Contexts for the disclosure/identification of domestic abuse perpetration

People perpetrating domestic abuse may not necessarily initiate self-disclosure, but may nevertheless display indicators of their abusive behaviour. Health professionals should understand that domestic abuse includes coercive and controlling behaviours used to control victims/survivors (Crown Prosecution Service 2023). Coercive and controlling behaviours are common and can happen alongside other types of abuse, including physical, sexual and economic abuse. Therefore, it is necessary to apply professional curiosity and sensitivity when asking about current and past relationships, including as part of enquiring about and assessing risk of violence to others. Statements made by individuals about having ‘a temper’ or about ‘problems at home’, ‘volatile’ relationships, jealousy or possessiveness should be assessed in depth. Perpetrators of domestic abuse may harbour a strong sense of grievance, for example referring to themselves as victims/survivors of intimate partner or family abuse, or describing instances where they themselves experienced harm. Responding from a neutral, non-judgemental stance by asking open-ended questions to explore the impacts and how they are managing the situation can avoid colluding with the perpetrator of domestic abuse. Professionals should acknowledge patients’ experiences of personal trauma, including those patients who may be perpetrating harm against others (Oram Reference Oram, Fisher and Minnis2022).

Example scenarios: how perpetrators might present to mental health services

In Table 2 we present an overview of clinical settings and circumstances where perpetrators of domestic abuse may present as patients. Clinicians should recognise that perpetrators of domestic abuse may also present to mental health services when accompanying a victim/survivor to an appointment. In this situation, the perpetrator may make efforts to prevent the victim/survivor being seen by the clinician on their own. Clinicians should also be wary of claims by people that their partners are mentally ill/symptomatic, which are sometimes made to deflect attention from a perpetrator's responsibility for abuse.

TABLE 2

How perpetrators of domestic abuse may present to mental health services^a

CAMHS, child and adolescent mental health services; NHS, National Health Service.

a In all assessments ask about children or contact with children. Document names and dates of birth of children. Follow child safeguarding protocols if any risk identified.

Why should mental health professionals enquire about perpetration of domestic abuse?

Mental health professionals have professional obligations to protect the public, including family members of patients. Effective risk assessment and management is a critical part of good clinical care. Making appropriate enquiries about a patient's use of harmful behaviour is an important part of assessing the context for a patient's presenting complaint (e.g. paranoid thoughts that their partner is having an affair, relationship distress and suicidal ideation), including where there are safeguarding concerns that the patient themselves is vulnerable. Children are considered victims/survivors of domestic abuse where they see, hear or are otherwise affected by domestic abuse among adults (Home Office 2022). Therefore, patients presenting with parenting-related distress should also be asked about relationship safety (both experiences and perpetration of domestic abuse, and the nature of relationships with children), and full information should be collected on children within the family, in consultation with safeguarding teams and domestic abuse teams in the trust/health board, and in line with taking a ‘whole family’ approach in clinical and risk interventions in mental health services (Woodman Reference Woodman, Simon and Hauari2020).

Indicators that might highlight domestic abuse perpetration

Mental health clinicians should always ask specific questions about domestic abuse (Howard Reference Howard2017) and should be ready to explore the history more carefully, particularly if any of the following indicators are present. Some of these reflect harmful behaviour and others do not; and some are closely related to, or overlap with, indicators of elevated risk of harm in perpetrators of domestic abuse shown in Box 1.

How to ask

There are many ways to explore what is happening in a patient's relationships in a neutral, curious and sensitive manner, in order to establish whether the patient is or may be perpetrating domestic abuse. Professionals should be alert to signs within the normal flow of a clinical encounter that should trigger further exploration, including signs of using coercive or controlling behaviour. A curious professional might explore current relationships in more detail if a patient reports that they are ‘struggling with managing anger’, for example when asked what happens when they argue with a partner/ex-partner/family member. Professionals may support someone to disclose by showing an understanding of the recognised consequences of a behaviour, for example by saying that sometimes when people are experiencing angry feelings, they may take this anger out on others around them.

Inquiry about perpetration of domestic abuse should be undertaken with victim/survivor safety as the core focus. This includes asking about harmful behaviour when the clinician is on their own with the patient, and after consideration of whether the environment is sufficiently private and safe for both the clinician and the patient to allow disclosure. Reminders should be given about duties to keep clinical information confidential, alongside duties to protect the patient, their family and the public. It can be helpful to present a rationale for asking these questions, which some patients may not consider to be directly relevant to their mental health.

Some individuals perpetrating domestic abuse will not disclose this despite direct and careful enquiry. It is possible that, through more frequent contact and developing a therapeutic relationship and rapport, disclosure of abusive behaviour might be made after more than one enquiry. Therefore, it is important to consider asking questions about perpetration of domestic abuse at regular intervals, where concerns/relevant indicators (as outlined elsewhere in this article) are present. It is also important to collect corroborative history from family members and partners.

What to ask

Asking questions about a patient's use of harmful behaviour should be (where possible) collaborative, non-judgemental and focused on change. Examples could be:

• • How are things in your relationships with your partner/family members?

• • How do you deal with not getting on with your partner/family members?

• • What happens when you argue?

• • Has anything changed to make your relationship(s) more difficult?

• • Do you ever feel worried about how you sometimes behave?

• • Do arguments ever become physical, such as through pushing or hitting your partner/family member? What is the worst that has ever happened?

• • How is this drinking/stress at work/depression affecting how you are with your family?

• • When you feel like that, what do you do?

Identifying non-physical types of harmful behaviour such as coercive or controlling behaviour is important and needs specific questioning. Examples might be:

• • Are you finding that you need to check on your partner (for example where they are, who they are with, what they are doing)?

• • Do you ever check their mobile phone/tablet/laptop?

• • Do you ever follow them when they go out (for example to check that they are OK)?

• • Do you ever stop them from leaving the house when they say they want to?

• • Have you ever stopped them from seeing friends or family?

• • Have you ever stopped them from going to work or doing what they want to do because of how it makes you feel?

• • Have you ever threatened to hurt yourself to stop them from doing something you didn't want them to do?

• • Have you ever threatened them to stop them doing something you do not want them to do?

• • Have you ever taken control of your partner's money, or stopped them spending money on things that they wanted?

Immediate considerations

Acting to reduce risk of serious harm to the victim/survivor should be the most important immediate consideration when perpetration of domestic abuse is identified or disclosed by a patient. Sharing information about a disclosure of domestic abuse perpetration with, for example, other family members, can increase risks. Where there is a disclosure of domestic abuse perpetration towards a specific person, it is important also to consider risk to other personally connected individuals, such as family members.

Assessing risks in patients who are perpetrating domestic abuse

It is important to consider the level of risk of harm to the victim/survivor posed by a patient who is perpetrating domestic abuse. If there is immediate danger, practitioners should seek advice from safeguarding leads to explore whether to contact emergency services, updating the victim/survivor if possible/safe. Professionals who have identified that a patient is perpetrating domestic abuse should carry out and document a risk assessment in line with local policies and procedures if they feel confident to do so – that is, covering all relevant domains of risk (including risk to self; see below) (Royal College of Psychiatrists 2016).

Specific structured professional judgement tools such as the Domestic Abuse, Stalking and Harassment and Honour Based Violence Risk Identification, Assessment and Management Model (DASH), the Spousal Assault Risk Assessment (SARA), the Ontario Domestic Assault Risk Assessment (ODARA) or the Brief Spousal Assault Form for the Evaluation of Risk (B-SAFER) may be helpful to ensure that all relevant factors are addressed in the risk assessment, but they should be completed in collaboration with forensic and safeguarding staff with specific training in using these tools (Fazel Reference Fazel and Wolf2018). Professionals should be able to access training in the risk assessment for domestic abuse perpetration and other forms of violent behaviour, to inform collaborative risk assessment within the multidisciplinary team (MDT). Factors identified in these tools that indicate greater risk of harm, including homicide, are described in Box 1.

Children should be considered victims/survivors of domestic abuse, regardless of whether they are present during abusive incidents. This is the case even if the victim/survivor does not recognise it. There are complex relationships between domestic abuse and violence towards children, with some evidence that perpetrators of domestic abuse may also perpetrate harm towards children. The harmful impact on children of being exposed to/witnessing/being aware of the domestic abuse is also well recognised. Therefore, risks towards children (specifically) posed by the perpetrator of domestic abuse should be assessed, including by asking the victim/survivor when they are on their own (and not in front of the perpetrator) if they are concerned about risks to children, and obtaining a full list of children in contact with the perpetrator. Family members or partners may be reluctant to disclose harm to children – there may be fear of social services action or of increased risk of abuse from the perpetrator if disclosures are made.

Refractory symptoms of mental illness such as delusions and hopelessness may be relevant to evaluating risk of future violence in perpetrators of domestic abuse. Ongoing misuse of alcohol and street drugs is related to greater risks. In addition to risk of harm to themselves, suicidal ideation and attempts at suicide by a perpetrator of domestic abuse indicate increased risk of perpetrating serious physical violence/homicide (Flynn Reference Flynn, Gask and Appleby2016).

Sharing information within the safeguarding team/health provider/trust

It is important to recognise that many cases of domestic abuse perpetration present substantial uncertainties and risks while not meeting criteria for onward referral and may present a clinical and risk management need that is not currently being met. Professionals should make contemporaneous records of clinical encounters and assessments in line with good medical practice, recording all information that is relevant to clinical care. Therefore, professionals should record suspicions of domestic abuse, even where they feel that they cannot be definitive – in these situations it is important to differentiate clearly between evidenced statements and impressions. Service managers can advise on where it is safe to document clinical information that the suspected perpetrator is unable to access. Safeguarding teams can advise on arrangements to share information on vulnerable individuals, including victims/survivors of domestic abuse. Professionals who identify that a crime has been committed, such as a physical assault as part of domestic abuse, or who witness a clear threat made against a named individual, should report their concerns to the police (e.g. in line with General Medical Council guidance) and make appropriate clinical documentation of this (e.g. recording a crime number in the notes). Reporting people perpetrating domestic abuse can introduce risks if it is done without the knowledge of the victim/survivor. Where possible, the professional, or a designated colleague professional such as an independent domestic violence advisor (IDVA), should speak to the victim/survivor prior to any reporting.

Mental health services are well placed to play a role in the coordinated community response (CCR) to domestic abuse (Shorey Reference Shorey, Tirone and Stuart2014). The CCR model acknowledges domestic abuse as a complex problem that has an impact on people, communities and systems across society, including health services, housing agencies and the criminal justice system (Robinson Reference Robinson and Tregidga2007). In this model, each agency that has a responsibility for dealing with perpetrators, their children and/or victims/survivors must work effectively internally and with all other agencies. This includes agencies taking appropriate actions within the remit of their role with victims/survivors and perpetrators, sharing information and working effectively and systematically with other services to increase the safety of victims/survivors and holding abusers to account.

The England and Wales Domestic Abuse Act 2021 includes provisions for domestic abuse protection orders (DAPOs), which can stipulate ‘positive requirements’ for domestic abuse perpetrators to engage with agencies such as substance misuse, mental health and behaviour change services at sentencing (Hester Reference Hester, Feder and Westmarland2020). In addition, under the statutory Serious Violence Duty, all integrated care boards (ICBs) must collaborate across the care system to act to prevent and reduce serious violence, including domestic abuse (Hopkins Reference Hopkins and Floyd2022).

Where there are concerns that a perpetrator poses a high risk of harm to a victim/survivor, local safeguarding teams can advise regarding referring the case to a local multi-agency risk assessment conference (MARAC). A MARAC is a meeting at which information on the highest-risk domestic abuse cases is shared between local sector services, including the police, probation, health, child protection, housing practitioners and other specialists from the statutory and voluntary sectors. There will also be a representative from a local domestic abuse service, often an IDVA, who can connect victims/survivors to local specialist services if they want this support. Determinations of whether a case is high risk can be made based on professional judgement supported by multidisciplinary discussion, the completion of the DASH tool in collaboration with safeguarding staff (DASH advises MARAC referral where 14 or more boxes are ticked) or evidence of escalation in the number of police call-outs in the past year. However, there are no definitive thresholds for assigning ‘high risk’ categorisations to cases of domestic abuse. There may be considerable uncertainty regarding risk level, and all available information and content of MDT and interdisciplinary discussions should be documented.

Patients perpetrating domestic abuse may also meet criteria for referral to multi-agency public protection arrangements (MAPPA). These are statutory arrangements to assess and manage the risk posed by certain sexual and violent offenders, including ‘high-risk, high-harm’ and serial domestic abuse perpetrators. MAPPA were established by sections 325 to 327 of the Criminal Justice Act 2003. Local MAPPA guidance, the designated MAPPA lead and community forensic mental health services can advise further on suitability (Royal College of Psychiatrists 2013). Consultation with forensic psychiatry should be considered on a case-by-case basis, recognising that not all perpetrators of domestic abuse will be eligible for forensic mental health input or meet criteria for MAPPA discussion. Where the patient is discussed (as a victim/survivor and/or a perpetrator of domestic abuse) at a MARAC or under MAPPA it is usually local policy to highlight risk concerns in the form of a ‘risk alert’ in the patient record. In liaison with clinical managers, it may be wise to add alerts in patient records if you have significant risk concerns, even in the absence of referrals to multi-agency meetings. Previous evidence suggests that information sharing on perpetrators of domestic abuse within health services and with other agencies could be improved (Dheensa Reference Dheensa2020).

Address mental health conditions and/or comorbid substance use

Evidence on specific interventions to reduce violence by perpetrators of domestic abuse specific to people with mental health conditions is limited. One exception is in the context of substance use disorders, where behaviour change interventions may have benefit (Lila Reference Lila and Gilchrist2023). Evidence suggests that violent behaviour is pharmacologically modifiable in the context of established mental health conditions, including psychotic disorders (Bhavsar Reference Bhavsar, Kosidou and Widman2020; Fazel Reference Fazel, Zetterqvist and Larsson2014). No evidence currently can inform on the effectiveness of psychological interventions for domestic abuse perpetration, although many perpetrator programmes incorporate cognitive–behavioural methods into group sessions.

Interventions for perpetrators of domestic abuse

Perpetrator interventions are deliberately and intentionally designed to disrupt a perpetrator's use of abuse towards a victim/survivor and/or offer help to change. Specialist domestic abuse services for both victims/survivors and perpetrators are a key component of a CCR model.

There is geographical variation within the UK in resources available to perpetrators of domestic abuse who wish to change their behaviour. The range of interventions includes initial help-seeking services such as the national Respect Phoneline (respectphoneline.org.uk) and longer-term behaviour change work and intensive case management, ideally delivered by services that meet Respect or Home Office standards for perpetrator interventions (Respect 2022; Home Office 2023). The Respect Phoneline offers people concerned about their behaviour access to accredited support and direction to local behaviour change programmes. It provides honest, non-judgemental support and advice on addressing abusive behaviour. It also signposts callers to local behaviour change programmes. The Respect Phoneline can also provide health professionals with confidential advice and information on how to work safely with someone perpetrating or suspected of perpetrating domestic abuse.

Male perpetrators of domestic abuse may be referred to individual (one-to-one) or group-based perpetrator programmes (Hester Reference Hester, Eisenstadt and Ortega-Avila2019). These programmes are informed by behaviour change principles, a feminist perspective (emphasising the gender imbalance inherent in domestic abuse) and a focus on the definition of domestic abuse. Maintaining the safety of the victim/survivor is central to programme aims, and therapeutic/management work within these programmes aims to address and increase the accountability that the perpetrator takes for their abusive behaviour. Conducting randomised controlled trials to robustly evaluate the effectiveness of perpetrator programmes presents important challenges (Turner Reference Turner, Morgan and Hester2023). There is limited high-quality evidence for the effectiveness of perpetrator programmes, including for populations with mental health conditions, for female perpetrators and for perpetrators abusing non-partner family members. The priority outcome of any perpetrator interventions should be enhanced safety and freedom for all victims/survivors, including children.

Mental health professionals should consider their own personal safety in advance of any assessment for interventions (Royal College of Psychiatrists 2016). Patient records should be checked beforehand for relevant alerts, and arrangements made to assess with a colleague or to invite the patient to clinic rather than visiting them at home. Professionals should not attempt motivational or behaviour change work with perpetrators in the absence of specific training. It is important to consider straightforward health promotion advice for perpetrators of domestic abuse with mental health conditions, including advice on accessing social support and on sleep hygiene, diet, exercise and working habits. We also recognise that professionals may themselves have experienced domestic abuse, and they should ensure that they are accessing appropriate support where needed.