Safety and Sobriety Manual
Best Practices in Domestic Violence and Substance Abuse
The prevalence of substance abuse among men entering batterers' programs has ranged between 40 percent and 92 percent, depending on the proportion of the men who were referred by the criminal justice system (Easton & Sinha, 2002). However, assessing whether a man abuses alcohol or drugs prior to the batterers' program is not enough. In one study of 840 men in batterers' programs in four U.S. cities, substance abuse during the batterers' program was the best predictor the man would abuse a partner in the future (Gondolf, 2002). This suggests that evaluation of substance abuse by men in batterers' programs needs to occur, not just at intake, but throughout his time in the program
For most men who batter, alcohol or drug use does not directly cause their abusive behavior. However, for most men who batter, alcohol and drug use may:
- lncrease the risk that he will misinterpret his partner's behavior.
- lncrease his belief that violent behavior is due to alcohol or drugs.
- Make him think less clearly about the repercussions of his actions.
- Reduce his ability to tell when a victim is injured.
- Reduce the chance that he will benefit from punishment, education, or treatment.
Ongoing research is providing new perspectives on intervening with men who batter and have co-existing substance abuse problems. These developments are not necessarily endorsed as safe practices, but are offered here because they have established some empirical support. Motivational enhancement therapy (MET) has been shown to be useful in increasing readiness to change substance abuse behavior by men in batterers' programs (Easton, Swan, & Sinha, 2002). A number of well established batterer intervention programs (e.g. EMERGE in Denver) employ detailed professional assessment and intervention for substance abuse and new models are being developed to incorporate an alcohol component into batterer intervention programs (Conner & Ackerly, 1 994).
While programs for men who batter may have several goals, including behavioral change and accountability, the most essential consideration is the safety of domestic violence victims. All interventions must account for the safety of victims whether they are in domestic violence programs or in substance abuse treatment.
Screening for Substance Abuse
Because so many batterers are also substance abusers, all batterers should be thoroughly screened for substance abuse problems. A substance abuse screening is an opportunity to begin discussing how substance abuse impacts a man's life. It is a preliminary step that determines the likelihood that an alcohol or drug problem exists. Screening for substance abuse involves honest talk 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:
- Ensure privacy. The first step in screening is to ensure that it occurs in private.
- Communicate respect and trust. It is important to establish a respectful and trusting relationship. Assure him that his honest and candid answers will not impact his ability to be in the program.
- Observe behavior. Using the symptoms in the box, observe 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. Ask open-ended questions. This allows the man to share and offer more information than closed-ended questions. He may want to discuss his partner' use of alcohol or drugs or the use of his peers, rather than his own. If this is the case, follow-up with questions about his use.
Screening is not a one-time only activity. Batterer intervention programs may screen for substance abuse through:
- Initial interviews. Program staff should ask established questions and be trained to interpret responses. In response to direct questioning about alcohol and drug use, substance abusers often deny the importance or effect of alcohol or drugs in their lives. (Examples of screening questions and formal screening tools are in the Appendix.)
- Observations of behavior and interactions during the batterers' program. Lateness, fatigue, aggression, or the smell of alcohol point toward the need for formal alcohol and other drug assessment. Look for signs of alcohol or drug use. (See box.) Interactions with recovering alcoholics and addicts in the batterers' program are usually revealing, because recovering men can often identify substance abuse patterns in others. Exposure of batterers who are substance abusers to recovering alcoholics and addicts is one of the more compelling reasons for not excluding active substance abusers from batterers' programs.
- Existing records. The contract signed between the batterer and the program should include access to criminal justice, mental health, and medical records.
If screening reveals the possibility of substance abuse, the batterer should be referred for formal assessment (unless the evaluator has appropriate training and certification). Formal assessment of substance abuse problems should be conducted by specialists qualified by the Illinois Alcohol and Other Drug Abuse Professional Certification Association (IAODAPCA). The batterers' program should not regard the referral for assessment as a referral to another agency that will then assume responsibility for the case, since this has led to men "slipping between the cracks."
- 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 Assessment
When a man from a batterers' program has been referred to a substance abuse treatment provider, a counselor will use assessment techniques to characterize the problem and to develop a treatment plan. IAODAPCA evaluates counselor competency and grants recognition to those counselors who meet specified standards. All substance abuse treatment programs licensed by the Department of Human Services must have credentialed staff. The system identifies the functions, responsibilities, knowledge, and skill bases required by counselors in the performance of their jobs.
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 man'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, treatment is generally recommended. In some settings, urinalysis may be required. Urinalysis is most commonly done to monitor treatment compliance rather than as part of the assessment.
Substance Abuse Treatment
Treatment follows from the assessment process with the purpose of addressing 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. ASAM criteria are used to match a person to the different levels of care and increase 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 their problem and the appropriate intensity of treatment needed. The six criteria from the ASAM PPC-2R are:
- lntoxication/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 displacement from their environment. Residential treatment attempts to provide the structure that may have been lost due to the substance abuse problem.
- Intensive 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 has 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. Outpatient can be from 1-8 hours, allowing the flexibility to step up or decrease support as needed.
- 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. Many of the men seen in batterer intervention programs will fall into this category.
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.
Substance Abuse Confidentiality
Unique confidentiality laws apply to almost all substance abuse treatment programs. Coordination between batterers' programs and substance abuse programs must accommodate the constraints of these laws to be successful. 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 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.
- Evaluate abstinent batterers. Abstinent and recovering alcoholics and addicts will usually score positive on the Short Michigan Alcoholism Screening Test (SMAST), CAGE-D, and other screening tools. (Examples of such screening tools are in the Appendix of this document.) Abstinent batterers with no observable supports for staying sober should be considered at high risk for relapse, and consequently, a safety risk.
- Case manage active substance abusing batterers who accept alcohol and other drug intervention. Assertive case management by probation officers has been found to effectively increase community safety, hold batterers accountable, and increase batterers' coping skills (Johnson, 2001). Case management and service coordination for substance abusing batterers is likely to produce a similar effect. Men who are assessed as abusing, or dependent on, alcohol or other drugs require integrated or coordinated concurrent substance abuse and domestic violence programming. In cases where addiction impairs the man's ability to utilize the batterers' program, the batterer/addict may complete an initial phase of addiction treatment such as medical detoxification and engagement with a support program. He then continues in counseling and/or a support program while in the batterers' program. The batterers' program should receive regular reports from the substance abuse program about the man's progress in substance abuse treatment. The substance abuse treatment provider may also be bound by further confidentiality constraints such as the Health Insurance Portability and Accountability Act of 1996 (HIPPA). It's best to have a frank discussion with the provider on how best to work together.
- Intervene with active substance abusing batterers who refuse alcohol and other drug intervention. When a batterer is also a substance abuser but does not understand or accept the situation, it is recommended that he should still be admitted into a batterers' program, with ongoing monitoring of substance use and effects. One goal for being in the batterers' program is successful referral to substance abuse treatment. Under the conditions of a court mandate, programs should communicate to probation officers or case managers that a man requires substance abuse treatment. The current or former partners of voluntary or non-court-referred batterers should be notified of his refusal to enter substance abuse treatment, along with the risk that such a refusal represents. Acceptance of an addiction treatment referral (including support group attendance) should be made a priority goal of the intervention program.
- Integrate substance abuse and batterers' programs with caution. An integrated program provides domestic violence and substance abuse services under the same program, with differing degrees of integration. lntegrated programs under substance abuse programs should actively utilize domestic violence programs as consultants and compensate them for their services. They should also actively participate in the community's coordinated domestic violence council. lntegrated programs under domestic violence agencies should actively utilize addiction program staff as consultants and pay them for their services. Sharing certain staff members across agencies may be an alternative to an integrated program. Programs that are not integrated (i.e., batterers' program and substance abuse program are in different settings) should utilize networking, case management, joint staffing, or some other means of increasing continuity. Coordinating, collaborating programs may provide safer, more accountable interventions than integrated programs.
- Recognize safety and sobriety are interconnected. Lack of sobriety in batterers, increases the risk for further violence against victims. Lack of victim safety threatens the sobriety of the batterer. However, abstinence and sobriety are not sufficient conditions for safety.
- Key Points
- Victim safety must guide all assessment and intervention.
- Screen all batterers for substance abuse.
- Coordinated, concurrent programs are preferred.
- Batterers' programs should provide case management whenever possible.
- Do not terminate batterers who refuse substance abuse treatment.