Substance Abuse Treatment and Domestic Violence
Treatment Improvement Protocol (TIP) Series 25
Patricia Anne Fazzone, R.N., D.N.Sc., M.P.H., C.S.
John Kingsley Holton, Ph.D.
Beth Glover Reed, Ph.D.
Consensus Panel Co-Chairs
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 97-3163
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number ADM 270-95-0013. Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT Government project officer. Writers were Paddy Cook, Constance Grant Gartner, M.S.W., Lise Markl, Randi Henderson, Margaret K. Brooks, Esq., Donald Wesson, M.D., Mary Lou Dogoloff, Virginia Vitzthum, and Elizabeth Hayes. Special thanks go to Daniel Vinson, M.D., M.S.H.P., Mim J. Landry, Mary Smolenski, C.R.N.P., Ed.D., MaryLou Leonard, Pamela Nicholson, Annie Thornton, Jack Rhode, Cecil Gross, Niyati Pandya, and Wendy Carter for their considerable contributions to this document.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized patient care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcohol and other drug disorders are increasingly recognized as a major problem.
The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's HSTAT home page at the URL: http://text.nlm.nih.gov/ The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Substance Abuse Treatment and Domestic Violence, presents treatment providers with an introduction to the field of domestic violence. It gives providers useful information on the role of substance abuse in domestic violence -- both among the men who batter and the women who are battered. Useful techniques for detecting and eliciting such information are supplied, along with ways to modify treatment to ensure victims' safety and to stop the cycle of violence in both parties' lives. Legal issues, including duty to warn and confidentiality, are discussed. Finally, the Panel provides a blueprint for a more integrated system of care that would enhance treatment for both problems. This section includes practical suggestions for establishing linkages both between substance abuse treatment providers and domestic violence support workers and with legal, health care, criminal justice, and other relevant service agencies.
Other TIPs may be ordered by contacting The National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Karen Allen, Ph.D., R.N., C.A.R.N.
President of the National Nurses Society on Addictions
Department of Psychiatry, Community Health, and Adult Primary Care
University of Maryland
School of Nursing
Richard L. Brown, M.D., M.P.H.
Department of Family Medicine
University of Wisconsin School of Medicine
Dorynne Czechowicz, M.D.
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Linda S. Foley, M.A.
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Directors
Wayde A. Glover, M.I.S., N.C.A.C. II
Commonwealth Addictions Consultants and Trainers
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Thomas W. Hester, M.D.
Former State Director
Substance Abuse Services
Division of Mental Health, Mental Retardation and Substance Abuse
Georgia Department of Human Resources
Office of Substance Abuse
American Psychological Association
Douglas B. Kamerow, M.D., M.P.H.
Office of the Forum for Quality and Effectiveness in Health Care
Agency for Health Care Policy and Research
Stephen W. Long
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Richard A. Rawson, Ph.D.
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Sidney H. Schnoll, M.D., Ph.D.
Division of Substance Abuse Medicine
Medical College of Virginia
Patricia Anne Fazzone, R.N., D.N.Sc., M.P.H., C.S.
School of Nursing
Kansas University Medical Center
Kansas City, Kansas
John Kingsley Holton, Ph.D.
Maternal and Child Health
School of Public Health
Beth Glover Reed, Ph.D.
School of Social Work and Program in Women's Studies
University of Michigan
Ann Arbor, Michigan
Larry Bennett, Ph.D.
Jane Addams College of Social Work
University of Illinois at Chicago
Vivian Brown, Ph.D.
President and Chief Executive Officer
Culver City, California
Candace M. Shelton, M.S., C.A.D.A.C.
Guiding Star Lodge
Indian Rehabilitation, Inc.
Kimberly Smith-Cofield, M.Ed.
Casa Myrna Vasquez, Inc.
Carey Tradewell, M.S., C.A.D.C. III
President and Chief Executive Officer
Milwaukee Women's Center, Inc.
Oliver J. Williams, Ph.D.
Graduate School of Social Work
University of Minnesota
Roland Byrd, C.C.D.C., M.A.
Montana Chemical Dependency Center
Montana State Department of Public Health and Human Services
Lonnie Hazlewood, M.S.H.P.
Austin Stress Clinic, Ltd.
Judy Howard, M.D.
Professor of Pediatrics
Developmental Studies Program
Department of Pediatrics
School of Medicine
University of California at Los Angeles
Los Angeles, California
Kate Malliarakis, C.N.P., M.S.M., N.C.A.D.C. II
American College of Nurse Practitioners
Jan Mickish, Ph.D.
Colorado Domestic Violence Coalition
Brenda Miller, Ph.D.
Research Institute on Addictions
Buffalo, New York
Beth E. Richie, Ph.D.
Program in Public Health
City University of New York
New York, New York
Eric D. Wish, Ph.D.
Center for Substance Abuse Research
University of Maryland at College Park
College Park, Maryland
Abused Adult Resource Center
Bismarck, North Dakota
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.
Nelba Chavez, Ph.D.
Substance Abuse and Mental Health Services Administration
David J. Mactas
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Substance Abuse Treatment and Domestic Violence is one of the most ambitious documents in the Treatment Improvement Protocol (TIP) series. The Consensus Panel responsible for developing this TIP aimed to open a line of communication between two fields that have worked largely in isolation from each other, despite the considerable overlap in their client populations. Because both the domestic violence and substance abuse treatment fields are relatively young and new to each other, neither has yet consistently implemented programs that facilitate interagency coordination and cooperation. Basic differences in philosophy and terminology have also blocked the collaborative care that the Consensus Panel considers critical for treating substance-abusing clients who are survivors or perpetrators of violence.
This TIP primarily represents the views of domestic violence experts. Panel members combined their hard-won experience working with survivors and perpetrators of domestic violence with research literature from both disciplines to create an integrated knowledge base about substance abuse and domestic violence and to outline a system of integrated care. For some providers, implementing the collaborative model of service delivery described in the TIP may prove untenable at this time. It is the Panel's hope, however, that the suggestions presented will help providers move toward a more integrated delivery system that can provide the appropriate holistic care to their clients who suffer from both of these complex, intertwined problems.
Domestic violence is the use of intentional verbal, psychological, or physical force by one family member (including an intimate partner) to control another. This TIP focuses only on men who abuse their female partners (batterer clients) and women who are battered by their male partners (survivor clients). Child abuse and neglect, elder abuse, women's abuse of men, and domestic violence within same-sex relationships are important issues that are not addressed in depth in this document, largely because each requires separate comprehensive review. Other patterns of domestic violence outside the scope of this TIP are abused women who in turn abuse their children or react violently to their partners' continued attacks and adult or teenage children who abuse their parents.
Researchers have found that one fourth to one half of men who commit acts of domestic violence also have substance abuse problems (Gondolf, 1995; Leonard and Jacob, 1987; Kantor and Straus, 1987; Coleman and Straus, 1983; Hamilton and Collins, 1981; Pernanen, 1976) and that a sizable percentage of convicted batterers were raised by parents who abused drugs or alcohol (Bureau of Justice Statistics, 1994). Studies also show that women who abuse alcohol and other drugs are more likely to be victims of domestic violence (Miller et al., 1989).
The primary purpose of this document is to provide the substance abuse treatment field with an overview of domestic violence so that providers can understand the particular needs and behaviors of batterers and survivors as defined above and tailor treatment plans accordingly. This requires an understanding not only of clients' issues but also of when it is necessary to seek help from domestic violence experts. The TIP also may prove useful to domestic violence support workers whose clients suffer from substance-related problems. As the TIP makes clear, each field can benefit enormously from the expertise of the other, and cooperation and sharing of knowledge will pave the way for the more coordinated system of care discussed in Chapter 6. Future publications will examine those aspects of the problem that concern such special populations as adolescent gang members, the elderly, gay men and lesbians, and women who batter. The first of these is an upcoming TIP that addresses the connections between substance abuse and child abuse and neglect.
Because there has been so little study of the connections between the two fields, recommendations in this TIP are largely based on the clinical experience of Consensus Panel members. Studies, mostly in the domestic violence field, are cited when appropriate.
Chapter 1 establishes the connections between substance abuse and domestic violence. While there is no direct cause-and-effect link, the use of alcohol and other drugs by either partner is a risk factor for domestic violence. The Consensus Panel concludes that failure to address domestic violence issues among substance abusers interferes with treatment effectiveness and contributes to relapse. Therefore, the Panel recommends that substance abuse treatment programs screen all clients for current and past domestic violence, including childhood physical and sexual abuse. When possible, domestic violence programs should screen clients for substance abuse. (Screening instruments and techniques for identifying domestic violence appear in Chapters 2, 3, and 4 as well as Appendix C.)
Chapters 2 and 3 provide an overview of, respectively, survivor clients and batterer clients, each of whom present complex treatment challenges. Chapter 4 builds on this information and discusses screening and referral in more detail. Though Chapters 2 and 3 serve primarily to introduce these populations and their specific problems, recommendations for treatment do appear in those discussions. To provide a clearer picture of the process, therefore, recommendations from Chapters 2, 3, and 4 are presented below to follow each type of client chronologically through screening, referral, and treatment.
Chapter 5 discusses the Federal, State, and local regulations that bear upon domestic violence, particularly the 1994 Violence Against Women Act (VAWA). Also covered are issues such as restraining orders, duty to warn, the legal obligation to report threats and past crimes, and confidentiality.
Chapter 6 recommends linkages between substance abuse treatment programs and domestic violence programs and among other agencies as well. A model for systemic reform is provided in addition to suggestions for implementing community-based systems of coordinated care.
The TIP also includes resources to help providers implement the recommendations in the TIP. Appendix B explores how the Federal confidentiality regulations affect treatment decisions for batterer and survivor clients. Appendix C is a collection of instruments to screen for domestic violence and to assess a batterer's dangerousness. Appendix D reproduces a safety plan that a provider can use with survivor clients, and Appendix E lists national programs and hotlines concerning domestic violence.
Domestic violence is the use of intentional emotional, psychological, sexual, or physical force by one family member or intimate partner to control another. Violent acts include verbal, emotional, and physical intimidation; destruction of the victim's possessions; maiming or killing pets; threats; forced sex; and slapping, punching, kicking, choking, burning, stabbing, shooting, and killing victims. Spouses, parents, stepparents, children, siblings, elderly relatives, and intimate partners may all be targets of domestic violence (Peace at Home, 1995). (See Figure 1-1.)
This Treatment Improvement Protocol (TIP) focuses on heterosexual men who abuse their domestic partners and on women who are abused by men, because these individuals constitute a significant portion of the population seeking substance abuse treatment. Though domestic violence encompasses the range of behaviors above, the TIP focuses more on physical, or a combination of physical, sexual, and emotional, violence. Therefore men who abuse their partners are referred to throughout as batterers; women who are abused are called survivors. Child abuse and neglect, elder abuse, women's abuse of men, and domestic violence within same-sex relationships are important issues that are not addressed in depth in this document, largely because each requires separate comprehensive review. Other patterns of domestic violence outside the scope of this TIP are abused women who in turn abuse their children or react violently to their partners' continued attacks and adult or teenage children who abuse their parents.
The primary purpose of this document is to provide the substance abuse treatment field with an overview of domestic violence so that providers can understand the particular needs and behaviors of batterers and survivors as defined above and tailor treatment plans accordingly. This requires an understanding not only of clients' issues but also of when it is necessary to seek help from domestic violence experts. The TIP also may prove useful to domestic violence support workers whose clients suffer from substance-related problems.
As the TIP makes clear, each field can benefit enormously from the expertise of the other, and cooperation and sharing of knowledge will pave the way for the more coordinated system of care discussed in Chapter 6. Future publications will examine aspects of the problem that concern such special populations as adolescent gang members, the elderly, gay men and lesbians, and women who batter. The first of these is an upcoming TIP that addresses substance abuse by victims of child abuse and neglect.
In the United States, a woman is beaten every 15 seconds (Dutton, 1992; Gelles and Straus, 1988). At least 30 percent of female trauma patients (excluding traffic accident victims) have been victims of domestic violence (McLeer and Anwar, 1989), and medical costs associated with injuries done to women by their partners total more than $44 million annually (McLeer and Anwar, 1987). Much like patterns of substance abuse, violence between intimate partners tends to escalate in frequency and severity over time (Bennett, 1995). "Severe physical assaults of women occur in 8 percent to 13 percent of all marriages; in two-thirds of these relationships, the assaults reoccur (Dutton, 1988)" (Bennett, 1995, p. 760). In 1992, an estimated 1,414 females were killed by "intimates," a finding that underscores the importance of identifying and intervening in domestic violence situations as early as possible (Bureau of Justice Statistics, 1995).
An estimated three million children witness acts of violence against their mothers every year, and many come to believe that violent behavior is an acceptable way to express anger, frustration, or a will to control. Some researchers believe, in fact, that "violence in the family of origin [is] consistently correlated with abuse or victimization as an adult" (Bennett, 1995, p. 765; Hamberger and Hastings, 1986a; Kroll et al., 1985). Other researchers, however, dispute this claim. The rate at which violence is transmitted across generations in the general population has been estimated at 30 percent (Kaufman and Zigler, 1993) and at 40 percent (Egeland et al., 1988). Although these figures represent probabilities, not absolutes, and are open to considerable interpretation, they suggest to some that 3 or 4 of every 10 children who observe or experience violence in their families are at increased risk for becoming involved in a violent relationship in adulthood.
Researchers have found that one fourth to one half of men who commit acts of domestic violence also have substance abuse problems (Gondolf, 1995; Leonard and Jacob, 1987; Kantor and Straus, 1987; Coleman and Straus, 1983; Hamilton and Collins, 1981; Pernanen, 1976). A recent survey of public child welfare agencies conducted by the National Committee to Prevent Child Abuse found that as many as 80 percent of child abuse cases are associated with the use of alcohol and other drugs (McCurdy and Daro, 1994), and the link between child abuse and other forms of domestic violence is well established. Research also indicates that women who abuse alcohol and other drugs are more likely to become victims of domestic violence (Miller et al., 1989) and that victims of domestic violence are more likely to receive prescriptions for and become dependent on tranquilizers, sedatives, stimulants, and painkillers and are more likely to abuse alcohol (Stark and Flitcraft, 1988a). Other evidence of the connection between substance abuse and family violence includes the following data:
Clearly, substance abuse is associated with domestic violence, but it is not the only factor. As discussed above, witnessing or experiencing family violence during childhood is a risk factor as is a history of childhood aggression. Another factor that must be acknowledged is societal norms that indirectly excuse violence against women (tacit support for punishing unfaithful wives, for example, or stereotyped views of women as obedient or compliant) (Kantor and Straus, 1987; Reed, 1991; Bennett, 1995; Flanzer, 1990).
The overt or covert sexism that contributes to domestic violence also bears on connections between violence and substance abuse. Manifestations of that sexism vary across social classes and cultural groups: Some groups more than others accept domestic violence or intoxication as a way of dealing with frustration or venting anger. Though they range from subtle to blatant, sexist assumptions persist and are reflected by society's different responses to domestic violence and substance abuse among men and among women.
For example, substance abuse treatment providers have observed that society tolerates a man's use of alcohol and other drugs more readily than a woman's. They note that batterers often blame a woman they have victimized for the violence, either implicitly or explicitly, and other people, including police, judges, and juries, often accept this argument. Research suggests that intoxicated victims are more likely to be blamed than sober victims and that aggression toward an inebriated victim is considered more acceptable than aggression toward a sober one (Aramburu and Leigh, 1991). At least one other research team (Downs et al., 1993) argues that sexist attitudes may in fact contribute to the alcoholism of some women. "The alcoholic woman," they write, "may internalize previous negative stigmatization and subsequently use alcohol to cope with negative feelings resulting from the stigma. Conversely, the partner may use the woman's drinking as a rationale to label her negatively" (p. 131).
Attitudes toward rape are another example of how this rationalization works. Even when alcohol or other drugs are not involved, women victims frequently are assumed to have provoked their rapists by the way they behaved or dressed. This widely accepted misperception is often internalized and accounts for the guilt and shame that many rape victims experience. Not surprisingly, some victims of rape and other violence report using alcohol and other drugs to "self-medicate" or anesthetize themselves to the pain of their situations.
Though experts agree there is a connection between the two behaviors, its precise nature remains unclear. One researcher writes, "Probably the largest contributing factor to domestic violence is alcohol. All major theorists point to the excessive use of alcohol as a key element in the dynamics of wife beating. However, it is not clear whether a man is violent because he is drunk or whether he drinks to reduce his inhibitions against his violent behavior" (Labell, 1979, p. 264).
Another expert (Bennett, 1995) observes that
[I]f substance abuse affects woman abuse, it does so either directly by disinhibiting normal sanctions against violence or by effecting changes in thinking, physiology, emotion, motivation to reduce tension, or motivation to increase interpersonal power (Graham, 1980). Despite its popularity, the disinhibition model of alcohol aggression is often discredited because of experiments that have found expectation of intoxication a better predictor of aggression than intoxication itself (Lang et al., 1975).An alternative to disinhibition, is 'learned disinhibition,' or expectancy of a drug and violence relationship ... Drug and alcohol use occur in a cultural context in which behavior can be attributed to 'I was loaded' (MacAndrew and Edgerton, 1969). (p. 761)
Within this theoretical framework, the societal view of substance abusers as morally weak and controlled by alcohol or other drugs actually serves some batterers: Rather than taking responsibility for their actions, they can blame their violent acts on the substance(s) they are abusing. Although drugs or alcohol may indeed be a trigger for violence, the belief that the violence will stop once the drinking or drug use stops is usually not borne out. The use of alcohol or other drugs may increase the likelihood that a batterer will commit an act of domestic violence -- because it reduces inhibitions and distorts perceptions, because alcohol is often used as an excuse for violence, and because both alcohol abuse and domestic violence tend to follow parallel escalating patterns -- but it does not fully explain the behavior (Pernanen, 1991; Leonard and Jacob, 1987; Steele and Josephs, 1990). The fact remains that nondrinking men also attack their partners, and for some individuals, alcohol actually inhibits violent behavior (Coleman and Straus, 1983).
Batterers -- like survivors -- often turn to substances of abuse for their numbing effects. Batterers who are survivors of childhood abuse also frequently say that they use drugs and alcohol to block the pain and to avoid confronting that memory. It is a self-perpetuating cycle: Panel members report that batterers say they feel free from their guilt and others' disapproval when they are high.
Though it cannot be said that substance abuse "causes" domestic violence, the fact remains that substance abuse treatment programs see substantial numbers of batterers and victims among their patient populations and increasingly are compelled to deal with issues related to abuse (Flanzer, 1993).
As substance abuse treatment programs have grown more sophisticated, the treatment offered patients has become more comprehensive and more effective. Questions about vocational, educational, and housing status; coexisting mental disorders; and presence of human immunodeficiency virus (HIV) and other infectious diseases are routinely raised during the assessment process. Treatment providers now recognize the importance of addressing issues that affect clients' patterns of substance abuse (and vice versa) so that these issues do not undermine their recovery. Today, mounting evidence about the varied associations between domestic violence and substance abuse attests to the need to add violent behavior and victimization to the list of problems that should be explored and addressed during treatment. Based on their clinical experience, members of the Consensus Panel who developed this TIP conclude that failure to address domestic violence issues interferes with treatment effectiveness and contributes to relapse.
Practitioners in both fields must be attuned to the connections between the two problems. By sharing knowledge, substance abuse treatment providers and domestic violence workers can understand the complexity of the problem, address their own misperceptions and prejudices, and better serve individual clients -- as well as lay the foundation for a coordinated community response. Building bridges between the fields requires an understanding of the way each problem can interfere with the resolution of the other and of the barriers posed by the two fields' differing program priorities, terminology, and philosophy.
Battering and victimization undermine substance abuse treatment in both direct and indirect ways. Consensus Panel members report that a substance-abusing woman often finds that her abusive partner becomes angry or threatened when she seeks help, and his violence or threats of violence may push her to drop out of treatment. Panel members have also seen a violent partner sabotage a woman's treatment by appearing at the program and threatening physical harm unless she leaves with him or by bullying or manipulating her to use alcohol or other drugs with him. Another variation on this theme occurs when a woman manages to continue in treatment, a violent episode occurs, and, as part of "making up," is persuaded to take alcohol or other drugs. Although these patterns occur in nonviolent relationships as well, the threats of physical harm, withholding of financial support, or abuse directed toward children can lead survivors to resort to using substances to buffer their distress. For this reason, recovery from a substance use disorder may not be possible unless client survivors improve their self-esteem, sense of competence, and ability to make sound decisions. Survivors must get to the point where they can recognize and take advantage of their options and alternatives before they can replace their substance use with positive coping strategies.
When batterers enter treatment, their partners also may subvert their efforts to achieve sobriety. Some batterers are less violent and easier to handle when they are drunk or high. If a batterer is more violent when sober or abstinent, his partner may encourage drinking or taking drugs. "Enabling" is actually a safety measure in these cases. Another complicating factor is some women's perception that they are responsible for their partners' substance abuse, a perception that often is reinforced by their partners, friends, and family. In the same way that they hold themselves culpable for their battering, those women believe that their "bad" behavior prompts their partners' use of alcohol or other drugs, a position that abusers exploit to rationalize their continued substance abuse.
The problems of substance abuse and domestic violence intersect in destructive ways; furthermore, differences in priorities, terminology, and philosophy have hampered collaboration between providers in the two fields. For substance abuse, attaining abstinence is a key goal; for domestic violence programs, ensuring survivors' safety is of paramount concern. While both goals are valid, the reality is that they may be difficult to balance. The problem for substance abuse and domestic violence staff then lies in the perception that one goal invariably must be selected to the exclusion of the other for a program to preserve its identity and thereby carry out its mission.
A heightened awareness of the two problems, however, reveals that programs can forego an "either/or approach," shift priorities to accommodate a client's situation, and still retain program identity and orientation. A female substance abuser's living arrangements, for example, may be so dangerous that regular attendance at treatment will be impossible until safety issues are resolved. In this case, substance abuse treatment could be temporarily postponed and then reinitiated after a more secure environment can be achieved. Conversely, some survivors remain in traumatic relationships because of their addiction. Their batterer is their supplier, and they endure the intolerable in order to feed their habit. Delaying development of a safety plan until the drug problem is addressed could be a more effective strategy under those circumstances. Adjusting priorities on a case-by-case basis does not undermine a particular program's philosophy; instead it recognizes the need for flexibility in responding to individual client needs.
Differences in terminology pose another potential barrier to effective networking. Domestic violence programs try to avoid negative language by using such positive terms as empowerment to encourage battered women to move forward and build a new life. Denial, enabling, codependency, and powerlessness -- terms widely used in the substance abuse field to describe typical client behaviors and aspects of recovery -- strike some domestic violence workers as stigmatizing, repressive, and counter to appropriate goals for violence survivors.
Increasingly, substance abuse is considered a brain disorder that deserves treatment in much the same way as hypertension and diabetes do. In contrast, domestic violence counselors tend to distance themselves from medical models that imply that survivors are "sick" when, in fact, they have been battered by someone else. To forestall divisions between the two fields, etiological differences must not only be recognized, but accepted as legitimate.
Other features of substance abuse treatment that have posed problems for domestic violence programs and have inhibited collaboration between the two fields are the largely male clientele, the emphasis on family involvement, and the use of confrontational group therapy. Some domestic violence professionals worry that the male orientation in many substance abuse treatment programs makes these programs irrelevant to the realities of women's lives, insensitive to their needs, and inapplicable to the issue of domestic violence. They also believe that enlisting the help of family members and significant others in the treatment process can, in the case of violent partners, endanger the survivor. Likewise, domestic violence professionals who work with survivors consider the confrontational techniques used by some substance abuse treatment providers to overcome denial and resistance to treatment as "bullying" and inappropriate.
Although there is some validity to these characterizations (as well as to the claim that domestic violence staff are uninformed and naive about substance abusers and the manipulative behaviors they sometimes employ), education, communication, and cross-training can help to overcome barriers between substance treatment and domestic violence programs. Increased understanding within both disciplines will equip practitioners to address the particular problems of substance abusers who are victims or perpetrators of domestic violence.
The disagreements between experts in the fields of substance abuse and domestic violence can inhibit the exchange of essential information to the detriment of the client's recovery. This TIP represents an initial effort to bridge that gap. In the chapters that follow, experts in the respective arenas share their understanding about the impact of domestic violence on batterers and survivors. In addition, this TIP provides suggestions for screening and assessing for past and current experience with domestic violence, offers ideas for intervening with survivor and perpetrator clients, and summarizes legal and ethical issues that substance abuse providers should consider when working with this population. In addition to presenting guidelines to improve client outcomes, the information included in this document is intended to begin a dialogue between domestic violence and substance abuse treatment staff about the larger issue of systemic reform. Currently, domestic violence and substance abuse treatment function as parallel programs within the overall social services system.
In the short term, the ideas presented in this TIP should enhance the responses of both programs to the problems of domestic violence survivors and batterers who are also substance abusers. However, to effect lasting change and reduce morbidity, people working in both fields must accept the fact that the two problems often exist together, must recognize the importance of a holistic treatment approach, must be willing to set aside concerns about "turf," and must learn to collaborate effectively on the client's behalf. Impediments to systemic reform are scattered throughout substance abuse and domestic violence programs and in the public and private funding organizations supporting them. The insistence on identifying a single problem as primary or the need to conceal a problem in order to receive services can complicate admission to treatment, interfere with the development of appropriate treatment plans, and ultimately derail progress. In the concluding chapter of this TIP, Chapter 6, the Panel offers ideas for forging systemwide linkages that exemplify a new, collaborative way of thinking about problems and their solutions. This chapter builds on the practical suggestions described in earlier chapters to create a blueprint for a system of coordinated care. Such a unified system would be better equipped than the current fragmented one to interrupt the cycle of violence, fear, intimidation, guilt, and relapse to substance abuse that jeopardizes clients' recovery.
This chapter presents an overview of those issues likely to affect survivors of domestic violence seeking treatment for substance abuse. Its purpose is to help substance abuse treatment providers understand the impact of this experience on the treatment and recovery process and appreciate the differences in approach between the fields of substance abuse and domestic violence as they affect the survivor, so that treatment programs can respond more appropriately to this client group. The primary focus of substance abuse treatment services is to initiate the recovery process and reinforce the skills needed to stay sober or abstinent, while domestic violence programs seek to interrupt the cycle of violence and help the survivor client access the information and resources she needs to increase her safety and to develop and implement a safety plan. Holistic care is impossible if a treatment provider cannot understand the profound effect of domestic violence on a survivor.
The battered woman lives in a war zone: She rarely knows what will trigger an abusive episode, and often there is little, if any, warning of its approach. She spends a great deal of time and energy trying to read subtle signs and cues in her partner's behavior and moods in order to avoid potential violence, but she is not always successful. Financial constraints and fear that the batterer will act on his threats to harm family members or continually harass, stalk, and possibly kill her often inhibit victims from leaving (Rodriguez et al., 1996). If the batterer is also the victim's drug supplier, that further complicates the situation. Assuming all these issues can be resolved, the effects of continual abuse and verbal degradation can be so inherently damaging to self-esteem that the survivor may believe that she is incapable of "making it" on her own.
When a client presents for substance abuse treatment and informs staff that she is a victim of domestic violence, treatment providers should focus on
These three goals remain important for a survivor throughout treatment. Other needs that must be addressed immediately are
Once survivor clients' physical safety and symptoms have been addressed, treatment providers can obtain the information necessary to design a treatment plan.
A number of issues unique to domestic violence survivors must be considered by substance abuse treatment providers who work with these clients. Chief among these is the need to uncover the extent of the client's history of domestic violence. The survivor client's current substance abuse problems must be placed in the context of whatever violence and abuse she may have experienced throughout her life, both within her current family and in her family of origin. Childhood sexual abuse has been associated with a higher risk for "revictimization" later in life (Browne and Finkelhor, 1986). (See Chapter 4 for a discussion on how to elicit information regarding domestic violence.)
Studies have found a higher incidence of substance abuse among women who were victims of childhood sexual abuse and sexual assault (Ryan and Popour, 1983; Reed, 1985). Data suggest that substance abuse often begins at an early age and may become part of a self-destructive coping style that is sometimes seen in incest victims (Harrison et al., 1989; Conte and Berliner, 1988; Briere, 1989). It is not unusual for the abuser to foster the child's initiation into alcohol and drugs in order to make the child more compliant.
A discussion of substance abuse in the client's history should cover her current use, her treatment history, and alcohol or other drug use in her family of origin. In addition, patterns and frequency of alcohol or other drug use by her batterer are key to understanding the relationship of substance abuse to the violence.
Substance abuse counselors should be aware that survivors often are reluctant to disclose the extent of violence in their lives. Often a survivor's denial that violence occurs is so pervasive that it has become an integral element of her psyche. And, especially if violence existed in her family of origin, she may simply consider it a normal part of an intimate relationship.
At the same time, it is important to recognize that many survivors consciously keep the fact or extent of their battering concealed for good reasons, such as fear for themselves, their children, or other family members. When a battered woman leaves her abuser, her chances of being killed increase significantly (Wilson, 1989; Casanave and Zahn, 1986; Rasche, 1993; Dutton-Douglas and Dionne, 1991). Furthermore, the batterer may be the primary source of income, so his incarceration could leave her destitute (Rodriguez et al., 1996). Instruments for uncovering domestic violence appear in Appendix C.
Treatment providers can best serve clients by establishing strong linkages to domestic violence referral and intervention services and by employing staff who are thoroughly familiar with local and State laws regarding domestic violence and with the unique needs of the domestic violence survivors. Ideally, counselors should be able to refer to those services and staff members when domestic violence is suspected and call on them for consultation as needed. If a client denies a history of domestic abuse but the treatment provider still suspects it is possible, additional attempts to discuss it with the client should be made and documented. Once the client has entered treatment, a treatment plan that includes guarantees of safety (see Appendix D) and a relapse prevention plan should be developed. Considerations specific to domestic violence survivors should be integrated into each phase of the treatment plan.
In the early stages of the survivor's treatment, the substance abuse counselor should help her develop a long-term safety plan either by referring the client to or employing domestic violence service providers. If substance abuse counselors have been well trained in this area, they can work with clients to develop such a plan as part of intake.
One of the purposes of screening is to assess the degree to which the survivor is in physical danger. Screening for this purpose should be conducted early in the treatment process. However, domestic violence and safety issues do not always arise in the early stages of treatment of these clients. Thus substance abuse treatment providers are wise to be prepared to develop a safety plan whenever the need becomes known or acknowledged. (See Chapter 4 on screening and assessment for a discussion on assessing danger and lethality and Appendix C for an example of a danger assessment instrument). In this regard, it is also important to remember that the client's sobriety may threaten the batterer's sense of control. In response, he may attempt to sabotage her recovery or increase the violence and threats in order to reestablish control. It is important to address this issue in treatment and to help the client minimize her risk of harm so that she can continue to comply with her treatment plan. In addition, although involving the family in counseling is usually a precept of successful substance abuse treatment, couples and family therapy may be dangerous for domestic violence survivors and should be undertaken cautiously, if at all.
It is also important for the substance abuse provider to assess the degree to which an addicted client's drug problem is tied to the abusive partner: Her batterer may be her supplier. A survivor client who relies on a batterer to obtain or administer drugs may have a difficult time remaining in treatment or avoiding the batterer. A batterer who understands his partner's addiction may simply wait for the victim to resurface. The treatment provider should be alert to the possibility that a survivor client may sabotage both her treatment and her safety in the service of her addiction.
Domestic violence survivors often present with acute injuries and long-term sequelae of battering as well as the physical health problems more commonly associated with substance abuse (e.g., skin abscesses and hepatitis). Cuts and bruises from domestic violence tend to be on the face, head, neck, breasts, and abdomen (Randall, 1990). The body map in the Abuse Assessment Screen (see Appendix C) can help identify these injuries. Abdominal pain, sleeping and eating disorders, recurrent vaginal infections, and chronic headaches are also common among survivors (American Medical Association, 1992; Beebe, 1991; Stark et al., 1981; Randall, 1990). While it may be necessary to attend to pressing legal and financial concerns before chronic health problems can be addressed, medical staff should be available to assess the client's most immediate physical, emotional, and mental health needs.
When a woman presents for treatment with obvious signs of or complaints about physical battering or sexual abuse, staff should consider enlisting a forensic expert to help the survivor client obtain proper medical documentation of her injuries. Forensic medicine programs have been employed successfully in pediatric populations (Corey Handy et al., 1996), and are now being expanded to include adult victims of abuse. Forensic examiners are medicolegal experts (e.g., nurses, emergency room physicians, and forensic pathologists) specially trained to evaluate, document, and interpret injuries for legal purposes (Corey Handy et al., 1995). They can assess whether an injury is consistent with events as described by the victim or perpetrator client, information especially valuable when the victim is unable to accurately recount the circumstances surrounding her injuries because she was using alcohol or other drugs at the time of the assault. Forensic examiners frequently are called to testify in court and may be viewed as a valuable asset in any court proceeding relating to the assault (Corey Handy et al., 1995).
Other health concerns that need attention early in treatment include screening and care for pregnancy, HIV infection, and other sexually transmitted diseases (STDs). Battered women are at extraordinarily high risk for STDs because they are frequently unable to negotiate the practice of safe sex with their partners and are often subjected to forced, unprotected sex. They also may have been forced by their partners to share needles. Not only do STDs and pregnancy require immediate medical attention, but they can also be triggers for more battering.
One of the coping mechanisms used by many survivors is the repression of physical sensations, including physical pain. Often the survivor's awareness of physical pain and discomfort resurfaces only when the traumatic effects of the abuse have been relieved. An increase in a client's somatic symptoms is also common as emotional issues surrounding her victimization begin to emerge. Such a newfound awareness can be confusing and frightening for the survivor, and it is important to ensure that this awareness is addressed both in her medical care and through psychotherapeutic counseling.
A key aspect of treatment for substance abuse is encouraging the client to assume responsibility for her addiction. For a survivor client, it is critical at the same time to dispel the notion that she is responsible for her partner's behavior. She is only responsible for her own behavior.
The survivor client must realize that she does not and cannot control her partner's behavior, no matter what he says. Treatment should help move her toward becoming an autonomous individual who is not at the mercy of external circumstances. Concrete steps to ensure her safety or, if she decides to leave the batterer, to set up a new life will do more toward this end than anything else. As she frees herself from the violence, she will feel more independent. A counselor can help reinforce the client's view of herself as capable and competent by eliciting information about her efforts to address the violence, even if they were unsuccessful. A counselor can point out that her efforts reflect determination, creativity, resourcefulness, and resilience, many of the same qualities that will equip her to take responsibility for her substance abuse.
Poorly developed decisionmaking skills is a problem for many substance abusers. When a client is a battered woman, that inadequacy may be compounded by the domestic abuse (American Medical Association, 1993). For some battered women, every aspect of their lives has been controlled by the batterer, and a "wrong" decision (as perceived by the batterer) may have served as another excuse to batter her. The paralyzing effect of being battered for making independent decisions must be overcome as the survivor begins to exercise choices without fear of reprisal. Thus one of the first steps in the process of empowering the survivor client is to help her develop, strengthen, focus, or validate her decisionmaking skills.
For a proportion of domestic violence survivors, decisionmaking is a new skill that must be acquired for the first time rather than a lost skill that must be relearned. Exploring her own wants, needs, and feelings, although an unfamiliar and sometimes uncomfortable process, can be a stepping stone to making larger and longer term decisions. It is important for the treatment provider to avoid underestimating the importance to the survivor of making even seemingly mundane decisions, such as what to wear or when to eat.
Like most substance abusers, the survivor client must examine those areas of her life that will either support or undermine her recovery. Like others in treatment, she must disengage from drug-using friends, and she will need support as she begins the task of making new social contacts who support her recovery.
Reevaluating relationships with partners who support and encourage drinking or drug-taking is another therapeutic task for those undergoing substance abuse treatment. In a pattern that parallels the experience of many survivors of domestic violence, female substance abusers are often introduced to and supplied with drugs by male partners. Among the myriad reasons for continuing use are to maintain a relationship, to please a partner, or to share a common activity. Since safety poses such a serious problem for survivor clients, reevaluating ties to her significant other in the context of her goals for recovery requires careful consideration. For many of these women, recovery will not be possible without separation from their partners -- a reality that may be extremely difficult for them to acknowledge, accept, and translate into action. Furthermore, because of the toll that the battering has taken on many survivor clients' belief in their ability to make decisions, they are likely to need additional help in evaluating and identifying sources of stress in their relationships. Despite the time and effort involved in working through this issue, however, it is not uncommon for survivor clients to change their views about which relationships feel safe as they begin to make choices that support recovery.
When working with some survivor clients, substance abuse treatment providers may have to discard traditional notions about the wisdom of making major life decisions, such as moving, early in the course of treatment. For a domestic violence survivor who fears being pursued by a batterer, relocation to another community may be a priority. As part of treatment, the stress of uprooting herself and her children and the accompanying risk of relapse must be weighed against safety issues. Should a client decide to move, every effort should be made to refer her to appropriate resources and supportive services within the new community.
Posttraumatic stress disorder (PTSD) is a psychiatric diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994). The first diagnostic criteria are being "exposed to a traumatic event in which . . . (1) the person experienced, witnessed, or was confronted with an event or events that included actual or threatened death or serious injury, or a threat to the physical integrity of self or others [and] (2) the person's response involved intense fear, helplessness, or horror" (American Psychiatric Association, 1994, pp. 427-428). Other criteria include recurrent nightmares, difficulty sleeping, flashbacks, hypervigilance, and increased startle responses -- symptoms shared by many battered women (Walker, 1991; Douglas, 1987; Follingstad et al., 1991; Woods and Campbell, 1993). One study of 77 battered women in a shelter found that 84.4 percent of them met the PTSD criteria in the DSM-IV (Kemp et al., 1991). Though the DSM-IV states that the disorder is "more commonly seen in association with an interpersonal stressor (e.g., childhood sexual or physical abuse, domestic battering, being taken hostage, incarceration as a prisoner of war or in a concentration camp, torture)" (p. 425), some domestic violence support workers have been reluctant to acknowledge PTSD among survivor clients. Their fear is that thus labeling the victim moves the onus for the violence from the abuser to the victim and provides another excuse for the batterer's behavior (e.g., "she's crazy"). A treatment provider, however, must be aware of the possibility that a survivor may be suffering PTSD and must make the appropriate referral.
Many survivor clients also suffered abuse as children (Browne and Finkelhor, 1986). Emotional and psychological trauma from childhood abuse is often repressed and may surface once the client is in a safe setting, such as an inpatient substance abuse treatment facility. The emergence of this memory can be an overwhelming experience, and treatment providers should not attempt to address it before the survivor is ready or if program staff are unprepared to handle the results. If the issue surfaces in a group setting, the substance abuse counselor should allow the survivor client to express her emotions initially. Thereafter, however, a client should be referred if possible to a therapist with special training in treating victims of childhood abuse.
Recovering substance abusers are trained to deal with relapse triggers -- events or circumstances that produce cravings and predispose them to resume their use of alcohol or other drugs. A potential trigger for relapse can be something as seemingly benign as walking through a neighborhood where the recovering individual once purchased drugs. A domestic violence survivor is vulnerable to an additional set of triggers -- situations or experiences that may unexpectedly cause her to feel the fear and victimization she experienced when being battered. Such life event triggers may cause the client to relapse and should be addressed directly by counselor and client. Examples of life event triggers are sensory stimuli (sights, sounds, smells); the close physical proximity of certain people, particularly men; or situations that trigger unpleasant memories (such as witnessing a couple arguing). They also include stressful situations that evoke trauma responses and recreate the sense of victimization (Craine et al., 1988). Such triggers may push these feelings to the surface many years later, after the survivor is out of the abusive relationship; some disappear over time, but others may always be present to some degree. Counselors should help patients identify these stressful situations and rehearse alternative responses, just as they should for substance use triggers.
Survivors of domestic violence usually experience strong emotional reactions when they stop abusing alcohol or other drugs, which may have been a form of self-medication. They may be flooded by formerly repressed emotions and physical sensations. Abstaining from substance abuse, which often helps a survivor repress her responses, may also eradicate her ability to psychologically dissociate (distance herself emotionally so she does not "experience" feelings) from what was happening during the abuse. This dissociation may have provided her with an effective coping mechanism that allowed her to function on a day-to-day basis, despite the abuse. Its elimination may give rise to somatic symptoms, such as headaches or backaches, as formerly blocked physical sensations and experiences reenter her awareness.
Another issue for the survivor upon becoming abstinent may be the freeing of time and energy formerly spent procuring alcohol or other drugs, leaving her feeling empty or directionless and with too much time to dwell on her life situation. Other problems may surface as well. In the Panel's experience, eating disorders as well as other kinds of obsessive-compulsive behavior tend to reemerge after substance abuse ceases. Treatment providers should be alert to this possibility and prepared to refer survivor clients for specialized help (such as a local eating disorders program or chapter of Overeaters Anonymous).
Paradoxically, the very concept of "safety" may itself seem "unsafe" to a survivor of domestic violence. As one survivor expressed it, "The minute you (think you) are safe, you are not safe." For these clients, feeling safe from the perpetrator, even if he is dead or incarcerated, is equated with letting one's guard down and making oneself vulnerable to attack. Survivors tend to be hypervigilant and are accustomed to always being on guard. The substance abuse treatment provider needs to understand and respect the domestic violence survivor's concept of and need for safety. Helping a client rebuild a more appropriate general level of trust is an important long-term therapeutic goal.
For some survivors, anxiety, depression, suicidal thoughts, and sleep disorders are severe enough to require medication during their treatment for substance abuse. In such cases, it is of utmost importance to strike a balance between the need for medication and the avoidance of relapse. On the one hand, the recurrence of the physical and emotional sequelae of abuse may tip a survivor into emotional trauma; on the other hand, however, the client may risk relapse with the possible misuse or abuse of the medication. Physicians should weigh carefully the risks and benefits of prescribing drugs to battered women for symptom relief. For battered women who use or are dependent on alcohol or other drugs, the drug may affect their awareness, cognitive reasoning, or motor coordination, which can, in turn, reduce their ability to protect themselves from future incidents of physical abuse. A thorough medical and psychological assessment should be conducted by a trained clinician experienced in addiction medicine before any psychoactive medications are prescribed. As with other medicated substance abusers, regular monitoring and reassessment of symptoms are essential.
Practical concerns overwhelm many survivors of domestic violence after they become abstinent. These include resolution of legal problems, housing, transportation, employment or supported vocational training, and child care, among others. Linkages with other programs and agencies become extremely important in meeting these clients' needs. (See Chapter 6 for a discussion of the importance of forming collaborative relationships.) In addition, there are some special concerns that merit particular attention when working with survivor clients. "Welfare to Work," "Workfare," and other initiatives designed to rapidly move welfare recipients into employment may prove especially problematic for these clients. Both Panel members and reviewers described the inordinate pressure survivors experience when they are compelled to accept several new responsibilities at the same time. Panel members recommended developing, if possible, a schedule for the graduated assumption of responsibilities. Field Reviewers concurred and observed that providers should plan on providing extra support during this crucial postabstinence period.
In addition, survivor clients are likely to need education or reeducation about meeting sexual needs without drugs or alcohol. Referral to or staff training by experts in this area is recommended to ensure that this topic is approached sensitively. In addition, classes in healthy nutrition are a useful adjunct to treatment for survivor clients as for other substance abusers.
Although a strong family or friendship support system can be invaluable to substance abusers as they reenter the mainstream from the drug culture, the domestic violence survivor who is recovering from substance abuse may find it especially hard to reestablish ties, make new friends, or, in some cases, build a completely new life for herself. Social isolation is common among domestic violence survivors, as batterers curtail their victims' contacts with friends and family members. While a survivor client will likely need help and advice about creating a new nondrug, nonviolent social milieu, treatment providers should be careful not to make decisions for her, but rather support her in finding new activities and pastimes. Many women who are victims of domestic violence are surprised to discover that they have a continuum of choices, especially in social situations: The idea of enjoying a party without getting intoxicated, for example, may not have occurred to a survivor in the past.
Parenting is an issue for many substance abusers but may be a special challenge for survivor clients. The time spent in treatment initially may provide a respite from the concerns of parenting for many mothers, and the resumption of child care may be a source of additional stress. Some children become extremely needy after separation from their mother, and their demands could trigger a relapse or provoke an episode of violent behavior on her part.
An additional stressor may be the fact that some children are not supportive of their mother's choices. For example, they may not like her decision to separate from her abusive partner. They may pressure her, become depressed, act out, and try to coerce her into going home. This can create extreme conflict as the survivor client struggles to act in the best interests of her children. To further complicate the situation, it is not uncommon for older children (particularly boys) to ally with the batterer and become verbally or physically abusive to their mother.
To handle these issues effectively, a postabstinent domestic violence survivor may need to learn new parenting skills that take into account the realities of her status as a domestic violence survivor. These clients and their children commonly have a great deal of suppressed rage; handling frustration and anger is a crucial life skill that must be addressed directly in treatment. If treatment providers have not been trained in anger management and violence prevention, survivor clients should be referred to domestic violence support programs for these services.
Discussing the realities of everyday living and plans for the future that may increase the client's chances of a successful recovery is essential to the design of an effective treatment plan. Treatment providers should explore with the client her plans for future education and employment and should have information available about a variety of options. Through linkages with other agencies, the treatment provider can also help the client develop realistic plans for addressing any legal issues that may be unresolved and are interfering with recovery.
Domestic violence survivors who are newly abstinent may feel overwhelmed by pressures inherent in the responsibilities just described. For many, harassment and threats from their partners will be a continuing concern, and custody disputes and divorce hearings may further complicate their lives. All of these factors are potential triggers for relapse to which the provider should remain attuned. However, as a number of Field Reviewers pointed out, revictimization by their abusive partners poses the greatest risk of relapse for battered women. Whether these women remain in the relationship or not, the likelihood of revictimization is great -- domestic violence is a highly recidivistic crime (Zawitz et al., 1993; Browne, 1993). Careful attention to recurring episodes of violence is essential to working with survivor clients to prevent relapse and, if relapse does occur, to minimizing its negative effects.
Children of domestic violence survivors have special problems and needs that may not be readily apparent to the substance abuse treatment provider. Often this is because the more obvious, acute needs of the mother tend to eclipse those of her children. Children's issues must be addressed; if ignored, they can become antecedents to more severe problems, such as conduct disorders or oppositional defiant disorders.
Children of survivor clients typically display strong feelings of grief and loss, abandonment, betrayal, rage, and guilt. Older children also may have feelings of shame. Some indications that such feelings may be developing into serious problems for the child include
The child of a survivor may have his or her own, less apparent triggers for emotional trauma that may be quite different from the mother's. Children's triggers generally have to do with abandonment and separation issues, particularly if the children have been in foster care. Possible problem behaviors include the child's becoming overly clinging and needy upon reuniting with the mother, being fearful of a separation from her again, and acting out with hostility and violence to gain attention.
Children of survivors may also become "parentified," trying to be "perfect." Often this is the result of the child's feelings that he or she is somehow to blame for a parent's anger and subsequent violence. These children may also become extremely protective of their mothers. Other children may have somatic complaints, such as hives, headaches, stomachaches, or other unexplained aches or pains.
Children's responses to family violence vary according to individual temperaments and their age at the time the violence occurred. Posttraumatic symptoms, including sleeplessness and agitation, are common among children who experience violence within the family home (Pynoos, 1993). Some young children exposed to domestic violence may demonstrate regression in toileting behaviors and emotional distress (Arroyo and Eth, 1995). Developmental delays and language disorders also have been linked to parental domestic violence (Kurtz, 1994; Arroyo and Eth, 1995). Some school-aged children become more aggressive and anxious and lose ground academically (Pynoos et al., 1987).
Adolescents who have observed their fathers abusing their mothers exhibit high levels of aggression and acting out, anxiety, learning difficulties in school, revenge seeking, and truancy. Children who witness or experience domestic violence are at increased risk of adopting these same strategies in their interactions with their partners and children (Bell, 1995; Kalmuss, 1984). They may also become hypervigilant to the point of immobility or, in extreme cases, catatonia.
Some substance abuse programs allow children to accompany the mother to the facility where she receives services. Depending on the program's resources, children can be assessed at that time, treated onsite with counseling groups that coincide with adult sessions, or referred to a qualified children's treatment or counseling program for concerns such as
Ideally, substance abuse treatment programs will establish collaborative relationships with children's programs available through public and private, nonprofit, family service mental health and developmental assessment agencies. In many areas, these programs provide sophisticated case management services that access respite care, home aid, and parenting skills training that are beyond the scope of most substance abuse treatment programs. Collaboration with such specialized programs would free substance abuse counselors to concentrate on providing treatment to their survivor clients. The family services case manager would assume responsibility for making linkages with the myriad institutions that affect the mother through the child, including
Some survivor clients may be or will become involved with children's protective services (CPS) agencies because their children have been or are being abused and neglected. Since many battered women fear that CPS will take their children from them, they may resist efforts to involve CPS, and some will undermine their treatment to do so.
Treatment providers must adhere to the laws in their States regarding mandated reporting of child abuse and neglect even though clients may perceive those actions as a betrayal of trust. One way to minimize problems is to discuss reporting requirements and the procedures the treatment program follows prior to treatment. Providers should also establish working relationships with CPS to ensure an appropriate and best-case response to the family situation and the child's protection.
The substance abuse counselor is involved with the children -- directly or indirectly -- through the mother. A key responsibility, then, is to understand how to interact with and support the mother in her parenting role.
Substance abuse treatment counselors must understand that the mother may be involved with multiple agencies, all of which make demands on her limited time and energy. To help her focus on her abstinence, treatment providers should
Treatment providers also can assist survivor clients by inviting staff from domestic violence agencies such as Homebuilders and from CPS, jobs training agencies, and other organizations involved with domestic violence survivors to the substance abuse program so they can better understand the treatment and recovery process. Substance abuse treatment counselors also should request cross-training in domestic violence support as well as in-service training on the mission and operation of those agencies that come in contact with survivor clients.
As the chapter makes clear, survivors of domestic violence present unique substance abuse treatment challenges. Because domestic violence can be so psychologically damaging, particularly if it has been sustained since a client's childhood, a treatment provider should refer to domestic violence experts whenever possible. The treatment provider must also be careful not to unintentionally place the survivor client in danger by making inappropriate recommendations.
Central to the discussion of survivors' issues is the overarching need for informed, ongoing collaboration with the agencies that can help the survivor rebuild her life. Substance abuse treatment providers should try to facilitate this collaboration to the greatest extent possible. Treatment outcomes are substantially improved when interventions encompass all the relevant areas of a client's life, services are coordinated, inconsistent messages and expectations are reduced, and the effects of both domestic violence and substance abuse are well understood by all those interacting with the survivor client.
Judy, a white high school graduate in her late 20s, is a recovering substance abuser and a survivor of domestic violence. Her story is typical of the many problems and circumstances faced by women who enter both the domestic violence support and substance abuse treatment systems.
She was molested by her uncle from the age of 3 until she was 10; the molestation included vaginal penetration. Like many victims of sexual abuse, Judy was threatened by her abuser and never disclosed the abuse. On one occasion, her mother asked whether her uncle had ever touched her, and she replied, "No, he does nice things for me."
At age 15, she became sexually active with her 23-year-old boyfriend, Alex. Alex and she began using marijuana. When she was 18, she started using cocaine with Alex, who was now occasionally slapping her and forcing her to have sex.
At that time, she also discovered that she was pregnant. She decided to have the baby but received only sporadic prenatal care. During her pregnancy, both Judy and Alex used cocaine and marijuana and drank alcohol. The infant, a girl named Candace, was born at full term but was small for her gestational age. Alex left Judy soon thereafter, and she and Candace moved in with a new boyfriend, Billy. He used drugs and was both extremely possessive and violent. He intimidated Judy and sometimes threatened to kill her, Candace, and himself.
When Candace was 3, Judy, then 21, became pregnant again. Billy did not welcome the pregnancy and began hitting her in the abdomen and breasts when he was angry. Judy received no prenatal care during her second pregnancy and delivered a preterm, small-for-gestational-age baby whom she named Patricia. Neither Judy nor her baby was screened for drugs or HIV before or immediately after the birth.
By the time Patricia was born, Judy's drug use had escalated to include crack and increasing amounts of alcohol. Despite her mounting problems, Judy recognized that her new baby was a poor feeder. Judy was frightened enough to keep a 6-week postdelivery pediatric visit during which Patricia was diagnosed as "failing to thrive." At the same visit, 3-year-old Candace was weighed and found to be only in the 10th percentile of weight for her age.
Two weeks later, Judy and Billy were arrested on drug charges -- Judy for possession and Billy for dealing. She received probation, and she and her children moved in with her mother, Vivian. Billy was incarcerated, and Judy was required by the court to participate in substance abuse treatment.
In a group therapy session in her substance abuse treatment program, Judy acknowledged her history of family violence, childhood sexual abuse, and battering. Her case manager in this program wanted her to join another group of childhood incest survivors, but Judy felt ashamed and did not want to discuss the incest further. She began attending treatment sessions sporadically and, after 2 months, dropped out. In the meantime, tension developed between Judy and Vivian. Judy felt that her mother cared more for her granddaughters than she had about Judy when she was a child. Now that Judy had acknowledged her history of sexual abuse, she found herself blaming her mother for "allowing" it to happen. She also was jealous because she felt that Vivian was a better mother to Patricia and Candace than she was.
After a series of violent fights with her mother, Judy moved out and got a minimum-wage job, leaving her children with Vivian.
Around this time, Judy met Cody, a drug dealer. Cody moved in with her, but their relationship was characterized by frequent arguing and mutual battering. Judy's work habits became erratic; she often had bruises and sprains that she refused to discuss when her concerned coworkers questioned her about them. Although she saw her children infrequently, she would call late at night when she was high and criticize Vivian for keeping her children from her.
Meanwhile, under Vivian's care, Candace gained weight but exhibited a language delay. Her preschool teacher called Vivian repeatedly about Candace's problem behavior and acting out; she was having trouble paying attention in school, was defiant to her teachers, and was domineering with her peers. The school also reported that Candace had language problems and that she frequently cried for her mother.
Meanwhile, Vivian had quit her job in order to care for her grandchildren and was receiving Aid to Families with Dependent Children (AFDC). At this time, Vivian's health began to deteriorate, and she asked for help with Candace and Patricia. When a social worker began to talk about sending the children to a foster home, Judy was scared into action. Developmental evaluations were recommended for both children, and Judy took them to those appointments. Both children were found to have marginal developmental problems, possibly due to Judy's drug use during pregnancy. In response to the psychologist's advice, Judy enrolled Candace in a developmentally more appropriate preschool program that required parental involvement. Judy participated in this program with her daughter and resumed treatment.
For a brief time, Judy's life appeared to stabilize. Although she had not finished her substance abuse treatment program, she and Cody were both working, and she continued to receive negative screens for drugs (although she was still using occasionally). At the next CPS hearing, the children were returned to Judy's custody with the stipulation that she participate in parenting classes as well as continue in treatment.
Once her two children moved in with her and Cody, the situation began to deteriorate. Cody could not tolerate the children, and his episodes of violent behavior increased. He put his fist through the wall and kicked the door down. He became increasingly angry at Judy's frequent absences as a result of "all this kid stuff" (parenting classes and Candace's preschool program). He began to "spank" the children or grab them roughly by their arms when he wanted their attention. They showed up at their respective day care and preschool programs with bruises, which were attributed to "accidents." No one at the day care or preschool programs was aware of Judy's history or her disclosures of childhood abuse and battering in the treatment program.
Cody's violence continued to escalate and, increasingly, was directed at the children. While Judy was concerned about his hitting and yelling at the children, she didn't know what to do about it. She was feeling overwhelmed by her job, the parenting classes, her meetings with social services workers and her probation officer, and her child care responsibilities. In time, however, she began intervening when Cody yelled at or hit the children, deliberately provoking him in order to divert his attention away from the children and onto herself. The neighbors called 911 frequently, but the police never found any substantial evidence of violence.
A year passed with no improvement. The children continued to attend school, but Judy appeared only sporadically at her parenting classes and the preschool program. She was now beginning to suspect that Cody was sexually abusing 5-year-old Candace. She had begun to notice the same kinds of behavior in her daughter that she remembered in herself when she was sexually abused at that age. One day she asked Candace whether Cody had ever touched her in certain ways. Candace replied, "No, he is always nice to me." Judy remembered using almost identical words to her own mother years before and was certain that her daughter was being victimized in the same way. All the rage from her own abuse by her uncle erupted. She verbally and physically confronted Cody, and a battle ensued, which Candace witnessed. (Later this episode became a major treatment issue for the child, who believed that the violence in her household was her fault.)
Both Judy and Cody sustained injuries in their fight. Candace ran next door with her little sister, screaming about "all the blood." The neighbors called the police; Judy and Cody were both taken to the hospital, and the children were taken to a CPS emergency shelter. Judy and Cody were arrested for disturbing the peace and for possessing drug paraphernalia. Cody was charged with first degree (later reduced to third degree) assault, for which he eventually received a suspended sentence.
In the hospital, a social worker referred Judy and the children to a program for domestic violence survivors. After she was treated and released from the hospital, Judy stayed overnight in jail. The next day she was given a court appearance date, and a domestic violence advocate arranged transportation to the domestic violence program for her and her children. Program staff also assisted Judy in obtaining a restraining order against Cody and accompanied her to court to obtain it. When Candace and Patricia were reunited with their mother in the domestic violence facility, they clung to her, crying. Over the ensuing days, they experienced nightmares.
Despite the minor drug charge, the domestic violence program agreed to accept Judy because her drug screens were negative; the program had no knowledge of Judy's substance abuse treatment history. During intake, staff explained the program's drug use policy: If Judy used while in the program, her choices were to leave the facility or participate in treatment. The domestic violence program advocates did not think Judy was using drugs at the time of her admission and did not believe that she would use during her stay.
One day, Judy returned to the domestic violence program intoxicated, and a joint fell out of her purse. The program staff members saw and reported it to CPS. CPS then took away her children and again sent them to live with their grandmother. Judy's choices were now to either get substance abuse treatment or leave the facility. She entered a 1-year residential treatment program and was assigned to a counselor who was not only a recovering addict but a survivor of domestic abuse and with whom Judy felt an immediate rapport. The counselor and Judy together developed a treatment plan that took Judy's concerns and goals as well as the needs of her children into account. Although they agreed that intensive outpatient treatment would have been preferable, she had no place to stay where she would have been safe from Cody. She could not stay at the domestic violence program for that long, and Cody knew where her mother lived. Without a safe haven, her recovery and her life would have been in jeopardy, so Judy and her counselor decided on residential treatment. The counselor walked her through the admissions process.
Judy has been in recovery for 2 years, and her mother -- who was encouraged to participate in family sessions -- is supportive. Judy goes to work every day and has begun to date an older, recovering alcoholic she met at an AA meeting. He is more established and sees her children regularly. Vivian has again quit her job and is receiving AFDC. Cody is receiving substance abuse treatment and counseling for domestic violence, which were conditions of his suspended sentence. Another condition is that he remain in treatment and make no attempt to contact Judy or the children. The children are seen on a daily basis in the domestic violence program. But because the program can provide only supportive care and play activities, the children have been referred to a local agency with special supportive and mental health services for children.
There are myriad reasons why substance abuse counselors should address the domestic violence of clients who batter their partners. Consensus Panel members have observed that the violent behavior of a batterer client can interfere with his treatment for substance abuse, and conversely, his substance abuse can interfere with interventions aimed at changing his violent behavior (Bennett, 1995). Clients who are incarcerated, for example, or accused of assault or murder have limited access to substance abuse treatment. Practitioners have observed that for those clients in treatment, battering may precipitate relapse and thwart the process of true recovery, which includes "adopting a lifestyle that enhances one's emotional and spiritual health, a goal that cannot be achieved if battering continues" (Zubretsky and Digirolamo, 1996, p. 225).
Use of psychoactive substances, on the other hand, may interfere with a client's capacity to make a safe and sane choice against violence by impairing his ability to accurately "perceive, integrate, and process information" about another's behavior toward him (Bennett, 1995, p. 761). Intoxication appears to increase the likelihood that a batterer may misinterpret or distort a partner's remarks, demeanor, or actions by "blunting whatever cognitive regulators the abuser possesses" (Stosny, 1995, p. 36). While abstinence from drugs and alcohol does not alter battering behavior, substance abuse problems negatively affect a batterer's capacity to change and increase the chance that violence will occur (Tolman and Bennett, 1990; Bennett, 1995).
Both battering and substance abuse result in harm to the client and others. Responding to a client's penchant for violent behavior is as vital as responding to his depression or to the array of other conditions that may impede progress in treatment and interfere with recovery.
Although domestic violence occurs in the absence of substance abuse, there is a statistical association between the two problems. Alcohol use has been implicated in more than 50 percent of cases involving violent behavior (Roy, 1982). Research by Kantor and Straus suggested that approximately 40 percent of male batterers were heavy or binge drinkers (Kantor and Straus, 1987). A recent study found that more than half of defendants accused of murdering their spouses had been drinking alcohol at the time (Bureau of Justice, 1994). Another study of incarcerated batterers found that 39 percent reported a history of alcoholism and 22 percent reported a history of other drug addiction. A total of 50 percent self-reported current addiction; however, this figure rose to 89 percent when the researchers examined court documents. All but one of the subjects admitted to having been drunk at the time the battering occurred (Bergman and Brismar, 1994). Higher rates of substance abuse consistently correlate with higher rates of domestic violence, although one important study concluded that "[c]hronic alcohol abuse by the male rather than acute intoxication is a better predictor of battering" (Tolman and Bennett, 1990, p. 91). As one field reviewer noted, however, "Assaultive men, in general, have high alcohol use scores. Indeed the more a man matched the gauge for having an abusive personality, the greater his alcohol consumption. When a batterer says, 'the alcohol made me do it,' he's blaming one symptom -- violence -- on another -- alcohol abuse."
Most Consensus Panelists and field reviewers concur that the exact nature of the correlation between battering and substance abuse remains unclear.
Anger and hostility are more frequently generated by interactions between people, and alcohol or other drug use is likely to be linked to violent behavior through a complicated set of individual, situational, and social factor ... The prevalence of violence between partners cannot be adequately explained merely as the consequence of alcohol and other drug abuse, nor can it be understood outside the context within which it occurs. (Gorney, 1989, p. 231)
Current research supports the finding that substance abuse is only one of many factors that influence a batterer's violent behavior (Collins and Messerschmidt, 1993). As with substance abuse, other factors are also correlated, such as depression, psychopathology, violence in the family of origin, social norms approving of violence (especially toward women), high levels of marital and relationship conflict, and low income (Tolman and Bennett, 1990; Bennett, 1995; Hotaling and Sugarman, 1986; Hotaling and Sugarman, 1990; Bograd, 1988). Although intoxication may trigger an individual episode of violence, addiction does not predispose one to be a batterer. This distinction is crucial for a provider to understand when treating batterer clients, because a batterer's violence does not necessarily end when he stops abusing alcohol or other drugs.
In characterizing substance abuse and domestic violence, practitioners have observed that the two problems are "separate but similar, and they each interact and exacerbate each other. For example, both problems are passed on from generation to generation; both involve denial, with substance abusers and batterers blaming victims for their behavior; usually, neither problem decreases until a crisis occurs; and secrecy is often the rule, with victims of abuse (wrongly) blaming themselves for their partner's substance abuse or violent behavior" (Engelmann, 1992, p. 6).
In the past, research has focused more on attempts to identify characteristics of victims rather than perpetrators of violence (Hotaling and Sugarman, 1990). While information about batterers is relatively sparse and subject to some debate, it can provide the basis for a rudimentary understanding of their behavior. One caution is in order, however. Exploring batterers' individual characteristics addresses only one dimension of the domestic violence phenomenon. Some experts believe that battering is driven by socially supported sexism and inequitable distributions of power that feed the batterer's belief that he has an inherent right to control his partner's behavior. Others contend that analysis of batterers' characteristics has limited value if attention is not also directed to the larger culture of violence and social injustice in which battering occurs (Adams, 1988; Tolman and Bennett, 1990; Stosny, 1995). Research has clearly asserted the importance of socioeconomic factors in understanding battering: Approval of violence against women, low income, and belief in gender-based stereotypes emerge repeatedly as correlates of domestic violence (Bennett, 1995). As in the case of substance abusers, multiple internal and external risk factors appear to influence problem development among men who batter.
Although batterers are a heterogeneous group, research has uncovered a number of characteristics that differentiate men who batter from men who don't. Many batterers (particularly those who engage in severe physical assaults against their partners) witnessed parental violence when they were children (Hotaling and Sugarman, 1990; Pagelow, 1984). While not replicated, findings from the large-scale National Family Violence Survey that included over 6,000 families suggest that experiencing corporal punishment as an adolescent may be a risk factor for later partner abuse (Straus and Kantor, 1994). As mentioned above, chronic alcohol abuse is another predictor of violence (Tolman and Bennett, 1990), and some studies have found that batterers are more likely to suffer from depression (Hamberger and Hastings, 1986a; Saunders and Hanusa, 1986).
Many experts believe that batterers use violence or the threat of violence to achieve a sense of control, both over their victims and generally (Gondolf, 1995). Violence may also reflect a personal need for power and domination over others. Gondolf, building on McClelland's theory of alcohol and power motivation (McClelland, 1975), suggested that the need for personal power (reinforced by societal norms of male dominance) may be the factor that accounts for the high correlation between substance abuse and spousal abuse. According to this theory, men who have a high need for power over others are more likely to abuse alcohol and to use violence. Alcohol provides an illusion of power; so does beating one's wife. In some cases, a batterer who is drunk can gain instant control of his wife -- and in a sense his entire marital situation -- by terrorizing her. Furthermore, if the violent incidents are stopped through intervention, arrest, or treatment, the lack of control perceived by the batterer often increases not only the frequency of assault, but its severity as well.
In addition to inflicting physical pain and injury, a batterer may also abuse his partner psychologically and emotionally. A batterer attempts to control the thoughts and feelings of the partner by monitoring her behavior, making her accountable for his emotional highs and lows, denigrating her, criticizing and blaming her, and calling her names. Nonphysical abuse generally targets the victim's sense of self-esteem, well-being, and autonomy. Psychological abuse can be defined as behavior intended to control the victim's actions and functioning in everyday life (often by making her fearful). It may take the form of isolating her from her friends, family, and other sources of support or keeping her from having money to pay bills and other expenses. Another form is threatening physical harm -- not only to the victim but to family members, friends, or himself. It can also be the "silent treatment": The batterer may refuse to speak directly to the victim for extended periods, such as days or weeks, leaving her guessing about how she has displeased or offended him. Emotional abuse is denigrating, shaming, ridiculing, or criticizing the victim and otherwise attempting to damage or destroy her self-esteem. These types of abuse often accompany physical violence to some degree, although they can also occur in relationships that are not physically violent. It is unclear how men who batter differ from those who don't in the use of nonphysical forms of abuse (see Figure 1-1).
Any intervention with a batterer that does not concomitantly address issues of power and control may simply allow the batterer to become more sophisticated at other, nonphysical kinds of manipulation. To interrupt these types of abuse, couples and/or family therapy may be recommended once domestic violence experts ascertain that the victim is out of danger.
The precise role of anger in battering is unclear. When treatment for batterers was first being developed, some practitioners viewed anger as a primary cause of abuse and believed that imparting anger management skills would curtail and ultimately eliminate battering behavior; others viewed anger as just another excuse for violent behavior. Today, many researchers and practitioners consider anger as only one of a number of antecedents or precipitants for violence. Addressing the anger is not the same as addressing the larger problem of violence, but it may be a useful technique in preventing the expression of violence against intimate partners (Tolman and Saunders, 1988; Tolman and Bennett, 1990).
Consensus Panelists and field reviewers concur that although anger is a common emotional theme among violent batterers, a batterer's violence is not "caused" by anger. They also agree that while anger management groups can play an important treatment role, they caution that if such groups are not judiciously mediated by highly trained specialists in domestic violence, they may indirectly reinforce violent behavior. Inadequately facilitated groups can turn into "gripe sessions" that fuel batterers' anger instead of educating them about how to handle their feelings without resorting to violence. (For an informative debate about anger management and batterers' interventions, see Gondolf and Russell  and Tolman and Saunders .)
Another anger-related issue concerns the false belief that "explosive anger" is a hallmark of batterers (Stosny, 1995, p. 65), whereas, in reality, many batterers are afraid to reveal their anger to the outside world and successfully present themselves as victims to the clinicians charged with treating them ("nothing I do is right; she's always criticizing me"). Some clinicians look for overt anger and fail to find it, then label batterers as "in denial" about their anger. Treatment revolves around "getting batterers in touch with their anger and letting it out." Too often, this ill-conceived approach (which has been debunked by much contemporary literature) has had "disastrous consequences for both batterers and their loved ones" (Stosny, 1995, p. 66). When responding to batterers, it is important to understand the complex role that anger plays in both precipitating and sustaining violent behavior. Responsible treatment incorporates techniques for regulating as opposed to revealing anger (Stosny, 1995).
Substance abuse also skews the motivational mix of anger and battering in a variety of ways. Alcohol and other drugs often serve as mood regulators and anger management tools, which sometimes exert a calming effect, but also may intensify angry feelings. The Consensus Panel did not discuss the specific psychopharmacological effects of cocaine, amphetamine/methamphetamine, or phencyclidine or other hallucinogens on violence, because there is no evidence to suggest that these drugs have any effect on domestic violence (although a few studies suggest that chronic use may influence aggressive behavior in general [Brody, 1990]). Much like efforts to understand the links with alcohol, both research and experience indicate that personality, preexisting brain disorders, and environment also play important roles in the relationship between substance abuse, anger, and violence (Brody, 1990).
As clinicians and researchers have learned more about battering, some have begun to consider it within the context of an individual's total personality rather than as an isolated behavior. In this view, problems with attachment when young, compounded by the experience of growing up in a home environment marred by a father's violent behavior and shaming "put-downs," contribute to the development of a "violence-prone borderline personality [who is] ... addicted to brutality to keep his shaky self-concept intact. The only time he feels powerful and whole is when he is engaged in violence" (Dutton, 1995, p. xi). At the same time, the painful experience of rejection as a child has also bred a deep-seated fear of intimacy or "engulfment" (Dutton, 1988; Dutton and Browning, 1988).
Practitioners of psychologically based approaches to understanding and treating batterers are acutely sensitive to the criticism that they are excusing batterers on the basis of their underlying psychological problems (Dutton, 1995). Supporters of what is often termed the psychoeducational approach are quick to assert that psychological insights help to explain batterers' behavior; they do not justify or excuse it (Dutton, 1995; Stosny, 1995).
While experts agree that the relationship between substance abuse and battering is far more complicated than cause and effect, some attitudes and patterns reappear in men who abuse their partners. In an effort to better understand and improve treatment for batterers, researchers have attempted to group them on the basis of common characteristics (Gondolf, 1988; Hamberger and Hastings, 1986a; Dutton, 1995; Saunders, 1992). Gondolf organizes batterers into three clusters:
Hastings and Hamberger characterize batterers as having borderline personality disorder, antisocial personality disorder, or a form of compulsive personality disorder (Hamberger and Hastings, 1986a). Saunders looked at a range of variables including extent and levels of violence inside and outside the home, levels of anger and depression, attitudes toward women, substance abuse, conflicts in relationships, and need for power. According to his analysis, those who were violent outside the home were the most brutal batterers. They also were the most likely to abuse alcohol and to have been abused as children (Saunders, 1992).
In his work, Dutton has observed three types of batterers that he classifies as
By their very nature, typologies are artificial constructs, subject to change as new information develops. Despite their limitations, however, these groupings suggest that substance abuse programs will encounter those batterers who are among the most difficult to treat. As an example, members of the Consensus Panel observed that unlike the cyclical/emotionally volatile wife abuser (above), many severe batterers, among whom substance abusers are overrepresented (Roberts, 1988), do not fit the patterns of behavior seen by Dutton and Walker. Instead of following up a battering episode with a period of remorse (Walker, 1979; Dutton, 1995), they use the postviolence period as an opportunity to blame the victim for starting the abuse or to break up with her, or both.
The following section of this chapter focuses on the batterer who is more likely to be seen in a substance abuse program. These men have multiple problems and function, for the most part, in socially and economically impoverished environments. Involvement with the criminal justice system is almost a certainty, although domestic violence may not be the cause. At this time, few evaluations exist of batterers' treatment and even the developers of the popular "Duluth model" (see Figure 3-1) "have no illusion that most men will stop their violence and give up their power" (Pence and Paymar, 1993, p. xiv). Nevertheless, efforts by Consensus Panel members, field reviewers, and Statewide Networks Against Domestic Violence (such as those in Virginia and Maryland, to name just two) indicate that batterers' treatment can be effective if programs place a premium on survivor safety (even though the batterer is the client), insist that batterers take personal responsibility for their behavior, mandate "no-violence contracts," impart emotional regulation techniques, follow up on treatment completers and dropouts, and evaluate program outcomes regularly (Stosny, 1995).
Like any client entering substance abuse treatment, the batterer is typically in a crisis state when he first presents for services. He may have been referred to treatment by the courts after being arrested for drug- or violence-related charges, or he may have been left alone by a battered partner seeking safety for herself and the children. Even when his outward demeanor is calm and accepting, violence may be imminent.
Substance abuse counselors typically regard a crisis situation as a prime opportunity to intervene with a client and engage him in the treatment process. In this context, a crisis is frequently transformed into a positive event for both the substance abuser and those who care about him. With substance-abusing batterers, the situation is different. Because batterers tend to defer responsibility and to project their anger onto others, a crisis situation may spur a violent incident at home. Examples of crises that may precipitate violence include loss of employment, the impending loss of family relationships through separation or divorce, emotional and psychological breakthroughs during psychotherapy, a citation for driving while intoxicated, court-mandated treatment for substance abuse, being served with a restraining order, a partner's pregnancy, or the birth of a child. For this reason, when a substance-abusing batterer experiences a crisis, treatment providers should have a plan in place for addressing the fallout. Although it requires a shift in focus from the client to the family, the most immediate concern when a crisis occurs is the safety of those who have been or may become the batterer's victims, in particular his partner and children, whether they remain with the batterer or not (see Chapter 5 and Appendix B for specifics on notification procedures and conformance with Federal and State confidentiality regulations).
Family members, and in particular the client's partner, should be consulted regarding what is best for their safety (although the provider should bear in mind that their version of the situation may be somewhat skewed). Extreme caution and tact should be used to avoid further endangering the victim(s). If available, substance abuse counselors should refer and defer to trained violence support professionals or the partner's advocate to develop a safety plan that includes logistics for leaving the home quickly or, if she does not want to leave him, other strategies for increasing her safety.
Because batterers tend to shift responsibility and blame onto others, the degree to which a client begins to assume responsibility for his actions can serve as a barometer for his substance abuse treatment progress. To that end, assessment and monitoring can be incorporated into the treatment plan to evaluate the degree to which the batterer is taking responsibility for his violent actions. The batterer's accountability can be highlighted by linking his actions with tangible consequences. One way to achieve this is through the use of a "no-violence contract" with clearly delineated sanctions for violation (see Chapter 4). The substance abuse counselor must also be familiar with and understand the legal status of the batterer and how it affects his access to ongoing treatment services.
In addition, the use of multiple screening measures such as the Revised Conflict Tactics Scale (CTS2) for couples (Straus et al., 1996) and the Psychological Maltreatment of Women Inventory (Tolman, 1989, 1995), both reproduced in Appendix C, can aid the treatment provider in determining the extent of abuse while focusing the batterer's attention on his behavior.
If available, collaboration with and referral to batterers' intervention programs can facilitate the treatment of substance abusing batterers. Some of the models being used today are summarized in Figure 3-1.
During screening and throughout the treatment process, substance abuse counselors should explore the context in which the batterer client uses alcohol and other drugs in order to identify the chain of events and emotions that preceded or accompanied particular instances of substance abuse and violent episodes. Based on their experience, the Consensus Panelists recommend eliciting the following information about the relationship between the substance abuse and the violent behavior:
By understanding the dynamics of intoxication and abstinence as a precursor to violence, the treatment provider can formulate a treatment plan that incorporates strategies for ensuring the partner's and other family members' safety and for helping the batterer focus on modifying the behaviors and events that precipitate substance abuse and violence. The focus in treatment must be on encouraging the batterer client to develop enough self-awareness to recognize the beliefs and attitudes as well as to control the emotions that contribute to his violent behavior.
Friendships with members of the same sex are generally seen as a positive expression of self-development in both male and female clients being treated for substance abuse. Treatment staff must be on the alert, however, for signs of collusion among male batterer clients who have formed close friendships during treatment. Although such bonds often help clients learn about forming close and trusting relationships with others and examine their behavior in relation to that of their peers, in some cases, violent behavior can be instigated or condoned among batterer clients who reinforce each other's excuse-making mechanisms (see Figure 3-2).
One field reviewer who works with batterers writes that
In our anger management class, we pursue a new definition of manhood through the proper exercise of personal power. Personal power does not include violence of any kind, except for self defense. Personal power involves the negotiation of a system that is often seen as indifferent and hostile in a productive way ...giving the batterer an opportunity to feel powerful in a rational manner. We redefine manhood in terms of emotional cost-benefit analysis and problem solving. Clinically, it appears to be working.
Many substance abusers, male and female, have poor parenting skills, whether or not they are in a battering relationship. An examination of the client's parental role is essential to understanding his violent behavior, since a batterer may use alcohol, other drugs, or violence to respond to conflict within the family structure. Young boys often learn violent behavior from male role models. Among the challenges in substance abuse treatment for batterer clients are to
The effects of a batterer's violence on his children has important implications for his treatment plan. Although family therapy is often an effective component of substance abuse treatment, this approach is inadvisable for the violent batterer until he has learned to take responsibility for his behavior and has learned how to respond to crises without using violence. Given the potential for harm to both partner and children, the Consensus Panel recommends postponing family and couples counseling until the batterer has demonstrated a pattern of nonviolent and noncoercive behavior for a given period of time (usually a year). The decision to provide or refer for family or couples therapy also should be conditional upon whether or not the victim freely chooses to participate in counseling (the request should be made privately; a victim should never be asked to make that decision in a batterer's presence). Until these conditions are met, the batterer should be treated independently of other family members.
Over the past 50 years, the substance abuse treatment field has grown and developed into a national network of 12-Step groups, church affiliations, and social systems. In contrast, there are no ongoing organizations that support change for men who batter or for their victims. Although some batterers may enter an aftercare program following substance abuse treatment, most do not. Widely scattered groups called Batterers Anonymous (BA) (Goffman, 1984) have not been totally embraced by domestic violence workers because their emphasis on participant anonymity appears to be incompatible with the violence field's focus on accountability. Some Consensus Panel members fear that, unless a batterer has already successfully completed a batterers' program, groups like BA may unwittingly encourage misogyny (see Figure 3-2). On the other hand, some field reviewers who work with violent substance-abusing clients have found that the antiviolence messages of BA and similar groups appear to help batterers contain their violence by emphasizing the consequences of violent behavior. Accredited or certified domestic violence programs are sound resources for information and referrals to appropriate batterer self-help support groups.
A number of batterers' intervention programs are beginning to offer aftercare services. Some are experimenting with mentors, who fulfill roles similar to sponsors in 12-Step programs. In this approach, a recovering batterer, under the supervision of a batterers' program or shelter that ensures his accountability, mentors a batterer who has completed a batterers' program. Continuing contact is essential because program completion is not necessarily an indication of whether a participant has stopped or even reduced his use of violence and coercion.
It is crucial for substance abuse treatment providers to learn if their clients are either perpetrators or victims of domestic violence as early as possible in the treatment process. This chapter details signs to look for and techniques for eliciting information about domestic violence, which many affected clients are understandably reluctant to discuss. The suggestions and recommendations in this chapter are presented primarily for substance abuse treatment providers who work with clients involved in domestic violence as either batterers or survivors. They may also prove helpful to those providing domestic violence support services to their clients who have concomitant substance abuse problems.
Because of the well-documented relationship between domestic violence and substance abuse (Leonard and Jacob, 1987; Kantor and Straus, 1989; Amaro et al., 1990; Pernanen, 1991; Windle et al., 1995), and because domestic violence affects survivors' and batterers' recovery from substance abuse (Cronkite and Moos, 1984; Smith and Cloninger, 1985), the Consensus Panel recommends that all clients who present for substance abuse treatment services be questioned about domestic violence. Questions should cover childhood physical and sexual abuse as well as current abuse. (See Appendix C.)
Screening for domestic violence in substance abuse treatment settings is undertaken to identify both survivors and batterers. The domestic violence assessment, like the other elements of a substance abuse assessment, gathers the specific and detailed information needed to design appropriate treatment or service plans (Sackett et al., 1991). While the Consensus Panel believes that addictions counselors can be trained relatively easily to screen clients for domestic violence, assessment services are more complex and require in-depth knowledge and skill. Assessment should be conducted by a domestic violence expert if possible.
Once it is determined that a client is a victim of domestic violence, a provider must determine the client's needs for violence-related services such as medical care and legal advocacy. In addition to identifying violence as an issue affecting substance abuse treatment planning, another important purpose of screening for domestic violence is to ensure the safety -- both physical and psychological -- of a survivor client. (A word of caution: There is a tendency to think of residential treatment as a safety zone for both batterers and survivors with substance abuse problems. Domestic violence experts, however, note that batterers in treatment frequently continue to harass their partners by circumventing program rules and threatening them by phone, by mail, and through contacts with other approved visitors. Telephone and other communication and visitation privileges should be carefully monitored for identified batterers and survivors in residential programs.)
Substance abuse treatment providers and domestic violence support staff use different terms to describe the screening process. Domestic violence programs refer to the initial contact with a client as intake, which is roughly analogous to what substance abuse treatment providers refer to as screening. Once a woman has been accepted to the program, domestic violence staff will conduct a psychosocial intake, which is similar to assessment in the substance abuse treatment field.
The most obvious indicator of domestic violence is the presence of physical injuries, especially patterns of untreated injuries to the face, neck, throat, and breasts. Many survivors of domestic violence may be reluctant to seek medical treatment because they are afraid that documentation of violence in the household will result in their children being removed or because they are afraid of further violence as a result of the disclosure. These women may get their injuries treated at a number of different clinics or emergency rooms in order to avoid documentation of recurrent injuries.
Other indicators may include a history of relapse or noncompliance with substance abuse treatment plans; inconsistent explanations for injuries and evasive answers when questioned about them; complications in pregnancy (including miscarriage, premature birth, and infant illness or birth defects); stress-related illnesses and conditions (such as headache, backache, chronic pain, gastrointestinal distress, sleep disorders, eating disorders, and fatigue); anxiety-related conditions (such as heart palpitations, hyperventilation, and panic attacks); sad, depressed affect; or talk of suicide (McKay, 1994). According to Consensus Panelists and field reviewers, many batterers intensify their physical attacks when they learn their partner is pregnant.
Another clue is documented or reported child abuse perpetrated by the partner of a client. Evidence suggests that a father who abuses his children often abuses his wife as well (Bowker et al., 1988). Providers should be alert to the possibility that the mother of a child who has been or is being abused by her partner is also being abused herself.
The provider can also glean information from a woman's description of her partner's treatment of her. Behaviors that suggest he may be abusing her include
During an initial interview, many survivors will deny that they have been battered. Therefore, treatment staff must be alert to indicators of possible domestic violence and must continue to pursue them, with sensitivity and tact, over the course of treatment.
Screening for domestic violence should take into account the client's cultural background and environment. Interviewers should be knowledgeable about the social mores of clients' groups and trained to avoid culturally bound stereotypes and jargon. Anecdotal evidence suggests that female interviewers may be more effective at working with survivors.
A substance abuse treatment provider who suspects that a client is being abused by her partner must use caution and tact in approaching this subject. Timing is important, too; in most cases, more information about a survivor's experience of violence will begin to emerge as she gains confidence and as treatment staff continue to foster an atmosphere of trust and respect. It is important not to ask potentially painful questions too soon; otherwise, a client may feel overwhelmed and reluctant to return.
Screening for domestic violence is more likely to be effective when the interviewer offers concrete examples and describes hypothetical situations than when the client is asked vague, conceptual questions. If using a yes/no questionnaire, interviewers should be prepared to follow up on "no" answers.
Another helpful screening technique is to focus questions on the behavior of the client's partner in order to ameliorate any discomfort she may feel in talking directly about herself. An important caveat to this recommendation, however, is that the interviewer should beware of "bad-mouthing" or otherwise attacking the batterer, as doing so may cause the abused client to defend the batterer and assume the role of his ally.
Setting is also important in asking clients sensitive questions about their home lives. Privacy and an atmosphere of trust and respect are necessary if the interviewer expects to obtain candid answers to screening questions, especially since survivors may for many reasons be unable to tell the whole truth about being abused. It is of utmost important for treatment staff to be aware that a client who may be a survivor of domestic violence should never be asked about battering when she is in the presence of someone who might be her batterer. In fact, providers should always interview clients about domestic violence in private, even if the woman requests the presence of another person who is unlikely to be her batterer. It is not uncommon for batterers to manipulate friends and family members into relaying information they heard in the interview that would put the client at risk. Her potential abuser may be a boyfriend or spouse, a stepfather or father, a mother's boyfriend, or a male sibling. Querying her in the presence of the abuser can seriously endanger her and may place her at risk of reprisal. In addition, obtaining accurate information from a survivor is highly unlikely in this situation.
The Consensus Panel recommends that treatment providers ask about the substance-abusing client's family of origin in a way that gives the client "permission" to talk about it openly. For example, providers might preface their questions with, "In most homes where there is substance abuse, families have other problems, too. I'm going to ask some questions to see whether any of these things have happened to you or your family." Again, the interviewer should keep reassuring the client of confidentiality and safety while asking the following questions:
Discussion of childhood abuse may open the door to discussion of current violence. In moving the interview from past to current violence, the possibility that they are survivors should be explored first, before questions about perpetrating violence themselves. This initial screening can be done by asking questions such as
At this point, the interviewer can ask more specific questions regarding the nature and circumstances of specific incidents. Three questions have been cited as key to identifying victims of domestic violence:
The interviewer might go on to say, "We will be talking about these situations at different times throughout your treatment, and I want to know about any upsetting experiences that you may have had. Even if you don't feel like talking about this with me today, it is important that we eventually address all aspects of your life." The client should also be asked about her thoughts, feelings, and actions in particular situations. Questions (such as the following) about marital rape and nonconsensual sex should be included:
The interviewer needs to keep in mind that the client who has been sexually assaulted by her partner may normalize her experience, particularly if it has been a repeated one. If sex has always, or nearly always, been accompanied by violence or substance abuse, she may believe this is typical of all sexual relations.
If it becomes evident during a screening interview that a client has been or is being abused by her partner, the following four key questions can help delineate the frequency and severity of the abuse:
Sometimes pointing to a body map is easier for a survivor client than naming where she has sustained injuries from battering (see Appendix C). It is also important to include questions about the extent of her injuries and the batterer's involvement in the criminal justice system.
The interviewer should be aware that many survivors of domestic violence see the batterer's substance abuse as the central problem or cause of the abuse, believing that "if he would just stop drinking (or taking drugs)," the violence would end. In framing screening questions, it is extremely important to convey to the survivor that there is no justification for the battering and that substance abuse is no excuse. Questions such as, "Does he blame his violence on his alcohol or other drug use?" or, "Does he use alcohol (or other drugs) as an excuse for his violence?" serve the dual purpose of determining whether the client's partner may be a substance abuser while reinforcing to her that substance abuse is not the real reason for his violence.
Nor should questions feed into the batterer's excuse-making mechanism. The interviewer can shift the focus and the blame for the abuse away from the survivor by asking her questions about the batterer such as "Has he always handled problems by getting violent?"
In keeping a client-centered perspective, treatment providers must be aware of cultural factors that bear on the survivor's view of her experience and her willingness to talk about it. For many survivors, being battered is often a source of great shame that must be kept secret at almost any cost. Others may be unaccustomed to talking about family matters openly and directly with nonfamily members. To put the client at ease as much as possible, it may be helpful and appropriate for the interviewer initially to seek her permission to ask the screening questions, using language such as: "In order to help you, I need to know about what has been happening in your home. May I ask you some questions about you and your [partner, boyfriend, husband]? Or would you rather be asked these questions at another time?"
Respecting the survivor's sense of privacy in this way can boost her sense of control over her present situation. This can be especially important in light of the fact that most survivors present for services in a crisis. For example, a battered woman who seeks help with a substance abuse problem may have been abandoned by her abusive partner or may be in drug withdrawal. Her general feelings of powerlessness may be eased somewhat by this approach.
Although most women who are victims of abuse appear to respond better to a female interviewer, a client should be asked, and granted, her preference (Bland, 1995; Minnesota Coalition for Battered Women, 1992). If translators or hand signers are needed, a neutral party (not a family member) should be enlisted to perform this function.
As mentioned previously, it is common for a survivor of domestic violence to evade the issue or lie when asked about her abusive experiences. Survivors' reasons for lying about being abused are numerous and varied. Many blame themselves for the violence and make excuses for the batterer's erratic or destructive behavior. For example, a client who has been battered by her partner may attempt to justify his behavior with comments such as, "I deserved it," "I nagged him," or, "It was my fault." It is common for a survivor to believe that if only she would stop upsetting the batterer, or "pushing his buttons," the abuse would stop (American Medical Association, 1994). As one field reviewer noted, this self-blame may be more a mechanism to explain the violence that dominates survivors' lives than to justify it.
Some survivors go further than downplaying and self-blame and deny that there is abuse. Such denial may be a functional mechanism for her that helps her avoid dealing with problems that seem overwhelming and insurmountable. Denial is also, in some cases, an adaptive survival technique developed as a direct response to unsuccessful attempts to obtain help. Additionally, the survivor of domestic violence may not be entirely truthful because she may be accustomed to using manipulation as a survival mechanism. Because survivor clients do not know how interviewers will use information about battering, they do not always divulge it.
Finally, as discussed in Chapter 2, many survivors have concrete reasons for hiding domestic violence. A survivor could lose custody of her children if it is discovered that they live in a violent household. And the batterer may well have told her that he will beat or kill her or her children if she reports the abuse.
A discussion of family relationships is an element of all substance abuse screening interviews. Based on their experience, the Consensus Panel recommends using this component of the interview to address the issue of domestic violence with male clients. To initially gauge the possibility that the client is being abusive toward his family members, the interviewer can ask whether he thinks violence against a partner is justified in some situations (Kantor and Straus, 1987). This is the concept of "circumstantial violence." It is best to explore this possibility using a third person example so as not to personalize the question or make the client feel defensive; for example: "Some people think that, under certain circumstances, it's OK to hit your wife (girlfriend, etc.). Under what circumstances do you think violence might be justified?"
The answer reveals clues about whether and when a client might use violence against his partner. The interviewer can now shift the questions to the client himself. The interviewer can ask questions to assess the client's sense of self-efficacy and self-control:
Specific questions about events in the client's family, particularly his own current worries, may provide a sense of the environment in which violence may be occurring.
Part of an interviewer's aim here is to give the client a good reason to discuss the violence in a manner similar to that described for interviewing survivors ...to help the client see that there are benefits to acknowledging the abuse. The interviewer may tell the client that violence toward a partner is not uncommon among the other people enrolled in a treatment program, opening the door for the client to respond truthfully.
By taking an open-ended social and family history, the interviewer can gradually move to specific, direct questions regarding violence and abuse in the current relationship. For example:
Some batterers are so focused on their substance abuse problems that the violence is relatively unimportant to them. Others have lived with violence for so long that they have little understanding of the nature of their own behavior. Such individuals may provide information about their abusive behavior only incidentally or may dismiss it as unimportant. In their Guidelines for Talking to Abusive Husbands (EMERGE, 1995), experts from the EMERGE domestic violence support program recommend that providers:
Avoiding the implication that substance abuse is the "cause" of violence is as important in screening batterers as it is in screening survivors. Batterers often blame the victim, the victim's substance abuse, or their own substance abuse for the battering. In asking screening questions such as those just described, substance abuse treatment providers must be careful not to enable a batterer to place the blame for the battering on the victim or the drug. Interviewers must neither directly nor indirectly support the batterer's assertion that some other force has caused the violence or substance abuse (Cayouette, 1990).
An example of collusion would be the interviewer's assent that the client drinks because of some external source of stress, such as his job or his wife's "nagging." It is common for the survivor herself to think, feel, and act in accordance with this view, so often a tacit agreement exists between a batterer and a survivor to blame the latter for the violence. The client's failure to take responsibility for his behavior is further reinforced when a treatment provider or other team member speculates that circumstances, rather than the individual, are the cause.
Since clients who disclose their violence toward their partners often minimize its frequency and severity, experienced domestic violence staff may interview the batterer's partner in order to obtain salient information about his dangerousness to himself, his partner, and others. In fact, many batterers' programs require batterers to give permission for staff to interview the female partner as a prerequisite for acceptance into the program. This type of collateral interviewing, however, is quite different from that practiced in the substance abuse treatment setting and requires specialized skills and expertise. Prior to conducting the interview, violence support staff and the involved partner carefully weigh the risks associated with participating in such an interview (e.g., the possibility that it may precipitate another battering incident). If the partner agrees to the interview, she will be interviewed alone. Her perspective will be compared with the batterer's and used carefully and sensitively by the violence specialist in working with the batterer. (Appendix C presents an example of a survivor questionnaire that is used as a tool in assessing a batterer's dangerousness.)
Many substance abuse treatment providers routinely facilitate therapy sessions with substance abusers and their families. However, this approach should not be used with substance-abusing batterers and their partners. While substance abuse programs can cooperate with batterers' programs by reinforcing "no violence" messages and behaviors, providers should refer the client to a domestic violence specialist for further assessment and intervention. Some batterers' programs will not accept active substance abusers. In that case, participation in a batterers' program can become a specified part of the aftercare plan (Engelmann, 1992).
When family violence comes to the attention of the treatment provider, it is essential to determine whether children have been present or have been involved in any way. During the initial screening of the client, the Consensus Panel recommends that the interviewer should attempt to determine whether the children have been physically harmed and whether their behavior has changed (e.g., they have become mute or they scream or cry).
The confidentiality regulations spelled out in Title 42, Part 2, of the Code of Federal Regulations require that a client be given notice regarding the limitations of confidentiality ...orally and in writing ...upon admittance to a substance abuse treatment program (see Appendix B). Inquiries into possible child abuse should not occur until this notice has been given and the client has acknowledged receipt of it in writing. Great care must be taken when approaching either a batterer or a survivor of domestic violence about whether any children in the household have been abused.
There may be a number of barriers to obtaining a complete and accurate picture of the children's situation from these clients. First, adults who abuse children are generally aware of the laws that require substance abuse treatment providers, among others, to report suspected child abuse to agencies such as children's protective services (CPS), and they tend not to volunteer such information for fear of recrimination. Second, a survivor may be aware that her perceived "failure" to protect her children from violence may have implications for her retaining custody of them. Such fears are likely to be reinforced by her feelings of shame and guilt over "letting it happen." Or she may be abusing the children herself.
It is not advisable for the substance abuse treatment provider to perform an assessment of children for abuse or incest; this function should be performed by personnel with special expertise. The substance abuse treatment provider should, however, note any indications of whether abuse of children is occurring in a client's household and pass on what they find to the appropriate agency.
In the Consensus Panel's experience, clues to possible child abuse may be obtained by questioning the client regarding
This area of questioning need not be repeated for each child in the household, but rather can be done in a general way in order to get a sense of the overall family environment.
If a treatment provider suspects that the child of a client has been a victim of violence, he or she must refer the child to a health care provider immediately. If it appears that the parent will not take the child to a doctor (who is required by law to report the suspected abuse), the provider must contact home health services or CPS. This should be done even if a child appears to be unharmed, because some injuries may not be immediately apparent.
Immediate attention to the child's emotional state is also important. Emergency room physicians or nurses who conduct physical examinations may not be in a position to thoroughly assess the impact of abuse on the child's emotional status. Initially, it may be that the most that can be done is to reassure the child that he is safe and will be taken care of. Ideally, however, he should be referred to a therapist who specializes in counseling traumatized children.
Clients must be informed that mandated reporters, a category that includes substance abuse treatment providers, are required to notify CPS if they suspect child abuse or neglect (see Chapter 5, Legal Issues). In addition, a client can be informed of the right to report his or her partner's abuse of children. Whatever decision is made concerning who will actually notify CPS, ultimately it is the mandated reporter's responsibility to ensure that this is done.
The treatment provider must assess the impact on a survivor client of reporting suspected or confirmed child abuse or neglect. If she cannot be protected from her abuser on a 24-hour basis, she may become the object of his violence if he blames her for the report, so a safety plan should be developed. It is equally important to prepare for the impact of reporting child abuse on the children and on the family as a whole. The possible results of such a report must be considered and explained to the client in advance. For instance, if CPS is unable to confirm that abuse or neglect has occurred, the children could be endangered if the abuser learns of the report. In other instances, CPS may remove the children from the home until further investigation can be undertaken. If the investigation confirms abuse or neglect, a series of court appearances will be required, and children may be placed in foster care either in the short or long term. In any case, it is imperative for professionals working with family members to provide information about what to expect and, if at all possible, talk with the CPS caseworker and accompany the family to court hearings. Child abuse and neglect is a complicated issue and will be discussed in detail in a pending Treatment Improvement Protocol.
When answers to screening questions suggest that clients may be either batterers or survivors of domestic violence, the Consensus Panel recommends an immediate referral to a domestic violence support program. When referrals are not possible, ongoing consultation with a domestic violence expert is strongly encouraged. In some instances, clients have been mandated into substance abuse treatment by the courts. Participation in a battering program may be another court-mandated requirement. Substance abuse treatment providers should not hesitate to use the leverage provided by the criminal justice system to ensure that clients who batter participate in batterers' treatment as well.
If, during the screening, the client reveals that she is in immediate danger, the counselor needs to attend to this danger before addressing other issues and, if necessary, should suspend the interview for this purpose (Sullivan and Evans, 1994). The treatment provider should be familiar with methods for de-escalating the situation or obtaining help (see Appendix D for a safety plan) and may advise the client to take some simple legal precautions and to safeguard important documents (see Figures 4-1 and 4-2). If the client and counselor decide to involve the police, they should first discuss possible reprisal by the batterer and plan a response.
A substance abuse treatment provider may be the first person to whom the survivor has revealed her victimization. Whether she has previously disclosed the abuse to other agencies or programs will have a bearing not only on the level of danger she is in or perceives herself to be in, but will also have an impact on the process of establishing linkages with other agencies and sources of support.
If screening reveals domestic violence, then further assessment is required. Though the substance abuse treatment provider should help the client build a safety plan, assessment is best performed by a domestic violence support program. Questions that will aid referral include
If a survivor client expresses concern about the safety of her children, especially if they are left in the care of the batterer while she is in treatment, this is the time to refer the client for shelter and legal advocacy. Resources can be identified by contacting a local domestic violence program, or, if one is not available, a State program. The National 24-Hour Domestic Violence Hotline (1-800-799-SAFE) is another resource for domestic violence programs. Substance abuse treatment facilities should ensure that these resources are readily available to their staff.
When suspected batterers are identified during the screening process, substance abuse treatment providers should refer them to batterers' intervention programs as a key part of the treatment plan. With the client's signed consent to release information, substance abuse counselors can share pertinent information with domestic violence staff in an effort to ensure that both problems are addressed.
Well-run batterers' treatment programs may not be available in every community. Before initiating referrals, the Consensus Panel recommends that substance abuse treatment staff compile a list of potential programs and providers, check their credentials with domestic violence support programs for survivors or local battered women's shelters, and contact appropriate programs or specialists to establish agreed-upon referral procedures.
The confidentiality regulations do not inhibit such referrals as long as consent to release information has been obtained and the procedures detailed in Appendix B have been followed.
Even though a provider has referred a client involved in domestic violence to a survivors' or batterers' program or incorporated participation in such programs as part of the aftercare plan, domestic violence remains an issue. The treatment provider should see that the following actions are taken, either by the substance abuse or violence program or by a case manager assigned responsibility for the client's holistic care.
Some survivors' programs require participants to sign a contract agreeing to have no contact with their batterers for the duration of the program. In addition to helping to ensure her safety, such contracts can provide opportunities for staff to evaluate a survivor's current attitudes toward and thinking about the batterer. Such "reality checks" can be helpful if, as is often the case, a survivor begins to believe the batterer's assurances that he has changed and is no longer violent. The staff can point out the reality of the situation if the batterer is still abusing alcohol or other drugs and has not changed his life in any significant way.
Batterers entering treatment for substance abuse can be required to sign a contract agreeing to refrain from using violence. While such "no-violence contracts" are most effective when linkages with batterers' intervention programs are also in place, they can help structure treatment by specifying an achievable behavioral goal. It is more difficult for clients to play one agency against another when all those involved in a particular case prescribe common goals. When the court has a role in mandating treatment services and specifying sanctions for failure to comply, clients have an added incentive to adhere to such stipulations as "no-violence" contracts. Consensus Panel members believe that the prospects for positive outcome (e.g., reductions in substance abuse and domestic violence) will be improved when substance abuse and batterers' treatment programs and the courts collaborate to ensure that needed services are provided, consistent behavioral messages are communicated, and consequences for violating contracts and other programmatic stipulations are upheld.
A number of violence support experts, including members of the Consensus Panel, have observed a tendency among some substance-abusing batterers to twist the messages of 12-Step programs in order to evade responsibility for their violent behavior:
Men in recovery often gain more tools of abuse from their distorted interpretation of 12-Step and treatment programs. One of the most frequently used tools by batterers in groups has been the label of codependent. Men use it to put down their partners, saying this means battered women are as sick or sicker than them, to define victims as at least partly responsible for their violence, and to manipulate women into feeling guilty and ashamed of their expectations that men stop abusing. (Cayouette, 1990, p. 3)
Providers should be alert to signs that clients are misinterpreting the 12-Step philosophy to justify or excuse continued violence, especially since 12-Step programs can play a valuable role in supporting batterers' treatment as well as recovery from substance abuse when its principles are followed rather than distorted (Wright and Popham, 1995). Men who have embraced the 12-Step model will often challenge the excuse-making of batterers, encouraging them to take responsibility for all their actions, including the domestic violence. (Cayouette, 1990).
Group therapy is an essential feature of most substance abuse treatment programs. However, members of the Consensus Panel who have worked extensively with substance-abusing survivors observe that survivors "may have an especially difficult time talking about past experiences if men are included in the group. Often, the safest and most comfortable time for her to discuss violence is during one-on-one sessions with her counselor. These sessions are also an opportune time to ask about her needs regarding the abuse" (Minnesota Coalition for Battered Women, 1992, p. 39). Survivors also appear to benefit by participating in same-sex groups that do not use confrontational techniques (Minnesota Coalition for Battered Women, 1992; Wright and Popham, 1995).
As discussed previously in this chapter, many survivors and batterers presenting at substance abuse treatment facilities do not disclose domestic violence on intake, and treatment providers must rely on signs of violence that become apparent as the client spends time in treatment. Ongoing attention to issues of domestic violence is particularly important in these clients not only because it may take time for them to begin talking about it, but also because as they become abstinent, additional issues arise that are integrally related to the violence (Prochaska et al., 1992, 1994a, 1994b; Snow et al., 1994; Velicier et al., 1990). As with substance abuse, the full dimensions of a domestic violence problem are seldom immediately clear and may emerge unexpectedly at a later stage in treatment. If this happens, questions posed during screening can be asked again, and a referral to a violence support or batterers' intervention program can be initiated.
All jurisdictions in the United States have implemented regulations and laws designed to protect victims of domestic violence. The Violence Against Women Act (VAWA), which was signed into law by President Clinton in September 1994, strengthens many of these protections and outlines Federal as well as State enforcement provisions and penalties. The Federal penalties mandated by VAWA are more stringent than existing State penalties: The bill, for example, makes it a Federal offense to cross State lines in violation of a civil protection order. In order to provide useful advice and support, substance abuse treatment providers should be familiar with VAWA and with relevant State and local regulations as well as with the legal resources available to victims of domestic violence.
Substance abuse treatment providers should also have working relationships with the criminal justice system and local providers of legal and domestic violence services to whom they can refer a client with such problems. (See Appendix E for a listing of national programs and hotlines that can help providers identify local services.)
VAWA is a civil rights statute that was passed as part of the Violent Crime Control and Law Enforcement Act (Public Law 103-322). Besides strengthening prevention and prosecution of violent crimes against women and children, the law made domestic violence a civil rights violation. What this means is that a victim of "crimes of violence motivated by gender" can bring a suit for damages in civil court in addition to any charges made in criminal court.
Some of the more important provisions of the law include
Some provisions of VAWA may be particularly important to women in substance abuse treatment who are also survivors of domestic violence. Under VAWA,
One of the most important aspects of VAWA is the civil rights remedy for gender-motivated violence mentioned above. Relief in civil court may include monetary damages, injunctions, or declaratory judgment to redress the civil rights violation.
As of this writing, at least one district court decision has been issued that upholds the provisions of VAWA. In Doe v. Doe (929 F.Supp.608 D.Conn. 1996), a woman sought damages for 17 years of "physical and mental abuse and cruelty" by her husband. He moved to dismiss the case on the grounds that VAWA was unconstitutional. The Federal district court denied the motion to dismiss and upheld VAWA's constitutionality. If VAWA withstands other pending challenges, it may become an important weapon for women seeking to break free from battering partners.
The issue of preventing domestic violence has important implications for welfare reform; when considered in conjunction with issues involving substance abuse treatment, the overall picture becomes extremely complicated. In fact, some States (such as Kansas) have established laws that require people receiving welfare to be screened, assessed, and treated for substance abuse. It is important for treatment providers to be aware of the issues involved; careful coordination of services with domestic violence workers can help to avoid serious problems (Raphael, 1996).
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law 104-193), signed into law on August 22, 1996, calls for greater use of paternity determinations to enforce child support regulations. This can be problematic for welfare recipients who are victims of domestic violence. Abuse is often exacerbated or reactivated when legal action is taken against the batterer for child support. Many abused women are afraid to seek child support because they fear that doing so will result in the batterer being given visitation rights, which would force disclosure of their new location. Although current Federal law does provide "good cause" exemptions in a number of situations, including domestic violence, this option is used by fewer than 1 percent of welfare applicants nationally (Raphael, 1996; Zorza, 1995b). Providers should tell survivor clients concerned about confidentiality that these exemptions exist.
The most common and easily obtainable mechanism of relief for victims of domestic violence is the civil protection order. This general term includes any injunction or other order (such as a restraining order) that is issued for the purpose of preventing violent or threatening acts against another person. Generally, these orders prohibit harassment, contact, communication, or physical proximity. Protection orders may be temporary or final and may be issued by a civil or a criminal court. Protection orders can be issued independently or as part of another proceeding, such as a divorce or criminal complaint, but are separate from support or child custody orders.
Statutes and case law in all States and the District of Columbia allow an abused adult to petition the court for an order of protection, and in most State courts, a parent or another adult can file for a civil protection order on behalf of a minor child (Klein and Orloff, 1993). Depending on the relevant statutes and case law on the books of any given jurisdiction, conduct sufficient to support issuance of a civil protection order can include
State courts have consistently upheld the constitutionality of domestic violence statutes. Civil protection order statutes have been held to rationally and reasonably uphold the State's interest in preventing domestic abuse, because these statutes do not
In addition, courts have found that procedural aspects of civil protection orders do not violate the defendant's right to a jury trial. Most jurisdictions allow an individual to petition for civil protection with or without the aid of a lawyer. In fact, some courts have upheld laws that permit court clerks to assist petitioners in filing for protection orders.
Although the assistance of legal counsel is preferable, pro se representation -- or self-representation -- is an option for victims who cannot afford the services of an attorney. Pro se actions allow domestic violence survivors to seek the immediate protection of the courts, and it can also empower them as they seek to gain control of their lives. Furthermore, many areas lack attorneys who are able and willing to act as advocates for battered women, although in some jurisdictions lay advocates are available to counsel victims of domestic violence, help prepare court papers, and handle uncomplicated cases in court.
For many clients, treatment for substance abuse includes an effort to acknowledge -- to themselves and perhaps to others -- the harm they have visited on family and friends. A victim of domestic violence will explore the role substance abuse played in the abusive relationship. A perpetrator of domestic violence may have agreed to enter treatment in lieu of trial or incarceration; he will need to examine that aspect of his behavior as well as his substance abuse. Finally, a client who enters treatment presenting an entirely different constellation of issues may disclose during the course of counseling that he or she has either assaulted or been assaulted by a spouse. During the course of counseling victims -- or perpetrators -- of domestic violence, substance abuse program staff will hear about violent behavior. What is the program's legal obligation in such circumstances? How should programs deal with inquiries from lawyers or criminal justice officials? What should a program do when a counselor or client records are subpoenaed or the police come armed with a search warrant? This section discusses these issues and the tension between the need to protect people from harm and the need to respect the client's confidentiality. Confidentiality is protected under 42 Code of Federal Regulations (C.F.R.), Part 2, implementing 42 U.S.C. §290dd-2. (All references to §2 . . . below refer to these regulations.)
Although the Federal confidentiality regulations may prohibit reporting domestic violence to law enforcement authorities, substance abuse treatment providers should still ask about it. Whether the information is passed along or not, it still bears on treatment. Providers should acknowledge the abuse; help the client separate her responsibility from that of the batterer; counsel her that the violence may escalate; help assess her safety and offer available options; clearly document the abuse (enlisting the aid of a forensic examiner, if necessary); provide referrals to shelter, legal services, and counseling; and facilitate such referrals with her consent. Treatment providers must not let confidentiality restrictions prevent them from routinely inquiring about domestic violence in the course of providing appropriate care to clients.
What should a program do when a client admits he has battered his spouse at some time in the past -- or during his participation in treatment? Does the program have a duty to call law enforcement officials if a woman threatens to assault her husband or child -- an act the counselor knows she has committed in the past? What can a program do if a client attacks his wife at the program? These are three very different questions that require separate analysis.
The general question about the duty to report past criminal activity is one that arises frequently for substance abuse treatment programs. Many substance abusers engage in criminal behavior while they are abusing drugs and even during the course of treatment. In a situation in which a client has told a substance abuse counselor that he or she has battered a spouse or child in the past, there are generally three questions the program needs to ask as it considers whether to make a report: (1) Does State law require the program to make a report? (2) Does State law permit the program to make a report? (3) How can a report be made without violating the Federal law and regulations governing confidentiality of patients' records (42 U.S.C. §§290dd-2 and 42 C.F.R. Part 2)?
First, under State law, is there a legal duty to report child abuse or other domestic violence? For substance abuse counselors the answer to this question is "yes" if child abuse is involved and generally "no" if battering of a spouse is involved.
All States (and the District of Columbia) require a broad range of care providers -- including substance abuse treatment programs -- to report when there is reasonable cause to believe or suspect child abuse or neglect. While many State statutes are similar, each has different rules about what kinds of conditions must be reported, who must report, and when and how reports must be made. In most States, failure to report may result in civil or criminal charges. All States extend immunity from prosecution to persons reporting child abuse and neglect; in other words, a person who reports abuse cannot be sued.
While all States require agencies to report child abuse, most alcohol and drug programs are limited by Federal law in the kind and amount of information they may disclose to anyone without a patient's written consent. (The regulations require that a particular form of written consent be used. Appendix B contains a full discussion of these regulations as well as a sample consent form.) However, the Federal confidentiality regulations do permit substance abuse treatment programs to comply with State mandatory child abuse reporting laws.
Note, however, that this is a narrow exception to the regulation's general rule prohibiting disclosure of any information about a client. It permits only initial reports of child abuse or neglect. Programs may not respond to followup requests for information or subpoenas for additional information, even if the records are sought for use in civil or criminal proceedings resulting from the program's initial report, unless the client consents or the appropriate court issues an order under §2.64 or §2.65 of the regulations.
Assault of another person, including a spouse, is a crime. Few States impose a duty to report a crime committed in the past, although some States do require physicians treating certain types of injuries incurred as the result of a violent criminal act (e.g., a shotgun wound) to make a report to the police. Even those States that still have laws that require reports of past criminal acts rarely prosecute violations of the law. Therefore, unless a particular State should mandate reporting of spousal abuse by health care providers and mental health counselors, it is unlikely that a substance abuse treatment counselor will have a legal obligation to report.
Does State law permit counselors to report a crime involving domestic violence to law enforcement authorities? Whether or not there is a legal obligation imposed on citizens to report past crimes to the police, occasions may arise when counselors feel a personal obligation to report an admission of domestic violence to law enforcement authorities. However, State law may protect conversations between counselors of substance abuse programs and their clients (by making them privileged) or exempt counselors from any requirement to report past criminal activity by clients. Such laws are important to clients in substance abuse treatment, many of whom have committed offenses during their years of alcohol or drug abuse. If part of the therapeutic process for clients includes acknowledging the harm they have done others, substance abuse programs that routinely reported clients' admissions of past criminal activity would have limited ability to work with clients in the recovery process. Laws protecting conversations between counselors of substance abuse programs and their clients are designed to protect that relationship, an important part of the treatment process. Survivor clients as well as batterers need to know that their disclosures are protected.
State laws vary widely in the protection they accord communications between patients and counselors. In some States, admissions of past crimes may be considered privileged and counselors may be prohibited from reporting them; in others, admissions may not be privileged. Moreover, each State defines the kinds of relationships protected differently. Whether a communication about past criminal activity is privileged (and therefore cannot be reported without the patient's consent) may depend on the type of professional the counselor is and whether he or she is licensed or certified by the State.
Any program that is especially concerned about this issue should ask a local attorney for an opinion letter about whether there is a duty to report and whether any counselor-patient privilege exempts counselors from that duty.
Any program that decides to report a client's admission of past spousal abuse must do so without violating either the Federal confidentiality regulations or State laws. A program that decides to report a client's admission of battering or any other criminal activity can comply with the Federal regulations by following one of these three methods:
By using any one of these methods, the program will have discharged its reporting responsibility without violating the Federal regulations. Before reporting, however, the program should also be sure that a report would not violate any State laws making communications between clients and counselors privileged. Because of the complicated nature of this issue, any program considering reporting a batterer's admission should seek the advice of a lawyer familiar with local law as well as the Federal regulations.
In working with batterers, substance abuse treatment programs may face questions about their "duty to warn" someone of a client's threat to harm his spouse or child. Even when a counselor has no legal obligation to report a client's threat, a treatment professional may feel an ethical, professional, or moral obligation to try to prevent a crime.
Over the past 20 years, States across the nation have adopted a principle -- through legislation or court decision -- requiring psychiatrists and other therapists to take "reasonable steps" to protect an intended victim when they learn that a patient presents a "serious danger of violence to another." This trend started with the case of Tarasoff v. Regents of the University of California, 17 Cal.3d 425 (1976), in which the California Supreme Court held a psychologist liable for money damages because he failed to warn a potential victim his patient threatened to, and then did, kill. The court ruled that if a psychologist knows that a patient poses a serious risk of violence to a particular person, the psychologist has a duty "to warn the intended victim or others likely to apprise the victim of the danger, to notify the police, or to take whatever other steps are reasonably necessary under the circumstances."
In most States, therapists and other care providers must warn a victim or the police when a patient makes a credible threat of violence to another identified person. (Of course, not every threat uttered by a patient should be taken seriously. It is only when a patient poses a serious threat of violence toward a particular person that the duty to warn arises.) Counselors who fail to warn either the intended victim or the police may be liable for money damages or license revocation.
In a situation where a client threatens to assault a spouse, and the counselor believes he is serious, the counselor must ask him- or herself at least two -- and sometimes three -- questions:
The first question can only be answered by an attorney familiar with the law in the State in which the substance abuse program operates. If the answer to the first question is "no," it is advisable to discuss the second question with a knowledgeable lawyer too.
The problem is that there is an apparent conflict between the "duty to warn" imposed by the many States that have adopted the principles of the Tarasoff case and the Federal confidentiality requirements. Simply put, the Federal confidentiality law and regulations prohibit the type of disclosure that Tarasoff and similar cases require unless a substance abuse program can use one of the Federal regulations' narrow exceptions. These aside, the Federal regulations make it clear that Federal law overrides any State law that conflicts with the regulations (§2.20). In the only case, as of this writing, that addresses this conflict between Federal and State law (Hasenie v. United States, 541 F. Supp. 999 (D. Md. 1982)), the court ruled that the Federal confidentiality law prohibited any report.
There are five ways a substance abuse treatment program can report a client who makes a serious threat to harm someone (or himself). The first three of those methods have already been outlined above in the discussion about reporting admissions of past crimes:
If none of these options is practical, what should a program do? If a program believes there is clear and imminent danger to a client or another person, it is probably prudent to report the danger to the authorities or the threatened individual, particularly in States that follow the Tarasoff rule. While each case presents different questions, it is doubtful that any prosecution (or successful civil lawsuit) under the confidentiality regulations would be brought against a program or counselor who believed in good faith that there was real danger to a particular individual. On the other hand, a civil lawsuit for failure to warn might well result if a threat were actually carried out. In any event, the program should try to make the warning in a manner that does not identify the individual as a substance abuser.
As in other areas where there are no clear-cut answers and the law is in flux, programs should find a lawyer familiar with State law who can provide advice on a case-by-case basis. Programs would also be well advised to establish a protocol ensuring that the clinical or program director has a chance to review the situation before a report is made. "Duty to warn" issues are an area in which staff training may be helpful.
The answer is more straightforward when a client has committed or threatens to commit a crime on program premises or against program personnel. In this situation, the Federal regulations permit the program to report the crime to a law enforcement agency or to seek its assistance. Moreover, in these circumstances, the program can disclose details about the incident, including the suspect's name, address, last known whereabouts, and status as a client at the program (§2.12(c)(5)).
Counselors working with victims -- or perpetrators -- of domestic violence may find that lawyers, law enforcement officials, and others view them as a good source of information. A call from a lawyer asking about a client, a visit from a law enforcement officer asking to see records, or the arrival of a subpoena to testify or produce treatment records -- what should a program do in each of these circumstances?
The answer is (1) consult the client, (2) use common sense, and (3) as a last resort, consult State law (or a lawyer familiar with State law).
Starting with the first scenario -- a lawyer calls and asks about Jane White's treatment history or treatment. As a first approach to the question, Jane's counselor must tell the lawyer, "I don't know that I have a client with that name. I'd have to check my records." This is because the Federal confidentiality regulations prohibit any other response without the client's written consent. The regulations view any response indicating that Jane White is the counselor's client as an unauthorized disclosure that Jane White is in substance abuse treatment.
Even if the counselor has the client's written consent to speak with the lawyer, she may find it helpful to consult with the client before having a conversation about her: "I'm sure you understand that I am professionally obligated to speak with Jane White before I speak with you." It will be hard for any lawyer to disagree with this statement.
The counselor should then speak with the client to ask whether the client knows what information the caller is seeking and whether the client wants her to disclose that or any other information. She should leave the conversation with a clear understanding of the client's instructions -- whether she should disclose the information, and if so, how much and what kind. It may be that the lawyer is representing the client and the client wants the counselor to share all the information she has. On the other hand, the lawyer may represent the client's spouse or some other party with whom the client is not anxious to share information. There is nothing wrong with refusing to answer a lawyer's questions, but a polite tone is best. If confronted by what could be characterized as "stonewalling," a lawyer may be tempted to subpoena the requested information and more. The counselor will not want to provoke the lawyer into taking action that will harm the client.
If the lawyer represents the client and the client asks the counselor to share all information, the counselor can speak freely with the lawyer once the client signs a proper consent form. However, if the counselor is answering the questions of a lawyer who does not represent the client (but the client has consented in writing to the disclosure of some information), the counselor should listen carefully to each question, choose her words with care, limit each answer to the question asked, and take care not to volunteer information not called for.
A police officer, detective, or probation officer who asks a counselor to disclose information about a client or a client's treatment records must be handled in a similar manner. The counselor should give a noncommittal response, such as "I'll have to check my records to see whether I have such a patient." Of course, if the patient was mandated into treatment in lieu of prosecution or incarceration, program staff may be obligated to speak with someone from the referring criminal justice agency, and the client will have signed a criminal justice system consent form authorizing the program to do so.
If the officer's inquiry has come "out of the blue," the counselor should speak with the client to find out whether the client knows the subject of the officer's inquiry, whether he wants the counselor to disclose information and if so, how much and what kind and whether there are any particular areas the client would prefer she not discuss with the officer. Again, the counselor must get written consent from the client before speaking with the officer.
If the counselor knows that a client is a fugitive from justice, a refusal to assist or give officers information is a criminal offense in some States.
Subpoenas come in two varieties. One is an order requiring a person to testify either at a deposition out of court or at a trial. The other -- known as a subpoena duces tecum -- requires a person to appear with the records listed in the subpoena. Depending upon the State, a subpoena can be signed by a lawyer or a judge. Unfortunately, it can neither be ignored nor automatically obeyed.
In this instance, the counselor's first step should be to call Jane White -- the client about whom she is asked to testify or whose records are sought -- and ask what the subpoena is about. It may be that the subpoena has been issued by or on behalf of Jane's lawyer with Jane's consent. However, it is equally possible that the subpoena has been issued by or on behalf of the spouse's lawyer (or the lawyer for another adverse party). If that is the case, the counselor's best option is to consult with Jane's lawyer (after getting Jane's written consent) to find out whether the lawyer will object -- ask the court to "quash" the subpoena -- or whether the counselor should simply get the client's written consent to testify or turn over her records. An objection can be based on a number of grounds and can be raised by any party, including the person whose medical information is sought. Often, the counselor may assert the client's privilege for the client.
A program may unknowingly admit a client who is sought by the police. If the police discover that someone they are seeking is at the program and come armed with an arrest warrant, what should the program do? How should programs handle search warrants? The answers to these questions are quite different.
An arrest warrant gives police the authority to search the program facilities; however, the program is not authorized to help the police by pointing out the client they are seeking unless the client is being sought because he or she committed a crime on program premises or against program personnel. The unfortunate result is that the confidentiality of all clients in the program may be compromised when the police enter and search for a fugitive. There is no solution to this problem unless the police secure a court order under §2.66, which would authorize the program to disclose the identity of the client, or the program convinces the client to surrender. (Voluntary surrender by a client is a disclosure by the client, not the program.) It is usually in the client's best interest to surrender voluntarily, since arrest is probably inevitable and his cooperation may weigh in his favor with the prosecutor and judge when the question of bail arises. The risk is that the client will attempt to escape, which might expose the program to a charge of assisting unlawful escape. To reduce this possibility, the program should work with the police so that law enforcement personnel have secured the area around the program.
A search warrant does not authorize the program to permit the police to enter the premises. Even if signed by a judge, a search warrant is not the kind of "court order" that the Federal regulations require before the program can allow anyone to enter and see clients or client records when clients have not consented. Law enforcement officials are unlikely to know about the restrictions of the Federal regulations, however, and they will probably believe that a search warrant permits them to enter and search the program. What should a program do?
Presented with a search warrant, program staff should show the officer a copy of the Federal regulations and explain their restrictions. Staff can suggest that the officer obtain a court order that will authorize the program to make the disclosure called for in the search warrant. No harm will ordinarily be caused by resultant delay (although the police may not agree with this view). The program should call its lawyer and let him or her talk with the police. Failing that, a program could try to call the prosecutor who has sent the police, explain the regulations, and point out that any evidence seized without the proper court order may be excluded at trial, since it will have been seized illegally.
If none of these steps works, the program must permit the police to enter. Refusal to obey a direct order of the police may be a crime, even if the police are wrong, and forcible resistance would be unwise. If the program has made a good faith effort to convince the law enforcement authorities to pursue the proper route, it is unlikely that it would be held liable for allowing entry when argument fails.
Programs should develop protocols for dealing with the constellation of legal issues that may arise during the treatment of victims -- or perpetrators -- of domestic abuse. Programs should have a copy of the Federal regulations available at all times to show law enforcement officials and establish a relationship with an attorney who can be called upon to help in these situations. Finally, programs should reach out to law enforcement agencies before a crisis arises and work with them to develop ways of dealing with these kinds of issues. If the regulations are explained when there is no emergency and there can be no suspicion that the program is hiding anyone or anything, and a protocol is established, unpleasant confrontations may be avoided.
Isolation is a salient characteristic of domestic violence: It occurs in isolation and it isolates its victims from community life. Countering this pervasive isolation with a coordinated community response is perhaps the strongest way to eliminate domestic violence from our society (Clark et al., 1996). "If we are ever to eradicate domestic violence, the whole community must become alerted to the problem and how best to support the victims and convey to the abusers that abuse is a crime that is never justified" (Zorza, 1995a, p. 54).
Although the primary focus of this Treatment Improvement Protocol is on linking substance abuse treatment and domestic violence support services, the linkages cannot stop there: Other efforts to link and integrate community resources are essential -- not only to ensure that the needs of individual survivors and batterers are met but also to raise public awareness and to begin to create the coordinated community response that is necessary for change. Coordinated intervention is crucial. These efforts must address needs for housing, child care, emotional and physical safety, health and mental health care, economic stability, legal protection, vocational and educational services, parenting training, and support and peer counseling, among others.
Linkages will also help each agency fulfill its own mission. Few programs have the resources available to address the sometimes overwhelming number of problems faced by substance abuse treatment clients who are affected by domestic violence. Increasingly, programs are looking to strong collaboration and linkages with other service agencies to meet their clients' needs. Such collaboration is particularly important in isolated rural communities where lack of resources and distance from services are significant problems.
In all communities -- urban, rural, and suburban -- individuals who provide substance abuse and domestic violence services in the public sector generally have experienced the negative consequences of fragmented and unintegrated service systems. Historically, their resourcefulness in obtaining necessary care for their clients has created an informal system of referrals and unofficial case management. Such linkages are becoming more formalized as system administrators realize the cost-effectiveness of collaboration and coordination of services and as public sector purchasers of Medicaid managed care become more sophisticated in contracting with managed behavioral health care organizations to ensure a continuum of services for clients served in the public sector.
Thus the current behavioral health care environment may be one especially open to change in the direction of linkages, collaboration, coordination, and service integration. This chapter calls on providers to be especially positive and creative in thinking about these issues and designing action plans. Those who have seen past efforts at service integration fail, who are skeptical about structural change within State service delivery systems, and who may be ambivalent about giving up turf are encouraged to support coordination and collaboration -- that is, separate agencies planning together and working together to create new delivery approaches with support at the State level. This chapter focuses on two approaches to building linkages; the first based on systemic reform and the second rooted in the community. Two crucial linkages are highlighted -- that between substance abuse treatment and domestic violence support services and that between these services and the criminal justice system.
Linkages are frequently conceived of as local program-to-program relationships, and much of the remainder of this chapter is devoted to such linkages. While not disputing the importance of community-based interagency networking, the Consensus Panel believes that a new way of thinking about linkages on the systems level can help address the multiple social service needs of substance-abusing victims and perpetrators of violence. In calling for substantive, top-down reform, the Panel allies itself with those domestic violence experts (Hart, 1995b; Hart et al., 1995) and mental health experts (Stroul, 1993) advocating a new approach to organizing and institutionalizing coordinated social service delivery systems.
Under this new paradigm, the familiar concept of a "continuum of services" is elevated to the State level and substantially expanded to include a formal structure and process to oversee system-level coordination among agencies. While specific goals would vary from State to State, the Panel believes that such systemic reform would enable States to create a collaborative infrastructure that, in turn, would allow programs to deliver care that is
Currently, most social services -- including substance abuse treatment and domestic violence support -- function as a series of parallel programs with their own sources of funding, leadership, and constituencies (Hart, 1995b; Hart et al., 1995; Stroul, 1993). Clients needing services from more than one program not only face a number of hurdles (e.g., differing eligibility requirements, hours of operation, and locations), but may also receive services that are counterproductive because they are not part of a coordinated treatment plan (Hart, 1995b).
In the environment that would emerge after converting from parallel services to an integrated delivery system, cooperation on the client's behalf would replace competition for the client and for the attendant funding that follows admission to a specific program or to a treatment slot or bed. Collaboration would eliminate duplication of services and receipt of inappropriate services. With a client-centered philosophy prevailing, the provision of adjunctive support services like child care, transportation, and housing would assume greater importance and would more likely be funded (Stroul, 1993).
Systemic reform on this scale requires structural, administrative changes at the State level. As a first step toward revamping service delivery to multiple-needs clients, the Panel envisions a mechanism that would
In its assessment of systems of care for children (Stroul, 1993), Georgetown University's Child Development Center discovered that, as expected, integrated systems of care expanded access to services, including adjunctive support, and increased the use of case management to monitor service delivery and advocate for individual clients and their families. The study also found that this approach, in some instances, reduced costs. For example, three counties in California saved more than $35 million over 4 years for residential care by using a systems model of service delivery. Similarly, Fort Bragg, North Carolina, reduced the costs of caring for children with serious emotional disturbances by 51 percent through the systems of care approach. The State of Kentucky likewise reduced the cost of services from $13.5 million to $9.5 million (Stroul, 1993).
Although these models have yet to be applied to the substance abuse and domestic violence fields, the Consensus Panel believes they hold promise for redefining the existing service delivery system to ensure more appropriate and effective care for substance-abusing domestic violence victims and perpetrators. The Panel strongly recommends that Federal and State policymakers consider a series of demonstrations designed to test the feasibility of changing the current system to institutionalize a formal administrative structure for promoting and supporting collaboration and linkages among social service programs.
The health care environment is increasingly forced to respond to the demand for cost containment; therefore, undertaking collaborative endeavors is critical to the future of many programs, especially at the community level. As noted, few have the resources to offer under one roof all the specialty services that clients need. Creative linkages can supplement and complement programs, building on their strengths and compensating for their weaknesses. Linkages can open avenues to diverse sources of funding to offset the inevitable ebb and flow of resources. And in a practical vein, a growing number of funding sources are granting funds only when presented with evidence of coordinated activities among grant applicants.
Before linkages can be developed, it is necessary to know what resources exist within the community. Each entity has its own organization and its own culture that must be understood for collaboration to be successful. Every State has a unique infrastructure for housing the health care, legal, social, and other services related to substance abuse treatment and domestic violence services. Communities themselves also vary in government structure, available resources, and funding streams. Some combine alcohol treatment with treatment for other substance abuse, whereas others separate the two. Some locate services for victims of domestic violence in the criminal justice system, which affects the tone and procedures used to deliver services, while others locate such services in a hospital system linked to the emergency department. A program within a nonprofit entity in the private sector has far different restraints than one housed in a government agency.
Disciplines also differ dramatically in structure and orientation. Some substance abuse treatment programs, for example, are staffed by nurses, and others are staffed by certified addiction counselors. Many existing programs, such as Minnesota's Turning Point and African American Services, have incorporated family violence issues into substance abuse treatment, and communities throughout the United States are increasingly integrating the two areas (Clark et al., 1996). A single treatment approach would be enhanced by making programs accountable to the local community, strengthening the linkages between the two fields and the court system, and improving evaluation procedures.
In the current early state of development of linkages between the fields of substance abuse treatment and domestic violence services, it has been suggested that "the linkage mechanism that seems most appropriate is case management" (Collins et al., 1997, p. 400). Increasingly, the substance abuse treatment field has recognized that case management may be a key contributor to successful treatment (Ridgely and Willenbring, 1992). In the case management approach, a specially trained single practitioner or case management team is responsible for coordinating linkages to the wide variety of services -- including domestic violence support -- needed by many if not most clients in substance abuse treatment (Sullivan, 1994).
Although locating and gaining initial access to these services can be challenging, many programs have found that use of case management is well worth the effort, since it helps clients work through problems that may trigger use of alcohol and other drugs or that interfere with progress in treatment. Such problems may include homelessness, mental illness, HIV infection, lack of vocational skills, and unemployment (Willenbring, 1994). An additional advantage is that the case manager serves as a client advocate, representing the client's interests in both accessing other agencies and ensuring that their services are used effectively (Rapp et al., 1994).
Several locales have attempted to develop model programs integrating substance abuse and domestic violence services. These include the Amend Program in several Colorado communities (Rogan, 1985-1986), the Intercede Program of Longford Health Sources in Ohio (Burkins, 1995), and the Pittsburgh Veterans Affairs Medical Center (Gondolf, 1995). A study of linkage efforts in Illinois found that staff cross-training is inadequate to meet the goals of these efforts (Bennett and Lawson, 1994).
This TIP takes some of the first steps in formalizing linkages between the two fields. Chapters 2 and 3 present substance abuse treatment providers, who may lack knowledge about this population, with psychosocial profiles of survivors and batterers and their needs for specialized care. Such training is a key ingredient in bringing the two fields closer. Chapter 4 stresses the need for screening for domestic violence early in the substance abuse treatment process and the importance of timely referral of clients affected by domestic violence to the appropriate agencies. Routine screening for cross-problems by both types of programs is a major step toward linkage.
One of the first linkages that must be identified by a substance abuse treatment program that is working with domestic violence survivors is with the legal system (see Chapter 5). A legal professional or legal service is the best resource for resolving problems that pertain to individual clients' involvement in the justice system and may be the best resource for information and guidance regarding the Violence Against Women Act (VAWA). Many of the Act's provisions -- such as those relevant to immigrants -- are complex and detailed. In addition, other Federal and State statutes may include provisions that appear to contradict those of the VAWA.
To treat substance abuse clients who are either survivors or batterers, treatment providers must be knowledgeable about policies and laws related to domestic violence; they must understand the roles of police, judges, probation staff, and other representatives of the justice system and be able to interact effectively with these individuals when necessary. As one field reviewer noted, "Integrating the criminal justice system's efforts should be the first step in forming linkages. If a provider wants assistance protecting a woman or getting a batterer to attend treatment, it is the criminal justice system that can get this done."
Specialized courts to process domestic violence cases, which combine intensive survivor services, treatment for batterers, and an active judicial role in the social contexts of the community, have been established. The Dade County, Florida, Domestic Violence Court, which commenced in late 1992, is a noteworthy example, and outcomes are still being evaluated (Fagan, 1996). However, some early data indicate that recidivism rates among treated batterers processed through these courts are high and comparable to rates found in studies of the deterrent effects of protective orders and arrests. Failure rates are strongly correlated with lengthy prior records and a history of abuse in the batterer's family of origin (Fagan, 1996).
In pursuing victim protection goals, criminal justice agencies have been required to expand their traditional focus on the detection and punishment of crimes. Placing these expectations on police and prosecutors may require tasks and roles for which they are not well trained. Such role and policy ambiguities can affect the performance of agencies with respect to their missions. As Fagan notes:
There is no doubt that linkages between legal institutions and services for domestic violence victims are critical to stopping violence. However, these linkages may best be accomplished through a strategic division of roles among institutions that tap the strengths of each organization. . . . Although legal systems should be open and accessible to battered women, these institutions should not take on the role of managing the coordination of services that involve social service, shelter, and other interventions. (Fagan, 1996, pp. 39-40)
Treatment plans for substance abuse clients who are survivors or batterers must incorporate all the issues surrounding both sets of problems and ideally will be coordinated by a case manager. Treatment planning for matters such as time sequencing (e.g., when to start support for a domestic violence survivor in substance abuse treatment) and goals of treatment is not effective without consideration of all the factors that have a bearing on the client's best interests. Substance abuse treatment providers, domestic violence experts, and legal or other relevant professionals should plan treatment collaboratively.
Because treatment plans for domestic violence survivors are built around the premise that safety must always be the first priority, substance abuse treatment may initially take a back seat. For example, a client who lives with a violent partner may report being pressured or coerced by him to use alcohol or other drugs. In these instances, some degree of relapse may need to be tolerated in light of the threat to the client's safety. A survivor's frequent reporting of such a situation, however, signals the need for substance abuse treatment and domestic violence staff to jointly reconsider treatment priorities.
A batterer entering treatment for substance abuse can be required to sign a contract agreeing, among other stipulations, to refrain from using violence (see Chapter 4). Such "no-violence contracts" are most effective when linkages are made with other agencies involved with his case, and violations should be reported to all involved agencies, especially the criminal justice system.
Treatment providers can help persuade the courts to consider alternative sanctions that take the victim's circumstances into account. Incarcerating batterers can actually harm their victims by taking away the family income. On the other hand, not incarcerating the batterer may give him the false message that his behavior is not that bad and thus tacitly give him "permission" to continue his violence. Courts may order the batterer to receive counseling, perform public service, or a variety of other sanctions.
Figure 6-1 highlights some of the key linkages substance abuse programs should consider in developing collaborative strategies to assist clients with domestic violence problems. Some duplication across the lists is intentional.
Figure 6-2 lists some of the potential obstacles to forming collaborative relationships between substance abuse treatment and domestic violence programs, as well as opportunities for collaboration and ideas for taking action to form such relationships.
All relationships begin with a "getting-to-know-you" phase; initial, face-to-face interactions often establish the tone for future interaction. These initial meetings should include a discussion of the origins of both communities in order to help each understand the other's beliefs and attitudes. Other topics for discussion include each program's goals for its clients, the barriers routinely faced with clients, typical interactions with clients, and expected outcomes. Key individuals in each system can coach the staff of the other in working with and understanding that system and the needs of its clients. During the initial phase, it also may be helpful to acknowledge some of the stereotypes held by each field about the other and to discuss them frankly.
At these initial meetings, using a staff member with strong facilitation skills can be invaluable. An alternative is to use a facilitator from an outside agency not affiliated with either program (e.g., from a university or community college). The facilitator can recognize burgeoning problems and defuse them before group members become defensive and uncooperative, and he or she can help participants bridge gaps in understanding by clarifying terminology and asking for feedback to ensure that all parties are interpreting information the same way. A followup memo documenting the understandings that emerged from the meeting and listing areas of agreed-upon responsibility can also assist the collaborative process.
In collaborative relationships, difficulties can arise if one entity feels taken advantage of, perceives that the other is deriving more benefits from the association, receives more credit, or believes that power is unequal between the two groups. Balance is central to an effective collaboration that satisfies the expectations and needs of all involved. When a collaborative domestic violence effort, for example, used the letterhead of one participating organization, the other partners were displeased because their participation was not acknowledged. To give equal recognition to all partners, a new project-specific letterhead reflecting all the collaborators was designed. Not all solutions will be so simple, but this example demonstrates the importance of frank communication, responding to the concerns of all the partners in the network, and moving quickly to resolve problems.
Many programs have in place a system for periodic internal evaluation of their success in meeting their goals. Decisionmakers may find it useful to reexamine a program or organization specifically in terms of its readiness to take advantage of and maintain a collaborative association.
For successful linkages, program staff -- beginning with boards of directors -- must be sensitive to the other program's requirements and culture. A board that consists of members who are committed to supporting program goals and overcoming challenges is essential to effective operation. Motivated and well-connected directors can, for example, help identify community funding sources that will support the development of collaborations.
Administrators can promote linkages by identifying conflicts or economies of scale in the areas of fiscal management, accounting, contract management, funding development, program evaluation and organizational audits, human resources and payroll management, management information systems, and other technology. They can also enhance linkages and develop funding sources by working with other agencies and programs to compete for block grant funds and to split funding for substance abuse and domestic violence. Program managers should appoint a staff member as a contact and liaison for each linkage. Administrators and managers should seek to create an organizational environment that encourages and supports staff members' collaboration activities, which are often time-consuming. Staff members' new collaborative relationships, as well as their existing relationships with other agencies, are critical to success.
Substance abuse treatment and domestic violence professionals also must educate themselves on issues particular to each cultural or ethnic subgroup their clients represent. Failure to do so diminishes outcomes and completion rates for minority populations. Cultural competence is more important than ever now, as the country moves toward a "majority-less" ethnic composition and major cities become pluralities of cultures rather than majority-minority paradigms. Responding to the needs of clients will require an awareness of practice and attitude and an organizational structure that continually monitors:
Lastly, cultural competence implies that agencies are equipped to respond to "insensitivity" and that they make inclusiveness an institutionalized value, in part by employing highly skilled multicultural staff (Cross et al., 1989).
Evaluation helps programs measure how effective they are in achieving their goals and gives them information to redesign and improve program components. Increasingly, funding sources require documentation of the program's success and of individual outcomes. However, in the fields of substance abuse treatment and domestic violence, outcomes may not always be as clear-cut or as measurable as funders would like. Administrators must be aware that a funding source or other outsider to the field may not agree with or approve of a program's criteria for success. For example, relapse is an expected part of recovery from substance abuse, and abstinence may not be the sole indicator of treatment success. Treatment effectiveness should also be measured by larger social indicators, such as higher employment rates, better personal relationships, and fewer legal entanglements (Wolk et al., 1994). After treatment, some people will not be drug-free for the rest of their lives, but they will experience more stability and more productive lives, resulting in significant benefits to society.
Even if an organization takes all the steps above, the path to collaboration is still paved with unforeseen difficulties. The importance of differences in perspectives between the two fields, as discussed in Chapter 1, should not be underestimated. One survey of staff in both types of program found that more than half of all staff cited "conflicting beliefs about personal responsibility" as a reason for noncooperation between programs (Bennett and Lawson, 1994). Service delivery structure and funding also can block collaboration.
Furthermore, confidentiality and informed-consent practices vary among fields (see Appendix B). Large programs may have trouble linking with small programs, especially if documentation and tracking procedures are incompatible. Conversely, small grassroots programs may have problems following the formal procedures required by larger organizations or may lack staff to ensure that paperwork is completed in a timely fashion. Professionally led and staffed organizations may doubt the competence of paraprofessional staff members who are in recovery and may discount their suggestions in the course of treatment planning. Similarly, untrained staff may fail to recognize the validity of the insights and suggestions proffered by professional social work and mental health care givers.
Other issues affecting the costs of collaboration include the number of approvals and layers of bureaucracy that must be negotiated to obtain services from a linked agency, requirements for research and evaluation that may be attached to participation in a network, and the amount of staff time required to maintain linkages and resolve problems.
Funding sources for domestic violence support include the criminal justice system through Federal block grants, State money, or fines levied against perpetrators. Private and community organizations also represent funding sources. Employee assistance programs (EAPs) can serve as both allies and access points to solicit and obtain corporate funding. Third party reimbursement for domestic violence services is slowly gaining some acceptance. At one time, insurers might have refused to pay for these services for a woman who was covered under the batterer's policy, reasoning that the woman's injury was self-inflicted because she chose to stay with the batterer. In some cases, the batterer must authorize payment for treatment for the survivor if medical, health, or disability coverage is in his name.
One reason domestic violence has not been incorporated into concepts of managed care is that, as discussed in Chapter 1, some advocates for domestic violence survivors have rejected the use of a medical model to define the problem. In addition, most managed care companies have specific requirements about who can deliver services; if no program staff meet those requirements, it is not likely that the program will be reimbursed. Domestic violence support encompasses services such as housing and job training that are outside the realm of health care and that have outcomes difficult to measure in terms of health improvement, which are the outcomes of interest to health maintenance organizations (HMOs). However, many managed care organizations are investing funds to help their enrollees deal with issues that are not traditionally medical; many HMOs offer strss management and exercise programs. All health systems are increasingly recognizing the cost-effectiveness of early detection and prevention in general in their covered populations, and some have set up routine screening for substance abuse. Furthermore, increased interest in outcomes measurement and consumer satisfaction has broadened the spectrum of behaviors monitored and outcomes measured by health care providers.
Reimbursement from managed care organizations and other third parties relies on diagnostic classifications and treatment categories. Advocates for reforms in health care and social welfare must find ways to classify joint substance abuse-domestic violence problems to ensure reimbursement. Although some domestic violence programs use the classification "trauma" and receive reimbursement for treatment, services are frequently provided as nonreimbursable advocacy or coaching. Victims who are thought to have underlying problems are typically referred to other programs (e.g., for psychological or substance abuse treatment). Research indicates that there are no psychological risk markers for becoming a victim of adult domestic violence (Hotaling and Sugarman, 1990). However, certain characteristic symptoms are seen in many people following highly traumatic life events. Some battered women experience these symptoms as a result of violence-associated trauma, and they are normal psychological responses to stressful life events. Often, these symptoms dissipate as women achieve greater safety from the abuse. Other women may require more intensive therapeutic interventions to heal from the effects of violence. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994), offers some diagnoses that may be helpful in classifying survivors' symptoms and helping programs receive reimbursement for treatment. Some survivors may meet criteria for posttraumatic stress disorder (see Chapter 2) or for depressive and anxiety disorders.
Credentialing processes for substance abuse treatment providers must assess their ability to screen for violence and create a safety plan, as well as their knowledge of legal issues related to domestic violence. They should demonstrate a knowledge of child abuse and neglect, child sexual abuse, partner violence, elder abuse, extended family violence, and violence as an issue in relationships other than marital or partner relationships.
In Bismarck, North Dakota, the Federation of Family Funding promoted and supported the development of a multiagency partnership plan to help families experiencing domestic violence. All providers involved with the family meet face-to-face every month to share information, make plans, and discuss strategies for ensuring progress. In a Los Angeles program for pregnant or substance-abusing battered mothers, a team of providers involved in all aspects of a client's treatment meets as a group with the client. Children's grandmothers, if they are the formal court-appointed caretakers of the children, are included in the case conferences; perpetrator fathers are not. Interagency agreements are made in advance to protect confidentiality.
Many of the linkages between domestic violence support services and other service organizations that have been most effective have occurred in health care settings, especially in hospitals. Linkages of the type described here might benefit from involvement of staff from substance abuse treatment programs. At the Dekalb Medical Center in Atlanta, emergency room nurses who suspect that a woman has been battered call a patient representative with specialized knowledge to interview the patient after medical treatment is provided (Dekalb Medical Center, 1993). The representative, who is able to spend more time with the patient than the nurses, refers the patient to a community shelter or makes other referrals and also provides feedback to the emergency room staff.
Other examples of hospital-based service linkages come from Boston, Minneapolis, and Seattle (Loring and Smith, 1994). At Children's Hospital in Boston, staff from AWAKE, an advocacy program for battered women and their children, are called in to provide safety planning and support for patients who are violence survivors. In Minneapolis at the Hennepin County Medical Center, an advocate from a battered women's shelter makes rounds in all services -- not just the emergency room -- to speak directly with medical staff and interview violence survivors. In this way the hospital administration and medical staff are assured that in addition to receiving appropriate medical care, survivors are assisted in other areas, such as locating the batterer, obtaining legal protection, and proceeding with assault charges when appropriate. Harborview Hospital in Seattle employs an "adult abuse protocol" with components of various systems to ensure comprehensive services to the battered woman patient. Finally, health maintenance organizations, many of which maintain detailed databases to track service utilization and outcomes, may find it easier than general hospital systems to identify and reach out to survivors of domestic violence.
In 1994 the Board on Children and Families, the National Research Council, and the Institute of Medicine sponsored a 3-day workshop, Violence and the American Family (Chalk, 1994). Although the focus was a broad one and included child and elder abuse as well as other forms of family violence, many of the participants suggested action ideas for linkages among agencies involved in the treatment of domestic violence survivors and batterers. As can be readily seen, no single agency or system can successfully undertake the broad tasks and initiatives outlined below that were suggested by workshop participants. Rather these projects invite broad collaboration and cooperation.
In the area of social services, tasks to be undertaken included (Chalk, 1994)
In the area of health, the workshop participants identified three specific initiatives (Chalk, 1994):
In the area of criminal justice, three issues were raised as fruitful areas for activities (Chalk, 1994):
In addition to these recommendations, the workshop participants outlined three broad steps necessary to establish a much-needed basis for future research and program plans (Chalk, 1994):
A public health approach has been effective in reducing morbidity and mortality by modifying behavior in many areas (e.g., campaigns to reduce smoking, to reduce alcohol abuse among pregnant women, and to prevent head injuries by wearing helmets). A public health approach to violence has been suggested (Koop and Lundberg, 1992) in response to the surge in morbidity and mortality due to violence (Prothrow-Stith, 1991). As the epidemiological evidence mounts that society's rising mortality figures are due in large part to violence, public health professionals acknowledge the destruction of "quality years of life" as well as the expensive healing process and now study the problem in terms of understanding and changing unhealthy outcomes (Koop and Lundberg, 1992).
Public health officials, generally solution-driven rather than theory-driven, view domestic violence as the result of a complex array of causal factors. By focusing on "risk factors," they can identify structural, cultural, and situational conditions that accompany, precede, and follow events of interpersonal violence (Moore, 1995). They also monitor public health, identify at-risk groups, and implement programs with evaluation components.
Education is a critical component of a public health campaign. In Houston, for example, the March of Dimes targeted both health care professionals and the public with educational interventions and brochures about battering during pregnancy; public service announcements were developed for the media.
Though the examples above do not include substance abuse treatment as one of their linkages, they provide a blueprint for the coordination of care that the Consensus Panel recommends. While the Panel believes the current system of parallel services should be integrated at the State level, meaningful change can occur at the community level. For either substance abuse treatment or domestic violence support services to be successful, the two fields must pool their energies to address gaps in client services outside the immediate networks of substance abuse treatment and violence support. Enduring linkages with other agencies and programs must be established to supply those ancillary services essential for positive client outcomes.