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.
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.
If a client believes that she is in immediate danger from a batterer, the treatment provider should respond to this situation before addressing any other issues and, if necessary, should suspend the screening interview for this purpose. The provider should refer the client to a domestic violence program and possibly to a women's shelter and to legal services.
To determine if a woman is a victim of domestic violence, look for physical injuries, especially patterns of untreated injuries to the face, neck, throat, and breasts. 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.
Always interview clients about domestic violence in private.
Ask about violence using concrete examples and hypothetical situations rather than vague, conceptual questions.
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 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.
Though addictions counselors can be trained relatively easily to screen clients for domestic violence, once it is confirmed that a client has been or is being battered, domestic violence experts should be contacted. Violence assessment requires in-depth knowledge and skill and should be conducted by a domestic violence expert.
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 should contact a forensics expert to document the physical evidence of battering.
Once the client has entered substance abuse treatment, a treatment plan that includes a relapse prevention plan and a safety plan (see
Appendix D) should be developed.
Survivors appear to benefit by participating in same-sex treatment groups that do not use confrontational techniques.
Survivors can be asked to sign a "no-contact contract" agreeing not to communicate with their batterers for the duration of treatment.
Referrals should be made whenever appropriate for psychotherapy and specialized counseling. Even so, staff training in this area is important so that treatment providers can respond effectively in a crisis.
Should a client decide to relocate to another community, she should be referred to the appropriate programs within that community.
Because batterers in treatment frequently harass their partners by circumventing program rules and threatening them by phone, by mail, and by sending messages through other, approved visitors, telephone and visitation privileges should be carefully monitored for identified batterers and survivors in residential substance abuse treatment programs.
A discussion of family relationships is an element of all substance abuse screening interviews. Use this component of the interview to address the issue of domestic violence with male clients.
To initially gauge the possibility that a client is being abusive toward his family members, the interviewer can ask whether he thinks violence against a partner is justified in some situations, using a third person example.
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?").
Once it has been confirmed that a client is a batterer, the provider should contact a domestic violence expert, either for referral or consultation. Treatment providers should collaborate with a batterers' program to ensure that an assessment of dangerousness is performed.
Be direct and candid; avoid euphemisms such as, "Is your relationship with your partner troubled?" 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."
In asking screening questions, 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.
Domestic violence staff sometimes interview the batterer's partner in order to obtain salient information about his dangerousness to himself, his partner, and others. This type of collateral interviewing is quite different from that practiced in the substance abuse treatment setting and should only be performed by someone with specialized skills and expertise in domestic violence.
Treatment providers should try to ensure the safety of those who have been or may become a perpetrator client's victims, in particular his partner and children, during any crisis that precedes or occurs during the course of his treatment.
Treatment providers should mandate that batterers in treatment sign a "no-violence contract" that states that the client will, among other stipulations, refrain from using violence both inside and outside the program.
Treatment providers should elicit the following information about the relationship between the substance abuse and the violent behavior:
Exactly when in relation to substance abuse the violence occurs
How much of the violent behavior occurs while the batterer is drinking or on other drugs
What substances are used before the violent act
What feelings precede and accompany the use of alcohol or other drugs
Whether alcohol or other drugs are used to "recover" from the violent incident.
After identifying the chain of events that precede or trigger violent episodes, provider and client should together formulate strategies for modifying those behaviors and recognizing emotions that contribute to violent behavior.
Providers should be alert to signs that batterer clients are misinterpreting the 12-Step philosophy to justify or excuse continued violence. Another danger is that they will call their victims "codependent" in order to shift blame for the battering onto the woman.
Referrals to self-help aftercare groups like Batterers Anonymous (BA) groups should be made only after the client has completed a batterers' intervention program and has remained nonviolent for a specified period of time.
During the initial screening of a client, the Consensus Panel recommends that the interviewer should attempt to determine whether the client's children have been physically harmed and whether their behavior has changed (e.g., they have become mute or they scream or cry).
Inquiries into possible child abuse should not occur until notice of the limitations of confidentiality as defined in Title 42, Part 2, of the Code of Federal Regulations has been given and the client has acknowledged receipt of it in writing. Clients also must be informed that mandated reporters, a category that includes substance abuse treatment providers, are required to notify a children's protective services (CPS) agency if they suspect child abuse or neglect.
The substance abuse treatment provider should not perform an assessment of children for abuse or incest; this function should be performed by personnel with special expertise. The treatment provider should, however, note any indications of whether abuse of children is occurring in a client's household and pass on what he or she finds to the appropriate agency. Indications of child abuse that can be gleaned in a client interview include:
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.
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.
The treatment provider must assess the impact on a survivor client of reporting suspected or confirmed child abuse or neglect and develop a safety plan if necessary.
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.
Substance abuse treatment providers should be familiar with relevant Federal, State, and local regulations as well as with the legal resources available to victims of domestic abuse.
Treatment providers must fulfill their legal obligation to report domestic violence and suspected child abuse and neglect.
Treatment providers should never discuss their clienout the client's permission. Only certain types of subpoenas and warrants (discussed in Chapter 5) require that records be turned over.
Treatment providers should coordinate their efforts with domestic violence workers to ensure that clients avoid problems under the provisions of "welfare reform" (The Personal Responsibility and Work Opportunity Reconciliation Act of 1996).
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.
Treatment providers and domestic violence support workers should foster a new way of thinking about linkages on the systems level. Both fields would benefit from a coordinated system that could address the multiple social service needs of substance-abusing victims and perpetrators of violence.
A new mechanism should be developed at the State level to coordinate planning among disparate agencies based on client needs assessments; devise financing strategies that would allow for blended funding and strive for equitable allocation of resources among agencies; and establish a vehicle for resolving any problems that emerge in the course of providing integrated services.
Linkages should address needs for housing, child care, emotional and physical safety, health and mental health care, economic stability, legal protection, vocational and educational services, parenting training, and support and peer counseling, among others.
The services provided should be holistic, flexible, collaborative, coordinated, and accountable.
Linkages should address needs for housing, child care, emotional and physical safety, health and mental health care, economic stability, legal protection, vocational and educational services, parenting training, and support and peer counseling, among others.
Federal and State policymakers should consider a series of demonstrations designed to test the feasibility of changing the current system to institutionalize a formal administrative structure for promoting and supporting collaboration and linkages among social service programs.
In the absence of systemic reform, substance abuse treatment providers, domestic violence experts, and legal or other relevant professionals should plan treatment collaboratively.
A legal professional or legal service is the best resource for resolving problems that pertain to individual clients' involvement in the justice system and may be the best resource for information and guidance regarding VAWA.
Initial meetings between organizations trying to establish linkages should include discussion of the origins of both communities in order to help each understand the other's beliefs and attitudes.
The choice of outcomes to measure must be made carefully: The definition of success must be palatable to funders and third party payers as well as experts in the field.
Credentialing processes for substance abuse treatment providers should assess their ability to screen for violence and create a safety plan, as well as their knowledge of legal issues related to domestic violence.
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.
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