Lessons from the Illinois Substance Abuse/Domestic Violence Pilot Initiative

Safety and Sobriety Manual
Best Practices in Domestic Violence and Substance Abuse

January 2005

---

At the time the first edition of this manual was produced and distributed by the Domestic Violence/Substance Abuse Interdisciplinary Task Force, the idea of working with women toward safety and sobriety was conceptually rich but empirically untested. The "best practices" manual and the discussions it provoked over the course of three summer conferences led to the state of lllinois funding the Substance Abuse/Domestic Violence Pilot lnitiative to implement integrated services for women. The pilot project was a joint effort of the Office of Alcohol and Substance Abuse (OASA) and the Bureau of Violence Prevention and Intervention. The project included the development of treatment/services for women by four collaborations covering six agencies and an evaluation of the Initiative by the University of Illinois at Chicago/Jane Addams College of Social Work. This chapter provides some of the literature on the co-occurrence of substance abuse and domestic violence and describes the evaluation and its findings with some recommendations for further development and study.

Co-occurrence of substance abuse and domestic violence

One million episodes of intimate partner violence are documented each year (Bachman & Saltzman, 1995), and this figure probably underestimates the extent of the problem. About 5% of women over age 18 use illegal drugs and 40% have used alcohol in the past 30 days (SAMHSA, 2001). The lifetime prevalence of substance abuse and domestic violence among women in community samples is 18% and 34% respectively (Miller & Downs, 1993).

Among substance abusing women, the prevalence of intimate partner violence has been estimated between 40% and 80% (Bennett & Lawson, 1994; Miller, Downs, & Gondoli, 1989; Stark & Flitcraft, 1996). Downs (2001) found that a majority of women in substance abuse treatment had been the victim of intimate partner violence. Links between adult female substance abuse have been established for both violence in the family of origin (Miller & Downs, 1993) as well as intimate partner violence (Miller, Downs, & Gondoli, 1989). Our best evidence-based perspective is that substance abuse by women and domestic violence toward women have a reciprocal relationship: either one increases the risk for the other (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997) and likely a reduction in either one leads to a reduction in the other.

• Note:  This summary is excerpted from Lessons from the lllinois Substance Abuse/Domestic Violence Pilot: Results of the Implementation and Outcome Evaluation, by Patricia O'Brien, University of lllinois at Chicago, Jane Addams College of Social Work. The study was supported by State of lllinois General Revenue Funds and made possible by a grant from the lllinois Department of Human Services, Office of Alcoholism and Substance Abuse, Melanie Whitter, Associate Director.

Explanations for the role of substance abuse in the abuse of women by intimate partners are fraught with difficulty, in part because these explanations suggest, directly or indirectly, that a woman's abuse of alcohol or drugs plays a causal role in her victimization. The general population believes that women who are drinking are more responsible for their own victimization than women who are not drinking (Richardson & Campbell, 1982). In an emergent traumatological perspective on domestic violence and substance abuse, women are seen abusing alcohol or drugs as a means of coping with earlier trauma (Harris & Fallot, 2001). Such perspectives do not usually address resiliency, the strengths of battered women, or the social etiology of men's abuse of women. Nor is this perspective unequivocally supported in clinical samples. In one recent study of 125 primarily African-American women in substance abuse treatment, there was no direct link between violence in their family of origin and adult substance abuse (Call, 2002). Self-silencing beliefs and subjective distress combined with male partner abuse offered the best picture of women's current substance abuse.

In addition to the woman's own use of drugs and alcohol, living with someone who has drug or alcohol problems also increases her risk of partner violence (El-Bassel, Gilbert, Schilling, & Wada, 2000). Substance abusing women are more likely than non-substance abusers to live with men who are substance abusers, and they are more likely to use physical violence to retaliate for being battered, which in turn increases their risk of more serious injury. Substance abusing women may also be less likely to have the social and financial means to escape from their batterer, and so may remain in a relationship longer. While some women may use alcohol or drugs to self-medicate physical and emotional pain, feminists suggest the key dynamic in the link between substance abuse and domestic violence is power motivation by male abusers and indirect cultural support for men abusing both substances and women as mechanisms of male dominance (Gondolf, 1995).

Pilot description

From July 2000 to June 2001, all women who requested domestic violence or substance abuse services from the six pilot agencies were screened on an 8-item survey regarding the cross-issue. If the screen identified a need for the cross service, or if women in conversation with a staff member indicated a need for the cross-service, they were invited to participate in the pilot evaluation and admitted to the specialized services which, depending on the program, could be in the same building, down the street, or several miles away. Table 1 presents the community locations across Illinois and the population served in their project. As defined by the Office of Alcoholism and Substance Abuse, in the coordinated model, the DV and SA agencies collaborated to provide services to mutual clients. In the integrated model, the same agency provided both DV and SA services to their clients

Table 1 - Description of 4 pilot projects

Project	Type of Project	Community	Sample in the Study
A	Integrated (23% of sample)	Large town	Mostly white
B	Integrated (8% of sample)	Suburban	Mostly white
C	Coordinated (49% of sample)	Urban	African American & Spanish Speaking
D	Coordinated (20% of sample)	Urban	African-American

All of the pilot agencies had a similar mix of treatment/services for the women who had been identified as eligible for the enhanced services. These services included crisis intervention to assist women to get into emergency shelter, case management services, counseling, and advocacy, and assessment, planning, and referral for substance abuse treatment and aftercare.

Study Methods

The evaluation recruited 255 participants at program entry and conducted follow-up interviews with 128 participants (50% of the total). The study examined women's substance use, perceived vulnerability to abuse, and perceived self-efficacy over a four to six month period. A series of repeated interviews of a total of 23 pilot staff at three different points of implementation elicited their perceptions of the collaborative development of services and satisfaction with the outcomes. Focus groups with 50 pilot participants assessed their satisfaction with the services and recommendations for additional services.

Findings

Though each pilot project served different constituencies located in different parts of the state, demographics are presented in Table 2 as a total of all participants in the pilot agencies.

Table 2 - Participant demographics and other participant data (total number = 255)

Note the Average Age of a Participant:  35.2 years

Participant Outcomes

At follow-up, almost 80% of the 128 women had received more than 20 sessions of individual or group counseling, and 32% were still receiving treatment or services from the pilot.

• Drug and alcohol abuse decreased markedly from baseline to follow-up. The number of days that women reported using a substance in the past 30 days declined significantly, from 6.36 to .94. The percentage of women reporting that they had not used in the past 30 days increased from 57% to 87%.
• Women reported increases in the average number of days they had attended a 12-step meeting in the past 30 days, from 4.84 to 7 days
• Women reported increases in the average number of days they had attended a 12-step meeting in the past 30 days, from 4.84 to 7 days
• The percentage of women reporting that they had not been arrested in the past six months increased from 66.7% to 96.9%.
• Women's degree of self-efficacy, as demonstrated by the Domestic Violence Self-Efficacy (DVSE) scale (Riger, Bennett, Schewe, Campbell, & Frohmann, 2002), increased from 28.5 to 32.3. This indicated a greater degree of confidence in managing life situations (and indirectly, in making choices about their sobriety and safety).
• The women's scores on the Women's Experience of Battering scale (Smith, Tessaro, & Earp, 1993) showed a reduction of 28.4 to 25.4 from baseline to follow-up indicating a perceived reduction in their vulnerability to domestic violence.
• Women participating in the pilot indicated a high degree of satisfaction with the services they received. 89.3% of the women said they would recommend the program to someone they knew was experiencing domestic violence or had substance abuse problems. The average score on the Client Satisfaction scale was 70.22 (the range was 64-71.6), indicating a positive opinion of services provided by the pilot programs.

Discussion

Based on the results of the pilot evaluation study, women participating in enhanced services in Illinois experienced reductions in their alcohol and other drug use, as well as increases in their ability to manage their lives (as reflected in increased scores on the DVSE scale) and a lessening of their perceived threat of violence (as reflected in lowered scores on the WEB). Women also experienced improvements in employment and physical and mental health, and were arrested fewer times. Clients were highly satisfied with the services, as indicated by their scores on the CS scale and their comments during the follow-up interviews and focus groups. Each agency's services resulted in some improvement to participants in the pilot. There was no difference in this overall finding between those that were located in more rural areas of the state as compared to the urban-located agencies; there was no difference between the coordinated agencies versus the integrated agencies. Participants in the focus groups articulated a sense of relief for the opportunity to discuss both substance abuse and domestic violence in the same program. As one participant said, "They go hand-in-hand." Women mentioned minor gaps in service delivery including transportation for getting to individual or group sessions and inconsistencies in child care availability. A major overarching strength that participants identified was the caring and compassion demonstrated by staff members, a hallmark of empowering practice with women.

Providers were also satisfied with their involvement in the pilot project, though they recognized the multiple challenges in creating the coordinated services that their clients need. If practitioners in both the disciplines of domestic violence and substance abuse treatment have trouble understanding and accepting one another's world views, this clearly affects the effectiveness of services. By the conclusion of the implementation of the pilot, all of the pilot staff recognized that participants were "better off' as a result of the pilot, even though most still articulated continuing frustration with differences in practice approach, treatment approach, or even work style. The outcomes for participants however, outweighed the procedural issues.

The small sample for this cross-sectional study with one follow-up point with half the baseline sample indicates a need for further study with a larger sample with a longer follow-up period. We also don't know if the changes demonstrated by the women might have happened without engagement in the enhanced services the pilot projects provided since there was no control or non-treatment group. A strategy that bolsters the credibility of this study was the use of multiple methods for data collection and analysis. The quantitative study of outcomes was consistent with findings from the qualitative study of implementation.

Models that focus on empowerment and validation for each woman's historical efforts to help herself and manage her relationships, combined with advocacy and safety planning hold the most promise. To be successful, these approaches require the development of ongoing and collaborative partnerships by addiction treatment professionals and battered women's advocates. There was no difference in this study whether services were provided by two collaborating agencies (coordinated) or by the same agency providing DV and SA services (integrated). Comprehensive training about domestic violence, its effect on women's health and the social and political issues that perpetuate its prevalence should be available to all providers of addiction treatment. Cross-training for staff of battered women's shelters, rape crisis centers, and child protection agencies about addiction and the process of recovery is needed to help all these systems work together effectively. Cultural competence in treatment and service approaches should reflect the diversity among women in class, race, ethnicity, age, disability, and sexual orientation, as each woman's cultural identity and history can be a central source for her healing and recovery.

Given the high percentage of women in this study who were mandated to drug abuse treatment (58%), and who were also addressing the effects of abuse, it is important to discuss how mandates for treatment have an impact on agencies' capacity to deliver collaborative and confidential services. Evaluation of partnerships between systems once working in opposition to provide integrated programs that serve women in a holistic manner can inform future efforts that respond to the profound impact domestic violence and substance abuse has on the lives of many women. Clients and providers alike recognize the value of integrated services. More integrated treatment and increased cooperation among providers will reduce service delivery gaps and help more women finish treatment successfully. One of the notable benefits of this pilot initiative was a statewide investment in the pilot projects and a "buy-in" from agency administrators and line staff to implement the integrated and coordinated services. Such a commitment bodes well for future planning efforts for moving women to safety and sobriety.