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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 1—Effects of Domestic Violence on Substance Abuse Treatment

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 .)

Figure 1-1: Manifestations of Domestic Violence.

Figure

Figure 1-1: Manifestations of Domestic Violence.

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.

Defining the Problem

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.

Identifying the Connections

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:

  • About 40 percent of children from violent homes believe that their fathers had a drinking problem and that they were more abusive when drinking (Roy, 1988).
  • Childhood physical abuse is associated with later substance abuse by youth (Dembo et al., 1987).
  • Fifty percent of batterers are believed to have had "addiction" problems (Faller, 1988).
  • Substance abuse by one parent increases the likelihood that the substance-abusing parent will be unable to protect children if the other parent is violent (Reed, 1991).
  • A study conducted by the Department of Justice of murder in families found that more than half of defendants accused of murdering their spouses -- as well as almost half of the victims -- had been drinking alcohol at the time of the incident (Bureau of Justice Statistics, 1994).
  • Teachers have reported a need for protective services three times more often for children who are being raised by someone with an addiction than for other children (Hayes and Emshoff, 1993).
  • Alcoholic women are more likely to report a history of childhood physical and emotional abuse than are nonalcoholic women (Covington and Kohen, 1984; Miller et al., 1993; Rohsenow et al., 1988; Hein and Scheier, 1996).
  • Women in recovery are likely to have a history of violent trauma and are at high risk of being diagnosed with posttraumatic stress disorder (Fullilove et al., 1993).

The Societal Context

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.

The Connection Between Substance Abuse and Domestic Violence

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.

The Impact of Violence on Substance Abuse Treatment

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.

Barriers To Addressing Domestic Violence in the Treatment Setting

Battering, victimization, and treatment effectiveness

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.

Program priorities, terminology, and philosophy

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.

A New Way of Thinking

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.

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