An Interview with our Guest Contributor, Dr Vishal Bhavsar

Could you share your journey from preclinical studies at Oxford to your current role as a consultant in forensic psychiatry and parental mental health?

My medical school course was really about how medical practice is informed by research, and I got interested early on in how scientific evidence is made and shared. I moved to London in the middle of medical school, not sure of what specialty I wanted to do within medicine. I really loved my placement on an inpatient psychiatric ward in Lewisham, and I decided I wanted to do psychiatry as a career. Over time I developed research experience on different projects- I enjoyed thinking about problems in psychiatry in depth, particularly around the role of culture and society in shaping mental health. After qualifying in medicine, I specialised in psychiatry and had a series of research placements, to help me build experience before applying for the Fellowship I hold now. This appointment combines research in domestic abuse which I do around four days a week, and clinical practice as a consultant psychiatrist. In my clinical role I work with two teams- a community forensic team and a parental mental health team.

Looking back on your career, what would you say has been your proudest moment or achievement?

My first competitive research funding was a fellowship awarded by the Wellcome Trust, which allowed me to do a Master’s degree in epidemiology and a PhD to begin my proper research training. This was a difficult process of interviews with a big committee and a long application form, completed while I was working full time as a trainee psychiatrist. This success put me on the path to developing an independent research career, and to develop my current role as a researcher on domestic abuse and mental health.

What impact did your elective placement at the National Institute of Mental Health and Neurosciences in Bangalore have on your approach to psychiatry?

I came away from my early experiences in learning about psychiatry thinking a lot about how culture and societal forces shape mental health. I went to India during my medical school elective partly to explore a different mental health system, and partly to visit my family (who live in Gujarat in India). In Bangalore I saw a different way of delivering mental health care, particularly through the involvement of families in outpatient clinics and on wards-national centres where patients would be accommodated with their families. Developing how mental health professionals can work better with the whole family is a big part of my work now.

Your current work focuses significantly on violence, particularly in mental health service users. What drew you to this area of research, and what do you hope to achieve in this space?

I found during my training in psychiatry that professionals sometimes tended to under-estimate the frequency and impact of violence in the lives of patients and their families. I encountered many people with mental health problems who had been exposed to violence over the course of their lives, both before and after the onset of their health problems, and I got interested in the reasons underlying this greater experience of violence.  Often, our underlying assumptions around violence as professionals is that a. we can reduce violence by more effectively treating mental illness, so we don’t need to do anything specific to reduce violence, and b. violence reduction doesn’t fall within the role of mental health services. Ultimately my work aims to help health professionals and services recognize that identifying, reducing and preventing is a core role of health services, and a key way of achieving health equity.

Given your research into mental health service responses to domestic violence, what do you see as the most critical factors in effectively addressing domestic abuse within these services?

There needs to be a stronger care pathway for domestic abuse within mental health services, greater emphasis on safe identification and assessment of domestic abuse(including coercive control) in the training and supervision of mental health professionals, and targeted support for victim/survivors which can be delivered at scale. Experiencing domestic abuse as a victim can sometimes go with a history of perpetrating domestic abuse, and this is an area in need of specific solutions. Children are victims of domestic abuse and mental health services have a big challenge to work with the whole family, including parents, children, and extended family members, where domestic abuse may be occurring.

In your experience, how do domestic abuse and mental health issues intersect, and what challenges do mental health professionals face when addressing these overlapping concerns in their practice?

As I said, I think developing the confidence and maintaining the curiosity to ask questions to identify domestic abuse is a really important challenge for mental health professionals. But once it is identified, professionals experience challenges around discussions about what to do in the relationship, how to record information safely and correctly, and how to respond adequately to the perpetrator (who might not have health issues or be in contact with any services or the criminal justice system).

The For Baby’s Sake Trust aims to break cycles of domestic abuse and give babies the best start in life. Could you share any insight on the importance of early intervention in the domestic abuse space and its impact on long-term outcomes for children and families?

Lots of research carried out since the 1960s shows that children living in households where there is domestic abuse experience other adversities (like experiencing violence themselves or being taken into care), and this has impact on later life outcomes including health and wellbeing.

Early intervention means lots of different things! Addressing children as victims of domestic abuse in their own right is crucial for offering the right support as children develop into adults. I would say (personally) that this is particularly relevant for boys living with domestic abuse, because of the gender asymmetry we see in who perpetrates abuse in adulthood.

In health services, domestic abuse is often not picked up by health professionals because they don’t have the confidence or skills or time to ask. This is particularly the case for perpetration of domestic abuse, possibly because there has more attention paid to identifying and supporting victims, and responses to perpetrators have been overlooked.

How do you see the role of collaborations between mental health services and organisations like The For Baby’s Sake Trust in creating more comprehensive support systems for families affected by domestic abuse?

We need to improve the way in which health services respond to families, and organisations like The For Baby’s Sake Trust have a great deal of knowledge to share with health services about safe and equitable practice with complex families. On the other hand, organisations like The For Baby’s Sake Trust and the complex families they work with can sometimes experience difficulties in accessing mental health care and support, and health services could put better systems in place for offering targeted support, e.g. when a father working with a parenting programme experiences worsening mood and suicidal thoughts.

Your recent publication of clinical guidance for mental health professionals working with patients who may use abusive behaviours is a significant contribution. What motivated this project, and what are its key recommendations?

Thanks. The aim of my research is to develop evidence which we can use to inform guidelines, tools and training for professionals on responding to perpetrators of domestic abuse. The aim of the guidance we wrote was to consolidate existing sources, highlight gaps, and provide professionals with specific recommendations about what to do when they encounter a perpetrator of DA in routine clinical practice. Some readers of the guide will find that the guide reinforces what they are already doing, but others will come across information they have not met before, for example on the national helpline for male perpetrators of DA run by Respect. We also present a comprehensive justification argument for developing better responses to DA perpetrators. We identify clinical settings and scenarios where identifying perpetration of DA may be especially important, highlighting the (many) areas where we need much better evidence.

How is your work incorporating machine learning to improve the measurement of violence in mental health services, and what potential does this technology hold for future developments in this field?

Our research team have developed computer tools which can detect sentences which refer to domestic abuse. If we can apply these tools to anonymised electronic patient notes, researchers can understand more about how domestic abuse is identified by health professionals, and how they respond, and what future learning and support needs might be for services.

Whether these tools might be useful in routine clinical practice is an interesting question, and something we should look at in the future. Accurate tools of this type could be helpful in informing professionals if the person they are seeing has ever been asked about domestic abuse, or whether there are historic references to domestic abuse in the person’s history that should be explored further.

Based on your extensive experience and research, what new policies or government initiatives would you like to see implemented to better support mental health services and address domestic violence and abuse?

Health settings are a critical place for improving the societal response to domestic abuse. I would like to see a greater shift in policymaking emphasis from criminal justice and punitive responses toward improving healthcare responses to domestic abuse and people perpetrating domestic abuse. I would like to see better joint working between agencies, with guidance/operating models from government about how to do this. I would like national recording of domestic abuse as part of minimum data collection for all health services including mental health services. I would like to see more research and service development on parental mental health and the best way to deliver support for parents with mental health problems-e.g. a separate self-contained teams working within CAMHS, or in adult services, or in more dispersed models e.g. parenting practitioners spread out across community mental health teams. I am working towards building evidence to support better training and guidance for professionals on responding to patients who are or may be perpetrating domestic abuse.

Mental health services tend to have a binary response to violence- either to contain/minimise it, or to refer to forensic services and/or to police/criminal justice. Instead, mental health services should be collecting relevant information on violence and mental health and using this information to evaluate risks and share this with relevant parties, and co-develop management plans which are tailored to these risks- including prescribing, psychological support, and support for victims/potential victims including children. To achieve this vision, we need investment in evidence-based interventions to change behaviour and keep families safe, which are developed and designed with mental health and service users in mind. We need to be sharing expertise much more freely across the boundaries between the DA sector and health services.  

Thank you for sharing, Vishal! 

If you’d like to be involved in our Guest Contributor series, please email daisyobrien@forbabyssake.org.uk