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Trauma informed work: the key to supporting women

Jo Sharpen has worked for AVA - Against Violence and Abuse since 2006, managing the children and young people’s project and then as policy manager.  Prior to this she worked for the Institute of Psychiatry as a researcher and then at Eaves Women’s Aid for several years, in a refuge. As well as working for AVA she is also a freelance consultant, researcher and online counsellor.
 

“Some people think that a trauma-informed environment is putting a plant in a room!”

- Woman with lived experience

A generally accepted definition of trauma is ‘an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.[1]’ Domestic abuse is clearly a form of trauma, made all the more complex due to the fact that it is planned yet unpredictable and takes place in the context of a relationship.

Research shows a significant overlap between experiences of abuse, substance use issues, and mental health. Up to a half of women with dual diagnosis of mental health and substance use issues have experienced sexual abuse.[2] Between 60-70% of women using mental health services have a lifetime experience of domestic abuse[3]. Women who have experienced domestic and sexual abuse are 3 times more likely to be substance dependent than non-abused women[4]. These figures demonstrate a clear need for a more trauma informed approach to supporting women experiencing domestic abuse and multiple disadvantage. However, as this Spotlight series shows, access to gender specific, trauma-informed mental health services is often lacking for survivors of abuse.

“They don’t look below the surface as to why you are using. When a crisis hits, it’s never just about one thing. We need a service that deals with all our issues, not in silos.”

In our recent report, in conjunction with the Make Every Adult Matter coalition, Agenda, and St Mungo’s, ‘Jumping Through Hoops’ we spoke to survivors of abuse and multiple disadvantage who told us that statutory mental health services were the most difficult to access. Women told us that if they missed appointments, cases were often closed and they would need to be re-referred. Our report concluded that ‘non-engagement is therefore seen as a refusal of services, not a common symptom of mental health, trauma and complex needs, when sometimes attending appointments can feel overwhelming and frightening’.

These sentiments were echoed in our recent research for the National Commission into women facing domestic and/or sexual violence and multiple disadvantage. Our peer researchers, all women with lived experience of these issues, interviewed 29 other women with similar lived experience and found that mental health was the overall dominant narrative across all interviews and surveys, regardless of experience, age or any other individual characteristic.  Combined with long waiting lists, short term therapy, a lack of consistent practitioners and constantly having to re-tell their stories, women’s experiences of abuse and trauma were compounded and the experience of trying to access support was re-traumatising in itself.

The women we interviewed for both reports were very clear that practitioners needed to develop a more trauma informed approach.  Past experiences of trauma and complex needs can sometimes lead to conditioned behaviours, which serve as a psychological defence or coping strategy for women but may feel very difficult to understand for an untrained worker. In fact, some practitioners admitted that they found some women’s presenting behaviours difficult to understand and respond to. One specialist complex needs worker with Women’s Aid described her relational way of working whereby she takes time to sit, talk and listen. “Simply having a cup of coffee with someone, makes them feel human. You get told more, you may find out stuff before the more relevant service due to creating an informal, trusting, person-centred relationship.”

Services that embrace ‘resilience over pathology’ are ones that women are much more likely to use and feel supported by. A shift from ‘what’s wrong with this person?’ to ‘what happened to this person?’ is the essence of this approach. The Mapping the Maze report highlights the important role the voluntary sector plays in supporting women’s mental wellbeing, with 43% of women’s mental health services identified being run by the voluntary sector, who offer specific women-only support services. However, these vital services and a trauma informed understanding cannot just be the role of the voluntary sector. There are often challenges to partnership working, but the ‘Jumping through hoops’ report shows how co-ordinated approaches, rooted in trusting relationships with informed and trained practitioners, are critical to developing genuine, meaningful support for women who have experienced trauma.

For more details of AVA’s training on creating trauma-informed services, please visit our website.

 

Follow our Spotlight on domestic abuse and mental health for more blogs, podcasts, guidance and more.

Go to our Pathfinder mental health profile for blogs and guidance on the mental health sector response to domestic abuse. 

 

[2] Royal College of Psychiatrists (2002) Co-existing problems of mental disorder and substance misuse (dual diagnosis): an information manual

[3] Trevillion, K, et al (2012) Experiences of Domestic Violence and Mental Disorders: A Systematic Review and Meta-Analysis, Plos One, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530507/

[4] Rees, S., Silove, D., Chey, T., Ivancic, L., Steel, Z., Creamer, M., Teesson, M., Bryant, R., McFarlane, A.C., Mills, K.L., Slade, T., Carragher, N., O’Donnell, M & Forbes, D. (2011). Lifetime Prevalence of Gender-Based Violence in Women and the Relationship With Mental Disorders and Psychosocial Function. Journal of American Medical Association, 306:5, 513-521

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The role of the mental health representative at Marac

Alison Eley is the Named Nurse for Safeguarding Children, Domestic Abuse and Marac lead for South London and Maudsley NHS Foundation Trust. Alison has previously worked as a mental health nurse in a number of services in East London and has represented mental health services at various London Maracs for the past 11 years. She has also lectured in domestic abuse at City University of London.

Being asked to represent your mental health trust at a Marac meeting could make you feel a number of things. You might see it as a great learning opportunity. Alternatively, it may appear to be just another meeting in your diary. It might even seem daunting if you’ve never attended one and don’t understand the process or your role in it. There could be the assumption that your attendance is enough in itself to demonstrate agency sign-up and involvement.

I can recall having both of the latter responses when I first attended a Marac meeting many years back. Over time, however, I have come to appreciate and advocate the importance of Marac representation and processes being embedded across all mental health services. Mental health staff shouldn’t feel intimidated or doubt their role, as they can have so much to contribute to the action planning. And most importantly, they can help ensure victims/survivors access services they may desperately need.

If you’ve been asked to be a representative, a good start would be to ask to shadow any current representative from your trust, to get an idea of what the role involves. It can be a shock to take up the role only to discover the amount of preparation and follow-up work required. Find out if your local authority has any Marac training that you can access. SafeLives also offer free e-learning packages via the SafeLives Community. 

Make friends with your Marac co-ordinator; they are invaluable in tracking actions and providing information. Contact your trust DVA lead to see if there has been any guidance produced in-house, or any meetings that take place to help navigate the process.

It is important to familiarise yourself with your organisation’s information sharing and record keeping protocols, to ensure you are following your internal policy correctly. You will need to undertake careful research prior to the meeting, and attend prepared to share information, participate in proactive discussion and to assist in action planning, where appropriate. It is not enough to merely attend on a passive basis. The success of Marac depends on the involvement of all the agencies attending.

Ensure you have booked enough time in your schedule to undertake accurate prior research and subsequent actions. This can take a lot of time, depending on the number of cases being discussed. Even if there are few cases known to mental health services, the cases may be so complex that it can take hours to extract the required details and action outcomes. In extracting information to be shared, remember that this needs to be relevant, focused and proportionate to the case being discussed. Individual discussions in the meeting are time limited, so providing huge tracts of past history over many years, irrelevant facts or any personal beliefs held is neither helpful nor needed. Nor will it sit comfortably with information sharing agreements.

Ensure that cases are flagged on your electronic system, as a third party entry. This may be via an alert, or ‘red triangle’. It is crucial to flag cases up as having come to the attention of Marac. Victims and perpetrators of domestic abuse may present to different services within an organisation, and it is important that whoever picks up the case is aware of potential risks involved. It also helps workers to monitor ‘repeat’ cases. If undertaking a check on addresses, be aware of any other vulnerable people in the household who may not be included on the research list. This information can make a substantial difference within a case. We must consider the effects of domestic abuse on children and young people within a family or situation. I have come across a number of cases where CAMHS and/or perinatal staff have been involved, and have not previously been aware of domestic abuse within a family. It’s a crucial part of your role as Marac representative to reach out to and engage a range of clinicians within the trust.

If any person known to your trust is being care co-ordinated within mental health services, ask their care co-ordinator to liaise closely with you or if appropriate, attend the meeting for that one case. It’s important that you spend some time explaining to them the Marac process and their role within the meeting. Always ensure that you seek approval from the Marac Chair and Co-ordinator if you are inviting a member of staff to attend.

There are a number of actions you could offer at Marac. As one example, if you have reason to believe that the service user is needing urgent support, you might suggest to the Marac that you ask the care co-ordinator to issue an appointment earlier than planned. Other Marac representatives may have limited knowledge as to specific mental health diagnoses and the risk implications of them. Here the mental health representative can share their knowledge, enhance understanding and reduce stigma.

This might also lead to joint working outside of the Marac process: I have seen excellent joint training being provided in one mental health trust, in partnership between personality disorder services and DVA teams. There is real potential to develop shared learning opportunities, and to promote local service knowledge at a time where the health landscape can frequently shift.

Some cases on the Marac agenda may state that the people involved have mental health problems, but they are not known to secondary services. The role of the Marac rep here would be to help the meeting consider whether they are receiving support within primary care, what the thresholds are for higher tier services and/or whether they need help with accessing services. External agencies may not be aware of referral processes, how to access mental health services locally and the nature of these services. The Marac representative can provide an educative role, providing this information.

Another benefit of attending Marac is being in a position to potentially identify areas of your service where there are gaps in Marac referrals or indeed where there are high instances of clinicians working with victims and perpetrators. In one borough, it became noticeable that a high number of perpetrators were known to a therapeutic community team. This provided an opportunity to offer the team more focused support around working with perpetrators, in order for them to be better able to identify risk indicators attached, and to promote links with external agencies that could assist.

Finally, if there are a number of Marac representatives from your service, ensure you are meeting on a regular basis to discuss and log activity, monitor hotspots, consider how to embed Marac knowledge in directorates and services and to share information. Consistency of approach by Marac representatives in a borough – and indeed the organisation – means that all Marac meetings and cases discussed receive the same high quality input. Regular meetings can help you to support each other; knowing that there are people in-house who understand the work involved and possible challenges helps. Working together and promoting Marac brings so many benefits to the both the organisation and to victim/survivors and this cannot be underestimated.

Follow our Spotlight on domestic abuse and mental health for more blogs, podcasts, guidance and more over the coming weeks.

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Navigating the language - listening to the words women use to describe their mental health and hearing what they need

Medina Johnson is Chief Executive of IRISi, a social enterprise established to promote and improve the health care response to gender based violence. IRISi’s flagship programme is IRIS (Identification & Referral to Improve Safety), a general practice based domestic violence and abuse training, support and referral programme. Medina was one of the two original advocates working on the IRIS research trial from 2007-2009 and has been involved in the development of the project ever since. In this blog she discusses the experience of women referred into the IRIS programme over the last decade, the language they use to describe their feelings and how referral from their IRIS-trained primary care clinicians into specialist support has meant better outcomes for them around their mental and emotional health.

It was like screaming under water and no-one could hear me.

Domestic Violence and Abuse (DVA) can have a wide range of psychological and emotional consequences. As a result of their experiences, survivors can develop a number of serious mental health illnesses such as depression, anxiety, PTSD and panic disorders. Developing resilience, protective coping strategies and having support are all central to recovery from trauma which can be a long and arduous process, one that abusers actively seek to disrupt. The role of primary health care professionals in this recovery, coupled with specialist advocacy, is essential.

The IRIS programme trains and supports primary care teams to recognise when patients are affected by DVA, know how to ask about this, provide a supportive and validating response, carry out a simple risk assessment and safety check, offer a referral and make a clear record in the patient notes. The training around recognition includes understanding the mental health impacts that living with DVA can have on the survivor.

I worked directly with women affected by DVA for three years as part of the IRIS research trial and for the last seven years have trained and worked with dozens of IRIS Advocate Educators and Clinical Leads across over thirty sites in England and Wales who have supported over 10,000 women.

The data we gather annually from our sites and from the women referred in for support tell us that an average of 66% of women self-report having mental ill health, most commonly anxiety and depression. In addition, many women report self-harm and suicidal ideation. I suggest that any figure will be a vast under-representation of what the true picture is. I suggest this not least because the language women use to describe how they feel emotionally, how they feel they will be viewed and how they feel they will be supported is a sad reflection of bad past experiences.

Whether the words that women use are their own, what their perpetrators have told them or what those they have trusted have told them, they reflect a response that does not encourage further disclosure, help-seeking or a belief that there is anyone who can help them. They describe feeling “like a stupid woman”, being “mad” and “in a bad mental state”. Women report being told to “pull your socks up”, “get over it” and “get yourself together”. One woman says she was embarrassed to be asked about DVA but relieved at the same time:

‘I was embarrassed that my doctor asked me, and so pleased at the same time, he knew there was another reason for my depression and anxiety.’

A recurring theme is that that prior to being offered support via IRIS, women were offered medication while wanting instead to be asked about why they are feeling unwell, why their mood is low, why they feel they are struggling to cope. 

‘And you go to the doctors because you’re feeling very unwell and they take your blood pressure and give you some blood pressure tablets and I thought, I’ve got to talk to somebody. And I said, I don’t sleep at all. Oh well we’ll give you some tablets for that and some tablets for this.’

Being asked about DVA and having GPs make the link between low mood, depression and anxiety is a relief for women:

‘Hugely grateful that the doctor referred me. I wouldn't have done myself. I was in a very bad place. I was really lonely and she listened, heard me and just pick[ed] up where I was making excuses for my partner's behaviour. She didn't push anything at me, but made it clear there were options.’

GPs are pleased to have access to training and a referral route:

‘This is helpful, makes me think more holistically when assessing my patients. DV is something that can affect patients emotionally as well as physically’ (GP comment after IRIS training)

The language women use to highlight their feelings and experiences around their mental health at the point of disclosure and referral is both striking and poignant.  Women describe themselves as feeling overwhelmed, anxious, in torment, lonely, sad, isolated and in a bad place. The support via specialist advocacy to navigate some of their feelings and find their voice again is priceless.

‘This support is the best thing that ever happened to me. You guys (advocates) are the only ones who believed me. Although they didn't say so I felt everyone else looked at me as if I make things up and have mental health problems. You listened to me.’

‘Through some of the lowest and loneliest points in my life, IRIS was there, even if it was to help me remember to laugh, which sounds so simple, but it meant everything.’

Given the high rates of depression and anxiety reported by IRIS clients, IRIS pathways can provide a vital source of support to address these mental health needs.

‘When I felt I was falling about you were the one who held me together.’

The feedback questionnaires from survivors demonstrate that IRIS advocates are helping women improve their mental health. As a result of engaging with IRIS support, 99% of survivors felt they were listened to, 83% felt better able to cope, 85% felt more confident.

‘Before I was very sad and I was always thinking what will I do, now I am a confident person and a confident mum.’

81% of survivors reported feeling optimistic about their future and 70% said they visited their GP or nurse less.

We recognise that support via primary care and specialist advocacy are just two pieces in the recovery puzzle for women affected by DVA and whose mental health is affected. They are nevertheless significant pieces and part of the response we must all play in working to end DVA.

‘After our meeting, for a little while I felt I had come out of a tunnel. I could see the sun and the flowers and the trees and I felt OK, and I thought, this is how I should feel all the time.’

Note:

All data and quotes are from IRIS programmes running in England and Wales that are collated annually by IRISi and presented in a national data report.

 

Follow our Spotlight on domestic abuse and mental health for more blogs, podcasts, guidance and more over the coming weeks.

The impact of mental health on the response to perpetrators of domestic abuse

Jonathan Fowler has extensive experience, going back more than 25 years, as a therapist in (Secure) Psychiatric Settings (working with both violence & severe self-harm /trauma), working at the interface between mental health & the Criminal Justice System, with complex needs, and with Respect accredited DV perpetrator work.  He currently works as a facilitator on the Reprovide perpetrator programme, as a DVPP trainer and external supervisor, as mental health advisor for the Drive programme, and with specialised complex needs services.

Prior to working with male perpetrators of domestic violence, I spent many years as a therapist with survivors of violence; of physical, sexual and emotional abuse. Both in this work, and in my private life I have seen the devastating impact these experiences have on adults and children. It is vital that there are strong services that focus on safeguarding and supporting them. I feel strongly that part of this work must involve working with perpetrators, supporting them to take responsibility for their behaviour and reducing the risk of them abusing current, and future, partners and children. 

Supporting perpetrators to take responsibility becomes more complicated as soon as the possibility of their own mental health problems playing a role in their abusive behaviour arises. Are their mental health problems being presented as an excuse not to take responsibility for their behaviour, or are they an important factor in this behaviour? With some mental health conditions this can seem especially complex, as an inability to successfully manage emotions and/or form stable intimate relationships is at the heart of some problems. This is particularly the case for some of the personality disorders. In practice this need not always be as much as an issue as it seems; our work is always about supporting them to take responsibility, whether they have mental health problems or not. They join a programme in order to be able to take more responsibility.  

The challenges to relating that some mental health problems give, are sometimes more extreme versions, of some of the issues men already address in the work we do with them. An example is having difficulty in taking the perspective of others. A failure to appreciate the perspective of partners will be found in all the perpetrators we work with. How poor they are at doing this will vary. Sometimes their ability is so consistently poor that it is seen as indicating a mental health problem. 

Both in 1:1 work, and group-work we often ask perpetrators to think about and express the perspective of their partners and children. For many men, doing this is an emotionally challenging experience that encourages them to reflect on their behaviour. These men will typically have some perspective-taking skills that they seem to use, for example, in their work life. They fail to do this at home though, with this failure backed up by entrenched and unhelpful beliefs, for example about how men and women should be in relationships. These entrenched ideas become exposed and can be then questioned during this process. Some men will struggle to do this well, and will need more support. Some will have huge difficulties. These difficulties are typically very apparent, not only in their relationship but also, in the rest of their lives; at work, in their interactions with us, and if they are in a group, their interactions with other group members. In role play exercises, for example, I've seen men who seem only able to project their own perspective when role playing their partners or children. They can be shockingly unaware that they are unable to take someone else's perspective. For example, in voicing the perspective of their severely emotionally abused and very troubled son, a man was recently only able to express how much their son missed his father. Encouragements to think about any other feelings they might have, drew a blank. In the most extreme cases these men are not suited to the type of group work we do on perpetrator programmes. Their inability to take other's perspectives can result in constant conflicts with facilitators and other group members, and they are often severely limited in their ability to reflect on their own feelings and thoughts. 

Perpetrator groups are not focussed on working with high levels of conflict within the group, or with an extremely limited ability to reflect on thoughts and feelings. Skilled 1:1 work can help, as can specialised group-work, if available. But the immediate primary focus often needs to be on protecting their family members from them, and working closely with Maracs, probation, police and social services to do this. Ideally sometimes specialised mental health support may be needed, and attempts should be made to get these clients referred for assessment and treatment, if possible. Initiating actions which reduce risk to family members can, of course, impact a lot on these clients and we sometimes need to be aware of increased risks for them, their families, and us. Maintaining a relationship with them through these changes is important, both to help manage risk and to continue to build a relational foundation for further work. It can be hard to balance empathy for their distress, encouragement to them to take responsibility, and ongoing risk-management. Especially if, for example, their distress is expressed through direct or masked threats to us. Recently I found myself balancing empathy for the very painful feelings of loss that arose from a man's reduced and restricted access to his small child, with explaining why these steps had been taken, how he could submit a complaint about the steps we had taken, and gathering information to assess ongoing risk. I could also see, in this situation, how his relationship with this child was totally focused on his own needs, but how little capacity there was to reflect on this. 

Sometimes psycho-pharmaceutical support may be needed in order for some men to be able to engage with the programme we are running. For example, men who have experienced psychosis or the extreme impulsivity of ADHD, can do well on perpetrator programmes if their symptoms are stabilised by medication, and they see taking medication as part of what they need to do in order to effectively take responsibility for their behaviour in their relationship. We may need to monitor that the work we do is not de-stabilising them, and liaise with mental health services around support. Without taking steps to manage their mental health problems, it is not possible to work on further building their ability to take responsibility in their relationship. 

Generally, while mental health issues may complicate the work we do, or in some cases mean that we cannot work with a particular client, they never remove our focus on how the men we work with can more effectively take responsibility for their behaviour. If there appear to be mental health issues, I am interested in how they impact on a client's ability to take responsibility. What implications does this have for support from other services, what does this mean for what they need to focus on in the programme, and what are the implications for how we reduce the risk to their families? 

Follow our Spotlight on domestic abuse and mental health for more blogs, podcasts, guidance and more over the coming weeks.

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LGBT+ survivors and mental health

Lindsay Sutherland is a Research Analyst at SafeLives and has primarily worked on the national Insights and Marac datasets. as well as supporting the Spotlights series with data analysis and literature reviews. She recently moved onto SafeLives’ new Big Lottery Fund project in Scotland to provide research support and will also be involved in the evaluation of DA Matters domestic abuse training for Police Scotland which starts later this year.

The Spotlight series continues this month with the topic of mental health. For me, a standout lesson from the series is the importance of joining the dots between layers of identity and need. That might mean applying an intersectional lens to think through how individuals are affected by different systems of discrimination, or considering how multiple needs might interact to fuel disadvantage if left unsupported.

Central to the LGBT+ Spotlight was the troubling finding that victims of domestic abuse who identify as lesbian, gay, bisexual or transgender (LGBT+) are more likely to experience mental ill health. Statistics from our Insights national dataset provide us with a picture of victims who accessed specialist services for support. Two in five had a mental health problem in the previous year; among LGBT+ victims, this rose to over half. Appallingly, Insights data showed that LGBT+ victims were almost twice as likely to have attempted suicide and were more than twice as likely to have self-harmed. Double the proportion of LGBT+ victims were experiencing drug and alcohol addiction compared to non-LGBT+ victims.

Survivors of domestic abuse live through distinctly oppressive and outright dangerous situations. Given this, it may not surprise many to know that various studies[1] highlight increased prevalence of mental ill health among survivors. But our Insights data has highlighted that LGBT+ victims experienced higher levels of each type of domestic abuse and were more likely to have experienced historic abuse from a family member or previous partner. While there is a lack of research to probe these prevalence statistics further at present, what they do show is the complexity of risk that LGBT+ victims face – risk which threatens their safety, and all too frequently harms their mental health.

The patterns in our Insights data reflect a complex picture of wider inequalities in the world. In fact, regardless of whether they have experienced domestic abuse, LGBT+ people are more likely to experience mental ill health. The Mental Health Foundation links this to discrimination, isolation and homophobia in society.[2] The government’s national survey of LGBT+ people found that 40% of respondents had experienced a homophobic, biphobic or transphobic incident in the previous 12 months, committed by someone they did not live with[3]. Our Spotlight partner, Stonewall, has researched the discriminatory experiences LGBT+ people face in all avenues of life from school to work to the world of sport[4]. Not only does this discrimination impact on health, but it may also deter LGBT+ people from seeking much-needed support if they face abuse.

What does all this mean for practitioners and policy makers? The government is attempting to answer this question with their LGBT Action Plan (2018) where they acknowledge the significant impact sexual orientation or gender identity can have on health and wellbeing. Our report, Free to be Safe, full of the voices of LGBT+ survivors, also explored this urgent question. The complexity of need and wider societal discrimination we know LGBT+ victims often face means quick identification leading to effective support is crucial. Services must be ready to proactively identify and engage this vulnerable group, providing support that is sensitive to their particular experiences. In light of what the data we have tells us, mental health support must be considered as a central part of this response.

A wealth of learning material from the LGBT+ Spotlight and policy report is available to support services in this important work. So let’s listen to the voices of survivors who have experienced mental ill health alongside, or as a result of, domestic abuse. At the same time let’s join those dots back to the sixth Spotlight and continue to demand that LGBT+ victims are #FreeToBeSafe and also, well.   

Follow our Spotlight on domestic abuse and mental health for blogs, podcasts, guidance and more over the coming weeks.

 

[1] See 2.2.6 Mental Health Foundation Fundamental Facts (2016) https://www.mentalhealth.org.uk/publications/fundamental-facts-about-men...

[2] Mental Health Foundation (2018) Mental health statistics: LGBT people [online] https://www.

mentalhealth.org.uk/statistics/mental-health-statistics-lgbt-people [accessed 24th July 2018]

[3] Government Equalities Committee (2018) National LGBT Survey: Research Report [online]

https://www.gov.uk/government/publications/national-lgbt-survey-summary-... [accessed

24th July 2018]

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