Addressing Domestic Violence In Substance Abuse Treatment for Women

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

January 2005

Common Perspectives

The importance of addressing domestic violence in substance abuse treatment for women becomes evident when one reviews the research. Women who abuse substances are more likely to experience domestic violence in relationships (Miller, Downs, & Gondoli, 1989). One study found that of women in a drug treatment center, 90 percent had been physically assaulted and 95 percent had been raped (Stevens & Arbiter, 1995). Women who experience domestic violence are more likely to misuse prescription drugs as well as alcohol (Stark & Flitcraft, 1988).

To produce successful outcomes, both issues must be treated together. Otherwise, a vicious cycle of victimization, chemical use, retardation of emotional development, limited stress resolution, more chemical use, and heightened vulnerability to further victimization results (C. Steele, 2000).

Substance-abusing women and women who have experienced domestic violence report similar experiences. Both may demonstrate:

Isolation, shame, and guilt.
Behaviors that others describe as bizarre or dysfunctional.
Traumatization.
Initial denial of the problem.
Loss of support systems and fear of losing children as a result of admitting their problem.
Low ego strengths.
Magical thinking (a client's belief that the problem will simply go away as if by magic).
Impairment of their ability to make logical decisions.
Involvement in the criminal justice system, either as a victim or offender.
Often seeking services only when in crisis.
Several returns to the substance, or to a relationship where battering continues, before making a lasting change.

Interview Tips

Because of the incidence and prevalence of domestic abuse in the population of substance abusing women, it is recommended that all women served in the substance abuse treatment setting be screened for domestic abuse. When interviewing a client:

Use caution and tact. Don't initially refer to the partner's behavior as domestic violence. Instead use language such as inappropriate behavior, unhealthy behavior, behavior that is unsafe, and possibly abuse.
A woman might not feel safe disclosing information to you. She may disclose more about herself when she gains confidence and begins to trust you. "When a woman does disclose, it is important to emphasize that the battering is not her fault; educate her about domestic violence and substance abuse; reduce the stigma; and perhaps most importantly, ASK HER how you can best be of assistance" (Hill, 1996).
Proceed sequentially from the least sensitive to the most sensitive topics. Use the early (least sensitive) part of the interview for relationship-building and the establishment of trust.
Be careful about criticizing the partner. Battered women may care for their partners and may become defensive or shut down if the partner is criticized.
Avoid labeling survival strategies or other behaviors as co-dependent.
Get factual information. Often a woman will give vague answers to questions. Ask her to clarify her responses. For example, ask her to talk more about her experiences in relationships.
Avoid discounting her evaluation of her safeness. She is the expert regarding her safety.

Domestic Violence Screening

While there are formal domestic violence screening tools in the Appendix of this document, screening for domestic violence is a process which continues throughout your interactions with the woman. Also, be sure to listen for subtle disclosures of any misuse of power and control in the relationship, not simply physical abuse. Key questions which might lead to a formal screening include:

What happens when you argue with your partner?
How safe do you feel with your partner?
How safe do you feel when you leave here?
Can you tell me about a situation with your partner when yelling and screaming occurred?
Can you tell me about a situation with your partner when things were destroyed?
Can you tell me about a situation when your partner pushed, slapped, or hit you?
How does your partner show respect to you?
How does your partner attempt to control your alcohol or other drug use?
Have your efforts to get clean and sober been sabotaged by your partner?

In addition to formal screening, counselors may observe and should note:

Bruises or other untreated physical injuries.
Inconsistencies or evasiveness.
Frequently missed appointments or partner waiting for her during counseling sessions.
Reports that partner isolates her, prevents her from attending counseling or support groups, threatens her, or forces her to do things she does not want to do.
Evidence or reports of child abuse.
Reports of jealousy or statements beginning with "my partner won't let me."

While clinicians once thought it best to wait until a client had achieved a reasonable period of abstinence before addressing her abuse or trauma issues, most programs now routinely ask clients detailed questions about their abuse histories in the intake interview. Ann Uhler and Olga Parker (2002) offer some guidance. Counselors should:

Convey to every client during initial assessment that the counselor understands about abuse and trauma issues.
Explain how the program can help with these issues.
Determine whether the client is in a crisis related to ongoing abuse or recent trauma that calls for immediate attention.
Obtain the information necessary for a preliminary treatment plan, but reserve further probing for therapy rather than during assessment.

Referral

If the screening indicates a probability of abuse, you may first want to assure the client that the abuse is not her fault and declare that she doesn't deserve to be abused while you encourage her to consider either a shelter or a provider who deals with domestic violence issues. The more you know about the provider the more she will be able to determine if it is safe for her to access services.

If she chooses to not accept those services you may want to continue to encourage her while stressing the value and connectedness of both her safety and her sobriety. At a minimum, determine if there is anything about her treatment participation which places her at greater risk. Consideration for her safety should impact her level of care.

It is important to coordinate services as much as possible with the domestic violence advocate. Explain confidentiality regulations to domestic violence advocates when coordinating services, as well as the meaning of American Society of Addiction Medicine (ASAM) criteria. Ask domestic violence advocates what legal remedies may be available to the client through the Illinois Domestic Violence Act (IDVA). Joint staffings and collaborative case management involving both service providers have been shown to be particularly helpful in addressing her safety and sobriety. When serving a mutual client, it is also helpful for domestic violence and substance abuse providers to present a united effort when advocating with other systems (e.g., Department of Children and Family Services). Coordinate discharge planning, especially when discharging from a residential program. This coordination allows the woman to identify several options, such as staying at a shelter or staying with family or friends if it is unsafe to go home.

Intervention

As substance abuse professionals know, women often have treatment issues that are different from men's. When domestic violence is added, this difference is magnified. When providing services to women, keep these points in mind:

Safety issues can seriously affect the woman's ability to maintain sobriety. Make safety as well as sobriety a top priority. Treatment should focus on both issues. Develop relapse prevention plans that include safety planning and ways to cope if her partner gets violent.
When a woman is harmed, she may be more likely to use substances to cope. She may use alcohol or drugs to medicate physical and/or emotional pain. She may even be coerced into use by her partner - the abuser will often do whatever it takes to keep the woman under his control, including forcing use of substances and threatening her if she does not continue to use.
Often a domestic violence victim's partner is using as well, and if she leaves to find a more sober support network, there is increased risk to her safety. Be aware that the most dangerous time for women is when they leave their abusers.
Recognize that even though her relationship may be a trigger for continued use, it may also be unsafe for her to leave. Victims of domestic violence aren't so much choosing to stay in violent relationships as they are choosing when it is safe for them (and their children) to leave. For many victims, this may be never. Domestic violence advocates estimate that women make an average of eight attempts to leave violent relationships before they actually do so successfully, and that disclosure, contemplation and preparation (safety planning) are key elements of the process (Hill, 1996). Discuss these issues in terms of the dilemmas they create.
When addressing issues of noncompliance, counselors should take into account the batterer's ability to sabotage substance abuse treatment through threats or fear.
Couple or family counseling can be very dangerous for victims of domestic violence. DO NOT provide information to the partner. If the perpetrator finds out about disclosure of the violence or substance use, the woman may be punished. Residential substance abuse treatment programs with strong family components need to be sensitive to the victim's special needs for outside support
Domestic violence is not caused by substance abuse and is not merely a symptom of substance abuse. Domestic violence is an issue of power and control, however often people identify anger as a symptom. Battered women often blame themselves for the beatings they have suffered. Victims often believe they are being abused because of their substance use and some substance abuse counselors believe this as well. Therefore, it is important to stress that abuse is not the victim's fault.
Avoid language that implies there is something wrong with the victim or that she caused her own abuse. Some examples of words to avoid are codependency, enabling, and powerlessness. It is important to avoid codependency and enabling because these concepts do not hold the batterer fully accountable for his behavior. In the domestic violence community, codependency is a term for a woman's adherence to the socially sanctioned roles of women, and is always inappropriate when applied to domestic violence victims
Confrontational techniques are not appropriate for victims of domestic abuse. They can be interpreted by the woman as an extension of how the abuser treats her.
Confrontational techniques are not appropriate for victims of domestic abuse. They can be interpreted by the woman as an extension of how the abuser treats her.
Some 12 Step groups' concepts can pose problems for women. These include submission to a higher power referred to exclusively in male terms, emphasis on "character defects," limited emphasis on strengths, and discouragement from talking about the abuse that has happened to them. "Twelve-step programs rarely address the impact of post-traumatic stress disorder and fail to acknowledge the situational nature of substance use" (Hill, 1996).
Whenever possible, domestic violence victims should be referred to gender-specific treatment and support groups. Mixed groups may involve descriptions of male aggression directed toward female partners. When planning interventions with the victim, her need for self-sufficiency and possibly childcare should be considered. Treatment programs which incorporate harm reduction strategies and a trauma sensitive environment are particularly suited to domestic violence victims.
Some domestic violence victims experience a high degree of anger in the context of their survival. Some women are finally able to express their anger when they feel safe in a program. Staff should be trained to understand and facilitate expressions of anger, seeing it as a sign of healing for some women, and have the skills to balance a woman's need to release anger with the needs of other victims and survivors.
Given the complex nature of surviving both substance abuse and domestic violence, treatment programs need to acknowledge that treatment duration may be elongated.
In one study, substance abusing victims reported that using substances allowed them to feel more powerful, more sexy and less fearful of being alone (Parisi-Dunne, (1 992). Finding less harmful but more safe and sober ways to replace the benefit of the substance is a challenge.
Victims respond best to gender specific empowerment and self discovery. They often desire and benefit from all-female support groups. They often feel there are not many options. Language focusing on empowerment may help them develop the tools to stay safe and sober. Emphasize strengths and healthy decision-making.
Counselors may need to address domestic violence and substance abuse with different but integrated or coordinated interventions. Colocated services and substance abuse treatment which includes education about domestic violence co-facilitated by a domestic violence advocate have been shown to be particularly effective.
- Make safety as well as sobriety a top priority.
Consultation and review is advised to ensure efficacy of staff working with substance abusing victims. Support should be provided by staff experienced in dealing with both issues.
- Domestic violence is not caused by substance abuse and is not merely a symptom of substance abuse.

Harm Reduction

Harm reduction strategies are promoted for active drug users who are seeking to end their dependency or addiction, and non-drug users who engage in a range of potentially risky behaviors or live in environments which pose a threat to their health and well-being (Hill, 1996). The philosophy of harm reduction requires health care/service providers to set aside their judgments in order to address problems and crises on the client's terms.

With its emphasis on establishing trusting supportive relationships between providers and clients and accepting the client at her/his own level, harm reduction can in many ways be viewed as a bridge between currently fragmented domestic violence and substance abuse treatment services, with safety as a key concern (Hill, 1996). Thus, the goals of treatment for women impacted by substance use and domestic violence are:

To help the woman become more conscious of her risky behaviors and situations.
To help her develop a plan for reducing the risk to her personal safety and the safety of her children.

Models of recovery from addictions and from trauma both have as a primary goal the attainment of safety through the abstinence from chemicals and self destructive behavior (Hill, 1996). In order to accomplish this, both models:

Endorse behavior change and learning new ways to manage emotions.
Address the cognitive distortions that come with living with addiction, or living with trauma.
Have the creation of positive, consistent support systems as a component.
Unlike in previous years, now support the careful use of appropriate psychotropic medications.
While the stages or steps of change models have been studied relative to women with substance abuse problems and also victimization, the practitioner should acknowledge that motivation toward change does not ensure safety because it is the batterer who engages in the violent behavior. Perhaps readiness to explore additional safety options would be more apt to address the victim's choices.

Other Considerations

In its New York State Model Domestic Violence Policy for Counties (January 1998), the New York State Office for the Prevention of Domestic Violence suggests several accommodations that should be considered if a domestic violence victim chooses inpatient substance abuse treatment:

If the client is a mother, "no contact" rules that often apply during the first week of treatment should be waived to allow regular communication between the victim and her children while she is in treatment. This not only alleviates concerns that children might have about their mother, but also protects victims from charges of "abandonment" or "neglect" in custody cases.
If a victim has initiated legal action for an order of protection, custody, and/or support, and it is not possible or advisable for her to obtain a continuance, allow her to meet with legal counsel, a court advocate, and/or district attorney, and to appear at all court hearings.
Regardless of the treatment setting, inform all staff, with the client's consent, when a client has an order of protection and keep a copy of the order of protection in a confidential on-site location.

When a woman with these multiple issues makes the decision to accept help and enroll in substance abuse treatment, there are several questions that need to be investigated (Brown, Melchior, Panter, slaughter, & Huba, 2000):

Will such a woman enter drug treatment with these conflicting demands?
Which of these needs and demands and risks takes priority as the woman decides to enter treatment?
Will acute dangers of occurring or possible domestic violence propel such a woman toward or away from drug treatment?
Is the readiness to make changes in various co-occurring problem areas a single disposition or a series of more independent ones?
Is readiness to make changes in various problem areas related differentially to entry into different types of substance abuse treatment?

The Steps of Change Model is based on the woman's level of readiness and hypothesizes that women will wish to address the most immediately threatening issue first (and to seek help) before addressing significant problems that do not have the same degree of immediate threat (Brown, Melchior, Panter, Slaughter, & Huba, 2000). The Model covers four major areas in which women may seek to change their lives in order to enter a more stable and healthy lifestyle through entry into treatment:

Readiness to change a domestic violence situation.
Readiness to change sex risk behaviors.
Readiness to change substance abuse behaviors.
Readiness to deal with emotional problems.

Time urgency or immediacy appears to be an underlying issue of seeking help; that is, domestic violence is likely to be a more acute danger to the women than substance abuse. However, while a woman may feel the urgency to do something about her safety, she may also fear the loss of her children if she reports the violence in the home (Brown, Melchior, Panter, Slaughter, & Huba, 2000). The client's perception of need immediacy may differ from that of the therapist or provider. Also, individuals may be at different stages of recovery from substance abuse than the stage they are at in making choices about the violence in their lives.

Confidentiality

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 participating in services. Violations of this expectation of confidentiality are particularly harmful to the substance abusing victim. Both programs are encouraged to support and to remain vigilant of the victim's need for confidentiality.