Substance Abuse Treatment
and Domestic Violence
Chapter 2 -- Survivors of Domestic Violence: An
Overview
This chapter presents an overview of those issues likely to affect survivors
of domestic violence seeking treatment for substance abuse. Its purpose is to
help substance abuse treatment providers understand the impact of this
experience on the treatment and recovery process and appreciate the differences
in approach between the fields of substance abuse and domestic violence as they
affect the survivor, so that treatment programs can respond more appropriately
to this client group. The primary focus of substance abuse treatment services is
to initiate the recovery process and reinforce the skills needed to stay sober
or abstinent, while domestic violence programs seek to interrupt the cycle of
violence and help the survivor client access the information and resources she
needs to increase her safety and to develop and implement a safety plan.
Holistic care is impossible if a treatment provider cannot understand the
profound effect of domestic violence on a survivor.
The battered woman lives in a war zone: She rarely knows what will trigger an
abusive episode, and often there is little, if any, warning of its approach. She
spends a great deal of time and energy trying to read subtle signs and cues in
her partner's behavior and moods in order to avoid potential violence, but she
is not always successful. Financial constraints and fear that the batterer will
act on his threats to harm family members or continually harass, stalk, and
possibly kill her often inhibit victims from leaving (Rodriguez et al., 1996).
If the batterer is also the victim's drug supplier, that further complicates the
situation. Assuming all these issues can be resolved, the effects of continual
abuse and verbal degradation can be so inherently damaging to self-esteem that
the survivor may believe that she is incapable of "making it" on her
own.
Entering the Treatment System
Crisis Intervention
When a client presents for substance abuse treatment and informs staff that
she is a victim of domestic violence, treatment providers should focus on
- Ensuring her safety: Whether a client is entering inpatient or
outpatient treatment, the immediate physical safety of her environment must be
the chief concern. If inpatient, security measures should be intensified; if
outpatient, a safety plan (which may include immediate referral to a domestic
violence or battered women's shelter) should be developed. In both cases,
staff should be cautioned about the importance of vigilantly guarding against
breaches in confidentiality.
- Validating and believing her, and assuring her that she is believed:
Reinforcement of the counselor's belief of a survivor's victimization is a
critical component of ongoing emotional support. Affirming the survivor's
experience helps empower her to participate in immediate problem solving and
longer term treatment planning.
- Identifying her options: Treatment providers should ask the
survivor to identify her options, share information that would expand her set
of available options, explore with her the risks associated with each option,
and support her in devising a safety plan.
These three goals remain important for a survivor throughout treatment. Other
needs that must be addressed immediately are
- Stabilizing detoxification (including withdrawal symptoms, if any).
- Evaluating and treating any health concerns, including pregnancy. The
latter is especially important for a survivor client because batterers often
intensify their abuse when they learn their partner is pregnant (Hayes and
Emshoff, 1993; Stark et al., 1981). Injuries should be documented for any
future legal proceedings that might occur.
- Attending to immediate emotional and psychological symptoms that may
interfere with the initiation of treatment, such as acute anxiety and
depression.
Once survivor clients' physical safety and symptoms have been addressed,
treatment providers can obtain the information necessary to design a treatment
plan.
Obtaining a History
A number of issues unique to domestic violence survivors must be considered
by substance abuse treatment providers who work with these clients. Chief among
these is the need to uncover the extent of the client's history of domestic
violence. The survivor client's current substance abuse problems must be placed
in the context of whatever violence and abuse she may have experienced
throughout her life, both within her current family and in her family of origin.
Childhood sexual abuse has been associated with a higher risk for
"revictimization" later in life (Browne and Finkelhor, 1986). (See Chapter 4 for
a discussion on how to elicit information regarding domestic violence.)
Studies have found a higher incidence of substance abuse among women who were
victims of childhood sexual abuse and sexual assault (Ryan and Popour, 1983;
Reed, 1985). Data suggest that substance abuse often begins at an early age and
may become part of a self-destructive coping style that is sometimes seen in
incest victims (Harrison et al., 1989; Conte and Berliner, 1988; Briere, 1989).
It is not unusual for the abuser to foster the child's initiation into alcohol
and drugs in order to make the child more compliant.
A discussion of substance abuse in the client's history should cover her
current use, her treatment history, and alcohol or other drug use in her family
of origin. In addition, patterns and frequency of alcohol or other drug use by
her batterer are key to understanding the relationship of substance abuse to the
violence.
Substance abuse counselors should be aware that survivors often are reluctant
to disclose the extent of violence in their lives. Often a survivor's denial
that violence occurs is so pervasive that it has become an integral element of
her psyche. And, especially if violence existed in her family of origin, she may
simply consider it a normal part of an intimate relationship.
At the same time, it is important to recognize that many survivors
consciously keep the fact or extent of their battering concealed for good
reasons, such as fear for themselves, their children, or other family members.
When a battered woman leaves her abuser, her chances of being killed increase
significantly (Wilson, 1989; Casanave and Zahn, 1986; Rasche, 1993;
Dutton-Douglas and Dionne, 1991). Furthermore, the batterer may be the primary
source of income, so his incarceration could leave her destitute (Rodriguez et
al., 1996). Instruments for uncovering domestic violence appear in Appendix
C.
Treatment Planning for The Survivor Client
Treatment providers can best serve clients by establishing strong linkages to
domestic violence referral and intervention services and by employing staff who
are thoroughly familiar with local and State laws regarding domestic violence
and with the unique needs of the domestic violence survivors. Ideally,
counselors should be able to refer to those services and staff members when
domestic violence is suspected and call on them for consultation as needed. If a
client denies a history of domestic abuse but the treatment provider still
suspects it is possible, additional attempts to discuss it with the client
should be made and documented. Once the client has entered treatment, a
treatment plan that includes guarantees of safety (see Appendix D) and a relapse
prevention plan should be developed. Considerations specific to domestic
violence survivors should be integrated into each phase of the treatment
plan.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 97-3163
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