Substance Abuse Treatment
and Domestic Violence
Chapter 4 -- Screening and Referral of Survivors and
Batterers in Substance Abuse Treatment Programs
It is crucial for substance abuse treatment providers to learn if their
clients are either perpetrators or victims of domestic violence as early as
possible in the treatment process. This chapter details signs to look for and
techniques for eliciting information about domestic violence, which many
affected clients are understandably reluctant to discuss. The suggestions and
recommendations in this chapter are presented primarily for substance abuse
treatment providers who work with clients involved in domestic violence as
either batterers or survivors. They may also prove helpful to those providing
domestic violence support services to their clients who have concomitant
substance abuse problems.
Screening
Because of the well-documented relationship between domestic violence and
substance abuse (Leonard and Jacob, 1987; Kantor and Straus, 1989; Amaro et al.,
1990; Pernanen, 1991; Windle et al., 1995), and because domestic violence
affects survivors' and batterers' recovery from substance abuse (Cronkite and
Moos, 1984; Smith and Cloninger, 1985), the Consensus Panel recommends that all
clients who present for substance abuse treatment services be questioned about
domestic violence. Questions should cover childhood physical and sexual abuse as
well as current abuse. (See Appendix C.)
Screening for domestic violence in substance abuse treatment settings is
undertaken to identify both survivors and batterers. The domestic violence
assessment, like the other elements of a substance abuse assessment, gathers the
specific and detailed information needed to design appropriate treatment or
service plans (Sackett et al., 1991). While the Consensus Panel believes that
addictions counselors can be trained relatively easily to screen clients for
domestic violence, assessment services are more complex and require in-depth
knowledge and skill. Assessment should be conducted by a domestic violence
expert if possible.
Once it is determined that a client is a victim of domestic violence, a
provider must determine the client's needs for violence-related services such as
medical care and legal advocacy. In addition to identifying violence as an issue
affecting substance abuse treatment planning, another important purpose of
screening for domestic violence is to ensure the safety -- both physical and
psychological -- of a survivor client. (A word of caution: There is a tendency
to think of residential treatment as a safety zone for both batterers and
survivors with substance abuse problems. Domestic violence experts, however,
note that batterers in treatment frequently continue to harass their partners by
circumventing program rules and threatening them by phone, by mail, and through
contacts with other approved visitors. Telephone and other communication and
visitation privileges should be carefully monitored for identified batterers and
survivors in residential programs.)
Methods of Screening For Domestic Violence: Survivors
Substance abuse treatment providers and domestic violence support staff use
different terms to describe the screening process. Domestic violence programs
refer to the initial contact with a client as intake, which is roughly
analogous to what substance abuse treatment providers refer to as
screening. Once a woman has been accepted to the program, domestic
violence staff will conduct a psychosocial intake, which is similar to
assessment in the substance abuse treatment field.
Clues for the Substance Abuse Treatment Provider
The most obvious indicator of domestic violence is the presence of physical
injuries, especially patterns of untreated injuries to the face, neck, throat,
and breasts. Many survivors of domestic violence may be reluctant to seek
medical treatment because they are afraid that documentation of violence in the
household will result in their children being removed or because they are afraid
of further violence as a result of the disclosure. These women may get their
injuries treated at a number of different clinics or emergency rooms in order to
avoid documentation of recurrent injuries.
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
(McKay, 1994). According to Consensus Panelists and field reviewers, many
batterers intensify their physical attacks when they learn their partner is
pregnant.
Another clue is documented or reported child abuse perpetrated by the partner
of a client. Evidence suggests that a father who abuses his children often
abuses his wife as well (Bowker et al., 1988). 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 can also glean information from a woman's description of her
partner's treatment of her. Behaviors that suggest he may be abusing her
include
- Isolating her (keeping her away from family, friends, and others who are
supportive of her recovery from substance abuse)
- Forcing her to sell drugs or prostitute herself for drugs
- Preventing her from attending treatment or 12-Step meetings
- Threatening to harm her, himself, or others
- Engaging in reckless behavior that endangers himself or others
- Damaging property or belongings
- Harming other family members or pets
- Threatening to abandon her or to take children away.
During an initial interview, many survivors will deny that they have been
battered. Therefore, treatment staff must be alert to indicators of possible
domestic violence and must continue to pursue them, with sensitivity and tact,
over the course of treatment.
Conducting the Interview
Screening for domestic violence should take into account the client's
cultural background and environment. Interviewers should be knowledgeable about
the social mores of clients' groups and trained to avoid culturally bound
stereotypes and jargon. Anecdotal evidence suggests that female interviewers may
be more effective at working with survivors.
A substance abuse treatment provider who suspects that a client is being
abused by her partner must use caution and tact in approaching this subject.
Timing is important, too; in most cases, more information about a survivor's
experience of violence will begin to emerge as she gains confidence and as
treatment staff continue to foster an atmosphere of trust and respect. It is
important not to ask potentially painful questions too soon; otherwise, a client
may feel overwhelmed and reluctant to return.
Screening for domestic violence is more likely to be effective when the
interviewer offers concrete examples and describes hypothetical situations than
when the client is asked vague, conceptual questions. If using a yes/no
questionnaire, interviewers should be prepared to follow up on "no"
answers.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 97-3163
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