behaviour
In specifying the target behaviour, the BCW guidebook recommends consideration of who, what, when, where, and with whom. We would add ‘why’ as also being necessary as by understanding the function of the behaviour it becomes easier to understand how to change it. The target behaviour therefore would be for male substance users who have perpetrated IPA (who), to cease IPA (what), at all times (when), in all relationship settings, (where) against intimate partners (whom) in the context of substance use (why). Subsequently the three main target areas to address all issues were identified as being:
(1) Promote respectful egalitarian behaviours
- Identify the function of abusive behaviours within relationships
- Identify alternative goals and methods of achieving them for each man
- Focus on control of self, not control of others
(2) Promote alternatives to violent and aggressive behaviour
- Increase distress tolerance: in crisis and generally
- Increase recognition of negative mood and internal triggers
- Promote emotional self-regulation
(3) Reducing substance use
- Increase awareness of personal function of substance use
- Increase awareness of the relationship between substance use and IPA
- Plan to avoid IPA risk related to substance: acquisition, intoxication, withdrawal
3.1.4 Step 4: Identify what needs to change
In the COM-B model, behaviour change depends upon capability (physical and/or psychological), opportunity (environmental and/or social), and motivation (reflective and/or automatic). The ADVANCE intervention is based upon enhancing reflective motivation, by identifying the functions of aggression, violence, and control in relationships, challenging sexist and patriarchal beliefs and attitudes, and understanding the complex role of substance use in IPA perpetration. The purpose is to elucidate the need for change. While motivation is addressed through the intervention, other components increase participants’ capabilities, first by recognising areas that need to change and second by introducing skills for change. ADVANCE aims to identify the risks for IPA, including substance use, poor emotion regulation and poor stress-coping, and teach people how to reduce risks through promoting self-regulation, and goal setting.
Self-regulation refers to an individual's ability to alter a response or override a thought, feeling, or impulse (Baumeister, 2014; Baumeister et al., 1998; Baumeister & Heatherton, 1996). Self-regulation has demonstrated promise in promoting abstinence from the hazardous use of substances (Muraven et al., 2005). In terms of IPA, a lack of self-regulation has been indicative of perpetration (Finkel et al., 2009). Also, the ability to inhibit an impulse towards abusive behaviour in the context of intimate partner abuse is affected by substances, as highlighted in the multiple thresholds model. This model posits that substances changes the balance between ‘instigating and inhibiting’ factors. People affected by substances focus more on cues that instigate abuse and are less able to inhibit abuse (Leonard & Quigley, 2017). Strengthening the ability to read environmental cues accurately, avoid misreading natural cues as aggressive and managing the impulse to abuse, even when affected by substances, is indicated.
Personal goal planning using SMART goal setting (i.e., specific, measurable, achievable, relevant, and time-limited) (Locke & Latham, 2002) is used in the ADVANCE model to enhance task completion by making all goals personal, explicit and specific. These goals address reduction in substance use as well as building positive relationships and healthy lifestyles. Personal goals that are SMART, along with self-regulation enhance engagement and self-efficacy.
3.1.5 Step 5: Identify intervention functions
Derived from the analysis of risk factors (Table 1) and potential intervention targets, Table 2 outlines the intervention functions for men in substance use treatment who perpetrate IPA. The nine interventions functions are described here as being : education (knowledge), persuasion (increasing desire), incentivisation (rewarding), coercion (increasing potential negative consequences), training (skills), restriction (rules/laws to prohibit undesired behaviour or promote desired behaviour), environmental restructuring (physical changes to facilitate desired behaviour), modelling (demonstrating), and enablement (removing barriers to facilitate positive behaviours).
The APEASE criteria of Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side effects/safety and Equity considerations (Michie et al., 2014) were used in making context-based decisions on the content of interventions. Thus, we selected the intervention functions that were possible to implement, linked with the evidence from previous empirical studies, and linked with clinical knowledge about what has been found to be effective with IPA and SU populations.
From our research, education in IPA, substance use and the interaction between these criteria and studies was key. Training and modelling would provide alternative strategies to interpret environmental cues, whilst enhancing self-regulation and distress tolerance and reducing the need for control within intimate relationships. Incentivisation, through offering a £5 voucher for every session attendance. Men would accumulate these vouchers over the duration of the intervention for use in a pro social activity they chose (such as cinema tickets or restaurant vouchers). Vouchers are provided at session 6 and session 12. Persuasion to attend were identified as being helpful in promoting reflexive and automatic motivation (Lussier et al., 2006). Enablement was envisaged as being delivered at a more structural level in terms of setting the intervention within a multi-disciplinary framework to work with the perpetrator to manage risk and to remove barriers to help seeking and promoting safety management for partners of the perpetrating men.
Based on the ‘what works’ body of knowledge from forensic psychology, the intervention was delivered in line with best practice for enhancing motivation and responsivity, and was culturally competent, used active learning methods, visual and auditory materials. The intervention was manualised to maximise the integrity of the intervention. In line with the best practice guidelines of RESPECT, the UK domestic violence organisation, it was designed as a groupwork intervention to facilitate peer challenge and maximise positive learning based on the zone of proximal learning; and reflecting the goal of enablement.
3.1.6 Step 6: Identify policy categories
Whilst the ADVANCE intervention focused mostly at the individual change level, it was delivered alongside proactive support, case management and information sharing to manage risk and promote safety with partners and ex-partners of men in the group and was fully embedded within the justice, social services and child protection systems structures to allow risk management and referral. This inclusion fits with best practice models for IPA intervention developed from Duluth onwards and supported by RESPECT, and is in line with UK government policies, and reflects the outer ring of the BCW of using legislation, regulation, service provision and guidelines to promote desired goals.
3.1.7 Step 7: Select behaviour change techniques
Table 2 shows the specific behaviour change techniques (BCTs) linked to our formulation of the key elements underpinning change. BCTs are mapped to address each intervention function. Much of the theoretical thinking is based on in-depth interviews with 47 men receiving treatment for substance use who had a history of IPA perpetration (Gadd et al., 2019; Radcliffe & Gilchrist, 2016). Michie et al. (2008) developed a taxonomy of 93 distinct BCTs that are catalogued and described in detail. Providing a comprehensive resource for intervention development, the authors identified those BCTs considered as most applicable and encouraging in promoting behaviour change in men in substance use treatment who perpetrate IPA. In summary, for ADVANCE, we aimed to improve capability by the strategies described in Figure 2.
3.1.8 Step 8: Modes of delivery
Applying best practice from the ‘what works’ literature and RESPECT, the intervention was primarily face-to-face structured group work. Prior to group work, individual sessions assessed the client’s IPA, substance use, and motivation to change. Within groups, a range of modes was used: illustrative handouts of basic concepts, individual worksheets, exercises conducted in pairs and small groups, role plays, between-session assignments, groups discussion, presentations and skills practice. A major innovation was the inclusion of video scenarios which were enactments of interactions derived from an amalgamation of individual stories within the dyad research (Radcliffe & Gilchrist, 2016) used as a focus for group discussion.
3.1.9 ADVANCE model
The ADVANCE intervention consisted of up to four pre-group individual sessions to assess and motivate participants, followed by 12 x 2-hour group sessions (see Table 3). The intervention was delivered by substance use service workers trained in its delivery. Key workers contacted participants by telephone between sessions to deal with problems and motivate individuals to attend the next session. Integrated Support Services (ISS) workers provided support to participants’ current/ex partner’s at least three times across the intervention period on their current/ex-partner’s attendance and progression, with the consent of the participants. ISS workers attended case management meetings with the group facilitators and substance use workers (approximately five times across the duration of the research) to ensure good communication and to manage any risk.