Safety and Sobriety Manual
Best Practices in Domestic Violence and Substance Abuse
A significant number of women seen in domestic violence agencies suffer from substance abuse problems. A study of Illinois shelter staff suggests that as many as 42 percent of their clients abuse alcohol or other drugs (Bennett & Lawson, 1994). There are a number of reasons for this:
- Victims may begin or increase their use of alcohol/other drugs in response to domestic violence or other trauma. Alcohol/other drugs may be used to medicate the physical and emotional pain of domestic violence or to cope with the fears of being battered.
- Alcohol/other drug use may be encouraged or even forced by the partner as a mechanism of control. Efforts at abstinence may be sabotaged.
- Outcomes of victimization may include diminished self-image, guilt, shame, powerlessness, depression, sexual dysfunction, and relationship dysfunction. All of these provide a foundation for the development of substance abuse.
- Victims may have the disease of chemical dependency, and this may have preceded their victimization.
A victim with a substance abuse problem is at increased risk because:
- Acute and chronic effects of alcohol/other drug use may prevent the victim from assessing the level of danger posed by the batterer.
- Under the influence, victims may feel a sense of increased power. Victims may erroneously believe in their ability to defend themselves against physical assaults, or their power to change the batterer.
- The abuse of alcohol/other drugs impairs judgment and thought processes so that victims may have difficulty with adequate safety planning. Alcohol/other drug use makes it more difficult for victims to leave violent relationships.
- Victims may be reluctant to contact police in violent situations for fear of their own arrest or referral to the Department of Children and Family Services.
- Use of alcohol/other drugs may increase involvement in other illegal activities.
- Victims may be denied access to shelters or other services due to substance abuse.
Another perspective to keep in mind when working with substance abusing domestic violence victims is that a significant number of substance abusing women are experiencing symptoms of Post Traumatic Stress Disorder (PTSD) as a result of various forms of victimization in their life experience.
Domestic violence advocates need to be aware of this and be prepared to recognize the potential for PTSD in their clients.
Response to Substance Abuse
Because there is a significant correlation between victimization and substance abuse, all domestic violence service providers need to address the issue of substance abuse. A formal screening for substance abuse should be included in the intake process. If victims are to remain free of violence, they should understand the impact substance abuse has on their safety. It is an empowering process for both client and staff to address safety and sobriety at the same time. By assisting a woman to become safer a staff member may also be helping to eliminate the very reason that the battered woman feels the need to use or improve her ability to access treatment.
When to do a Screen
Because sobriety greatly impacts a woman's ability to get and stay safe, a screening for alcohol and drug abuse should be done with every client, whether she is seeking shelter or nonresidential services. It is important to remember when working with a victim that her substance abuse may be a very reasonable response to the trauma that she may be dealing with on a daily basis.
Screening is not a one-time occurrence but an ongoing process. The administration of a screening tool should happen early in the client's stay in shelter or by her second counseling appointment if she is not residing in shelter. The use of a screening tool is intended to not only elicit responses specific to the client's use of drugs or alcohol but also to open the door to continued dialogue. In this way the screening process continues. Ongoing screening is done through observing the client's behavior and continuing to listen to information the client shares during individual and group counseling sessions.
If a client self discloses or indicates through her actions that she has as a drug or alcohol problem, staff may decide to re-administer the screening tool to try to get more accurate responses.
Many times a client will leave services only to seek those same services later. In that instance the question arises as to whether or not to do another formal screening. Although this is not an issue with definite answers here are some guidelines:
- In the case of a known alcohol/drug abuser, it may not be necessary to do another full screen. It may be more appropriate to simply have a discussion with her to discuss her most recent use/abuse issues.
- In the case of a repeat client, it is necessary to re-screen even if her services were recent. It is imperative that it be determined where the client is today. Remember, she has gotten services from you previously, so she may be more ready to discuss how alcohol and/or drugs have impacted her abuse history.
- Signs of Alcohol or Drug Use
- Smell of alcohol
- Signs of IV drug use (tracks)
- Unusual or extreme behavior
- Nodding off
- Overly alert
- Slurred or rapid speech
- Glassy-eyed/pupils dilated or constricted
- Unable to sit still
- Disoriented or confused for no apparent reason
- Argumentative, defensive, or angry at questions about substance use
Substance Abuse Screening
A substance abuse screening is an opportunity to begin discussing how substance abuse impacts safety. It is a preliminary step that determines the likelihood that an alcohol or drug problem exists. Screening for substance abuse involves honest and nonjudgmental discussions with individuals about their alcohol and drug use, observing their behavior, and looking for signs of use. A screening differs from an assessment. An assessment uses diagnostic instruments and processes to determine if the person is abusing, or is dependent on, alcohol or drugs. When screening for substance abuse, be sure to:
- Ask open-ended questions. This allows the woman to share and offer more information than closed-ended questions. She may find it easier to discuss her partner's use rather than her own. If this is the case, follow-up with questions about her use.
- Ensure privacy. The first step in screening is to insure that it occurs in private. Take the client to a private office or room where she is able to feel comfortable and safe. Children should not be present because they may repeat what they hear.
- Communicate respect and trust. It is important to establish a respectful and trusting relationship. Assure victims that, except for safety concerns, anything discussed will be held in strictest confidence unless she permits otherwise. Ensure that her honest and candid answers will not jeopardize her ability to receive domestic violence services for her or her children. You may want to encourage her disclosure and give her permission to disclose by stating that it is very common to respond to trauma by using alcohol and/or drugs. Painting the substance abuse as expected or functional normalizes her behavior. In fact, her use may be keeping her safer. Remind her that this is a safety issue and will better allow staff to help keep her and her children safer.
- Observe behavior. Using the symptoms in the box (see "Signs of Alcohol or Drug Use"), observe the client's behavior, looking for signs of drug or alcohol use.
- Ask questions. There are several recognized screening tools for alcohol or drug use included in the Appendix, including the tool used by the Illinois Department of Human Services pilot sites. Also in the Appendices you will find a set of guidelines for the use of the screening tools from the pilot sites.
- Deal with denial. Denial can take two forms: knowing but withholding information; or not knowing the truth herself (i.e., the extent of substance abuse or the extent of domestic violence is suppressed, so she does not know it all, or it is minimized in her mind). Denial is the most frequent response to questions about alcohol/other drug use. This is especially true for women not only because they are ashamed of their behavior, but also because they fear losing their children. They also fear being denied services. It is important to give the client the support and time necessary to share her history with staff.
What should come first: domestic violence counseling or substance abuse treatment? It is not a question of either safety or sobriety first, but rather safety and sobriety, since one is less likely without the other. The presence or threat of abuse often interferes with ,a victim's ability to achieve abstinence. Continued use of substances interferes with safety. If screening leads you to suspect that a person has an alcohol or drug problem, refer or arrange for an onsite assessment.
Linking persons to substance abuse programs requires the domestic violence staff to:
- Be informed about treatment options/providers available in their community. Refer clients only to Illinois licensed treatment providers.
- Do cross-training with substance abuse programs to increase the awareness of both issues.
- Continue open dialogue and collaboration between agencies.
- Be willing to provide service options for victims who are substance dependent, whether they are in treatment or not.
Ideally, victims should be referred to a treatment provider sensitive to the issues of domestic violence. If the batterer is in treatment, avoid referring the victim to the same program. In rural areas, this may not be feasible, and advocates will have to be sure that the substance abuse provider understands that violence is an issue. (See section on confidentiality in the Appendix.)
- By assisting a woman to become safer the advocate may also be helping to eliminate the very reason that the battered woman feels the need to use or improve her ability to access treatment.
- When referring an individual to a treatment provider for an assessment, the first concern should be safety. Will an assessment interview place the client or children at risk for further harm? What strategies can be employed to ensure safety?
- What assurance does the person need to follow through with the referral? Victims who have suffered from physical and/or sexual abuse and intimidation may be traumatized by the prospect of talking with a stranger about their use of illegal drugs or fear a drug test. What concerns does the person have about substance abuse treatment and how can they be addressed?
- What information does the person need to follow through with the referral? If the individual is referred to an off-site location, be sure she understands where to go, who she will see, and how to get there. Inform her of the costs of programs. Provide her with a letter to give to the treatment provider when she attends her intake at the treatment program. This letter could state the reason for the referral and any identified initial needs or screening findings.
- Another concern is what support the individual needs to keep the appointment. Are transportation or child care needed? Are there other barriers? The referral process necessitates developing a good working relationship with a treatment agency to jointly address the individual's needs.
- Victims of domestic violence should not be referred to programs that require conjoint or family counseling as part of substance abuse treatment.
- Many treatment providers do outreach; that is, they will attempt to visit the person at their home to engage them in treatment. If outreach will place the person or treatment provider staff at risk, it is important to convey that information to the provider.
Substance Abuse Assessment
When a person is referred to a substance abuse treatment provider, a counselor will use assessment techniques to characterize the problem and to develop a treatment plan. The Illinois Alcohol and Other Drug Abuse Professional Certification Association (IAODAPCA) evaluates counselor competency and grants recognition to those counselors who meet specified minimum standards. All treatment programs licensed by the Department of Human Services must have credentialed staff.
Assessment involves five important tasks:
- Aid in diagnosis of the problem.
- Establish the severity of the problem.
- Develop a treatment plan.
- Define a baseline, which can be used to evaluate an individual's progress in treatment.
- Increase the individual's motivation to attend treatment.
A variety of methods may be used in assessing the individual, including medical examinations, clinical interviews, and formal instruments such as questionnaires. During an assessment, information is gathered to determine which aspects of the individual's life are affected by alcohol/other drug use. Areas of assessment include alcohol and drug use, social and family relationships, psychological functioning, legal status, medical conditions, and employment and educational status. The goal is to determine if treatment is needed, and if so, the appropriate level of care. If the individual is given a DSM IV (or ICD-9) diagnosis (alcohol abuse, alcohol dependence, etc.), treatment is generally recommended.
In some settings, urinalysis may be required. For domestic violence victims who have been sexually abused, the prospect of a urine drug test may be especially threatening. Urinalysis is most commonly done to monitor treatment compliance rather than as part of the assessment.
Treatment follows after the assessment process; the purpose is to address the substance abuse issue identified, dependence or abuse, and how it is exhibited in that particular person. Historically the focus of substance abuse treatment has been initial achievement of sobriety and then challenging the addicted individual to work towards a life of recovery. Recent changes within the field have lead substance abuse providers to start using Motivational Enhancement techniques and Stage of Change concepts. These are used in different levels of care to guide treatment, depending on the person's acceptance and desire to change. Licensed treatment providers use the ASAM PPC-2R (American Society of Addiction Medicine Patient Placement Criteria) to determine the most appropriate level of care to address the person's substance abuse problem.
The level of care is also dependent on a person's level of functioning. The criterion used matches a person to the different levels of care and increases the possibility of a successful outcome. The ASAM criteria are divided into six categories that represent different facets of a person's functioning. These are evaluated to determine the severity of the problem and the appropriate intensity of treatment needed. The six criteria from the ASAM PPC-2R are:
- Intoxication/Withdrawal Potential
- Biomedical Conditions
- Emotional/Behavioral Conditions That Can Detract From Treatment
- Readiness to Change (formerly Treatment Acceptance/Resistance)
- Relapse/continued Use Potential
- Recovery Environment
The level of care determines the therapeutic techniques used but most levels of care will have core elements that change in depth according to the person's understanding of their substance abuse problem. Counseling techniques usually are cognitive/behaviorally based and may include different formats of therapy such as group therapy, individual therapy, family therapy, education, relapse prevention, skills training and support/self help groups. Medications may be used during the withdrawal process and/or as conjunct therapy. Levels of care available for a person with a substance abuse problem include:
- Detoxification (Level IV)
- Residential Rehabilitation (Level III.5)
- Intensive Outpatient (Level II)
- Outpatient (Level I)
- OMT (Opioid Maintenance Therapy for those addicted to heroin using Methadone)
- Early Intervention (Level .5)
There are other treatment levels of care not indicated that are different intensities of those listed above. Each level has its purpose and its focus depending on the needs of the person in treatment. Detoxification can be separated into medical and social setting intensities with medical detoxification being the most intense due to possible life and/or health threatening withdrawals as well as possible self-harm.
Residential treatment programs provide primarily short term, one to three months, intensive treatment where a person can focus on their substance abuse problem without the influence of their living environment. This level of care is mainly for persons who cannot stop their drug use without complete separation from their environment. Residential treatment attempts to provide the structure that may have been lost due to the substance abuse problem.
lntensive Outpatient treatment consists of nine or more hours per week of direct contact with the person and helps them by initiating the process of recovery while the person remains in their environment. This level of intensity is usually necessary when the substance abusing person has no experience with treatment, has poor or no skills to cope with problems without using substances, has other issues that can easily distract them from treatment, needs large amounts of support and motivation to remain sober, or may have medical issues that are directly related to or exacerbated by their use of substances.
Outpatient treatment's focus tends to be on skill acquisition/practice and maintaining motivation to start or maintain a recovery process or not use substances. This level of care is appropriate for the person whose substance abuse issue is not as severe such as mild to moderate dependence or abuse.
Early intervention is usually used for educational purposes when a person is identified as a substance user but does not have a substance abuse diagnosis. This level of care has also been used as a stepping stone for individuals who may have a substance abuse issue but are not motivated and/or have not considered themselves to have a problem.
For the purpose of visualizing the ASAM criteria the following concept is suggested:
- SI = IS
Severity of Illness = Intensity of Service
Once the appropriate level of care is determined, an individualized treatment plan is developed that will guide the treatment process and clearly indicate what issues will be explored during treatment. The treatment plan is developed with the person seeking services so there is mutual agreement on the issues that will be explored. There are also clear goals and objectives identified regarding the problems identified. The treatment plan should also address barriers to treatment and resolution of these issues such as transportation to treatment, childcare arrangements, transportation to childcare, advocacy and placement. A limited number of substance abuse treatment providers are also integrating mental health services within the same agencies. This has been accomplished by providing psychiatric evaluations and follow-up as well as preparing counseling staff to provide mental health counseling in conjunction with substance abuse counseling.
In the case of a female domestic violence victim residing in a domestic violence shelter, the appropriate level of care may need to be a less or more intense level of care than the ASAM placement criteria indicate because of the other immediate psychosocial stressors, namely their domestic violence crisis. For example, often, the women who are actively abusing drugs meet the criteria for Level I1 (IOP), which requires a minimum of nine hours of treatment per week. It may be unrealistic and counterproductive to place them at that level. Instead, they may need to be placed in Level I (OP), which is a less intense level that only requires one hour of treatment per week. This may be much more realistic considering all of the other stressors and business that they need to attend to while in shelter. They may be more receptive to accepting treatment and not feel that too much is being required of them. This treatment could be provided in both individual and/or group sessions with varying intensity. For example, some women may need to agree to three or four hours of treatment per week (up to eight hours is permitted at this level). The substance abuse treatment provider could structure a model conducive to this, such as a two hour group and a one hour individual session per week, totaling three hours of treatment per week. It is also highly recommended that this treatment be provided at the shelter in order to facilitate the engagement process. It would be important to document the reasons for a less intense level of treatment despite what the ASAM criteria indicate, which are the immediate factors associated with the domestic violence crisis.
Performing urinalysis for the detection of drugs of abuse in a domestic violence setting is a very contentious issue. Urinalysis should not be undertaken in the domestic violence setting without first examining the motivation(s) behind such actions. If urinalysis is done, it should be done by substance abuse staff rather than by domestic violence advocates. If the agency does not have a good collaboration with a substance abuse agency, performing urinalysis is not advisable.
Reasons to not consider urinalysis in a domestic violence victim service program:
- Domestic violence staff members may feel that a client is using drugs and feel compelled to "catch" this client in lying about her drug use, thus validating the suspicions. Supervisors must teach staff members to understand the dynamics of drug and alcohol abuse because many clients may not be ready to quit their drug of choice or they may have relapsed. In addition, the agency's substance abuse policy should allow for these dynamics to take place. For example, terminating services of a chronic crack addict because she relapsed does not create the supportive environment necessary for recovery, let alone safety from abuse. Staff needing to be correct in their suspicions should examine their own power and control issues.
- Urinalysis may be desired to settle disputes between clients or confirm rumors that a client is using substances.
- Urinalysis results which demonstrate recent drug use may be the means by which staff are able to detach from difficult clients, even to the point of termination of services. Training and supervision should stress that behaviors are the issue to be addressed, not necessarily recent substance use which may be a means of survival.
- Urinalysis is only conclusive for a specific point in time. It does not indicate use before or after a specific window of time.
Reason to consider urinalysis:
- To use as a therapeutic tool with the client to monitor her sobriety in conjunction with her participation in substance abuse treatment. If the urinalysis demonstrates no drug use, it may empower her and validate her recovery work. If urinalysis demonstrates recent drug use, the staff member and client have an opportunity to address the need for more supportive services and safety concerns that may be impeding her recovery. It also holds the client accountable for her actions.
Domestic violence staff should not be performing the urinalysis because it highlights the power differential between staff and client. Even the trained substance abuse staff member collecting the urine sample should be aware of the power and control issues that this procedure can elicit. The staff member should be fully trained on domestic violence issues in order to sensitively proceed. Understandably, the client may feel she will be punished or judged as a result of either the test results or producing the sample observed by her advocate. Many clients have experienced trauma in the past (i.e. adult or childhood sexual and physical abuse). The abuser may have controlled and monitored most of the client's behaviors. For example, when making a phone call the abuser listens on the other line or demands to watch her dress, shower and use the bathroom. Observing the production of a urine sample may decrease the client's feelings of safety and invoke past traumas. Clients should be advised of how a sample is obtained, how the results are used and any benefits or consequences. And help the client to process the feelings evoked by urinalysis, as this can help alleviate feelings of victimization.
Most often a urine sample is either tested by a dip stick on site or sent to a laboratory for testing. Dip stick tests result in nearly immediate results but are costly and less accurate. Laboratory testing is more accurate, less costly and less immediate-up to seven (7) days for results. With any kind of testing there is a margin of erroneous results.
The length of time a drug stays in a body system varies based on many different factors such as frequency or duration of use and solubility of the substance. The table below estimates the length of time drugs can be detected by urinalysis; however, many other variables alter the estimates.
||Detectable in Urine
||12 to 48 hours
||Occasional Use: 1-7
Chronic Use: 1-4 weeks
||Occasional Use: 1-8 days
Chronic Use: Up to 30 days
||Pentobarbital: 1-3 days
Phenobarbital: 1-3 weeks
Despite the use of herbal supplements or consuming massive quantities of liquid, only time can remove drugs from detection by urinalysis, provided all the levels of testing are exhausted, including testing for Ph levels.
Biohazard/Chain of Custody policies detail how specimens are collected, stored and transported. Unless staff are trained in universal precautions regarding biohazards, like substance abuse staff, prudence would dictate not exposing staff to work related exposure. Local health departments are a good source of information regarding biohazards and universal precautions.
Domestic violence agencies can support victims struggling with the issues of substance abuse in the following ways:
- Assist staff in dealing with their own beliefs, feelings, and prejudices about substance abuse. Provide ongoing training to enable staff to recognize the characteristics of substance abuse and to make appropriate referrals.
- Minimize blame and moral reprobation for use or relapse, which may further disempower the victim and empower the batterer.
- Inform/advise the victim and treatment provider of the risks of conjoint couples counseling sessions.
- While providing advocacy-based counseling for substance-abusing victims, help them recognize the role substance abuse plays. It can keep them tied to the abusive relationship, increase their risk of harm and impair their safety planning ability.
- Be flexible with shelter programming to allow clients to attend out-patient treatment and/or support groups.
- Assist victims by helping them find an alternate means of empowerment as replacement for the sense of power induced by substances.
- Include plans for continued sobriety as part of the safety plan. Help the victim understand the ways the batterer may attempt to undermine sobriety before the victim exits the shelter or completes advocacy-based services.
- Encourage and facilitate linkage with substance abuse treatment resources and abstinence-based support groups.
- Remain cognizant of which local substance abuse programs and support groups (Alcoholics Anonymous, Narcotics Anonymous, Women For Sobriety, church groups, etc.) provide the highest degree of physical and psychological safety for victims.
- Review agency policies regarding substance abusing clients and revisit the policy if necessary.
- The probability that a victim will engage in treatment decreases if doing so will anger her perpetrator (Miller, Wilsnack, & Cunradi, 2000). The more domestic violence staff work toward the victim's safety the more likely she will be safe enough to access treatment.
- It is also empowering for the victim to realize that the abuser wants her to be active in her addiction and to plan for his interference with treatment.
- Each victim presents unique experiences and abilities which either motivate or discourage engagement in substance abuse treatment. As her advocate, the domestic violence staff member can help the substance abuse counselor realize that allowing her to choose what interventions are best for her is best practice.
Unique confidentiality laws apply to almost all substance abuse treatment programs. The law prohibits the disclosure of any information that would identify a person as having applied for, or having received treatment at federally assisted program for an alcohol or drug problem without the person's written consent. There are exceptions for mandated reports of child abuse, in certain medical emergencies or for court orders. A court may authorize a treatment program to disclose confidential patient information following a hearing at which good cause has been established and at which the patient and the treatment program have been represented. A subpoena, search warrant, or arrest warrant, even when it is signed by a judge, is not sufficient, by itself, to require or permit a program to release patient information.
Information protected by federal confidentiality laws may be disclosed if the client has signed a proper consent form. To be valid, the consent must be in writing and must specify:
- The client's name.
- The name of the program making the disclosure.
- The purpose of the disclosure.
- The name of the person/program that will receive the information.
- 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 on it.
- The date, event or condition on which the consent expires.
- The signature of the client and the date of the signature.
Because the potential exists for a judge to order release of the content of a substance abuse treatment file and because it may contain information that reflects negatively on the victim, special care should be taken to minimize file entries which may further victimize her. And while substance abuse treatment programs are legally hindered from rereleasing information received from programs governed by §§ 290dd-2,42 C.F.R. Part 2, information received from a domestic violence program may not apply to that statute and may be recoverable by a source harmful to the victim. Subtle and selective documentation may be the best practice.
Victims should always be advised of any potential for adverse consequences when consenting to release of information.
Domestic violence programs require that victims hold confidential any information seen or heard from other victims when attending services. Violations of this expectation of confidentiality impact the safety and sobriety of the substance abusing victim. Both programs are encouraged to support and remain vigilant of the victim's need for confidentiality.
Other Confidentiality Considerations
Particular care should be taken to avoid victim file documentation of substance abuse related information that may reflect negatively on the victim. Although the Illinois Domestic Violence Act provides protection for this information, the best protection requires subtle and selective documentation of any negative factors. Because substance abuse and addiction are legitimate health care concerns, documenting that she is addressing needs in those areas may be preferred. Documentation of referrals to recovery groups or substance abuse treatment is less harmful in that it could be argued that those organizations also serve the needs of families concerned about another's substance abuse. Each agency must weigh the value of documenting substance abuse recovery successes in victim files against the risk of stigmatizing the victim.
Special care should be taken when releasing any damaging information about the victim to the substance abuse treatment program because their files are not protected in the same way as domestic violence files. Under certain circumstances a judge may order the substance abuse treatment file released whereas the IDVA is less liberal on exceptions. Victims should always be advised of any potential for adverse consequences when consenting to release of information.
Should the domestic violence program release information to the substance abuse program the substance abuse treatment program is NOT legally forbidden to re-release information.
Substance abuse treatment programs require that patients hold confidential all information seen or heard from other patients when attending services. Violations of this expectation of confidentiality impact the safety and sobriety of the substance-abusing victim. Both programs are encouraged to support and to remain vigilant of the victim's need for confidentiality.
"If you take away substances and don't deal with the trauma and pain underneath, then you leave them completely bare and exposed, with no anesthesia." Angela Browne speaking at the Faces of Family Violence and Trauma conference, New Haven CT, May 12, 2000.