Plain English Summary
Background and study aims
Approximately 45% of all Dutch people experience one form of domestic violence (DV) during their lifetime. Domestic violence can be defined as 'any incident of threatening behavior, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been an intimate partner, family member, friend or otherwise closely involved. Recent studies have found a high prevalence of domestic violence among female and male psychiatric patients. Results from the Dutch nationwide study on victimization in psychiatric patients suggest a 6 fold increase of domestic violence in severe mental illness patients as compared to the general population. Domestic violence can result in anxiety, depression, post-traumatic stress disorder, addiction and psychosis. However, domestic violence in psychiatric patients is often not detected. Only around 10-30% of cases are detected by psychiatric service providers. Research has shown that identification of victims of domestic violence by health care professionals can increase with training and organizational change within health care systems. With the BRAVE (Better Reduction through Assessment of Violence and Evaluation) study we will train and educate professionals in health care on domestic violence and strengthen referral pathways to and from specialized services in domestic violence. By doing this, we aim to improve detection and referral rates of domestic violence and eventually reduce victimization of psychiatric patients.
Who can participate?
The study will include CMH service teams: FACT teams (Functional Assertive Community Treatment) which are teams specialized in outreaching health care. All FACT-teams operating in Rotterdam and around are eligible for inclusion. The FACT teams all have approximately 200-250 patients with severe mental illness in their care. One FACT team consists of a psychiatrist, psychologist, social psychiatric nurses and social workers.
What does the study involve?
The BRAVE intervention (or programme) is made up of 8-hours of training for 12 FACT teams on domestic violence, a 6 hour training of DV professionals at GGD Rijnmond about psychiatric patients, and a pathways for referrals back and forth between FACT teams and DV professionals at GGD Rijnmond (Municipal services specializing in specializing in domestic violence). FACT teams are randomized into 12 intervention, and 12 control teams. The control teams will give care as usual. We assess the referral rates and detection rates of cases of domestic violence over the period of one year from the start of the intervention. At the end of the study, we compare the number of detected cases of domestic violence and the number of referrals to the services for domestic violence of the intervention teams with the control teams. To evaluate the feasibility, sustainability and acceptance of the intervention, we interview a purposive sample of members of the FACT teams from the intervention group and the control group as well as some people from the teams working at GGD Rijnmond.
What are the possible risks and benefits of participating?
We hope that by an increase of detection of domestic violence, patients will be referred to the GGD Rijnmond teams faster and that they’ll receive fitting care regarding domestic violence. We also hope that, in time, the risk of domestic violence against psychiatric patients will decrease and that the burden for psychiatric patients being victimized by domestic violence will decrease. Adverse events will be reported.
Where is the study run from?
The study is run from the Erasmus Medical Center, Department of Psychiatry. The study is conducted at BAVO Europoort in Rotterdam and Antesgroep in Rotterdam (Netherlands)
When is the study starting and how long is it expected to run for?
September 2015 to January 2019
Who is funding the study?
Netherlands Organization for Scientific Research.
Who is the main contact?
Dr Roos Ruijne
Reduction of domestic violence against psychiatric patients: the BRAVE study, a cluster randomized controlled trial
BRAVE (Better Reduction trough Assessment of Violence and Evaluation)
Primary hypothesis: the intervention will be associated with a significantly higher detection – and referral rate of domestic violence (DV) in the intervention teams compared with the control teams.
Medical Ethics Committee Erasmus Medical Center, 07/07/2015, MEC-2015-409
Multi-center cluster randomised controlled trial
Primary study design
Secondary study design
Cluster randomised trial
Patient information sheet
Not available in web format, please use contact details to request a participant information sheet
Domestic violence against psychiatric patients
The proposed intervention consists of:
1. A training for clinicians (social psychiatric nurses, social workers, psychiatrists, psychologists) working in CMH services (FACT) teams , of 8 hours using the LARA training manual (Howard et al., 2013) but modified for the Dutch setting, and training materials on DV already used by DV and CMH services (see ‘Toolkit Meldcode Huiselijk Geweld en Kindermishandeling’ and ‘Toolkit implementatie meldcode’). The training will comprise:
1.1. Identification of DV by a clinician interviewing the patient and standardized risk taxation instruments, e.g. the Dutch DV screening instrument(s) developed by Verwey-Jonker institute (Tan & Verwijs, 2012), and comprehensive risk assessment
1.2. Appropriate initial response to disclosure of DV
1.3. Referral pathway to specialized public DV services
1.4. Knowledge of available specialized local and national services regarding DV
1.5. Knowledge on legislative measures available to prevent DV
1.6. Explanation on the guidelines for DV (NVvP, 2009)
1.7. Clinical techniques on how to support victims of DV
1.8. Personal safety (for patient and clinician)
1.9. Role playing for interviewing the patients
1.10. A training for clinicians on the use of self-help methods for victims of DV a ‘Spiraal van Geweld’ (Groen & Van Lawick, 2008).A violence manual for clinicians, incorporating good practice guidance and local/national DV services (in Dutch: sociale kaart)
2. A training for municipal DV professionals of 6 hours on:
2.1. Mental illness, including definitions of disorders, treatments and service provisions
2.2 Knowledge of DV experts/expertise available in MHC services
2.3. Personal safety (for patient and professional)
3. Provision of integrated service on DV for PPs, modified for this study and delivered by both the DV service professionals and CMH service clinicians (collaborative effort). Integrated care will comprise emotional and practical support, including DV education, facilitation of support groups, safety planning and legal/housing support. A named DV professional will be available to discuss cases, take referrals, feed outcomes back to the MHC team and to regularly attend meetings.
Primary outcome measures
1. Number of detected cases of DV per team at 6 and 12 months following training
2. Number of referrals to public DV services per team at 6 and 12 months following training
Secondary outcome measures
1. Whether the training program increases the skills and knowledge regarding DV of the professionals, as compared to the professionals in the control condition, on short – and long term will be assessed using a structured questionnaire (PREMIS). Our parameter will be the mean total score of the PREMIS, aggregated per team at 6 and 12 months following training
2. Feasibility, sustainability and acceptance will be assessed in detail using a qualitative method (e.g. semi-structured in-depth interview) for which no parameters are set
Overall trial start date
Overall trial end date
Participant inclusion criteria
In order to be eligible to participate in this study, a team must meet all of the following criteria:
1. MHC teams must be FACT teams employed by BAVO Europoort or the Antes Groep
2. Provide care to adult SMI patients (>18 years) in the Rotterdam-Rijnmond area
3. A functioning electronic patient file system, with at least 12 months of historical data
Target number of participants
We would like to include 24 FACT teams. We also include all the teams specialized in domestic violence at the Muncipal Health Service in Rotterdam.
Participant exclusion criteria
A potential subject (team) which meets any of the following criteria will be excluded from participation in this study:
1. Provide care outside the Rotterdam-Rijnmond area
2. Provide care to patients younger than 18 years
3. Consist of clinicians that are employed by more than one team
4. No functioning electronic patient file system
5. Less than 12 months of historical data in the electronic patient file system
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
Prins Constantijnweg 48
Trial participating centre
Trial participating centre
's Gravendijk wal 230
Nederlandse Organisatie voor Wetenschappelijk Onderzoek
Netherlands Organisation for Scientific Research, Dutch National Scientific Foundation, Dutch National Science Foundation, NWO
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Trial results will be published in scientific journals. Additionally main results will be communicated to the participating mental health institutions. The researchers intend to send the protocol paper for publication in June 2017. The main paper will be written in December 2018.
IPD sharing statement:
The datasets generated during and/or analysed during the current study are/will be available upon request from Roos Ruijne (email@example.com)
Intention to publish date
Participant level data
Available on request
Results - basic reporting