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Substance Abuse Treatment and Domestic Violence
Treatment Improvement Protocol (TIP) Series 25

[Tables and Figures]

Figure 1-1: Manifestations of Domestic Violence

Figure 3-1: Models for Batterers' Intervention Programs

Figure 3-1 Models for Batterers' Intervention Programs

The "Duluth model," as it is commonly called, was developed at the Domestic Abuse Intervention Project in Duluth, Minnesota, (Pence, 1989; Pence and Paymar, 1993) and is probably the most widely used model for batterers' intervention programs in the United States. There are many variations on the Duluth model, but all feature victim safety and community coordination as cornerstones and require batterers' programs to be accountable to victims and to victim advocates. The Duluth model is based on confronting the denial of violent behavior, exposing the manifestations of power and control, offering alternatives to dominance, and promoting behavioral changes. It calls for communitywide intervention that employs the resources of law enforcement, courts, domestic violence shelters and advocates, health providers, and batterers' programs. A batterers' program cannot, in this model, exist without the other components in the network. Although some experts feel that the Duluth model tends to encourage shame and guilt rather than real change, it sees domestic violence not as a form of personal pathology, anger and hostility, or substance-induced behavior, but as an outcropping of men's socially sanctioned domination of women. Batterers' programs developed under this model are designed to educate men about power and control, not merely to assist them in managing anger or personal problems. Communitywide coordination ensures that batterers are arrested and prosecuted and that victims are protected. The psychoeducational model promotes responsibility for violent behavior and the development of mechanisms for self-regulation, empathy or compassion for others, and appropriate emotional vocabulary to express intimacy. Safety precautions for significant others, no-violence contracts, provision of information, changing attitudes toward women, reinforcement or development of values via modeling, anger and stress management, and assertiveness skills are key features of this cognitive-behavioral approach (Palmer et al., 1992; Stosny, 1995). Group and individual treatment can be utilized within this model, although single-sex groups tend to be the norm. Results of one study suggest that highly structured groups (with defined curricula, homework assignments, and skilled facilitation) work more effectively than less structured groups (Edleson and Syers, 1990, 1991). Couples therapy treats men who batter together with their partners, often in a group setting. This is a controversial approach to batterers' intervention that has fallen into disrepute because of concerns about partner safety, its "implicit message that both partners are equally responsible for the violence," and its failure to acknowledge the role of gender and historical power inequities (McKay, 1994, p. 36). Substance abuse treatment providers should not treat batterer-and-victim couples together without consulting a domestic violence expert.

Figure 3-2: Positive and Negative Aspects of Bonding Among Batterers

Figure 3-2 Positive and Negative Aspects of Bonding Among Batterers

Positive Support for change Amelioration of feelings of isolation; support for communicating experiences with others Help in dealing with crisis Friendships Negative Support for control and dominant behavior over partners Support of counterproductive activities (e.g., having multiple sexual partners) Support of negative parenting activities (e.g., having children by different women) Support for a negative definition of manhood Support for believing he is correct and does not have to negotiate or compromise Access to information on how to violate laws such as orders of protection Use of alcohol and other drugs Opportunity to participate in "gripe sessions"-tirades against women under their control Reinforcement of perceived victim status

Figure 4-1: Safeguarding Important Documents

Figure 4-1 Safeguarding Important Documents

As part of the survivor's safety plan, it may be helpful to advise the survivor client to keep important documents in a safe deposit box or in a place where her partner cannot gain access to them. These materials may include some or all of the following: Social security documents Marriage license Passport(s) Copies of any protective orders or divorce or custody papers Green card Children's birth certificates Information about medical history, including vaccination schedules for children and records on health care visits Extra sets of home and car keys Photographic documentation of abuse Deeds or leases that document residence, titles to cars Other financial documents such as savings deposit books and payment books

Figure 4-2: Gathering Documentation

Figure 4-2 Gathering Documentation

All States have mandatory reporting laws for child abuse, but only some have or are developing such laws for reporting domestic violence. Some battered women's advocates support such laws because they "take the pressure off" the victims to report their batterers. Some domestic violence service providers also believe that it is the community's responsibility -- not the victim's -- to stop the batterer's behavior. Some States mandate the arrest of batterers whether or not their victims press charges, and some are proposing mandatory physician reporting of battering. Concerns have been raised, however, about preserving victims' ability to decide whether they want to become involved in the criminal justice system or in domestic violence programs. For this reason, such laws are opposed by some battered-women's groups, who believe they put women at greater risk. Regardless of whether a survivor elects to pursue legal remedies, she is well-advised to document the nature and extent of the domestic violence she and her family have experienced by compiling copies of Criminal justice reports, including prior legal actions (e.g., restraining orders) against batterers Any previous CPS reports that can be obtained Hospital records and health history of the client Complete criminal justice and medical records may be difficult to obtain. In the case of medical records, for example, survivors may have made visits to numerous institutions (e.g., clinics and emergency rooms) in order to avoid raising the suspicion of domestic violence. Issues of confidentiality also may be an impediment to obtaining these records. (See Appendix B for more information on confidentiality.) When clients are unsuccessful in compiling information from standard sources, their self-reports to substance abuse treatment providers, documented in their program records, can be used to fill in the gaps and to help support their claims. When entering notes into the client's record, however, it is important to include the facts as presented or observed. Records can be subpoenaed and "gratuitous comments or opinions" may be used against survivors in custody cases (Minnesota Coalition for Battered Women, 1992, p. 41).

Figure 6-1: Key Linkages

Figure 6-1 Key Linkages
Health Care Screening for Child Abuse and Neglect (SCAN) teams in hospital emergency rooms Health administrators Veterans health care systems Primary care physicians Obstetricians/gynecologists Pediatricians Nurses and nurses assistants Midwives Nurse practitioners in adult, obstetrician/gynecologist, and pediatric settings Physician assistants Public health workers Dentists	Emergency medical technicians Medical social workers Home health services Forensic examiners Plastic and maxillofacial surgeons Physical, speech, and occupational therapists Health educators Wellness groups Women, Infants, and Children (WIC) Supplemental Food Program specialists Alternative medicine practitioners Health care programs (e.g., infant mortality reduction programs, HIV/AIDS programs, and tuberculosis programs)
Justice System It is important to understand the operations of the court system in your jurisdiction and to identify the judges who oversee Drug cases Driving Under the Influence (DUI) and Driving While Intoxicated (DWI) infractions Child abuse and child neglect cases Domestic violence violations Custody cases It is also useful to identify experts in the following offices and programs: Probation and parole Legal Aid District Attorney's office	Family courts Specialty units of attorneys (e.g., for child abuse and neglect and family violence) Jails and prisons Bail bondsmen Law enforcement (all levels, e.g., sheriffs and police) Pretrial release agencies Public defenders Divorce attorneys Pro bono attorneys Juvenile detention facilities Victim assistance programs Appropriate section of the local Bar Association
Education/Schools School boards School administrators Teachers Teaching assistants School counselors Vocational education and training counselors Guidance counselors Special education specialists (emotional and physical problems) Early intervention specialists School psychologists	School social workers School nurses General equivalency diploma (GED) specialists Head Start and child care specialists Physical education teachers and coaches Prevention specialists Parent -- teacher organizations (PTOs) English as a Second Language (ESL) classes Literacy volunteers
Adult Education Night schools Community colleges Senior day care centers	Native-American centers Hispanic-American centers Asian-American centers
Employers Employee Assistance Programs (EAPs) Human resource administrators	Foundation administrators On-the-job counselors and social workers
Social Welfare Foster care (family foster care, relative foster care, and residential foster care, including group homes) Social welfare administrators Social workers Temporary Assistance to Needy Families Welfare-to-work programs Food stamp programs WIC Child protective services Adult protective services (especially for elderly persons) Head Start Income maintenance	Child care programs Transportation subsidy programs Community-based child abuse and neglect prevention services and programs Hotlines Family support programs Community-based family agencies (provide parent education and specialized counseling for children at low or no cost) Family preservation programs Homeless shelters Maternal and child health programs Women's programs
Domestic Violence Hotlines Shelters Child care workers and child advocates Programs for children in violent families Transitional living (homeless) experts Clinicians, public and private (e.g., therapists) Victim services Model programs offering specialized services for sexually abused children	Programs for batterers Legal advocacy systems Visitation centers for children Support groups Surveillance systems Abuse and assault hotlines Rape crisis programs College-based date rape programs Survivor support groups Forensic nurse examiners
Mental Health Clinicians (e.g., psychiatrists, social workers, psychologists, and psychiatric nurses) Child guidance centers Mental hospitals and institutions Community-based activity centers for deinstitutionalized persons	Group homes and halfway houses Hotlines and crisis centers Hospital inpatient units Hospital outpatient services Community mental health centers Outpatient day services (community mental health day hospitals)
Substance Abuse Residential or inpatient detoxification programs, intensive residential programs, and therapeutic community programs and services (private, public, and combined) Outpatient drug-free, methadone maintenance, and partial-day programs and services (private, public, and combined) Self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, and Rational Recovery) Al-Anon (support groups for families of substance abusers)	Prison- or jail-based substance abuse programs DUI and DWI programs Veterans Affairs substance abuse treatment programs Special programs for adolescents, children, and families Special treatment programs for pregnant women or women with dependent children Halfway houses, recovery homes Alcohol and drug prevention programs Community-based coalitions for the prevention of substance abuse EAPs (government and private)
Other Community Resources Governmental and regulatory agencies Funding sources Religious institutions (e.g., churches and synagogues) Community housing programs Recreation programs Neighborhood watch associations Immigrant services Child care programs	Transportation programs for persons with developmental and physical disabilities Support groups (e.g., Grandparents as Parents) Fathers' responsibility projects Nutritional centers, food banks Senior citizens' agencies Travelers Aid

Figure 6-2: Facets of Collaboration Between Substance Abuse Treatment and Domestic Violence Programs

Figure 6-2 Facets of Collaboration Between Substance Abuse Treatment and Domestic Violence Programs
Perceptions and Attitudes of Those Working in the Field
Barriers	Stereotypes, generalizations, and myths about the other field
Opportunities	Special joint conferences to explore common ground and bridge gaps
Action Ideas	Develop cross-training courses for providers in network through community college or other sources Exchange agency newsletters Serve on one another's board of directors Arrange continuing education unit credits for participants
Funding and Reimbursement
Barriers	Limitations on reimbursable services, particularly under managed care Limitations imposed by the terms of funded research, which may constrain the program's ability to provide needed services
Opportunities	Work with State Director to incorporate language in managed care contracts to support needed services Identify other funding sources more amenable to services being offered and seek funding for specific program components
Action Ideas	Learn about blended funding strategies Adjust program accounting system to receive and account for blended funds Track outcomes of clients receiving services from linkage partners and document their outcomes for research and funding entities; use results to secure additional funding
Welfare Reform
Barriers	Increased limits on shelter stays
Opportunities	Increased funding of collaborative and innovative programming
Action Ideas	For example, in Wisconsin, the Milwaukee Women's Center has developed a collaboration between employment maintenance organizations, health maintenance organizations, and community-based organizations to establish specialized services for survivors who are substance abusers
Fundraising
Barriers	Limited availability of funds from any source
Opportunities	Identify appropriate partners for funding opportunities and lay groundwork for response to funding opportunities Identifying funding sources is in and of itself an incentive to establish linkages
Action Ideas	Partner with a proven "fundraiser" to supply a needed specialized service (e.g., via subcontract) Send interested staff to grant-writing workshops Through board/community contacts, identify an advocate who will introduce the program to potential funders Identify a volunteer who will review the CBD and other resources for Requests for Proposals (RFPs) and Requests for Applications (RFAs) Publicize positive program results continually Convene a meeting with local funders and discuss the feasibility of encouraging joint applications between domestic violence and substance abuse providers
Sociopolitical Issues
Barriers	Prevailing political climate, which does not readily offer support for treatment programs Relative newness of both fields and their lack of history, which does not easily allow documentation of success Lack of social acceptance for both programs Perception of domestic violence as a "woman's field," in contrast to the perception of politics as a "man's world"
Opportunities	Grassroots-level recognition of the overlap of the problems of substance abuse and domestic violence Research and evaluation to document the effectiveness of both efforts in ways that are understood by policymakers
Action Ideas	Form political action coalitions
Programmatic, Staffing, and Logistical Concerns
Barriers	Wide variety of different agencies and agendas with which programs must work Growing push for higher credentials
Opportunities	Expanded roles of counselors and other professionals in each field; increased respectability and acceptance of these fields
Action Ideas	Work with the National Association of Alcohol and Drug Abuse Counselors to explore this issue fully and investigate credentialing implications Seek legitimacy for staff skills through courses developed and offered by recognized bodies (e.g., colleges and associations)
Recordkeeping and Data Management
Barriers	Increasing need for employees to have computer skills and for organizations to have access to on-line and other technological resources
Opportunities	Increased information available for staff to use Increased ability to provide documentation of successes
Action Ideas	Joint training, leadership programs, staff and materials exchange, information and evaluation exchange
Relationship With the Criminal Justice System
Barriers	Competing need for information Therapeutic alliance versus prosecution's adversarial need for information
Opportunities	Develop boundaries and administrative/therapeutic splits to protect information being used for treatment from information related to behaviors and actions
Relationship Between Workplace and Treatment
Barriers	Identification of domestic violence problems can have adverse impact on career no matter what the resolution of the case
Opportunities	Develop a problem-based definition of abuse that is linked to behavioral goals

Figure B-1: Client Consent Form: Required Items

Figure B-1 Client Consent Form: Required Items*

Name or general description of the program(s) making the disclosure Name or title of the individual or organization that will receive the disclosure Name of the client who is the subject of the disclosure Purpose of or need for the disclosure How much and what kind of information will be disclosed A statement that the client may revoke the consent at any time, except to the extent that the program has already acted in reliance on it Date, event or condition upon which the consent expires, if not previously revoked Signature of the client (and, for minors in some States, his or her parent) Date on which the consent is signed *As set forth in §2.31(a).

Figure B-2: Consent for the Release of Confidential Information

Figure B-2 Consent for the Release of Confidential Information

I, ____________________________________________________________________, authorize (Name of client) __________________________________________________________________________ (Name or general designation of program making disclosure) to disclose to ___________________________________________________________ (Name of person or organization to which disclosure is to be made) the following information: _______________________________________________ __________________________________________________________________________ __________________________________________________________________________ (Nature of the information, as limited as possible) The purpose of the disclosure authorized herein is to: _____________________________________ ________________________________________________________________________ ________________________________________________________________________ (Purpose of disclosure, as specific as possible) I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows: __________________________________________________________________________ (Specification of the date, event, or condition upon which this consent expires) Dated: _____________________________________________________________ (Signature of participant) _________________________________________________________________ (Signature of parent, guardian, or authorized representative when required)

Figure B-3: Prohibition on Redisclosing Information Concerning Substance Abuse Treatment Clients

Figure B-3 Prohibition on Redisclosing Information Concerning Substance Abuse Treatment Clients

This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by Federal confidentiality rules (42 C.F.R. Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

Figure B-4: Qualified Service Organization Agreement

Figure B-4 Qualified Service Organization Agreement

XYZ Service Center ("the Center") and the ____________________________________________ __________________________________________________________________________________ (Name of the program) ("the Program") hereby enter into a qualified service organization agreement, whereby the Center agrees to provide the following services: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (Nature of services to be provided) Furthermore, the Center: 1. Acknowledges that in receiving, storing, processing, or otherwise dealing with any information from the Program about the clients in the Program, it is fully bound by the provisions of the Federal Regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2; and 2. Undertakes to resist in judicial proceedings any effort to obtain access to information pertaining to clients otherwise than as expressly provided for in the Federal confidentiality regulations, 42 C.F.R. Part 2. Executed this _____ day of __________, 199__. __________________________ President XYZ Service Center (Address) __________________________ Program Directory (Name of Program) (Address)