Help-Seeking Behaviors for Intimate Partner Violence Perpetration by Men Receiving Substance Use Treatment: A Mixed-Methods Secondary Analysis

Abstract

Despite the high prevalence of intimate partner violence (IPV) perpetration by men receiving substance use treatment, little is known about their help-seeking behaviors for IPV. A secondary analysis of a mixed-methods study of men receiving substance use treatment who perpetrated IPV examined the prevalence, characteristics, and barriers associated with IPV perpetration disclosure and help-seeking. In total, 170 men were interviewed using a structured questionnaire, and a subsample of 20 were interviewed in-depth about their experiences. Logistic regression determined variables associated with disclosure and help-seeking. Thematic analysis of the in-depth interviews explored barriers to disclosure and help-seeking. Only half the participants had told anyone about their IPV perpetration and about one quarter reported having sought any sort of support. Whereas participants were more likely to disclose their IPV perpetration to informal resources (such as friends or family), they tended to seek help from formal resources (such as health professionals or the police). A greater proportion of physical IPV perpetrators, who had disclosed, had been arrested or had police involvement for IPV, suggesting that their disclosure may not have been voluntary. The following themes emerged from the qualitative data about the barriers to disclosure and help-seeking for IPV perpetration: fear that their children would be taken into care by social services, shame and embarrassment, and a minimization or normalization of their behavior. In addition, many participants highlighted that they had never been previously asked about IPV during treatment for substance use and stressed the need for greater expertise in or knowledge of this topic from specialist services. Substance use treatment services should enquire about men’s relationships and IPV perpetration to facilitate disclosure and provide support. Further research is necessary to determine the context of disclosure and help-seeking for IPV perpetration to increase the likelihood of identification.

Keywords

intimate partner violence domestic violence substance use treatment help-seeking behavior perpetration

Introduction

Intimate partner violence (IPV) refers to violence and abuse within an intimate relationship. IPV is included in the U.K. government redefinition of domestic violence and abuse that was introduced in 2013 as follows: “any incident or pattern of incidents of controlling, coercive or threatening behaviour violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality” (Home Office, 2013, p. 2).

The association between substance use and IPV perpetration in both clinical and general population samples has been well documented (Choenni, Hammink, & van de Mheen, 2017). Men in treatment for substance use report a higher prevalence of IPV perpetration (El-Bassel, Gilbert, Wu, Chang, & Fontdevila, 2007; Gilchrist et al., 2015; O’Farrell, Murphy, Stephan, Fals-Stewart, & Murphy, 2004) than men in the general population (Fleming et al., 2015).

Men are less likely than women to seek medical help (Wenger, 2011), with the rate of help-seeking for psychological problems ranging from 11% (Andrews, Issakidis, & Carter, 2001) to 30% (Gonzalez, Tinsley, & Kreuder, 2002). Previous studies suggest that men may not seek help medical or psychological problems for the following reasons: embarrassment, shame, fear of negative consequences, perception of their problems being minimized, conformity to hegemonic masculinities, and a poor rapport with health professionals (Galdas, Cheater, & Marshall, 2005; Yousaf, Grunfeld, & Hunter, 2015). Similar attitudinal barriers have been identified in relation to treatment seeking for substance use (Mojtabai & Crum, 2013; Verissimo & Grella, 2017). In addition, people may not disclose substance use or IPV due to concerns about negative views of others, denial, and fear of child services involvement (Gilchrist et al., 2014; Neale, Tompkins, & Sheard, 2008; Rose et al., 2011; Stringer & Baker, 2018). Help-seeking for IPV perpetration is hindered by men’s reluctance to discuss emotional and relationship issues, or feeling that relationship matters are private and that they can manage to resolve such issues themselves (Morgan, Williamson, Hester, Jones, & Feder, 2014). When men seek help for potentially abusive behaviors in relationships, they mostly rely on friends and/or family, than on general practitioners (GPs; Morgan et al., 2014).

One study of 73 men who attended community-run perpetrator programs reported that 63% had sought help for IPV prior to engagement in the program (Campbell, Neil, Jaffe, & Kelly, 2010). However, this program did not address substance use, and it is not clear whether these help-seeking behaviors were voluntarily or not. Only 38% of those who had sought help had actually received support or help from the services. Only around a quarter of those who received help reported that the services offered to them were helpful. Their main reasons for not seeking help were that they did not know from whom to ask for help (41%) and embarrassment (38%). Wu, El-Bassel, Gilbert, O’Connor, and Seewald (2011) emphasized that it is unclear how male IPV perpetrators, who are usually unwilling to engage in perpetrator programs, use other health care services. They investigated male IPV perpetrators who had engaged in methadone treatment to examine their engagement with other support services. Almost 90% of the subjects had used a service at least once in the past 30 days. Most participants had visited medical services (66%; with a mean number of visits of 3.4), 52% of participants had visited non-methadone treatment, and 26% had visited employment consultation services. Adherence to strong traditional male ideologies was found to be associated with a low rate of utilization of other support services. The authors concluded that further research was needed on the characteristics of male perpetrators who have engaged in other support services since these services must be made more accessible to perpetrators to reduce IPV (Wu et al., 2011).

There are no studies on help-seeking for IPV perpetration by men in substance use treatment. When men in substance use treatment are referred to IPV perpetrator programs, they often do not attend or complete treatment (Eckhardt, Samper, & Murphy, 2008; Schumacher, Fals-Stewart, & Leonard, 2003; Timko et al., 2012). It is important to better understand why some men receiving substance use treatment do not seek help for their IPV perpetration to improve access to treatment and ensure that effective responses can be better targeted to meet their needs, thereby improving outcomes for men and their partners and families.

This study examined the prevalence and characteristics associated with IPV perpetration disclosure and help-seeking among male IPV perpetrators receiving substance use treatment in England. Reasons for and barriers to disclosure and help-seeking were also sought.

Method

Secondary analysis of data from a mixed-methods study examining the prevalence and social constructions of IPV perpetration by men in treatment for substance use was conducted. A convenience sample of 223 men attending substance use treatment in England were interviewed face-to-face by trained researchers between October 2014 and June 2015 to determine a history of IPV perpetration (Gilchrist, Radcliffe, Noto, & d’Oliveira, 2017). Of the 223 men interviewed, 170 had ever perpetrated IPV. For the purpose of the quantitative secondary analysis, all the men with a history of IPV perpetration (n = 170) were included in the analysis. In-depth qualitative interviews were conducted with a subsample of 20 male perpetrators (Radcliffe, d’Oliveira, Lea, dos Santos Figueiredo, & Gilchrist, 2017).

Procedure

The study received ethical approval from the East Midlands-Northampton National Research Ethics Service in England (REC Ref: 14/EM/0088). Researchers explained the study to potential participants in the waiting rooms of community treatment services as well as providing written information before informed consent was gained. A £15 or £20 gift voucher or the cash equivalent was given to participants to compensate for the time spent participating in the quantitative and qualitative interview respectively.

Quantitative Interview

Age, relationship status, race/ethnicity, living arrangements, sexuality, education, current employment status, how the participant managed on their available income, religion, and self-reported hepatitis C and HIV status were recorded.

IPV perpetration and victimization were assessed using questions from the World Health Organization’s multi-country study on women’s health and domestic violence (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). Participants’ perception of whether their physical or sexual IPV perpetration was a crime or not was assessed by asking them the question, “Which one of these do you now think best describes what you did?” and letting them choose one of the four answers: “It was a crime,” “It was wrong but not a crime,” “It was just something that happens,” or “None of these” (Donovan & Hester, 2015; Hester, Donovan, & Fahmy, 2010; McCarry, Hester, & Donovan, 2008). Those who only perpetrated emotional IPV were not asked this question as emotional IPV was only included in the Serious Crime Act in the United Kingdom in 2015 (Home Office, 2015), and some of the reported incidents of emotional IPV may have taken place before this change in the law was implemented.

The Alcohol Use Disorders Identification Test (AUDIT) was used to assess hazardous drinking in the previous 12 months (AUDIT ⩾ 8; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Participants were asked how many days in the past 30 days they had used drugs (from a list) that had not been prescribed to them and the duration of their substance use treatment. They were also asked about their partner’s substance use and whether they perceived it to be problematic or not.

In total, 10 adverse childhood experiences were assessed using various measures, then summed to calculate a total score for participants who responded to all 10 experiences (149/170, 87.6%). The Child Maltreatment History Self-Report Childhood enquired about the occurrence of sexual and/or physical abuse in childhood (MacMillan et al., 1997). Other adverse childhood experiences assessed were as follows: witnessing interparental violence (Fergusson & Horwood, 1998), father never/rarely at home, mother never/rarely at home (Fulu, Jewkes, Roselli, & Garcia-Moreno, 2013), being looked after or adopted, neglect, parental death, separation/divorce, and being told you were weak or lazy.

Participants were asked to agree or disagree to 17 statements on “Attitudes about relations between men and women” from the United Nations multi-country cross-sectional study on men and violence in Asia and the Pacific (Fulu et al., 2013) and 16 statements about “Attitudes towards Gender Roles” from the World Health Organization’s multi-country study on women’s health and domestic violence (Garcia-Moreno et al., 2006). Total scores concerning attitudes about relations between men and women ranged from 17 to 69 with higher scores representing higher support for gender equitable norms (Fulu et al., 2013). Total scores for attitudes toward gender roles ranged from 16 to 32, with lower scores representing more gender stereotyped attitudes toward gender roles (Garcia-Moreno et al., 2006). For the purpose of this study, two additional variables were considered to reflect men’s masculinity—infidelity during their current/most recent relationship and physical fights with another man.

The severity of participants’ depressive symptoms was assessed using the Patient Health Questionnaire–9 (PHQ-9; Spitzer, Kroenke, & Williams, 1999). They were also asked whether they had ever been told by a health professional that they had manic depression or bipolar disorder.

The 57-item State-Trait Anger Expression Inventory–2 (STAXI-2; Spielberger, 1999) assessed anger expression, with higher total scores indicating greater anger expression. The participants’ current health state was assessed using a Visual Analog Scale, where 0 was the lowest and 100 the highest health state.

Statistical Analysis

Descriptive statistics were calculated using frequencies and percentages for categorical data and means and standard deviations for continuous data. Exclusive categories were created for different forms of IPV perpetration/victimization: emotional IPV includes perpetrators of emotional IPV only, physical IPV includes perpetrators of physical IPV with or without emotional IPV, and sexual IPV perpetration includes sexual IPV with or without physical and/or emotional IPV. To explore the variables associated with the disclosure of participants’ IPV perpetration or help-seeking behaviors, the odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression. Responses about disclosure or help-seeking for IPV perpetration were grouped for analysis into “informal” (i.e., family, friends, or neighbors) or “formal” (i.e., police, health professionals, religious community/leader, or other) resources. The relationship between the characteristics of IPV perpetrators and their utilization of informal and formal support/resources was also explored. Differences in categorical data were calculated using chi-square analysis. One-way ANOVA tests with post hoc Scheffe tests were performed only for continuous variables with normal distribution, and Kruskal–Wallis tests were conducted for other continuous variables.

Missing Data

There were missing data on help-seeking behaviors for 20 of the 170 perpetrators. The reason for the high proportion of missing data is unclear but may be due to some participants only disclosing emotional IPV (which was not considered a crime in the past) and researchers mistakingly not asking the questions about help-seeking as a result—or that participants were reluctant to answer these issues due to the sensitive nature of this topic.

Qualitative Interview and Analysis

In total, 20 semi-structured interviews were conducted with men in treatment for substance use who had reported in questionnaire interviews that they had experience of perpetrating (emotional, physical, or sexual) IPV. Men were purposively sampled to include a range of ages, types of substance and violence perpetrated to generate the maximum range of perspectives and experiences (Teddlie & Yu, 2007). The sample size was considered sufficient to reach data saturation (Guest, Bunce, & Johnson, 2006). The interviews were conducted by two female experienced qualitative researchers (P.R. and G.G.) and were digitally recorded and transcribed verbatim with participants’ consent. A topic guide was used to guide the interviews.

A thematic, narrative analysis was conducted (Mays & Pope, 1995). Data were organized and coded using NVivo 11.

Results

The characteristics of the participants are presented in Table 1. The majority of the participants had perpetrated physical IPV (with/without emotional IPV; 72.0%), 19.6% had perpetrated emotional IPV only, and 8.3% had perpetrated sexual IPV (with/without emotional IPV and/or physical IPV). Almost three quarters of participants were in treatment for drug use (74.1%) and 38.5% for alcohol use (answers not mutually exclusive).

Table 1.

Characteristics of Participants With a History of IPV (n = 170).

	n	(%)
Demographics
Age (years), M (SD)	42.24 (9.01)
Heterosexual	162	95.3
Born in the United Kingdom	145	85.3
Ethnicity (White)	137	80.6
Practices a religion	58	34.1
Homeless	46	27.1
No schooling/primary school education/left high school without any qualifications	53	31.2
Unemployed/receiving benefits	148	87.1
Difficult all the time/impossible to manage on available income	69	40.6
Number of children, M (SD)	1.79 (1.96)
At least one child lives with participant	12	7.1
Intimate partner violence (IPV)
Emotional IPV perpetration only	33	19.6
Physical IPV perpetration (with/without emotional IPV)	121	72.0
Sexual IPV perpetration (with/without emotional IPV and/or physical IPV)	14	8.3
Any IPV victimization	162	95.3
Perception of what they did was a crime	46	27.1
Substance use
In treatment for alcohol	65	38.5
Hazardous drinking	117	69.2
AUDIT total score, M (SD)	18.93 (13.73)
In treatment for drugs	126	74.1
Illicit drug use in the past 30 days
Heroin	76	44.7
Cocaine	17	10.1
Crack	69	40.6
Benzodiazepines	28	16.5
Cannabis	78	46.2
Poly drug use	90	52.9
Number of drugs, M (SD)	1.79 (1.55)
Believed that current/most recent partner has/had a problem with alcohol or drug use	82	48.2
Mental health
PHQ-9 total score (M [SD])	11.12 (6.53)
Probable depressive disorder (PHQ-9 case)	85	50.0
Ever told by a health professional that they had a manic-depressive illness or bipolar disorder	27	16.1
Quality of life, M (SD)
Current health state (Visual Analog Scale; M [SD])	50.50 (21.71)
Hepatitis C seropositive	50	29.6
HIV seropositive	4	2.4
Childhood adverse experiences
Number of adverse childhood experiences (M [SD])	4.36 (2.19)
Criminality (arrested for)
Crimes of IPV violence	128	75.3
Imprisonment for any crime	113	67.3
Masculinity-related variables
Infidelity	44	26.3
Ever had a physical fight with another man	154	91.1
Physical fight with another man in the past 12 months	71	44.1
Attitudes to gender relations score (M [SD])	49.00 (5.60)
Attitudes to gender norms score (M [SD])	29.21 (2.31)

Note. AUDIT = Alcohol Use Disorders Identification Test; PHQ = Patient Health Questionnaire.

Disclosure of IPV Perpetration

Of the 150 men who answered the question regarding the disclosure of IPV perpetration, 79 (52.7%) had told someone: mostly friends, family members, or health professionals (Table 2). Of the men who had disclosed their IPV perpetration and who responded to the question regarding help-seeking for IPV perpetration, 50.7% (38/75) had sought help, mostly from health professionals (Table 2). The main reasons reported for not confiding in anyone or seeking help for IPV were “Embarrassed/ashamed/would not be believed” or that “Violence is normal/not serious” (Table 3). A greater proportion of physical and sexual IPV perpetrators than perpetrators of emotional IPV had disclosed their actions to someone (mostly friends, family, the police, or health professionals) or had sought help (mostly from health professionals; Tables 4 and 5).

Table 2.

Help-Seeking Behavior for IPV Perpetration.

	Who Did Participants Tell About Their IPV Perpetration?n = 150^a		Where Did Participants Seek Help for Their IPV Perpetration?n = 75^b
	n (%)		n (%)
Told someone	79 (52.7)	Sought help	38 (50.7)
Family	31 (39.2)		9 (23.7)
Friends	43 (54.4)		9 (23.7)
Neighbors	3 (3.8)		0 (0.0)
Police	19 (24.1)		9 (23.7)
Health professionals	23 (29.1)		20 (52.6)
NGO/Men’s organization	n/a		1 (2.6)
Religious leader	4 (5.1)		3 (7.9)
Other	8 (10.1)^c		3 (7.9)^d

Note. IPV = intimate partner violence.

20 missing responses.

Four missing responses.

Counselor 1, current partner 1, key worker 1, liaison officer 1, parenting group 1, probation officer 2, victim support course in prison 1.

Alcoholics Anonymous 1, health relationships program 1, prison officers 1.

Table 3.

Reasons Why Participants Did Not Tell Anyone or Seek Help for Their IPV Perpetration.

	Told No Onen = 71	Did Not Seek Helpn = 111^a
	N (%)	N (%)
Don’t know/no answer	19 (26.8)	20 (18.0)
Fear of threats/the consequences	2 (2.8)	1 (0.9)
Violence normal/not serious	32 (45.1)	36 (32.4)
Embarrassed/ashamed/would not be believed	38 (53.5)	39 (35.1)
Afraid it would end relationship	2 (2.8)	1 (0.9)
Afraid they would lose custody of children	1 (1.4)	1 (0.9)
Bring bad name to family	6 (8.5)	5 (4.5)

Note. IPV = intimate partner violence.

One missing response.

Table 4.

The Relationship Between the Different Types of IPV Perpetration and Who Participants Told About Their IPV Perpetration.

Type of IPV	All Participants	Told Someone	Informal			Formal
	All Participants	Told Someone	Family	Friends	Neighbors	Police	Health Professionals	Religious	Other
	N = 168^a	N = 79	N = 31	N = 43	N = 3	N = 19	N = 23	N = 4	N = 8^b
Emotional IPV	33 (19.6%)	5 (15.2%)	1 (20.0%)	3 (60.0%)	0	0	1 (20.0%)	1 (20.0%)	1 (20.0%)
Physical IPV	121 (72.0%)	68 (56.2%)	28 (41.2%)	37 (54.4%)	3 (4.4%)	19 (27.9%)	18 (26.5 %)	3 (4.4%)	6 (8.8%)
Sexual IPV	14 (8.3%)	6 (42.9%)	2 (33.3%)	3 (50.0%)	0	0	4 (66.7%)	0	1 (16.7%)

Note. Answers are not mutually exclusive as participants can tell more than one person about their perpetration, so percentages may not add up to exactly 100%. IPV = intimate partner violence.

Two missing responses.

Counselor 1, current partner1, key worker 1, liaison officer 1, parenting group 1, probation officers 2, victim support course worker in prison 1.

Table 5.

The Relationship Between the Different Types of IPV Perpetration and Who Participants Sought Help From for Their IPV Perpetration.

Type of IPV	All Participants	Sought Help From Someone	Informal			Formal
	All Participants	Sought Help From Someone	Family	Friends	Neighbors	Police	Health Professionals	NGO/Men’s Organization	Religious	Other
	N = 168^a	N = 38	N = 9	N = 9	N = 0	N = 9	N = 20	N = 1	N = 3	N = 3^b
Emotional IPV	33 (19.6%)	3 (9.1%)	1 (33.3%)	1 (33.3%)	0	0	0	0	1 (33.3%)	0
Physical IPV	121 (72.0%)	31 (25.6%)	7 (22.6%)	7 (22.6%)	0	9 (29.0%)	16 (51.6 %)	1 (3.2%)	2 (6.5%)	2 (6.5%)
Sexual IPV	14 (8.3%)	4 (28.6%)	1 (25.0%)	1 (25.0%)	0	0	4 (100.0%)	0	0	1 (25.0%)

Note. Answers are not mutually exclusive as participants can seek help from more than one person for their perpetration, so percentages may not add up to exactly 100%. IPV = intimate partner violence.

Two missing responses.

Alcoholics Anonymous 1, health relationship program (part of sentence for a crime committed against a partner) 1, prison officer 1.

In total, 39 participants had disclosed their IPV perpetration only to informal sources (e.g., friends or family): 19 only to formal sources (e.g., health professionals or the police), and 21 had disclosed to both formal and informal sources.

Factors Associated With Disclosure of IPV Perpetration

There was a significant difference in attitudes to gender relations by resources disclosed to F(2, 76) = 3.49, p = .005. Post hoc comparisons using the Scheffe test indicated that participants who disclosed to both informal and formal resources (M = 52.62, SD = 5.83) demonstrated significantly higher support for gender equitable norms (p = .005) than those disclosing to informal resources (M = 47.46, SD = 5.62). IPV perpetrators who had a greater number of children were more likely to disclose their perpetration to formal resources than to informal resources, χ²(1) = 7.267, p = .007. Univariate analysis found that perpetrators who were unemployed, receiving benefits, who found it difficult all the time or impossible to manage on available income or who had perpetrated emotional IPV were less likely to disclose their perpetration. Conversely, those who had perpetrated physical IPV (with/without emotional IPV), who had been arrested for IPV perpetration, or who perceived that their behavior was a crime, were more likely to disclose their perpetration (Table 6). A greater proportion of physical IPV perpetrators (with/without emotional IPV), who had told someone about their IPV perpetration compared to those who had not, had been arrested for IPV, 39.7% (27/68) versus 18.2% (8/44), χ²(1) = 5.76, p = .021, and also reported that the police had been called as a result of their physical violence, 60.9% (39/68) versus 37.2% (16/44), χ²(1) = 5.80, p = .019. These findings suggest that disclosure of physical IPV perpetration may not have been voluntary for those involved with the criminal justice system. Among perpetrators of physical IPV (with/without emotional IPV), who had told someone about their behavior, a greater proportion of those who had reported their perpetration to the police than those who had not reported their behavior to the police had been arrested for IPV perpetration, 63.2% (12/19) versus 24.7% (23/93), χ²(1) = 10.84, p = .001, again implying their disclosure was probably enforced.

Table 6.

Factors Associated With Disclosing IPV Perpetration to Someone and Seeking Help for Their IPV Perpetration.

Univariate analysis	Told Someone				Sought Help
Univariate analysis	Yes (n = 79)	No (n = 71)	p	OR (95% CI)	Yes (n = 38)	No (n = 37)	p	OR (95% CI)
Demographics
Age, M (SD)	43.11 (9.48)	40.76 (8.95)	.123	1.03 [0.99, 1.07]	44.71 (8.66)	41.54 (9.97)	.148	1.04 [0.99, 1.09]
Heterosexual	74 (93.7%)	68 (95.8%)	.569	0.65 [0.15, 2.84]	36 (94.7%)	34 (91.9%)	.624	1.59 [0.25, 10.10]
Born in the United Kingdom	68 (86.1%)	60 (84.5%)	.786	1.13 [0.46, 2.80]	34 (89.5%)	31 (83.8%)	.472	1.65 [0.42, 6.38]
Practices a religion	31 (39.2%)	19 (26.8%)	.107	1.77 [0.88, 3.53]	18 (47.4%)	13 (35.1%)	.284	1.66 [0.66, 4.20]
Homeless	19 (24.1%)	23 (32.4%)	.257	0.66 [0.32, 1.35]	9 (23.7%)	9 (24.3%)	.948	0.97 [0.34, 2.79]
No schooling/primary school education/left high school without any qualifications	21 (26.6%)	25 (35.2%)	.254	0.67 [0.33, 1.34]	9 (23.7%)	12 (32.4%)	.400	0.65 [0.23, 1.79]
Unemployed/receiving benefits	64 (81.0%)	66 (92.9%)	.038	0.32 [0.11, 0.94]	28 (73.7%)	33 (89.2%)	.094	0.34 [0.96, 1.20]
Difficult all the time/impossible to manage on available income	24 (30.4%)	36 (50.7%)	.012	0.42 [0.22, 0.83]	11 (29.0%)	13 (35.1%)	.566	0.75 [0.28, 2.00]
Number of children, M (SD)	2.10 (2.25)	1.58 (1.65)	.115	1.15 [0.97, 1.37]	2.53 (2.50)	1.78 (1.99)	.168	1.17 [0.94, 1.46]
At least one child lives with participant	4 (7.5%)	7 (9.8%)	.220	0.44 [0.12, 1.63]	1 (3.6%)	2 (8.7%)	.453	0.39 [0.03, 4.59]
Intimate relationship
Had sex with another person during current/most recent relationship	19 (24.7%)	19 (27.1%)	.733	0.88 [0.42, 1.84]	7 (18.9%)	10 (27.8%)	.373	0.61 [0.20, 1.82]
Believed that current/most recent partner has/had a problem with alcohol or drug use	39 (49.4%)	35 (49.3%)	.993	1.00 [0.53, 1.90]	17 (44.7%)	21 (56.8%)	.299	0.62 [0.25, 1.54]
Substance use
In treatment for alcohol	34 (43.6%)	24 (33.8%)	.222	1.51 [0.78, 2.94]	15 (39.5%)	16 (44.4%)	.665	0.82 [0.32, 2.06]
Hazardous drinking (AUDIT) in the past 12 months	56 (71.8%)	47 (66.2%)	.461	1.30 [0.65, 2.61]	27 (73.0%)	26 (70.3%)	.797	1.14 [0.42, 3.14]
AUDIT total score (SD)	18.73 (13.49)	19.11 (14.17)	.865	1.00 [0.98, 1.02]	16.62 (12.45)	20.89 (14.24)	.172	0.98 [0.94, 1.01]
In treatment for drugs	55 (69.6%)	56 (78.9%)	.199	0.61 [0.29, 1.29]	26 (68.4%)	28 (75.7%)	.485	0.70 [0.25, 1.92]
Illicit drug use in the past 30 days
Heroin	33 (41.8%)	33 (46.5%)	.562	0.83 [0.43, 1.58]	15 (39.5%)	17 (45.9%)	.571	0.77 [0.31, 1.92]
Cocaine	10 (12.8%)	6 (8.5%)	.393	1.59 [0.55, 4.63]	4 (10.5%)	6 (16.7%)	.443	0.59 [0.15, 2.29]
Crack	29 (36.7%)	33 (46.5%)	.226	0.67 [0.35, 1.28]	12 (31.6%)	17 (45.9%)	.204	0.54 [0.21, 1.39]
Benzodiazepines	10 (12.7%)	11 (15.5%)	.618	0.79 [0.31, 1.99]	5 (13.2%)	5 (13.5%)	.964	0.97 [0.26, 3.67]
Cannabis	33 (41.8%)	38 (53.5%)	.151	0.62 [0.33, 1.19]	14 (36.8%)	19 (51.4%)	.207	0.55 [0.22, 1.39]
Poly drug use	41 (51.9%)	39 (54.9%)	.710	0.89 [0.47, 1.68]	17 (44.7%)	23 (62.2%)	.133	0.49 [0.20, 1.24]
Number of drugs used (SD) in the past 12 months	1.66 (1.48)	1.90 (1.55)	.325	0.90 [0.73, 1.11]	1.53 (1.54)	1.92 (1.40)	.249	0.83 [0.61, 1.14]
Mental health
Probable depressive disorder (PHQ-9 case)	39 (49.4%)	39 (54.9%)	.496	0.80 [0.42, 1.52]	20 (52.6%)	17 (45.9%)	.563	1.31 [0.53, 3.24]
PHQ-9 total score (M [SD])	11.00 (6.68)	11.58 (6.06)	.579	0.99 [0.94, 1.04]	11.05 (6.55)	11.08 (7.11)	.985	1.00 [0.93, 1.07]
Ever told by a health professional that they had a manic-depressive illness or bipolar disorder	10 (12.8%)	13 (18.6%)	.337	0.65 [0.26, 1.58]	5 (13.2%)	5 (13.9%)	.927	0.94 [0.25, 3.56]
Anger (M [SD])
Anger Expression index score	36.95 (14.59)	39.76 (13.69)	.230	0.99 [0.96, 1.01]	34.35 (13.58)	39.84 (15.67)	.114	0.97 [0.94, 1.01]
Health
Current health state (Visual Analog Scale; EQ-5D)(M [SD])	54.47 (21.73)	48.48 (19.45)	.081	1.01 [1.00, 1.03]	54.92 (23.47)	53.53 (21.18)	.786	1.00 [0.98, 1.02]
Hepatitis C seropositive (self-report)	18 (23.1%)	22 (31.0%)	.278	0.67 [0.32, 1.38]	5 (13.2%)	13 (36.1%)	.026	0.27 [0.08, 0.86]
Childhood adverse experiences
Any childhood abuse	55 (71.4%)	50 (71.4%)	1.000	1.00 [0.49, 2.05]	30 (81.1%)	23 (63.9%)	.104	2.42 [0.83, 7.04]
Childhood physical abuse	55 (70.5%)	48 (69.6%)	.900	1.05 [0.52, 2.12]	30 (81.1%)	23 (62.2%)	.076	2.61 [0.91, 7.51]
Severe childhood physical abuse	42 (53.8%)	32 (46.4%)	.366	1.35 [0.70, 2.58]	22 (59.5%)	19 (51.4%)	.483	1.39 [0.55, 3.49]
Childhood sexual abuse	16 (21.1%)	19 (27.1%)	.390	0.72 [0.33, 1.54]	7 (19.4%)	8 (22.2%)	.772	0.85 [0.27, 2.64]
Severe childhood sexual abuse	16 (21.1%)	16 (22.9%)	.792	0.90 [0.41, 1.97]	7 (19.4%)	8 (22.2%)	.772	0.85 [0.27, 2.64]
Number of adverse childhood experiences, M (SD)	4.14 (2.09)	4.59 (2.18)	.225	0.90 [0.77, 1.07]	4.46 (2.12)	3.76 (2.02)	.168	1.18 [0.93, 1.50]
Criminality (arrested for)
Crimes against property/fraud	35 (44.3%)	37 (52.9%)	.298	0.71 [0.37, 1.35]	17 (44.7%)	17 (45.9%)	.916	0.95 [0.38, 2.37]
Possession of or dealing drugs	51 (65.4%)	52 (73.2%)	.301	0.69 [0.34, 1.39]	19 (50.0%)	29 (80.6%)	.008	0.24 [0.09, 0.68]
Crimes of violence (other than IPV)	45 (57.0%)	37 (52.1%)	.552	1.22 [0.64, 2.32]	21 (55.3%)	24 (64.9%)	.397	0.67 [0.26, 1.70]
Crimes of IPV	29 (36.7%)	11 (15.5%)	.004	3.16 [1.44, 6.96]	17 (44.7%)	12 (32.4%)	.276	1.69 [0.66, 4.32]
Possession of a weapon	36 (45.6%)	25 (35.2%)	.198	1.54 [0.80, 2.98]	17 (44.7%)	19 (51.4%)	.567	0.77 [0.31, 1.90]
Imprisonment for any type of crime	53 (67.1%)	47 (68.1%)	.894	0.95 [0.48, 1.90]	23 (60.5%)	29 (78.4%)	.098	0.42 [0.15, 1.17]
Different types of IPV perpetration
Emotional perpetration	5 (6.3%)	19 (27.5%)	.001	0.18 [0.06, 0.51]	3 (7.9%)	0	—	—
Physical perpetration	68 (86.1%)	44 (63.8%)	.002	3.51 [1.57, 7.85]	31 (81.6%)	35 (94.6%)	.101	0.25 [0.05, 1.31]
Sexual perpetration	6 (7.6%)	6 (8.7%)	.807	0.86 [0.27, 2.81]	4 (10.5%)	2 (5.4%)	.422	2.06 [0.35, 11.99]
Perception of what they did being a crime	29 (36.7%)	15 (21.1%)	.038	2.17 [1.04, 4.50]	16 (42.1%)	12 (32.4%)	.388	1.52 [0.59, 3.89]
Different type of IPV victimization
Emotional victimization	7 (8.9%)	9 (12.7%)	.452	0.67 [0.24, 1.90]	2 (5.4%)	4 (10.5%)	.422	2.06 [0.35, 11.99]
Physical victimization	59 (75.6%)	47 (66.2%)	.205	1.59 [0.78, 3.24]	27 (73.0%)	29 (74.4%)	.588	1.34 [0.46, 3.90]
Sexual victimization	12 (15.4%)	10 (14.1%)	.823	1.11 [0.45, 2.75]	4 (10.5%)	8 (21.6%)	.215	0.44 [0.12, 1.61]
Masculinity-related variables
Infidelity	19 (24.7%)	19 (27.1%)	.733	0.88 [0.42, 1.84]	7 (18.9%)	10 (27.8%)	.373	0.61 [0.20, 1.82]
Ever had a physical fight with another man	70 (88.6%)	65 (92.9%)	.379	0.60 [0.19, 1.88]	32 (84.2%)	36 (97.3%)	.085	0.15 [0.02, 1.30]
Physical fight with another man in the past 12 months	35 (46.7%)	26 (38.8%)	.295	1.20 [0.85, 1.70]	12 (35.3%)	24 (63.2%)	.020	0.32 [0.12, 0.83]
Attitudes to gender relations score	49.39 (6.02)	48.52 (5.16)	.344	1.03 [0.97, 1.09]	50.55 (6.04)	47.89 (5.60)	.057	1.08 [1.00, 1.18]
Attitudes to gender norms score	29.29 (2.60)	29.07 (2.07)	.568	1.04 [0.91, 1.20]	29.34 (3.09)	29.19 (2.15)	.802	1.02 [0.86, 1.22]

Note. IPV = intimate partner violence; OR = odds ratio; CI = confidence interval; AUDIT = Alcohol Use Disorders Identification Test; PHQ: Patient Health Questionnaire. Significance p values (< .05) are in bold.

Help-Seeking Behaviors for IPV Perpetration

Six participants had only sought help for their IPV perpetration from informal sources (e.g., friends or family): 25 only from formal sources (e.g., health professionals or the police), and seven had sought help from both formal and informal sources. There was a significant difference in attitudes to gender relations by resources disclosed to, F(2, 35) = 6.595, p = .004. Post hoc comparisons using the Scheffe test indicated that participants who sought help from both informal and formal resources (M = 53.14, SD = 3.13) demonstrated significantly (p = .005) higher support for gender equitable norms than those seeking help from informal resources (M = 43.50, SD = 5.17). In the univariate analysis, participants who sought help were less likely to have hepatitis C, or to have been arrested for possession of or dealing drugs, or to have been in a physical fight with another man in the last 12 months (Table 6).

Qualitative Findings

Five themes emerged about the existing barriers to disclosure and help-seeking: fear that their children would be taken into care by social services, shame and embarrassment, minimization or normalization of IPV, never being asked about IPV within substance use treatment, and the need for greater expertise/knowledge from specialist services.

Fear That Their Children Would Be Taken Into Care By Social Services

Two men stated that the reason they did not disclose their perpetration was a result of fear that their children would be taken into care by social services:

If I said to this lot, “I got stabbed last night. My wife stabbed me,” and they phoned social services and the kids ended up in care, all right, had a little hole in me. . . . So I do think a lot of people just keep their mouth shut, try to grin and bear it, battle through it rather than ask for help. (Kenneth)

Shame and Embarrassment

Shame and embarrassment connected with disclosing IPV was a theme common to both the quantitative and qualitative findings, with six men admitting that reporting IPV perpetration to others would make them feel embarrassed:

No, I don’t tell people that because you feel embarrassed, don’t you? . . . It’s embarrassing. Admitting that you’ve just hurt your—no, no way. It’s embarrassing. (Wayne)

I’m very ashamed, even today, for what I’ve done and I always will be, I think, till the day I die. I should have acted better or walked away. (Jerry)

Minimization or Normalization

Five men reported that they did not tell anyone about their behavior or seek help because their relationship problems were not serious or that IPV was a normal part of relationships that did not warrant help-seeking:

Would you have liked any help for you and your partner?

IV:

No, because I didn’t think we needed it. We just fizzled out at the end. In between it was a nice ride while it lasted, you know. (Martin)

Have you told anyone about her violence towards you or your violence to her?

IV:

No, it’s just in the marriage, isn’t it? . . . I had more problems than. . . . (Edward)

The normalizing of IPV is emphasized with Edward’s comment that “it’s just in the marriage.” Normalizing violence in this way may also represent a barrier to male perpetrators’ help-seeking. Others suggested that they did not need help for their IPV perpetration and were not in fact violent, despite the positive answers to the IPV perpetration questions in the quantitative interview.

Never Being Asked About IPV Within Substance Use Treatment

Many men reported that they had not discussed their relationship problems with substance use treatment staff despite having apparently good relationships with key workers. Roy and Jerry stated that the research interview was their first ever opportunity to disclose any relationship problems. Roy’s statement after the research interview may highlight that relationship problems are not considered by service users as a legitimate topic for discussion in substance use appointments:

As I said, I don’t have people who I can speak about it with. I do speak with him (Key worker) but not about relationships. He knows that I’ve got, right now, a partner but I never speak with him about anything which is about past relationships and stuff like that. We talk about mostly, what’s going on right at the moment, you know. (Roy)

This suggests that directly asking male perpetrators about any existing relationship problems may create an atmosphere more conducive to disclosing IPV perpetration.

Substance use treatment staff often need to deal with many other aspects of their clients’ lives such as housing problems, child protection issues, risk assessment, financial, physical and mental health issues. In addition, heavy caseloads limit the time staff can spend with service users. This was alluded to in the following statements:

So do you talk to Substance Use staff about this kind of thing?

IV:

Not directly because we’ve been talking about other issues where I’m a bit stuck on this and that and she’s trying to sort it out for me you know, yeah. (William)

I think Substance Use Services have got enough on their plate. (Billy)

This theme highlights service users’ perception of the focus of the substance use consultations and their own awareness of the time constraints on busy substance use services. Interviews with practitioners also suggest their reluctance to raise the issue of IPV perpetration with clients in the absence of referral pathways (Radcliffe & Gilchrist, 2016).

Need for Greater Expertise/Knowledge in Specialist Services

Roy also suggested that if staff with specialist knowledge had been available, he would have sought help for his relationship problems. The professional limitations of substance use treatment staff were also emphasized by Billy who reported having tried to seek help from “Relate” (UK’s largest provider of relationship support) with his partner:

I don’t think they’re [Key Workers] qualified or experienced or any inkling for me to say that they could deal with anything like that. (Billy)

It was not always clear where the view that staff working in substance treatment services are not sufficiently qualified to deal with IPV issues had developed or whether there was an unspoken rule among participants that relationship problems and IPV cannot be dealt with within substance treatment services. Christopher, however, had direct experience of failing to elicit help for IPV perpetration from a substance use service:

. . . you didn’t tell anyone, and you didn’t seek any help for either using violence yourself, or . . . ?

IV:

I did. I went to—was using Drug Service in [name of town], which is like this, which is like this drug service. I went to them to ask if they could help me with anger management, but they never seemed to do anything. It was really slow up there . . . (Christopher)

This may reflect a lack of “role legitimacy” concerning IPV and relationship problems on the part of treatment staff or a lack of an appropriate referral pathway (Radcliffe & Gilchrist, 2016).

Discussion

This mixed-methods study investigated disclosure and help-seeking behavior by male IPV perpetrators receiving substance treatment. Findings suggest that about half of the male IPV perpetrators receiving treatment for substance use had disclosed their perpetration to someone; however, only one quarter had sought help. Determining whether this figure is high or low requires careful consideration because little comparable data exist relating to the prevalence of male help-seeking behaviors for IPV perpetrations.

The univariate analysis indicated that physical IPV perpetrators or those who had been arrested for IPV were more likely to disclose their perpetration to others. This may reflect the high rate of involvement of the criminal justice system among physical IPV perpetrators, which in turn might provide them with more opportunities for disclosure. However, it is unclear whether these disclosures were voluntary or not. Some perpetrators arrested for IPV would have needed to tell the police about their perpetration while under investigation. Others might have been referred to substance use treatment when their substance use problems were identified by the police and had to reveal their perpetration to substance use treatment workers in the context of explaining the reason for the referral. It was not possible to determine what proportion of the participants who sought help for IPV perpetration had done so because they were ordered to seek help by the criminal justice system. Future studies should enquire about the context of help-seeking to address this limitation. The finding that perpetrators who were unemployed or receiving benefits were less likely to report their perpetration to someone may indicate that they are more isolated and lack social networks. In this study, low support for gender equitable norms, holding gender stereotyped attitudes, being unfaithful or fighting with another man were considered masculinity-related variables. The finding that those who had had a physical fight with another man in the past 12 months were less likely to seek help and that perpetrators who supported gender equitable norms were more likely to seek help was compatible with previous research that suggests that support for hegemonic masculinity discourages men from seeking help (Galdas et al., 2005). The reason why perpetrators who had been identified as hepatitis C seropositive were less likely to seek help is uncertain. One explanation may be that perpetrators who were hepatitis C seropositive have currently or previously injected drugs, thus are highly stigmatized and may perceive it difficult to engage with health services (Treloar, Rance, & Backmund, 2013).

In the quantitative interviews, most participants reported “minimizing or normalization” and “shame and embarrassment” to explain their violent and abusive behavior toward a partner and reasons why they had not disclosed their behavior or sought help for it, respectively. The same themes were also evident in the qualitative findings.

Previous research on both male (Douglas & Hines, 2011) and female (Meyer, 2010) IPV victims and perpetrators (Morgan et al., 2014) suggest that they typically seek help from informal resources (e.g., family or friends), followed by GPs. Although the findings from the current study support this, with a large number of participants disclosing their behavior to informal resources, when they actually sought help they did so from formal resources (e.g., health professionals). This finding suggests that seeking help directly from formal resources was an important route for reporting and seeking help for perpetrators of IPV (44.7%). These findings highlight the need for formal resources including police and health care settings to be better equipped to respond to disclosures of IPV perpetration.

The current study found that perpetrators who disclosed or sought help from both informal and formal resources were more likely to have high gender equitable norms. As an explanation of this, perpetrators with higher equitable norms may tend to recognize that their behavior could be classified as a crime and therefore also recognize the need to change. Perpetrators with a large number of children were more likely to disclose their perpetration to formal resources. This may be related to a high likelihood of frequent involvement with social services or the police having been called by neighbors due to the presence of children at home. Interestingly, the relationship between having children or having children at home and the higher likelihood of help-seeking from mental health professionals has been shown by studies of both female (Leone, Johnson, & Cohan, 2007) and male IPV victims (Douglas, Hines, & McCarthy, 2012).

The findings from the current study indicate that IPV issues may not be sufficiently addressed in substance use treatment settings. Several studies (e.g., Campbell et al., 2010) suggest that men also consider health professionals as the main resource from whom they would seek help for IPV victimization or perpetration. For example, Morgan et al. (2014) investigated male attitudes to being asked about IPV victimization and perpetration in 16 GP surgeries. They found that 27% of the subjects thought that practitioners should ask all patients about IPV issues and 65% supported being asked depending on their symptoms. Further research is necessary into men’s attitudes toward being asked about IPV victimization and perpetration in substance treatment services. A potential way to overcome the stigma would be to offer interventions for IPV within substance use treatment settings. Indeed, a recent review reported promising short term (<12 months) results in relation to reductions in IPV perpetration from interventions that have integrated treatment for IPV and substance use, but the results for substance use were mixed, and some studies included small sample sizes and were not randomized controlled trials (Tarzia, Forsdike, Feder, & Hegarty, 2020).

This current study suggested that the reticence of being associated with illegal activities (having been arrested for drug possession or dealing) or the fear of losing their children to the care system may be a barrier to men’s disclosure of IPV perpetration. Child safe-guarding procedures in substance use services may discourage IPV perpetrators from disclosing their perpetration, and/or may make substance use staff hesitate to even raise the topic of IPV. In the qualitative study, more than half of the participants said that they felt better after the interviews, which partially supports men’s acceptability of being asked about IPV issues. To know how substance use staff should enquire about IPV, further research on men’s attitudes toward being approached about IPV victimization and perpetration in substance use treatment services is essential. The development of a training program for substance use staff to better identify and address male IPV perpetration among people receiving substance use treatment and research on the impact of such training are also needed.

Strengths and Limitations

This study has several limitations. Firstly, the results of the study may not be generalizable outside of England due to the different characteristics of males receiving substance treatment elsewhere. The second limitation is the number of missing responses (20/170) for the questions on help-seeking behaviors. Thirdly, the wording of the questions made it difficult to determine whether help had been sought from the police or if this had occurred as a result of an arrest. Fourthly, help-seeking behavior might be under reported by the participants due to recall bias. Despite these limitations, this is the first mixed-methods study to investigate help-seeking for IPV perpetration among men attending treatment for substance use. To some extent, triangulation supports the validity of the qualitative data.

Conclusion

While around half of male perpetrators receiving substance treatment had disclosed their behavior to someone, only about one quarter had sought any sort of support. While perpetrators were more likely to disclose their perpetration to informal resources, they tended to seek help from formal resources, such as health professionals or the police. Moreover, men highlighted certain barriers to disclosure including feeling embarrassed or ashamed, or that they had never been asked about IPV within substance use treatment settings. To increase the likelihood of identifying and responding to IPV, further research is necessary to determine the barriers and facilitators to disclosure of and help-seeking for IPV perpetration in substance use treatment services.

Footnotes

Acknowledgments

The authors thank the staff and patients from the substance use treatment services for their participation in the research. They are especially grateful to the interviewers: Paulina Romani Lopez, Kideshini Widyaratna, and Jill Fowler.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Economic and Social Research Council (ES/K002589/1).

ORCID iD

Nozomu Hashimoto

Author Biographies

Nozomu Hashimoto, MD, who is a designated psychiatrist for mental health accredited by Ministry of Health, Labor and Welfare, Japan, has been a unit chief of the addiction department at Okayama Psychiatric Medical Center of Japan for more than 5 years. He earned Master of Science in Addiction Studies at King’s College London. His research interests include psychiatric comorbidity among people with substance addiction and/or gambling addiction and how to improve treatment system for them.

Polly Radcliffe is a research fellow at the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London. She has over twenty years of experience of qualitative research that has focused on gender and identity in the context of the criminal justice system, substance use treatment and health care services. She has extensive experience of accessing and engaging hard to reach research participants and analysing qualitative data using discourse and narrative analysis.

Gail Gilchrist is a reader in Addictions Healthcare Research at the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London. Her research focuses on substance use and its relationship with psychiatric disorders, intimate partner violence and blood borne viruses and developing and testing psychosocial interventions to address these issues.

References

Andrews

Issakidis

Carter

(2001). Shortfall in mental health service utilisation. The British Journal of Psychiatry, 179, 417-425.

Babor

T. F.

Higgins-Biddle

J. C.

Saunders

J. B.

Monteiro

M. G.

(2001). AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization.

Campbell

Neil

J. A.

Jaffe

P. G.

Kelly

(2010). Engaging abusive men in seeking community intervention: A critical research & practice priority. Journal of Family Violence, 25, 413-422. doi:10.1007/s10896-010-9302-z

Choenni

Hammink

van de Mheen

(2017). Association between substance use and the perpetration of family violence in industrialized countries: A systematic review. Trauma, Violence, & Abuse, 18, 37-50.

Donovan

Hester

(2015). Domestic violence and sexuality: What’s love got to do with it? Bristol, England: Policy Press.

Douglas

E. M.

Hines

D. A.

(2011). The helpseeking experiences of men who sustain intimate partner violence: An overlooked population and implications for practice. Journal of Family Violence, 26, 473-485.

Douglas

E. M.

Hines

D. A.

McCarthy

S. C.

(2012). Men who sustain female-to-male partner violence: Factors associated with where they seek help and how they rate those resources. Violence & Victims, 27, 871-894.

Eckhardt

C. I.

Samper

R. E.

Murphy

C. M.

(2008). Anger disturbances among perpetrators of intimate partner violence: Clinical characteristics and outcomes of court-mandated treatment. Journal of Interpersonal Violence, 23, 1600-1617.

El-Bassel

Gilbert

Chang

Fontdevila

(2007). Perpetration of intimate partner violence among men in methadone treatment programs in New York City. American Journal of Public Health, 97, 1230-1232.

10.

Fergusson

D. M.

Horwood

L. J.

(1998). Exposure to interparental violence in childhood and psychosocial adjustment in young adulthood. Child Abuse & Neglect, 22, 339-357.

11.

Fleming

P. J.

McCleary-Sills

Morton

Levtov

Heilman

Barker

(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), Article e0118639.

12.

Fulu

Jewkes

Roselli

Garcia-Moreno

(2013). Prevalence of and factors associated with male perpetration of intimate partner violence: Findings from the UN multi-country cross-sectional study on men and violence in Asia and the Pacific. The Lancet Global Health, 1(4), e187-e207.

13.

Galdas

P. M.

Cheater

Marshall

(2005). Men and health help-seeking behaviour: Literature review. Journal of Advanced Nursing, 49, 616-623.

14.

Garcia-Moreno

Jansen

H. A.

Ellsberg

Heise

Watts

C. H.

(2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. The Lancet, 368, 1260-1269.

15.

Gilchrist

Blazquez

Segura

Geldschläger

Valls

Colom

Torrens

(2015). Factors associated with physical or sexual intimate partner violence perpetration by men attending substance misuse treatment in Catalunya: A mixed methods study. Criminal Behaviour and Mental Health, 25, 239-257.

16.

Gilchrist

Moskalewicz

Nutt

Love

Germeni

Valkova

…Baldacchino

(2014). Understanding access to drug and alcohol treatment services in Europe: A multi-country service users’ perspective. Drugs: Education, Prevention and Policy, 21(2), 120-130.

17.

Gilchrist

Radcliffe

Noto

A. R.

d’Oliveira

A. F.

(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 and Alcohol Review, 36, 34-51.

18.

Gonzalez

J. M.

Tinsley

H. E.

Kreuder

K. R.

(2002). Effects of psychoeducational interventions on opinions of mental illness, attitudes toward help seeking, and expectations about psychotherapy in college students. Journal of College Student Development, 43, 51-63.

19.

Guest

Bunce

Johnson

(2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18, 59-82.

20.

Hester

Donovan

Fahmy

(2010). Feminist epistemology and the politics of method: Surveying same sex domestic violence. International Journal of Social Research Methodology, 13, 251-263.

21.

Home Office. (2013). Information for local areas on the change to the definition of domestic violence and abuse. London, England: Author. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/142701/guide-on-definition-of-dv.pdf

22.

Home Office. (2015). Controlling or coercive behaviour in an intimate or family relationship: Statutory guidance framework. London, England: Author. Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/482528/Controlling_or_coercive_behaviour_-_statutory_guidance.pdf

23.

Leone

J. M.

Johnson

M. P.

Cohan

C. L.

(2007). Victim help seeking: Differences between intimate terrorism and situational couple violence. Family Relations, 56, 427-439.

24.

MacMillan

H. L.

Fleming

J. E.

Trocme

Boyle

M. H.

Wong

Racine

Y. A.

. . . Offord

D. R.

(1997). Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. Journal of the American Medical Association, 278, 131-135.

25.

Mays

Pope

(1995). Rigour and qualitative research. British Medical Journal, 311, 109-112.

26.

McCarry

Hester

Donovan

(2008). Researching same sex domestic violence: Constructing a survey methodology. Sociological Research Online, 13(1), 1-14.

27.

Meyer

(2010). Responding to intimate partner violence victimisation: Effective options for help-seeking. Trends and Issues in Crime and Criminal Justice, Article 389.

28.

Mojtabai

Crum

R. M.

(2013). Perceived unmet need for alcohol and drug use treatments and future use of services: Results from a longitudinal study. Drug and Alcohol Dependence, 127, 59-64.

29.

Morgan

Williamson

Hester

Jones

Feder

(2014). Asking men about domestic violence and abuse in a family medicine context: Help seeking and views on the general practitioner role. Aggression and Violent Behavior, 19, 637-642.

30.

Neale

Tompkins

Sheard

(2008). Barriers to accessing generic health and social care services: A qualitative study of injecting drug users. Health & Social Care in the Community, 16, 147-154.

31.

O’Farrell

T. J.

Murphy

C. M.

Stephan

S. H.

Fals-Stewart

Murphy

(2004). Partner violence before and after couples-based alcoholism treatment for male alcoholic patients: The role of treatment involvement and abstinence. Journal of Consulting and Clinical Psychology, 72, 202-217.

32.

Radcliffe

d’Oliveira

A. F.

Lea

dos Santos Figueiredo

Gilchrist

(2017). Accounting for intimate partner violence perpetration: A cross-cultural comparison of English and Brazilian male substance users’ explanations. Drug and Alcohol Review, 36, 64-71.

33.

Radcliffe

Gilchrist

(2016). “You can never work with addictions in isolation”: Addressing intimate partner violence perpetration by men in substance misuse treatment. International Journal of Drug Policy, 36, 130-140.

34.

Rose

Trevillion

Woodall

Morgan

Feder

Howard

(2011). Barriers and facilitators of disclosures of domestic violence by mental health service users: Qualitative study. The British Journal of Psychiatry, 198, 189-194.

35.

Schumacher

J. A.

Fals-Stewart

Leonard

K. E.

(2003). Domestic violence treatment referrals for men seeking alcohol treatment. Journal of Substance Abuse Treatment, 24, 279-283.

36.

Spielberger

C. D.

(1999). State-Trait Anger Expression Inventory-2. Odessa, FL: US, Psychological Assessment Resources.

37.

Spitzer

R. L.

Kroenke

Williams

J. B.

(1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study: Primary care evaluation of mental disorders: Patient Health Questionnaire. Journal of the American Medical Association, 282, 1737-1744.

38.

Stringer

K. L.

Baker

E. H.

(2018). Stigma as a barrier to substance abuse treatment among those with unmet need: An analysis of parenthood and marital status. Journal of Family Issues, 39, 3-27.

39.

Tarzia

Forsdike

Feder

Hegarty

(2020). Interventions in health settings for male perpetrators or victims of intimate partner violence. Trauma, Violence, & Abuse, 21(1), 123-137.

40.

Teddlie

(2007). Mixed methods sampling: A typology with examples. Journal of Mixed Methods Research, 1, 77-100.

41.

Timko

Valenstein

Lin

P. Y.

Moos

R. H.

Stuart

G. L.

Cronkite

R. C.

(2012). Addressing substance abuse and violence in substance use disorder treatment and batterer intervention programs. Substance Abuse Treatment, Prevention, and Policy, 7(1), Article 37.

42.

Treloar

Rance

Backmund

(2013). Understanding barriers to hepatitis C virus care and stigmatization from a social perspective. Clinical Infectious Diseases, 57(Suppl. 2), S51-S55.

43.

Verissimo

A. D. O.

Grella

C. E.

(2017). Influence of gender and race/ethnicity on perceived barriers to help-seeking for alcohol or drug problems. Journal of Substance Abuse Treatment, 75, 54-61.

44.

Wenger

L. M.

(2011). Beyond ballistics: Expanding our conceptualization of men’s health-related help seeking. American Journal of Men’s Health, 5, 488-499.

45.

El-Bassel

Gilbert

O’Connor

Seewald

(2011). Traditional male ideology and service system involvement among drug-involved men who perpetrate intimate partner violence: A longitudinal study. Journal of Interpersonal Violence, 26, 1646-1663.

46.

Yousaf

Grunfeld

E. A.

Hunter

M. S.

(2015). A systematic review of the factors associated with delays in medical and psychological help-seeking among men. Health Psychology Review, 9, 264-276.