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
Printed 1997
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
Associate Professor
Department of Psychiatry, Community Health, and Adult Primary Care
University of Maryland
School of Nursing
Baltimore, Maryland
Richard L. Brown, M.D., M.P.H.
Associate Professor
Department of Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin
Dorynne Czechowicz, M.D.
Associate Director
Medical/Professional Affairs
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Rockville, Maryland
Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Directors
Washington, D.C.
Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
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
Atlanta, Georgia
Gil Hill
Director
Office of Substance Abuse
American Psychological Association
Washington, D.C.
Douglas B. Kamerow, M.D., M.P.H.
Director
Office of the Forum for Quality and Effectiveness in Health Care
Agency for Health Care Policy and Research
Rockville, Maryland
Stephen W. Long
Director
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Rockville, Maryland
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia
Patricia Anne Fazzone, R.N., D.N.Sc., M.P.H., C.S.
Assistant Professor
School of Nursing
Kansas University Medical Center
Kansas City, Kansas
John Kingsley Holton, Ph.D.
Site Director
Maternal and Child Health
School of Public Health
Harvard University
Chicago, Illinois
Beth Glover Reed, Ph.D.
Associate Professor
School of Social Work and Program in Women's Studies
University of Michigan
Ann Arbor, Michigan
Larry Bennett, Ph.D.
Assistant Professor
Jane Addams College of Social Work
University of Illinois at Chicago
Chicago, Illinois
Vivian Brown, Ph.D.
President and Chief Executive Officer
PROTOTYPES
Culver City, California
Candace M. Shelton, M.S., C.A.D.A.C.
Clinical Director
Guiding Star Lodge
Indian Rehabilitation, Inc.
Phoenix, Arizona
Kimberly Smith-Cofield, M.Ed.
Executive Director
Casa Myrna Vasquez, Inc.
Boston, Massachusetts
Carey Tradewell, M.S., C.A.D.C. III
President and Chief Executive Officer
Milwaukee Women's Center, Inc.
Milwaukee, Wisconsin
Oliver J. Williams, Ph.D.
Associate Professor
Graduate School of Social Work
University of Minnesota
Minneapolis, Minnesota
Roland Byrd, C.C.D.C., M.A.
Counselor
Montana Chemical Dependency Center
Montana State Department of Public Health and Human Services
Butte, Montana
Lonnie Hazlewood, M.S.H.P.
Managing Partner
Austin Stress Clinic, Ltd.
Austin, Texas
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
Arlington, Virginia
Jan Mickish, Ph.D.
Executive Director
Colorado Domestic Violence Coalition
Denver, Colorado
Brenda Miller, Ph.D.
Deputy Director
Research Institute on Addictions
Buffalo, New York
Beth E. Richie, Ph.D.
Associate Professor
Program in Public Health
Hunter College
City University of New York
New York, New York
Eric D. Wish, Ph.D.
Director
Center for Substance Abuse Research
University of Maryland at College Park
College Park, Maryland
Diane Zainhofsky
Executive Director
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.
Administrator
Substance Abuse and Mental Health Services Administration
David J. Mactas
Director
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
