Substance Abuse Treatment
and Domestic Violence
Chapter 6 -- Linkages: A Coordinated Community Response
Isolation is a salient characteristic of domestic violence: It occurs in isolation and it isolates its victims from community life. Countering this pervasive isolation with a coordinated community response is perhaps the strongest way to eliminate domestic violence from our society
(Clark et al., 1996). "If we are ever to eradicate domestic violence, the whole community must become alerted to the problem and how best to support the victims and convey to the abusers that abuse is a crime that is never justified"
(Zorza, 1995a, p. 54).
Although the primary focus of this Treatment Improvement Protocol is on linking substance abuse treatment and domestic violence support services, the linkages cannot stop there: Other efforts to link and integrate community resources are essential -- not only to ensure that the needs of individual survivors and batterers are met but also to raise public awareness and to begin to create the coordinated community response that is necessary for change. Coordinated intervention is crucial. These efforts must 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.
Linkages will also help each agency fulfill its own mission. Few programs have the resources available to address the sometimes overwhelming number of problems faced by substance abuse treatment clients who are affected by domestic violence. Increasingly, programs are looking to strong collaboration and linkages with other service agencies to meet their clients' needs. Such collaboration is particularly important in isolated rural communities where lack of resources and distance from services are significant problems.
In all communities -- urban, rural, and suburban -- individuals who provide substance abuse and domestic violence services in the public sector generally have experienced the negative consequences of fragmented and unintegrated service systems. Historically, their resourcefulness in obtaining necessary care for their clients has created an informal system of referrals and unofficial case management. Such linkages are becoming more formalized as system administrators realize the cost-effectiveness of collaboration and coordination of services and as public sector purchasers of Medicaid managed care become more sophisticated in contracting with managed behavioral health care organizations to ensure a continuum of services for clients served in the public sector.
Thus the current behavioral health care environment may be one especially open to change in the direction of linkages, collaboration, coordination, and service integration. This chapter calls on providers to be especially positive and creative in thinking about these issues and designing action plans. Those who have seen past efforts at service integration fail, who are skeptical about structural change within State service delivery systems, and who may be ambivalent about giving up turf are encouraged to support coordination and collaboration -- that is, separate agencies planning together and working together to create new delivery approaches with support at the State level. This chapter focuses on two approaches to building linkages; the first based on systemic reform and the second rooted in the community. Two crucial linkages are highlighted -- that between substance abuse treatment and domestic violence support services and that between these services and the criminal justice system.
Linkages are frequently conceived of as local program-to-program relationships, and much of the remainder of this chapter is devoted to such linkages. While not disputing the importance of community-based interagency networking, the Consensus Panel believes that a new way of thinking about linkages on the systems level can help address the multiple social service needs of substance-abusing victims and perpetrators of violence. In calling for substantive, top-down reform, the Panel allies itself with those domestic violence experts
Hart et al., 1995) and mental health experts
(Stroul, 1993) advocating a new approach to organizing and institutionalizing coordinated social service delivery systems.
Under this new paradigm, the familiar concept of a "continuum of services" is elevated to the State level and substantially expanded to include a formal structure and process to oversee system-level coordination among agencies. While specific goals would vary from State to State, the Panel believes that such systemic reform would enable States to create a collaborative infrastructure that, in turn, would allow programs to deliver care that is
Currently, most social services -- including substance abuse treatment and domestic violence support -- function as a series of parallel programs with their own sources of funding, leadership, and constituencies
Hart et al., 1995;
Stroul, 1993). Clients needing services from more than one program not only face a number of hurdles (e.g., differing eligibility requirements, hours of operation, and locations), but may also receive services that are counterproductive because they are not part of a coordinated treatment plan
- Client-centered -- focused on meeting clients "where they are" and matching their needs with appropriate services as opposed to fitting clients into a predefined program; wraparound services follow the client
- Holistic -- offering comprehensive services from a variety of agencies that are designed to respond to a client's multiple needs: substance abuse treatment, mental health counseling, domestic violence support, parenting skills training, housing
- Flexible -- the service mix changes as the client's needs change
- Collaborative -- multiple agencies can work together freely on behalf of a client without having to consider agency funding or other administrative issues that may interfere with the assistance process
- Coordinated -- individualized service plans are developed for each client and monitored via case management
- Accountable -- encourages the client's input to the comprehensive treatment plan, adheres to standards or accepted best practices for treatment, establishes and tracks qualitative and quantitative outcome measures, and evaluates services on the basis of client and community satisfaction.
In the environment that would emerge after converting from parallel services to an integrated delivery system, cooperation on the client's behalf would replace competition for the client and for the attendant funding that follows admission to a specific program or to a treatment slot or bed. Collaboration would eliminate duplication of services and receipt of inappropriate services. With a client-centered philosophy prevailing, the provision of adjunctive support services like child care, transportation, and housing would assume greater importance and would more likely be funded
Systemic reform on this scale requires structural, administrative changes at the State level. As a first step toward revamping service delivery to multiple-needs clients, the Panel envisions a mechanism that would
In its assessment of systems of care for children
(Stroul, 1993), Georgetown University's Child Development Center discovered that, as expected, integrated systems of care expanded access to services, including adjunctive support, and increased the use of case management to monitor service delivery and advocate for individual clients and their families. The study also found that this approach, in some instances, reduced costs. For example, three counties in California saved more than $35 million over 4 years for residential care by using a systems model of service delivery. Similarly, Fort Bragg, North Carolina, reduced the costs of caring for children with serious emotional disturbances by 51 percent through the systems of care approach. The State of Kentucky likewise reduced the cost of services from $13.5 million to $9.5 million
- Coordinate planning among disparate agencies based on client and community needs assessments
- Devise financing strategies that would allow for blended funding and strive for equitable allocation of resources among agencies
- Establish a vehicle for resolving any problems that emerge in the course of providing integrated services (e.g., development of compatible management information systems, cross-training, and support and authority for case management).
Although these models have yet to be applied to the substance abuse and domestic violence fields, the Consensus Panel believes they hold promise for redefining the existing service delivery system to ensure more appropriate and effective care for substance-abusing domestic violence victims and perpetrators. The Panel strongly recommends that Federal and State policymakers 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.
The health care environment is increasingly forced to respond to the demand for cost containment; therefore, undertaking collaborative endeavors is critical to the future of many programs, especially at the community level. As noted, few have the resources to offer under one roof all the specialty services that clients need. Creative linkages can supplement and complement programs, building on their strengths and compensating for their weaknesses. Linkages can open avenues to diverse sources of funding to offset the inevitable ebb and flow of resources. And in a practical vein, a growing number of funding sources are granting funds only when presented with evidence of coordinated activities among grant applicants.
Before linkages can be developed, it is necessary to know what resources exist within the community. Each entity has its own organization and its own culture that must be understood for collaboration to be successful. Every State has a unique infrastructure for housing the health care, legal, social, and other services related to substance abuse treatment and domestic violence services. Communities themselves also vary in government structure, available resources, and funding streams. Some combine alcohol treatment with treatment for other substance abuse, whereas others separate the two. Some locate services for victims of domestic violence in the criminal justice system, which affects the tone and procedures used to deliver services, while others locate such services in a hospital system linked to the emergency department. A program within a nonprofit entity in the private sector has far different restraints than one housed in a government agency.
Disciplines also differ dramatically in structure and orientation. Some substance abuse treatment programs, for example, are staffed by nurses, and others are staffed by certified addiction counselors. Many existing programs, such as Minnesota's Turning Point and African American Services, have incorporated family violence issues into substance abuse treatment, and communities throughout the United States are increasingly integrating the two areas
(Clark et al., 1996). A single treatment approach would be enhanced by making programs accountable to the local community, strengthening the linkages between the two fields and the court system, and improving evaluation procedures.
The Argument for Case Management
In the current early state of development of linkages between the fields of substance abuse treatment and domestic violence services, it has been suggested that "the linkage mechanism that seems most appropriate is case management"
(Collins et al., 1997, p. 400). Increasingly, the substance abuse treatment field has recognized that case management may be a key contributor to successful treatment
(Ridgely and Willenbring, 1992). In the case management approach, a specially trained single practitioner or case management team is responsible for coordinating linkages to the wide variety of services -- including domestic violence support -- needed by many if not most clients in substance abuse treatment
Although locating and gaining initial access to these services can be challenging, many programs have found that use of case management is well worth the effort, since it helps clients work through problems that may trigger use of alcohol and other drugs or that interfere with progress in treatment. Such problems may include homelessness, mental illness, HIV infection, lack of vocational skills, and unemployment
(Willenbring, 1994). An additional advantage is that the case manager serves as a client advocate, representing the client's interests in both accessing other agencies and ensuring that their services are used effectively
(Rapp et al., 1994).
Linking Substance Abuse Treatment and Domestic Violence Services
Several locales have attempted to develop model programs integrating substance abuse and domestic violence services. These include the Amend Program in several Colorado communities
(Rogan, 1985-1986), the Intercede Program of Longford Health Sources in Ohio
(Burkins, 1995), and the Pittsburgh Veterans Affairs Medical Center
(Gondolf, 1995). A study of linkage efforts in Illinois found that staff cross-training is inadequate to meet the goals of these efforts
(Bennett and Lawson, 1994).
This TIP takes some of the first steps in formalizing linkages between the two fields.
Chapters 2 and
3 present substance abuse treatment providers, who may lack knowledge about this population, with psychosocial profiles of survivors and batterers and their needs for specialized care. Such training is a key ingredient in bringing the two fields closer. Chapter 4 stresses the need for screening for domestic violence early in the substance abuse treatment process and the importance of timely referral of clients affected by domestic violence to the appropriate agencies. Routine screening for cross-problems by both types of programs is a major step toward linkage.
Linkages With the Criminal Justice System
One of the first linkages that must be identified by a substance abuse treatment program that is working with domestic violence survivors is with the legal system
(see Chapter 5). 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 the Violence Against Women Act (VAWA). Many of the Act's provisions -- such as those relevant to immigrants -- are complex and detailed. In addition, other Federal and State statutes may include provisions that appear to contradict those of the VAWA.
To treat substance abuse clients who are either survivors or batterers, treatment providers must be knowledgeable about policies and laws related to domestic violence; they must understand the roles of police, judges, probation staff, and other representatives of the justice system and be able to interact effectively with these individuals when necessary. As one field reviewer noted, "Integrating the criminal justice system's efforts should be the first step in forming linkages. If a provider wants assistance protecting a woman or getting a batterer to attend treatment, it is the criminal justice system that can get this done."
Specialized courts to process domestic violence cases, which combine intensive survivor services, treatment for batterers, and an active judicial role in the social contexts of the community, have been established. The Dade County, Florida, Domestic Violence Court, which commenced in late 1992, is a noteworthy example, and outcomes are still being evaluated
(Fagan, 1996). However, some early data indicate that recidivism rates among treated batterers processed through these courts are high and comparable to rates found in studies of the deterrent effects of protective orders and arrests. Failure rates are strongly correlated with lengthy prior records and a history of abuse in the batterer's family of origin
In pursuing victim protection goals, criminal justice agencies have been required to expand their traditional focus on the detection and punishment of crimes. Placing these expectations on police and prosecutors may require tasks and roles for which they are not well trained. Such role and policy ambiguities can affect the performance of agencies with respect to their missions. As Fagan notes:
There is no doubt that linkages between legal institutions and services for domestic violence victims are critical to stopping violence. However, these linkages may best be accomplished through a strategic division of roles among institutions that tap the strengths of each organization. . . .
Although legal systems should be open and accessible to battered women, these institutions should not take on the role of managing the coordination of services that involve social service, shelter, and other interventions. (Fagan, 1996, pp. 39-40)
Collaborative Treatment Planning For Survivors and Batterers
Treatment plans for substance abuse clients who are survivors or batterers must incorporate all the issues surrounding both sets of problems and ideally will be coordinated by a case manager. Treatment planning for matters such as time sequencing (e.g., when to start support for a domestic violence survivor in substance abuse treatment) and goals of treatment is not effective without consideration of all the factors that have a bearing on the client's best interests. Substance abuse treatment providers, domestic violence experts, and legal or other relevant professionals should plan treatment collaboratively.
Because treatment plans for domestic violence survivors are built around the premise that safety must always be the first priority, substance abuse treatment may initially take a back seat. For example, a client who lives with a violent partner may report being pressured or coerced by him to use alcohol or other drugs. In these instances, some degree of relapse may need to be tolerated in light of the threat to the client's safety. A survivor's frequent reporting of such a situation, however, signals the need for substance abuse treatment and domestic violence staff to jointly reconsider treatment priorities.
A batterer entering treatment for substance abuse can be required to sign a contract agreeing, among other stipulations, to refrain from using violence (see Chapter 4). Such "no-violence contracts" are most effective when linkages are made with other agencies involved with his case, and violations should be reported to all involved agencies, especially the criminal justice system.
Treatment providers can help persuade the courts to consider alternative sanctions that take the victim's circumstances into account. Incarcerating batterers can actually harm their victims by taking away the family income. On the other hand, not incarcerating the batterer may give him the false message that his behavior is not that bad and thus tacitly give him "permission" to continue his violence. Courts may order the batterer to receive counseling, perform public service, or a variety of other sanctions.
Identifying Critical Linkages, Barriers, And Opportunities
Figure 6-1 highlights some of the key linkages substance abuse programs should consider in developing collaborative strategies to assist clients with domestic violence problems. Some duplication across the lists is intentional.
Figure 6-2 lists some of the potential obstacles to forming collaborative relationships between substance abuse treatment and domestic violence programs, as well as opportunities for collaboration and ideas for taking action to form such relationships.
Establishing a Linkage Relationship
All relationships begin with a "getting-to-know-you" phase; initial, face-to-face interactions often establish the tone for future interaction. These initial meetings should include a discussion of the origins of both communities in order to help each understand the other's beliefs and attitudes. Other topics for discussion include each program's goals for its clients, the barriers routinely faced with clients, typical interactions with clients, and expected outcomes. Key individuals in each system can coach the staff of the other in working with and understanding that system and the needs of its clients. During the initial phase, it also may be helpful to acknowledge some of the stereotypes held by each field about the other and to discuss them frankly.
At these initial meetings, using a staff member with strong facilitation skills can be invaluable. An alternative is to use a facilitator from an outside agency not affiliated with either program (e.g., from a university or community college). The facilitator can recognize burgeoning problems and defuse them before group members become defensive and uncooperative, and he or she can help participants bridge gaps in understanding by clarifying terminology and asking for feedback to ensure that all parties are interpreting information the same way. A followup memo documenting the understandings that emerged from the meeting and listing areas of agreed-upon responsibility can also assist the collaborative process.
Airing and Addressing Grievances
In collaborative relationships, difficulties can arise if one entity feels taken advantage of, perceives that the other is deriving more benefits from the association, receives more credit, or believes that power is unequal between the two groups. Balance is central to an effective collaboration that satisfies the expectations and needs of all involved. When a collaborative domestic violence effort, for example, used the letterhead of one participating organization, the other partners were displeased because their participation was not acknowledged. To give equal recognition to all partners, a new project-specific letterhead reflecting all the collaborators was designed. Not all solutions will be so simple, but this example demonstrates the importance of frank communication, responding to the concerns of all the partners in the network, and moving quickly to resolve problems.
Readiness for Collaboration: Program Evaluation
Many programs have in place a system for periodic internal evaluation of their success in meeting their goals. Decisionmakers may find it useful to reexamine a program or organization specifically in terms of its readiness to take advantage of and maintain a collaborative association.
For successful linkages, program staff -- beginning with boards of directors -- must be sensitive to the other program's requirements and culture. A board that consists of members who are committed to supporting program goals and overcoming challenges is essential to effective operation. Motivated and well-connected directors can, for example, help identify community funding sources that will support the development of collaborations.
Administrators can promote linkages by identifying conflicts or economies of scale in the areas of fiscal management, accounting, contract management, funding development, program evaluation and organizational audits, human resources and payroll management, management information systems, and other technology. They can also enhance linkages and develop funding sources by working with other agencies and programs to compete for block grant funds and to split funding for substance abuse and domestic violence. Program managers should appoint a staff member as a contact and liaison for each linkage. Administrators and managers should seek to create an organizational environment that encourages and supports staff members' collaboration activities, which are often time-consuming. Staff members' new collaborative relationships, as well as their existing relationships with other agencies, are critical to success.
Substance abuse treatment and domestic violence professionals also must educate themselves on issues particular to each cultural or ethnic subgroup their clients represent. Failure to do so diminishes outcomes and completion rates for minority populations. Cultural competence is more important than ever now, as the country moves toward a "majority-less" ethnic composition and major cities become pluralities of cultures rather than majority-minority paradigms.
Responding to the needs of clients will require an awareness of practice and attitude and an organizational structure that continually monitors:
Lastly, cultural competence implies that agencies are equipped to respond to "insensitivity" and that they make inclusiveness an institutionalized value, in part by employing highly skilled multicultural staff
(Cross et al., 1989).
- How are services provided to diverse groups?
- What is the environment in which services are offered?
- What is the composition of the group?
- How included do diverse clients feel during the treatment process, and what cultural activities are directed to a specific population?
- How can treatment be tailored to a particular group?
- Are there staff members who know the language of non-English-speaking clients?
- What networks have been created with other experts and members of the community to provide services to this population?
Evaluation helps programs measure how effective they are in achieving their goals and gives them information to redesign and improve program components. Increasingly, funding sources require documentation of the program's success and of individual outcomes. However, in the fields of substance abuse treatment and domestic violence, outcomes may not always be as clear-cut or as measurable as funders would like. Administrators must be aware that a funding source or other outsider to the field may not agree with or approve of a program's criteria for success. For example, relapse is an expected part of recovery from substance abuse, and abstinence may not be the sole indicator of treatment success. Treatment effectiveness should also be measured by larger social indicators, such as higher employment rates, better personal relationships, and fewer legal entanglements (Wolk et al., 1994). After treatment, some people will not be drug-free for the rest of their lives, but they will experience more stability and more productive lives, resulting in significant benefits to society.
Understanding the True Costs of Collaboration
Even if an organization takes all the steps above, the path to collaboration is still paved with unforeseen difficulties. The importance of differences in perspectives between the two fields, as discussed in
Chapter 1, should not be underestimated. One survey of staff in both types of program found that more than half of all staff cited "conflicting beliefs about personal responsibility" as a reason for noncooperation between programs
(Bennett and Lawson, 1994). Service delivery structure and funding also can block collaboration.
Furthermore, confidentiality and informed-consent practices vary among fields
(see Appendix B). Large programs may have trouble linking with small programs, especially if documentation and tracking procedures are incompatible. Conversely, small grassroots programs may have problems following the formal procedures required by larger organizations or may lack staff to ensure that paperwork is completed in a timely fashion. Professionally led and staffed organizations may doubt the competence of paraprofessional staff members who are in recovery and may discount their suggestions in the course of treatment planning. Similarly, untrained staff may fail to recognize the validity of the insights and suggestions proffered by professional social work and mental health care givers.
Other issues affecting the costs of collaboration include the number of approvals and layers of bureaucracy that must be negotiated to obtain services from a linked agency, requirements for research and evaluation that may be attached to participation in a network, and the amount of staff time required to maintain linkages and resolve problems.
Other Linkage Strategies
Funding Sources and Reimbursement
Funding sources for domestic violence support include the criminal justice system through Federal block grants, State money, or fines levied against perpetrators. Private and community organizations also represent funding sources. Employee assistance programs (EAPs) can serve as both allies and access points to solicit and obtain corporate funding. Third party reimbursement for domestic violence services is slowly gaining some acceptance. At one time, insurers might have refused to pay for these services for a woman who was covered under the batterer's policy, reasoning that the woman's injury was self-inflicted because she chose to stay with the batterer. In some cases, the batterer must authorize payment for treatment for the survivor if medical, health, or disability coverage is in his name.
One reason domestic violence has not been incorporated into concepts of managed care is that, as discussed in
Chapter 1, some advocates for domestic violence survivors have rejected the use of a medical model to define the problem. In addition, most managed care companies have specific requirements about who can deliver services; if no program staff meet those requirements, it is not likely that the program will be reimbursed. Domestic violence support encompasses services such as housing and job training that are outside the realm of health care and that have outcomes difficult to measure in terms of health improvement, which are the outcomes of interest to health maintenance organizations (HMOs). However, many managed care organizations are investing funds to help their enrollees deal with issues that are not traditionally medical; many HMOs offer strss management and exercise programs. All health systems are increasingly recognizing the cost-effectiveness of early detection and prevention in general in their covered populations, and some have set up routine screening for substance abuse. Furthermore, increased interest in outcomes measurement and consumer satisfaction has broadened the spectrum of behaviors monitored and outcomes measured by health care providers.
Reimbursement from managed care organizations and other third parties relies on diagnostic classifications and treatment categories. Advocates for reforms in health care and social welfare must find ways to classify joint substance abuse-domestic violence problems to ensure reimbursement. Although some domestic violence programs use the classification "trauma" and receive reimbursement for treatment, services are frequently provided as nonreimbursable advocacy or coaching. Victims who are thought to have underlying problems are typically referred to other programs (e.g., for psychological or substance abuse treatment). Research indicates that there are no psychological risk markers for becoming a victim of adult domestic violence
(Hotaling and Sugarman, 1990). However, certain characteristic symptoms are seen in many people following highly traumatic life events. Some battered women experience these symptoms as a result of violence-associated trauma, and they are normal psychological responses to stressful life events. Often, these symptoms dissipate as women achieve greater safety from the abuse. Other women may require more intensive therapeutic interventions to heal from the effects of violence. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
(American Psychiatric Association, 1994), offers some diagnoses that may be helpful in classifying survivors' symptoms and helping programs receive reimbursement for treatment. Some survivors may meet criteria for posttraumatic stress disorder
(see Chapter 2) or for depressive and anxiety disorders.
Licensing, Credentialing, And Certification
Credentialing processes for substance abuse treatment providers must assess their ability to screen for violence and create a safety plan, as well as their knowledge of legal issues related to domestic violence. They should demonstrate a knowledge of child abuse and neglect, child sexual abuse, partner violence, elder abuse, extended family violence, and violence as an issue in relationships other than marital or partner relationships.
Examples of Effective Community-Based Linkages
In Bismarck, North Dakota, the Federation of Family Funding promoted and supported the development of a multiagency partnership plan to help families experiencing domestic violence. All providers involved with the family meet face-to-face every month to share information, make plans, and discuss strategies for ensuring progress. In a Los Angeles program for pregnant or substance-abusing battered mothers, a team of providers involved in all aspects of a client's treatment meets as a group with the client. Children's grandmothers, if they are the formal court-appointed caretakers of the children, are included in the case conferences; perpetrator fathers are not. Interagency agreements are made in advance to protect confidentiality.
Examples in Health Care Settings
Many of the linkages between domestic violence support services and other service organizations that have been most effective have occurred in health care settings, especially in hospitals. Linkages of the type described here might benefit from involvement of staff from substance abuse treatment programs. At the Dekalb Medical Center in Atlanta, emergency room nurses who suspect that a woman has been battered call a patient representative with specialized knowledge to interview the patient after medical treatment is provided
(Dekalb Medical Center, 1993). The representative, who is able to spend more time with the patient than the nurses, refers the patient to a community shelter or makes other referrals and also provides feedback to the emergency room staff.
Other examples of hospital-based service linkages come from Boston, Minneapolis, and Seattle
(Loring and Smith, 1994). At Children's Hospital in Boston, staff from AWAKE, an advocacy program for battered women and their children, are called in to provide safety planning and support for patients who are violence survivors. In Minneapolis at the Hennepin County Medical Center, an advocate from a battered women's shelter makes rounds in all services -- not just the emergency room -- to speak directly with medical staff and interview violence survivors. In this way the hospital administration and medical staff are assured that in addition to receiving appropriate medical care, survivors are assisted in other areas, such as locating the batterer, obtaining legal protection, and proceeding with assault charges when appropriate. Harborview Hospital in Seattle employs an "adult abuse protocol" with components of various systems to ensure comprehensive services to the battered woman patient. Finally, health maintenance organizations, many of which maintain detailed databases to track service utilization and outcomes, may find it easier than general hospital systems to identify and reach out to survivors of domestic violence.
Promising Activities and Future Directions
In 1994 the Board on Children and Families, the National Research Council, and the Institute of Medicine sponsored a 3-day workshop, Violence and the American Family
(Chalk, 1994). Although the focus was a broad one and included child and elder abuse as well as other forms of family violence, many of the participants suggested action ideas for linkages among agencies involved in the treatment of domestic violence survivors and batterers. As can be readily seen, no single agency or system can successfully undertake the broad tasks and initiatives outlined below that were suggested by workshop participants. Rather these projects invite broad collaboration and cooperation.
In the area of social services, tasks to be undertaken included
In the area of health, the workshop participants identified three specific initiatives
- Developing a set of principles for designing violence interventions that would ensure client empowerment, build on family strengths, and be based on effectiveness evaluations
- Creating violence intervention and prevention systems at the community level that build on formal and informal social networks in diverse neighborhoods
- Requiring schools to make violence prevention education mandatory
- Exploring new methods of cash payments to families to deter violence resulting from economic stress.
In the area of criminal justice, three issues were raised as fruitful areas for activities
- A national campaign against violence to focus on health aspects and costs of family violence to society
- Improvement of screening and diagnosis among health and mental health professionals of risks and injuries associated with family violence
- Consensus-building about what is known about family violence, leading to the formation of a constituency to serve as an advocacy group to educate public officials.
In addition to these recommendations, the workshop participants outlined three broad steps necessary to establish a much-needed basis for future research and program plans
- Effectiveness research on the use and enforcement of restraining orders to deal with domestic violence; new methods of offender control, such as electronic monitoring may be effective
- Research on the availability and effectiveness of court-ordered treatment and on returning abusers to their families
- Consideration of new proposals that experiment with the development of a one-family, one-judge court system.
A Public Health Approach
- Develop a broad-based public education campaign to foster understanding of family violence
- Bridge the gap between research resources and policy needs, especially by developing rigorous evaluations of public sector programs to reduce domestic violence
- Integrate preventive measures for domestic violence into a comprehensive, community-based program of family support services across a spectrum of developmental milestones. The goal goes beyond information sharing and seeks to simplify access to services.
A public health approach has been effective in reducing morbidity and mortality by modifying behavior in many areas (e.g., campaigns to reduce smoking, to reduce alcohol abuse among pregnant women, and to prevent head injuries by wearing helmets). A public health approach to violence has been suggested
(Koop and Lundberg, 1992) in response to the surge in morbidity and mortality due to violence
(Prothrow-Stith, 1991). As the epidemiological evidence mounts that society's rising mortality figures are due in large part to violence, public health professionals acknowledge the destruction of "quality years of life" as well as the expensive healing process and now study the problem in terms of understanding and changing unhealthy outcomes
(Koop and Lundberg, 1992).
Public health officials, generally solution-driven rather than theory-driven, view domestic violence as the result of a complex array of causal factors. By focusing on "risk factors," they can identify structural, cultural, and situational conditions that accompany, precede, and follow events of interpersonal violence
(Moore, 1995). They also monitor public health, identify at-risk groups, and implement programs with evaluation components.
Education is a critical component of a public health campaign. In Houston, for example, the March of Dimes targeted both health care professionals and the public with educational interventions and brochures about battering during pregnancy; public service announcements were developed for the media.
Coordination of Care
Though the examples above do not include substance abuse treatment as one of their linkages, they provide a blueprint for the coordination of care that the Consensus Panel recommends. While the Panel believes the current system of parallel services should be integrated at the State level, meaningful change can occur at the community level. For either substance abuse treatment or domestic violence support services to be successful, the two fields must pool their energies to address gaps in client services outside the immediate networks of substance abuse treatment and violence support. Enduring linkages with other agencies and programs must be established to supply those ancillary services essential for positive client outcomes.
Source: The National Clearinghouse for Alcohol and Drug Information
DHHS Publication No. (SMA) 97-3163
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