Program Profile: Better Reduction and Assessment of Violence (BRAVE) Intervention (the Netherlands)

This was a system provider–level training for community mental health teams in the Netherlands to improve detection of and response to domestic violence and abuse in patients with mental illness. The program is rated No Effects. There was no statistically significant difference in the rate of detection or referral of current domestic violence and abuse for teams that received the intervention, compared with control teams that did not receive training, at the 12-month follow-up.

A No Effects rating implies that implementing the program is unlikely to result in the intended outcome(s) and may result in a negative outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Victims of domestic violence and abuse are at risk of serious physical and emotional consequences. Further, preexisting mental illness is associated with a higher risk of domestic violence and abuse victimization (Kamperman et al., 2014). Yet, despite the high risk of victimization, recent research has found that while examining cases of individuals from across numerous countries, only a small number (about 10 percent to 30 percent) of victims of domestic violence and abuse are identified while in the mental-healthcare system (Howard et al., 2010). The Better Reduction and Assessment of Violence (BRAVE) intervention was a gender-sensitive, system-level program that targeted community mental health teams and provided mental health training for domestic violence and abuse professionals in the Netherlands. The goal of the BRAVE intervention was to improve detection and referrals for domestic violence and abuse cases identified in the mental-healthcare system.

Program Components/Key Personnel

The BRAVE intervention was based on the “Linking Abuse and Recovery Through Advocacy” intervention (Trevillion et al., 2014) and adapted to the Dutch context and circumstances. The BRAVE intervention consisted of three parts: 1) a training course for community mental health teams to increase knowledge, attitudes, and skills in managing domestic violence and abuse, 2) a knowledge, attitudes, and skills training course on mental illness for domestic violence and abuse professionals, and 3) the provision and implementation of a direct-care referral pathway between community mental health services and domestic violence and abuse services for victims.

In the first component, clinicians from community mental health teams received an 8-hour training course, divided into two 4-hour sessions. The training covered four themes: 1) facts and theories about domestic violence and abuse; 2) identification and documentation techniques for the assessment of domestic violence and abuse; 3) safety for both patient and community mental health clinicians; and 4) treatment and/or follow-up, which consisted of a referral pathway and proposed strategies to empower and support patients who are victims of domestic violence and abuse. The training was delivered through lectures, documentary media, and interactive workshops. The information in the training focused on both male and female victims and also addressed possible cultural differences that clinicians could notice in their diverse patient population.

In the second component of BRAVE, domestic violence and abuse professionals received four 3-hour workshops about mental illness that consisted of three main themes: 1) information on mental illness (prevalence, definitions, and symptoms), 2) the organization of mental health care in the Netherlands, and 3) Dutch laws and legislation about health care, mental health care, and the communication and exchange of information with professionals working in mental health care. Because of a nationwide reorganization of the municipal public health service, participation in this component could not be made mandatory.

In the third component of the BRAVE intervention, community mental health teams received the information and tools needed to implement a direct-care referral pathway into their daily working routine. This pathway contained the mandatory Dutch decisionmaking protocol on whether to refer suspected victims of domestic violence and abuse, and possible institutions to refer them.

In the Netherlands, a typical community mental health team consists of 9 to 14 diverse mental health clinicians. The composition of each team can vary slightly but generally employs a psychiatrist, psychologists, general nurses, social psychiatric nurses, and social workers.

Study 1

Ruijne and colleagues (2021) conducted a cluster randomized controlled trial to assess the effectiveness of the Better Reduction and Assessment of Violence (BRAVE) intervention on community mental health teams’ detection and referral of domestic violence and abuse in serious mentally ill patients at the 12-month follow-up. The study took place in two urban areas of the Netherlands, from February 2016 to February 2017 for all Rotterdam teams and February 2017 to February 2018 for all The Hague teams.

Community mental health teams that provided outpatient care to serious mentally ill patients 18 years or older, with at least 20 percent of employees working in more than one team and who had a functioning electronic patient file with at least 12 months of historic data, were eligible for participation. Twenty-four community mental health teams were randomly assigned to receive the BRAVE intervention or to the control condition, with an allocation ratio of 1:1. Randomization was performed with block sizes of two, using a web-based computer-generated scheme. The socioeconomic status of the service region of each of the 24 community mental health teams (dichotomized into high versus low socioeconomic status) was used as a stratification factor.

Community mental health teams in the control condition (n = 12) provided care as usual, which consisted of outpatient care to patients with a severe mental illness. BRAVE intervention teams (n = 12) received the intervention as described in the Program Description. The mean age of community mental health professionals in the BRAVE intervention was 43.5 years, compared with 42.5 years in the control condition. Community mental health professionals in the 12 BRAVE intervention teams (n = 115) were 41 percent male, and the majority were either general nurses (40 percent), psychiatric nurses (21 percent), or social workers (15 percent). Community mental health professionals in the 12 control condition teams (n = 99) were 38 percent male, and the majority were either general nurses (38 percent), social workers (15 percent), or another discipline (14 percent). The study authors did not indicate whether there were any statistically significant differences between the intervention and control conditions at baseline.

An automatic search query was performed on electronic files of patients treated by each team during the 12-month period before the intervention, and at 6 and 12 months after the start of the intervention. Files flagged as potential cases of domestic violence and abuse were additionally vetted and categorized as either a detected current case of domestic violence and abuse or no domestic violence and abuse. Detected cases were then categorized as perpetrator or victim and type of violence (sexual, physical, material, or emotional). Violence was stratified to physical violence if it was described in the electronic patient file as a patient being, for example, slapped, hit, or otherwise physically assaulted. Violence was marked as sexual if a patient was, for example, raped or otherwise sexually assaulted. Violence was marked as emotional if the electronic patient file described a patient being threatened or stalked. Violence was marked as material if a patient was described to have been a victim of vandalism or financially exploited. Cases were also examined if they were referred to a domestic violence and abuse professional, externally discussed (discussed with a domestic violence and abuse service provider whether referral was necessary), internally discussed (discussed in a multidisciplinary setting whether referral was necessary), or no follow-up action was taken. Thus, detected cases were the sum of all cases in the patient files, and the number of domestic violence and abuse referrals was the sum of all follow-up actions.

The effect of the BRAVE intervention on the outcomes of interest (the rate of domestic violence and abuse cases detected and referred per team) at the 12-month follow-up, compared with the control condition, was estimated using a generalized linear mixed model with logit link and binomial distribution. The model included intercept, allocation (BRAVE intervention, compared with the control condition), time (as a continuous variable), and the interaction term of allocation with time. The number of patients detected or referred during the intervention period was used as the numerator, and the number of patients treated during this period was used as the denominator. Cases were stratified according to the type of violence (physical, sexual, emotional, and material), and whether the cases concerned victimization, perpetration, or both. Since the use of a structured domestic violence and abuse form in the electronic patient file was recommended during the BRAVE training, the rate of completed forms was assessed. Analyses were repeated, excluding cases of violence occurring among roommates (i.e., sheltered housing), and adjusted for standardized baseline rate. Subgroup analyses were conducted by type of domestic violence and abuse victimization.

Subgroup Analysis

Ruijne and colleagues (2021) conducted subgroup analysis by type of victimization and found no statistically significant difference between community mental health teams that received the Better Reduction and Assessment of Violence (BRAVE) intervention and control condition teams in the detection of current physical, sexual, emotional, or material domestic violence and abuse victimization at the 12-month follow-up.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: