Danielle Stephens-Lewis

Background: Despite the higher prevalence of intimate partner violence perpetration by men who misuse substances, the role of substance use in intimate partner violence is unclear. Evidence about what works to reduce intimate partner violence by men who misuse substances is lacking. Objectives: To (1) understand the role of substance use in intimate partner violence perpetration, (2) develop a perpetrator intervention for men in substance use treatment and (3) test the feasibility and (4) effectiveness of delivering the intervention to men receiving substance use treatment. Design: Objective 1: mixed-methods intervention development, including a qualitative meta-ethnography, narrative interviews with 14 men and their female (ex)-partners and a systematic review and meta-analysis of 9 perpetrator intervention trials. Objective 2: the ADVANCE 16-week group perpetrator intervention delivered in person, was developed and adapted for digitally supported remote delivery (ADVANCE-D) during the pandemic. Objective 3: a multicentre feasibility randomised controlled trial of ADVANCE plus substance use treatment as usual compared to treatment as usual only and a multicentre non-randomised controlled feasibility study of ADVANCE-D were conducted. Objective 4: a multicentre effectiveness and cost-effectiveness randomised controlled trial of ADVANCE was planned. Setting and participants: Six community substance use treatment services in England (London, the West Midlands and the Southwest). Adult men receiving substance use treatment who had perpetrated intimate partner violence, their female (ex)-partners and staff delivering/supporting ADVANCE/ADVANCE-D delivery. Interventions: The ADVANCE comprises 2–4 individual sessions and 1- to 2-hour weekly groups. ADVANCE-D includes 1 individual session, 7 fortnightly video groups and 12 website sessions, each followed by a coaching call. Main outcome measures: The feasibility randomised controlled trial and non-randomised feasibility study measured eligibility, consent, recruitment, attendance (men) and follow-up rates and experiences of receiving or delivering ADVANCE/ADVANCE-D. These feasibility studies also assessed whether the following outcomes could be measured in a future effectiveness trial: intimate partner violence perpetration (men)/victimisation (women), substance use (men), self-management (men), and for men and women, mental health, health and social care service use, criminal justice contacts and quality of life. The primary outcome for the effectiveness trial was men’s self-reported intimate partner violence perpetration in the previous 4 months, 12 months post randomisation, using the Abusive Behaviour Inventory. Review methods: Systematic searches of databases identified qualitative studies for the meta-ethnography and (non)-randomised controlled trials for the systematic review. Meta-analyses were conducted where comparable data existed. Study inclusion and data extraction processes were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: The meta-ethnography and narrative interviews identified the complex interplay between substance use and intimate partner violence perpetration in the context of intoxication, withdrawal, acquiring drugs, impact on relationships and wider dynamics of power, control and psychological vulnerabilities. Little evidence emerged for effective interventions to reduce intimate partner violence for men who misuse substances. Meta-analysis showed that integrated substance use and intimate partner violence perpetrator interventions were non-superior to substance use treatment as usual in reducing intimate partner violence (combined mean difference 0.1, 95% confidence interval 0.37 to 0.57; p = 0.68). One hundred and four men were randomly allocated to receive ADVANCE + substance use treatment as usual ( n = 54) or treatment as usual only ( n = 50), and at 16 weeks post randomisation, 49% (51/104) were followed up. Of (ex)-partners, 26% (27/104) were recruited and 63% (17/27) were followed up. Median rate of intervention session attendance was 28.6% (lower quartile 0 – upper quartile 50). Self-reported intimate partner violence perpetration reduced at follow-up among men allocated to ADVANCE (estimated group difference on Revised Abusive Behaviour Inventory: −1.31, 95% confidence interval −4.06 to 1.43). Progression to a definitive trial was supported, but the trial was suspended due to COVID-19. ADVANCE was adapted for remote digitally supported delivery. Of men screened to participate in the non-randomised controlled feasibility study of ADVANCE-D, 46% (57/125) were eligible and deemed suitable to participate by staff. Forty-five men were recruited, 40 were offered ADVANCE-D and 25 (25/45; 55.6%) were followed up. Of sessions offered, 68% of core sessions, 44% of website practice sessions and 33% of coaching calls were attended/completed. Mean number of sessions attended was 11.4 (standard deviation 9.1). Twenty-one (ex)-partners were recruited, and 11 were (52.4%) followed up. Reductions in intimate partner violence perpetrated or experienced were reported by 8/11 men and 17/25 women, respectively; however, outcomes measured lacked statistical power to show a difference. Limitations: The COVID-19 restrictions precluded undertaking the randomised controlled trial. Conclusions: Delivering ADVANCE and ADVANCE-D to men in substance use treatment services was feasible, acceptable and safe. Promising findings were reported. Definitive trials are needed. Future work: Evaluation and implementation of ADVANCE and ADVANCE-D in other settings and populations will be considered. Trial registration: The trial is registered as ISRCRTN79435190 and ISRCTN66619273. The review was registered in PROSPERO as CRD42107056596. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-1214-20009) and is published in full in Programme Grants for Applied Research ; Vol. 13, No. 10. See the NIHR Funding and Awards website for further award information.

Factors affecting physical and psychological outcomes for those with chronic conditions are complex, extending beyond medical symptomology to numerous demographic influences. Living with hypermobile Ehlers-Danlos Syndrome (hEDS) is characterised by diagnostic delay and numerous comorbidities, known to impact wellbeing. This high-powered study (n = 415 participants) investigates the mediating effect of diagnosis, comorbidity and age on wellbeing, and provides insights into the effects of the latest hEDS reclassification. Validated measures were used to assess quality of life, perceived social support, physical health, fatigue, anxiety, pain and loneliness. Results indicated worse outcomes for those diagnosed after the reclassification and for those with higher numbers of comorbidities. Conversely, improved outcomes were associated with older age. Findings were supported by insights captured in participants' demographic profiles where a wider breadth of comorbidities were recorded than previously identified. Meanwhile, there was no evidence of a change in the route to diagnosis over time, and data showed ongoing limitations in terms of options for effective treatment. These findings point to the potential effectiveness of self-management techniques for improving well-being with chronic conditions and highlight the need for improved awareness of hEDS and its management amongst primary care practitioners.

Despite the high prevalence of intimate partner violence (IPV) perpetration by men who use substances, limited evidence exists about how best to reduce IPV among this group. A systematic narrative review with meta-analysis determined the effectiveness of interventions to reduce IPV by men who use substances. Inclusion criteria were randomized and nonrandomized controlled trials; adult heterosexual male IPV perpetrators where at least 60% of participants were alcohol and/or drug users; the intervention targeted IPV with or without targeting substance use (SU); outcomes included perpetrator and/or victim reports of IPV, SU, or both. Methodological quality was assessed. Nine trials (n = 1,014 men) were identified. Interventions were grouped into (1) integrated IPV and SU interventions (n = 5), (2) IPV interventions with adjunct SU interventions (n = 2), and (3) stand-alone IPV interventions (n = 2). Cognitive behavioral and motivational interviewing therapies were the most common approaches. Data from individual trials showed a reduction in SU outcomes in the short term (≤3months; n = 2 trials) and IPV perpetration at different time points (n = 3 trials) for interventions compared with treatment as usual (TAU). Meta-analysis with integrated IPV and SU interventions showed no difference in SU (n = 3 trials) or IPV outcomes (n = 4 trials) versus SU TAU. Little evidence exists for effective interventions for male IPV perpetrators who use substances. Outcomes in integrated interventions were not superior to TAU in meta-analysis. Future trials should consider the nature of the relationship between IPV and SU in intervention design, duration of intervention, and type and timing of outcome measures.

Few studies have examined intimate partner violence (IPV) in relationships where one or both partners are in treatment for substance use, from the perspectives of both members of a couple. This study used thematic and narrative analysis of the accounts of 14 men recruited from substance use services and 14 women who were their current or former intimate partners. Separate researchers interviewed men and women from the same dyad pair. The psychopharmacological effects of substance use (including intoxication, craving, and withdrawal) were rarely the only explanation offered for IPV. Violence was reported to be primed and entangled with sexual jealousy, with perceptions of female impropriety and with women’s opposition to male authority. Both partners reported adversities and psychological vulnerabilities that they considered relevant to conflict and abuse. Male participants were more likely to describe IPV as uncharacteristic isolated events that arose from specific disputes—either aggravated by intoxication or withdrawal or about substance use and its resourcing—whereas women described enduring patterns of abusive behavior often linked to intoxication, craving, withdrawal, and to disputes linked to raising funds for substances. In relationships where both partners used substances, men described the need to protect their partners from addiction and from unscrupulous others while women described highly controlling behavior. In relationships where women were not dependent substance users, they reported the combined effects of psychological and financial abuse often linked to recurring patterns of substance use and relapse. These findings highlight the challenges faced by practitioners working with male perpetrators who use substances as well as the need of those working with women who have been abused to engage with the ways in which hesitance to leave male abusers can be complicated by shared drug dependency.