Most perpetrators of domestic violence will not come into contact with the criminal justice system – but many seek help for their behaviour.

In a small-scale study, researchers found that most men who sought help for their violent or abusive behaviour initially went to their GP but presented with a secondary concern such as depression or anxiety. Skilful practitioners may be able to point their patients to relevant sources for help rather than ‘mislabelling’ or ‘medicalising’ the actual underlying problem.

This chapter concentrates largely on male perpetrators of domestic violence as this is the most common and most researched group. Although there is thought to be great overlap and common traits between them, we cannot assume that perpetrators of domestic and of sexual violence share the same characteristics, nor that male and female perpetrators are similar. Nevertheless, simple practical skills should help health professionals deal with relevant issues for all these groups.

Some perpetrators will recognise their violent and abusive behaviour and ask for help—though usually they will have been motivated by a possible consequence. For example, their partner may have threatened to leave if they don’t seek help, the worst incident of violence and abuse may recently have taken place or there may be impending criminal justice proceedings.

Very few perpetrators of domestic violence will state clearly that they are a perpetrator, even when help-seeking (see Box 10.1).

If you are presented with ‘mitigating factors’, such as drinking, stress or depression, it may be useful to ask:

• ‘How is this [drinking/stress at work/depression/anger] affecting how you are with your family?’
  
• ‘When you feel like that, how do you behave?’
  
• ‘Do you find yourself shouting or smashing things?’
  
• ‘Do you ever feel aggressive or violent towards a particular person?’
  
• ‘It sounds like you want to make some changes, for your own benefit and for the sake of your [partner/child/parent]. What choices do you have? What can you do about it? What help would assist you to make these changes?’

If domestic abuse has been explicitly stated as an issue, it may be useful to ask:

• ‘It sounds as though your behaviour can be frightening; does your partner say she is frightened of you?’
  
• ‘How are the children affected?’
  
• ‘Have the police ever been called to the house because of your behaviour?’
  
• ‘What worries you most about your behaviour?’
  
• ‘Who else might be frightened of you?’

Certain factors and/or combinations of factors can indicate the likelihood of serious harm or homicide towards a partner, ex-partner or children:

• High levels of coercive control.
  
• Grabbing by the throat or strangulation.
  
• The victim indicating they are in fear for their life.
  
• Threats to kill or the use of weapons.
  
• Stalking, harassment, high levels of jealousy.
  
• Pregnancy.
  
• Substance/alcohol misuse.
  
• Escalation of levels of violence and increase in frequency.
  
• Continuation despite the intervention of services.

Direct questions relating to heightened risk factors may sometimes be appropriate:

• ‘Do you feel unhappy about your partner seeing friends or family; do you ever try to stop her?’
  
• ‘Have you assaulted your partner in front of the children?’
  
• ‘Have you ever assaulted or threatened your partner with a knife or other weapon?’
  
• ‘Did your behaviour change/has your behaviour changed towards your partner during pregnancy?’
  
• ‘What has been the worst occasion of violence?’
  
• ‘Have you ever grabbed your partner by the throat?’
  
• ‘Do you feel that your behaviour has got worse?’

Before offering an intervention, ask yourself, ‘Does the intervention I’m offering increase the safety of the victim and their children or have I just made it easier for the abuser to abuse?’ In other words, be careful to do no further harm.

To this end, you should look to work with services that are focused on victim and child safety and that support perpetrators of violence in becoming accountable for their behaviour. The dos and don’ts listed in Box 10.2 may help guide your actions and responses.