The effectiveness of sexual assault referral centres with regard to mental health and substance use: a national mixed-methods study – the MiMoS Study

Hughes E, Domoney J, Knights N, Price H, Rutsito S, Stefanidou T, Majeed-Ariss R, Papamichail A, Ariss S, Gilchrist G, Hunter R, Kendal S, Lloyd-Evans B, Lucock M, Maxted F, Shallcross R, Tocque K, Trevillion K
Record ID 32018005321
Authors' objectives: Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed. Sexual assault is a common but under-reported crime; the consequences can be devastating and wide-reaching, impacting on a person’s health, mental health, use of substances, as well as impacting on work, education and relationships. Sexual assault referral centres (SARCs) were established to provide an integrated service, offering forensic examination, sexual health, emergency contraception, pregnancy tests, and post-exposure prophylaxis to prevent HIV. SARC service specifications state that mental health problems should be identified and referrals made to address these needs. However, it is not clear how and when that assessment should happen, or by whom, and how best to offer mental health aftercare. Many people who attend a SARC had prior contact with mental health services (40%), so it is important to consider the needs of those with pre-existing mental ill health and those at risk of developing mental health problems as a result of the assault. An acute trauma response is a normal psychological reaction to sexual assault and many survivors will not require mental health care. However, it is important to identify and offer appropriate support to those with significant needs.
Authors' results and conclusions: People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have ‘complex’ needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault. Review: the most commonly reported method of assessing mental health and alcohol and/or drug use was using an unstructured and often unspecified assessment. Use of validated screening tools was rarely reported and where they were mentioned, this tended to be screening for post-traumatic stress disorder (PTSD) specifically. The most common support offered was ‘counselling’ but this was poorly described. There was limited mention of evidence-based therapies such as eye movement desensitisation reprocessing or cognitive behaviour therapy. There were five randomised controlled trials (RCTs) which evaluated psychoeducation tools. Overall, there was a lack of robust evidence to inform how best to address mental health and substance use in SARCs. A realist synthesis was undertaken to identify initial programme theories. WP2: In the audit, a 77% response rate was achieved. Few SARCs had mental health expertise in the team and 7% of SARCs had in-house or co-located psychosocial support. There were limited formal care pathways to partner agencies and respondents were less satisfied with level of integration with local mental health and alcohol/drug services compared with rape counselling and domestic violence services. WP3: Prevalence study – of the 275 people who gave consent to contact, successful contact was made with 157 (43%) and, of these, 78 were enrolled on the study; 76% scored moderate/severe distress on CORE-10; 94% of scores indicated PTSD; 63% of scores indicated a possible personality disorder; 12% were drinking at ‘risky’ alcohol levels (AUDIT-C) and 26% had a moderate to severe drug problem according to the DAST. In terms of quality of life, most (87%) had low quality of life from ReQoL scores. WP4: Case studies – SARC staff identified that the lack of having mental health expertise alongside fragmented care pathways meant that people who were identified as having continuing mental health needs were not able to efficiently get those needs met. In SARCs where there was in-house or co-located psychological support, this seemed to improve the speed and quality in which people received the right care at the right time. In addition, there were wider benefits to having a mental health professional in the team in terms of contributing to team discussions on care planning and referrals, as well as supporting staff in terms of informal support and reflection on practice. Survivors found the experience of the SARCs very helpful, specifically around the trauma-informed practices that helped them reframe their experiences, seeing themselves as survivors rather than victims. The survivors’ experiences of past and current mental health services was less positive owing to long waiting lists, limited sessions being offered due to resource issues, or not quite fitting into a service remit. WP5: In SARC 5, there was a stepped care model for counselling and therapy. Between April 2020 and December 2020, 467 people referred to counselling and 229 to psychological therapies. Those on the higher-intensity therapy track had higher needs at baseline and received more sessions than those referred for counselling. Despite this, the average change scores for both groups were similar at end of therapy. Reasons for disengagement with counselling were mainly about difficulty travelling to sessions (SARC 5 covers a large mainly rural area). There was less textual information regarding the therapy service but this information indicated that some referrals were not accepted because the person’s needs were too complex and were stepped up to other mental health provision. In the CRIS data analysis, the cohort identified as having been sexually assaulted compared with a control group had higher needs and complexity at baseline. They also had more sessions of therapy than those without a history of sexual assault. However, despite the baseline differences the sexual assault cohort has similar average change scores in the CORE-10 outcome data compared with the control group. People who attend SARCs have high levels of need in relation to mental health and alcohol/drug use, and clarity is required as to how these needs should identified and addressed by SARCs and partner agencies. The trauma-informed approach adopted by SARCs aids in survivor recovery and mental well-being. However, some survivors have multiple needs that may require intensive evidence-based therapies delivered by people who understand sexual trauma. There is a clear imperative for SARCs and partner agencies to develop closer relationships and agreed pathways so that survivors have their needs accurately identified and are referred to the right service for those needs.
Authors' recommendations: Further research should investigate whether routine screening improves access to mental health care and outcomes for survivors. There is a need for research to evaluate co-located bespoke therapy using a RCT to establish clinical and cost-effectiveness. In addition, there is a need to investigate how gaps in therapy provision can be addressed and evaluated, specifically for those who are perceived to have more ‘complex’ needs. Further research should investigate how to improve routine enquiry and recording of sexual violence in mental health and substance use.
Authors' methods: Staff and adult survivors in English sexual assault referral centres and partner agency staff. A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5). The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic. Staff who work in SARCs, representatives from relevant partner agencies, and survivors. WP1 consisted of a systematic review that sought to address three questions: (1) how mental health and drug/alcohol issues were identified and assessed; (2) evidence for interventions that aimed to improve mental health and/or drug/alcohol issues following an attendance at a SARC; and (3) stakeholder views (including survivors) of how SARCs can promote and support mental health. WP2 was a national audit of SARCs in England, which collected information about skill mix, assessment, what mental health support was available, and partnerships with other agencies. A cluster analysis was performed to group SARCs by their similar responses to these key variables. WP3 was a prevalence study. The sample included people who had recently attended a SARC (data were collected between one and six weeks of attendance). The study was impacted by the COVID-19 pandemic, especially WP3. The target of 360 people was not achieved and, even after extending recruitment period by three months, only 78 were recruited from four of the six sites. This had a knock-on effect for recruitment for the survivor qualitative interviews. All the data were collected using remote methods, which worked well, and there were no issues related to this method in terms of people declining to participate.
Project Status: Completed
Year Published: 2023
URL for additional information: English
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • Sexual Trauma
  • Mental Health
  • Substance-Related Disorders
  • Substance Abuse Treatment Centers
  • Intimate Partner Violence
  • Mental Health Services
Organisation Name: NIHR Health Services and Delivery Research programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
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