Addressing Domestic Violence In Substance Abuse Treatment for Men

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

January 2005

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Approximately half the men who batter their female partners have substance abuse problems. In one large treatment center in Chicago, which has been doing screening since 1997, a consistent pattern has emerged: 70 percent of funded clients (mostly indigent or below federal poverty-level incomes) and 92 percent of nonfunded male clients (mostly court-mandated for DUI or other non-domestic violence offenses) have used some level of violence in a primary relationship within the year prior to assessment (Haymarket Center, 1998). Counselors in addiction treatment programs for men may underestimate the number of men in their programs who use violence (Bennett & Lawson, 1994). Furthermore, the non-substance abusing female partner is often blamed for the actions of the substance abusing batterer. This practice includes labeling the woman as co-dependent or an enabler.

Domestic violence, like many other life problems, which affect chemically dependent persons, has traditionally been viewed within the substance abuse treatment field as a manifestation of the dysfunction resulting from long-term use of psychoactive chemicals including alcohol. Until recently most counselors may have expected that abstinence alone would reduce the incidence of violence, and that sobriety (understood as an ongoing connection to community support in addition to abstinence) would eliminate it. In discussions with counselors who are involved in providing intervention services to men receiving alcohol and other drug addiction (substance abuse) treatment, the task force has been reminded of the importance of making treatment providers aware of the experience of women who are victims of domestic violence. Substance use is neither a necessary nor a sufficient cause of intimate partner violence (Leonard, 1999). Consequently, violence does not always stop or even diminish when the batterer becomes abstinent, and when it does, an increase in other abusive and controlling behavior may replace it.

Common Perspectives

Addict/abuser common features:

• Continuation of behavior despite negative consequences.
• Preoccupation/obsession
• Adversely affect family members including across generational lines.
• Predisposition to relapse.
• Accountability for difficulties placed on others or external causes.
• Increased use (of substance and/or power/control) to maintain effect.
• Preoccupation, rituals, acting out, guilt/remorse.
• Late manifestation of involvement in workplace, further on the continuum of the disease or lethality.
• Adversely affect intimacy
• Characterized by denial, minimization, and rationalization
• Intervention or abandonment by family members exceptionally difficult. (Iron & Schneider, 1997)

Recent Developments

The link between substance abuse and intimate partner violence is becoming increasingly visible (Wekerle & Wall, 2002). Ongoing research is providing new perspectives on intervening with men who abuse alcohol or other drugs and also batter their female partner. These developments are not necessarily endorsed as safe practices, but are offered here because they have established some empirical support. For:

• alcoholic men
• whose violence has been minimal
• who are not court referred
• and whose partners wish to maintain the relationship

behavioral couple therapy (BCT) has been shown to reduce the risk of domestic violence for those men who discontinue drinking (0' Farrell & Murphy, 2002).

A recent study of domestic violence screening in seven substance abuse treatment facilities (Schumacher, Fals-Stewart & Leonard, 2003) found, paradoxically, that prior criminal justice involvement by men seeking substance abuse treatment decreased rather than increased the odds they would be referred to batterer programs. The study also found that, even when referred, men in substance abuse treatment rarely followed through with the referral. This finding supports the suggestions in the "Lessons Learned" chapter that integrated and coordinated programs are absolutely essential in preventing further violence by men in treatment for alcohol or drugs.

Tips for Safety and Sobriety

Screen substance abuse clients for domestic violence. Make it clear that all program participants are screened for violence. It is important for victim safety that the man not believe the evaluator has been "tipped off' by his partner. (See Appendix for examples of screening and assessment tools.) If you identify a man as having used violence, do the following:

• Refer him to a batterers' intervention program as soon as possible. If you are doing his treatment plan, address violence in Dimensions 3, 5, and 6 (Emotional/Behavioral Issues, Relapse Potential, and Recovery Environment) of the current Client Placement Criteria of the American Society of Addiction Medicine (ASAM).
• Use separate facilities to provide services to the batterer and his female victim if at all possible - unless staff and clients in men's and women's programs are distinctly separate. If this is not possible, at least schedule appointments at times when the perpetrator and victim are not likely to be in the facility at the same time or on the same day.
• Even if both the batterer and victim consent that their treatment progress will be shared with their partner consider how doing so may jeopardize the victim's safety.
• If the client is under court supervision, contact his probation officer to request that batterers' intervention programming be added as a condition of probation.
• Determine if anger management services are important to the treatment process but also determine how they may impact safety. (The differences between anger management and partner abuse intervention programs is further explained in the appendix.)
• Avoid group discussions and/or support groups that provide collusion among batterers. Instead, seek supports which hold the batterer accountable.
• Address how the batterer's abuse of power, control and substances have impacted exposed children.
• Reinforce how adults model mood regulation, substance abuse and equality for future generations.
• Recognize that the substance abusing batterer requires intensive case management to be successful in addressing both issues.
• Recognize that violence does not always stop or even diminish when the batterer becomes abstinent, and when it does, an increase in other abusive and controlling behavior often replaces it.
• Do not provide him with family sessions or conjoint therapy. The Illinois Protocol for Partner Abuse Intervention Programs recommends the following criteria be achieved before intervention with batterers and victims:
  1. The participant has been violence-free for six months.
  2. A determination by the participant's counselor and abused women's advocates that it is appropriate - not automatic at a set time.
  3. An affirmative desire by the victim, which must include provision for safety at the facility.
  4. Separate screening of participant and victim.
  5. A determination that the victim does not hold herself responsible for the abuse, and that she is aware of resources and knows how to use them.
  6. An affirmative statement from the participant that he accepts full responsibility for his actions.
  7. The joint arrangement must be able to be terminated at any time in the process. The person providing intervention must terminate any time it is determined to be unsafe to continue.
  8. Victims must never be required to go for counseling as a condition of services for the participant. Services for men who abuse must never be contingent upon the victim receiving services there or at a domestic violence victim services program.

In addition, talk with local courts and police regarding appropriate mandated sanctions for substance abuse clients who are found to be batterers. When courts mandate services, it empowers agencies to include batterer intervention as part of their treatment recommendations, even when the offense is not related to domestic violence (e.g., when a client is mandated to treatment for substance abuse after a DUI conviction).

Raising Awareness on Domestic Violence

Assess your own agency's tolerance toward the equality of women:

• Are women included in the decision-making processes of your agency?
• What are your agency's recruitment and promotion policies?
• Is there an equal partnership between male and female group cofacilitators?
• Is your agency actively involved in community networks that confront violence against women?
• Do staff exhibit supportive attitudes and beliefs about women and domestic violence?

Talk with local domestic violence service providers to get linkages going which include cross training of staff. This will increase awareness of the issues on both sides and help in providing services across both agencies.

Screening and Referral

The incidence of family violence perpetrated by substance abusing men is sufficiently high that universal screening is necessary and should become not only the norm but should be seen as an essential part of the screening and assessment.

• Screening tools (see Appendix for examples) should be implemented in consultation with domestic violence professionals.
• These tools should include a clear explanation of what constitutes abuse, rather than just asking a general question about violence or abuse.
• If you do not have on-site batterer intervention services, you will need to establish a relationship with local batterers' intervention services.
• Make a Mutual Service Agreement or another linkage agreement (see Appendix for example) which establishes regular communication between substance abuse treatment providers and local domestic violence programs. Linkage agreements should not be considered a substitute for regular direct communication between such programs

Timing of Batterer Intervention

Some substance abuse counselors want to wait 90 days or longer to put clients in batterers' intervention services. However, violence is a powerful relapse trigger which can sabotage recovery in its earliest stages. For this reason, many service providers recommend beginning batterer services well before a client is discharged from primary substance abuse treatment. Remember: Sobriety without accountability is unlikely.

There are other concerns regarding partner abuse intervention during treatment and early recovery. Some of them are:

• Clients may be very resistant to the whole concept of treatment, and may not react well to the traditionally confrontational format of some forms of batterers' intervention.
• Clients are likely to be suffering neurological complications of longterm use of psychoactive chemicals, which may have an impact on their ability to function in a highly confrontational group.
• Clients may have significant cognitive and educational deficits. These can have an impact on their ability to take responsibility for their violence, as well as on the ability of the program to screen for problems that might suggest that a client is inappropriate for partner abuse intervention.
• Denial is an active dynamic in both substance abuse and domestic violence. Clients must be individually assessed to determine readiness for partner abuse intervention groups. Carelessness in this area can easily foster bad outcomes by needlessly increasing client resistance and noncompliance.
  • Remember: Sobriety without accountability is unlikely.

Batterer Intervention and Relapse Prevention

Clients may respond better if the batterers' intervention is tied to the idea of relapse prevention. The process of relapse tends to be cyclical. The phases of the cycle may be related to the phases of the cycle of violence. Compare the two, and ask clients to identify experiences where an event in one cycle triggered an event in the other cycle for them. Stress to clients that violence-free life and sobriety are linked in a number of ways:

• In the Twelve Steps of Alcoholics/Narcotics/Cocaine Anonymous, inventory steps require admitting "to God, to ourselves and to another human being the exact nature of our wrongs." The "amend" steps require making a "list of persons we have harmed," and becoming "ready to make direct amends to them all." Accountability and responsibility can be framed in terms of these concepts.
• The A-B-C cognitive-behavioral approach of Rational Recovery and Rational Emotive Therapy asks clients to identify a relationship between their thoughts, feelings, and behaviors. Belief systems which exaggerate male privilege and demean women can be challenged in this context.
• Most religious traditions embrace some version of the Golden Rule: "Do unto others as you would have others do unto you." Stress the link between personal spirituality and relationships in ways which support equality and mutuality. Contrast concepts such as serenity and centeredness with violence, abuse, and chaotic family life. Relate surrender to giving up control of others' lives.
• Use tools such as the Cycle of Violence illustration and the Power and Control Wheel as concepts in treatment and relapse prevention.
• Explore the correlation between domestic abuse, substance abuse and the need for personal power.
• Explore what role the use of substances has as a mood regulator.

Confidentiality and Other Legal Issues

Federal laws governing the confidentiality of client records and client-identifying information apply to alcohol and drug abuse treatment providers (see 42 CFR Part 2, and the similar Illinois rule in 77 111. Adm. Code 2060.319).

Under these laws and the regulations implementing them, no client-identifying information can be disclosed without the client's written consent in a specific form. Exceptions are:

• Mandated reports of child abuse.
• Emergency medical care.
• Orders of a court of competent jurisdiction following a hearing in camera (in the judge's chambers) at which good cause has been established (and at which the client and the agency should be represented).
• Suicidal and homicidal threats.

See the relevant portion of the federal and state rule for specific language regarding the exceptions.

Potential problem areas include:

• Caller ID and Star 69. If your agency cannot place a total block on these services, you should block each call with *(Star) 67. If this is not possible, anonymous calls will have to be placed from phones which cannot be traced to the agency.
• Safety checks with partners. Agencies must carefully limit the amount of information they convey, even with consent, to that which is necessary to assure partner safety.
• Tarasoff situation (e.g., where consent has been revoked by a client who leaves an intervention group prior to completion). Safety checks to partners must, again, be as limited as possible while assuring the goal of partner safety. If consent has been effectively revoked, contact must be made anonymously or only in the name of the victim-service program. ("We have information which leads us to believe that you may be in danger from your partner.")
• Contracted providers of batterers' services. Using their own agency's identity rather than the substance abuse treatment provider's identity may avoid the problems specific to the substance abuse-related federal confidentiality regulations.
• Programs in hospitals or other institutions which are not primarily alcohol and drug abuse treatment providers. Using the name of the larger institution rather than the specific name of the substance abuse treatment program is also an option for exercising duty to warn.

Reverse Confidentiality

Full disclosure and discussion of treatment planning and ancillary services is the rule in substance abuse programs and reflects the need for transparency and genuineness in the therapeutic relationship. However, as a component of safety checks, programs may obtain reports from partners of men in treatment who are also receiving intervention services, and this information must remain confidential if the partner requests confidentiality. Substance abuse providers need to be scrupulous about informing clients who are receiving bafterers' intervention services of the fact that such reports will be accepted and will be kept in confidence if the victim requests it.