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Center for Substance Abuse Treatment. Substance Abuse Treatment and Domestic Violence. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Treatment Improvement Protocol (TIP) Series, No. 25.)

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Substance Abuse Treatment and Domestic Violence.

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Chapter 4—Screening and Referral of Survivors and Batterers in Substance Abuse Treatment Programs

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.

Screening

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.)

Methods of Screening For Domestic Violence: Survivors

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.

Clues for the Substance Abuse Treatment Provider

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

  • Isolating her (keeping her away from family, friends, and others who are supportive of her recovery from substance abuse)
  • Forcing her to sell drugs or prostitute herself for drugs
  • Preventing her from attending treatment or 12-Step meetings
  • Threatening to harm her, himself, or others
  • Engaging in reckless behavior that endangers himself or others
  • Damaging property or belongings
  • Harming other family members or pets
  • Threatening to abandon her or to take children away.

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.

Conducting the Interview

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.

Uncovering past sexual abuse

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:

  • "Were you ever told by an adult to keep a secret and threatened if you did not?"
  • "Were you ever forced to watch sex between other people?"
  • "Were you ever touched in a way you didn't like?"
  • "How old were you when you first had sex (including anal, vaginal, and oral penetration)?" Then, "How old was the person you had sex with?"

Uncovering current abuse

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

  • "Do you feel safe at home?"
  • "Has anyone in your family ever physically hurt you?"
  • "Has anyone in your family made you do sexual things you didn't want to do?"
  • "Have you ever hurt anyone in your family physically or sexually?"

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:

  • "Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?"
  • "Do you feel safe in your current relationship?"
  • "Is there a partner from a previous relationship who is making you feel unsafe now?" (Feldhaus et al., 1997).

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:

  • "Do you feel comfortable with the ways you have sex?"
  • "Has your partner ever forced you to do anything sexually that made you feel uncomfortable or embarrassed?"
  • "Do you feel you can say no if you don't want to have sex?"
  • "Are you ever hurt during sex?"
  • "How do you feel about talking about safe sex and HIV with your partner?"

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:

  • "When was the first time you were [punished, hurt, or whatever word reflects the survivor's interpretation of abuse]?"
  • "When was the last time you were abused?"
  • "What is the most severe form of abuse you have experienced?"
  • "What is the most typical way in which you are abused?"

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.

Framing the questions

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?"

Cultural considerations

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.

Barriers to an accurate screen

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.

Screening for Domestic Violence: Batterers

Screening Techniques And Questions

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:

  • "If you were faced with overwhelming stress (use a hypothetical situation), do you think you could keep your cool?"
  • "What do you think you'd do?"

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:

  • "Have you ever been physically hurt by someone in your family?" If the client's partner has hurt him or her, the reverse may also be true.
  • "Have you ever hurt someone in your family?"
  • "Have you ever physically controlled, hit, slapped, or pushed your partner?" (If yes) "When was the last time this happened?"

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:

  • Ask specific, concrete questions (e.g., "What happens when you lose your temper?").
  • Define violence (e.g., "When you hit her, was it a slap or a punch?" "Do you take her car keys away? Damage her property? Threaten to hurt or kill her?").
  • Find out when the violence occurs and who the target is.
  • Be direct and candid. (Resist the urge to use a euphemism such as, "Is your relationship with your partner troubled?" because you are uncomfortable asking the question. Instead, talk about "his violence" and keep the focus on "his behavior.")
  • Become familiar with batterers' excuses for their behavior:
    • Minimizing: "I only pushed her." "She bruises easily." "She exaggerates."
    • Citing good intentions: "She gets hysterical so I have to slap her to calm her down."
    • Use of alcohol and drugs: "I'm not myself when I drink."
    • Claiming loss of control: "Something snapped." "I can only take so much." "I was so angry, I didn't know what I was doing."
    • Blaming the partner: "She drove me to it." "She really knows how to get to me."
    • Blaming someone or something else: "I was raised that way." "My probation officer is putting a lot of pressure on me." "I've been out of work."
  • Don't be manipulated or misled by excuses. (Identify violence as a problem and hold the client responsible for his actions.)

Avoiding Collusion

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.

Interviewing the Partner

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).

Screening for Presence Of Child Abuse

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.

Indications of Child Abuse

In the Consensus Panel's experience, clues to possible child abuse may be obtained by questioning the client regarding

  • Whether CPS has been involved with anyone who lives in the home
  • Children's behaviors such as bedwetting and sexual acting out
  • "Special" closeness between a child and other adults in the household
  • The occurrence of "blackouts": Batterers often claim blackouts for the period of time during which violence occurs.

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.

Reporting Suspected Neglect or Abuse

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.

Referral

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.

Referring Survivors

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

  • "To whom have you talked about this in the past?"
  • "Are you, or is anyone in your family, currently in danger from someone in your household? Do you think that being here now, talking to me, could put you in danger? If so, how?"

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.

Referring Batterers

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.

Treatment Concerns for Survivors and Batterers

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.

The "No-Contact Contract"

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.

The "No-Violence Contract"

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.

Recovery Pitfalls for Batterers And Survivors

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).

Ongoing Attention to Issues Of Domestic Violence

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.

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