Substance Abuse Treatment
and Domestic Violence
Executive Summary and Recommendations
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.
Scope of the TIP
Domestic violence is the use of intentional verbal, psychological, or
physical force by one family member (including an intimate partner) to control
another. This TIP focuses only on men who abuse their female partners (batterer
clients) and women who are battered by their male partners (survivor clients).
Child abuse and neglect, elder abuse, women's abuse of men, and domestic
violence within same-sex relationships are important issues that are not
addressed in depth in this document, largely because each requires separate
comprehensive review. Other patterns of domestic violence outside the scope of
this TIP are abused women who in turn abuse their children or react violently to
their partners' continued attacks and adult or teenage children who abuse their
parents.
Researchers have found that one fourth to one half of men who commit acts of
domestic violence also have substance abuse problems (Gondolf, 1995; Leonard and
Jacob, 1987; Kantor and Straus, 1987; Coleman and Straus, 1983; Hamilton and
Collins, 1981; Pernanen, 1976) and that a sizable percentage of convicted
batterers were raised by parents who abused drugs or alcohol (Bureau of Justice
Statistics, 1994). Studies also show that women who abuse alcohol and other
drugs are more likely to be victims of domestic violence (Miller et al.,
1989).
The primary purpose of this document is to provide the substance abuse
treatment field with an overview of domestic violence so that providers can
understand the particular needs and behaviors of batterers and survivors as
defined above and tailor treatment plans accordingly. This requires an
understanding not only of clients' issues but also of when it is necessary to
seek help from domestic violence experts. The TIP also may prove useful to
domestic violence support workers whose clients suffer from substance-related
problems. As the TIP makes clear, each field can benefit enormously from the
expertise of the other, and cooperation and sharing of knowledge will pave the
way for the more coordinated system of care discussed in Chapter 6. Future
publications will examine those aspects of the problem that concern such special
populations as adolescent gang members, the elderly, gay men and lesbians, and
women who batter. The first of these is an upcoming TIP that addresses the
connections between substance abuse and child abuse and neglect.
Summary of Recommendations
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.)
Screening, Referral, and Treatment of Survivor Clients And
Batterer Clients
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.
Survivors
- 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.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 97-3163
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