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What Do Professionals Need to Know?

Substance Abuse Treatment System
Model Domestic Violence Policy for Counties


Despite the significant correlation between domestic violence and chemical dependency, very little research has been conducted and even less has been done to assist victims with chemical dependency problems to meet their dual need for both safety and sobriety. Similarly, little has been done to develop intervention strategies that address both the domestic violence and substance abuse problems of chemically dependent men who batter, and even less to address the needs of battered gay men and lesbians in alcohol/other drug treatment programs. As a result, workers in both systems are often ill-equipped to provide the range of services needed by battered women, lesbians and gay men, and abusers who are affected by chemical dependency.

 

For women, revictimization is predictive of relapse. Many victims begin or increase their use of alcohol/other drugs in response to the violence, as a way to medicate the physical and emotional effects of victimization. In fact, many chemically dependent victims are addicted to sedatives, tranquilizers, stimulants, and hypnotics, drugs that were prescribed by health care providers from whom they sought help. Elder victims may be at particularly high risk for prescription drug and alcohol interaction. About 2.5 million older persons (65-plus) have alcohol-related problems(24) and older people account for approximately 25% of all prescriptions filled, although they comprise only 12% of the total U.S. population.(25) In addition, many victims' use of substances is coerced by their partners as a mechanism of control. As a result, victims' recovery efforts are often directly sabotaged by their partners. Effectively addressing the safety needs of chemically dependent victims is an essential part of a successful recovery strategy.

 

Alcohol and other drug use and addiction do not cause men to perpetrate abuse in their intimate relationships,(26) and substance abuse treatment alone is unlikely to stop the violence. Victims with drug-dependent partners consistently report that during their partner's recovery the abuse not only continues, but often escalates, creating greater levels of danger than existed prior to their partners' abstinence. In the cases in which victims report that the level of physical abuse decreases, they often report a corresponding increase in other forms of coercive control and abuse-the threats, manipulation, and isolation intensify.(27)

 

Abusers who are also alcohol or other drug-involved need to address the alcohol/other drug problem separate from, and in addition to, being subject to appropriate criminal or civil justice sanctions for their abusive behavior. Not only is this a critical strategy to enhance victim safety, but abusers' continued use of coercive and violent acts against their partners is often a precipitant to relapse. Addictions self-help groups and substance abuse treatment programs were not designed to address battering and are not equipped to enforce abuser accountability, a role more appropriate to the criminal and civil justice systems.

 

In addition to incorporating the recommendations outlined in the Guiding Principles and the Employers sections into their responses to domestic violence, and being mindful of the potential need for individualized responses based on factors such as socio-economic status, race, ethnicity, sexual orientation, age, religious affiliation, physical and mental disabilities, immigrant status, education, employment status, urban vs. rural residency, and marital status, substance abuse treatment providers should also integrate the following recommendations specific to the alcohol/other drug treatment system. These recommendations are designed to promote responses that enhance victim safety, reinforce abuser accountability, and support recovery from chemical dependency.


  1. VICTIM SAFETY AND SELF-DETERMINATION

    1. Private, routine screening for domestic violence should be conducted with all female clients to determine if they are being abused by their intimate partners. Failure to identify domestic violence as a problem in the lives of chemically dependent women can compromise the effectiveness of substance abuse recovery strategies. Abusers often are resistant to their partners' attempts to seek help of any kind and may, therefore, sabotage the recovery process by preventing victims from attending meetings or keeping appointments, or they may increase their use of violence or threats in order to reestablish control. Many chemically dependent victims leave substance abuse treatment in response to the increased danger or are otherwise unable to comply with treatment demands because of the obstacles constructed by their partners. Even if a victim is able to complete a substance abuse treatment program, being revictimized is predictive of relapse.

    2. When domestic violence is identified, substance abuse treatment providers should collaborate with the victim in evaluating the impact of substance abuse treatment strategies on her safety, develop treatment plans that give priority to safety-related needs, and pro-actively assist victims in developing short and long-term safety plans. If a victim desires, arrangements should be made for her to meet with a local domestic violence service provider on or off-site.

      The ability of victims to follow through on chemical dependency treatment plans can be compromised by the actions of their abusive partners. Victims should not be expected to comply with treatment plans that require them to do things that directly or indirectly endanger them.

      Substance abuse treatment providers should integrate safety planning into a chemically dependent victim's treatment plan in order to reduce the risk of further harm from her abusive partner and to increase the chances of a successful treatment outcome. Providers should coordinate safety planning efforts with a domestic violence service provider, if a victim so desires. (See Guiding Principles, 1.d. re: safety planning.)

      This need for individualized substance abuse treatment planning that integrates the safety-related concerns of victims becomes even more critical when participation in the alcohol/other drug treatment program is court-mandated, for example, as a result of a DWI arrest. The absence of safety-related strategies in treatment planning increases the risk of danger to victims, interferes with their ability to comply with the plan, increases the risk of relapse, and may result in a report to the court of "non-compliance." Integrating the safety-related needs of a victim into her substance abuse treatment plan increases the likelihood of her ability to successfully comply with the plan, and to therefore fulfill the mandates of the court.



    3. Substance abuse treatment providers should recognize that, at times, the legitimate survival and safety strategies employed by victims (such as resistance, non-compliance, and dishonesty) may conflict with recovery strategies. Recovery strategies and activities should be continually reviewed and modified, as necessary, to reflect a victim's ongoing safety-related needs.

      The safety-related concerns of victims do not necessarily remain constant. As a result, victims may attempt to protect themselves from the violent and coercive acts of their partners in ways that conflict with agreed upon recovery strategies. A victim's use of survival strategies related to safety should be supported and encouraged and not seen as a failure to comply with substance abuse treatment, but as an indication that the treatment plan needs to be reviewed and modified.



    4. Substance abuse treatment providers should cultivate cooperative relationships with domestic violence service providers, provide victims with accurate information about available domestic violence residential and nonresidential services, and should actively assist victims in making the linkage with those services, if they so desire.

      In residential substance abuse treatment settings, patients should be allowed to meet with a domestic violence service provider for individual counseling or support, if so desired, in order to get the information they need to adequately plan for their safety. Accommodations should also be made to allow victims to leave the substance abuse treatment program in the company of a domestic violence service provider in order to attend a battered women's support group.



    5. When a victim is a mother and cannot or does not take the children to an in-patient substance abuse treatment program with her, the treatment provider should permit her to contact the caretakers and the children regularly to assess their well-being and to advise the children of her safety.

      Although in-patient substance abuse treatment programs often have "no contact" rules during the first week of treatment, if a victim is a mother, the rule should be waived to allow regular communication between the victim and her children while she is in treatment. In addition to alleviating concerns that children might have about their mother, allowing contact is important to protect victims from charges of "abandonment" or "neglect" in custody cases.



    6. If a victim in an in-patient substance abuse treatment program 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, accommodations should be made by the substance abuse treatment provider to allow her to meet with legal counsel, a court advocate, and/or a district attorney, and to appear at all court hearings.

    7. Because client records may be subpoenaed by the courts, particularly in custody cases, substance abuse treatment providers should ensure that client records are accurate, objective, and maintained in keeping with professional standards.

      Information obtained from the patient, as well as any pertinent observations, should be carefully and fully entered into the client record. Any future or pending legal proceedings might very well draw on the information recorded in the case record. The failure to document the abuse may be used by the abuser to deny its existence, or the provider may be held liable for failing to recognize the abuse and respond to the patient's complaints.

      While thorough and accurate case recording is necessary, be alert to the potential harmful uses of the information in the case record, such as an abuser using a partner's alcohol/other drug problem as evidence of the victim's unfitness as a custodial parent.



    8. In the event that an abuser and a victim of domestic violence are seeking treatment at the same substance abuse treatment site, and the victim has independent knowledge of her partner's participation in treatment and raises it with the treatment provider as a safety-related concern, full consideration should be given to transferring one or the other client to another treatment program or site, in consultation with the victim.

      Client transfers in these circumstances may or may not be in a victim's best interests. Providers should confer with the victim to determine the safest course of action and take the steps necessary to respond to her safety-related needs. For example, a victim may desire that her partner be transferred to another site, but doesn't want him informed that she is participating in substance abuse treatment or that she has made such a request. In such cases where staff are unable to divulge the reason for the transfer, it may or may not be feasible for the substance abuse treatment provider to effect a transfer. In some cases, it may be a victim's judgment that a transfer of either party may in fact increase her danger. When a transfer is neither a desired nor viable option, the substance abuse treatment provider should investigate the feasibility of alternative measures to increase safety for the victim, such as limiting the abuser's access to the victim by scheduling appointments for each party at different times, alerting security staff of the situation, arranging for security escorts when appropriate, etc.

      Substance abuse treatment providers should conduct initial, individual screenings for domestic violence before making referrals to or engaging couples or families in couples or family counseling, or mediation; and should conduct ongoing screening and assessment for domestic violence with couples or families who are engaged in these services.

    9. Providers should be prepared to share information with a victim about the risks and limitations of utilizing services that require joint participation with her partner (see Guiding Principles, 1.i.). Providers should be aware that abusers often actively engage in efforts to sabotage their partners' recovery and, even more seriously, may jeopardize the physical safety of their partners. Further, providing an abuser with the opportunity to participate in "interventions" or sessions designed to give feedback to the victim on how her addiction negatively affected him or the family simply gives an abuser one more opportunity to blame the victim and rationalize his own conduct.

      Consequently, an abuser should not be invited to participate in the victim's substance abuse treatment plan. Instead, victims should be allowed to identify other significant persons in their lives who may be in better positions to help and support their recovery efforts. Similarly, victims should not be asked to participate in their partners' substance abuse treatment plans, but should be offered safety-related services and/or referrals.

      In cases in which the domestic violence is not identified in an initial screening, but is recognized or exposed later in the intervention process, providers should develop strategies for terminating the family or conjoint sessions without further endangering victims.


    10. With the consent of the victim, substance abuse treatment providers should inform all staff when a client has an order of protection and should keep a copy of the order of protection in a confidential on-site location.

      It is helpful for staff of the substance abuse treatment program to be informed and/or have access to information regarding program clients who have orders of protection so that they will be prepared to take appropriate action regarding enforcement of the orders, if necessary. With a victim's consent, this information should be made available to all staff even if they do not have direct program responsibility for a particular client.


    11. Victims of domestic violence should be provided with a safe (gender and culturally affirmative) environment to discuss their safety-related concerns, such as in women-only groups with female leaders, and should be offered female clinicians if so desired.

      While most victims of domestic violence are likely to be more concerned about the nature of the clinician's response to their victimization, rather than to the gender or specific cultural, religious, or ethnic background of the clinician, clinicians should be sensitive to the particular needs and desires of individual clients, and when appropriate and possible, should offer clients the opportunity to work with a female clinician or a clinician from the same cultural background.


    12. When victims of domestic violence are not themselves involved with substances, but request or receive substance abuse treatment as family members of alcohol/other drug abusers, they should be referred to domestic violence services regarding their safety-related needs, and should be informed of the potential limitations of 12-step groups or co-dependency treatment to effectively address their safety-related concerns.

      Many of the behaviors that are associated with co-dependency-enabling, caretaking, over-responsibility for a partner's behavior, not setting limits or defining personal boundaries-are often, for victims, the life-saving skills necessary to protect themselves and their children from further harm. When victims are encouraged to stop these behaviors through self-focusing and detachment, they are, in essence, being asked to stop doing the very things that may be keeping them and their children most safe.

      Because resources such as 12-step groups or co-dependency groups were not designed to meet the needs of victims of domestic violence, there is no assurance of accuracy in the information victims might get about domestic violence in 12-step groups. In fact, the kinds of behavior changes encouraged in such forums may well result in an escalation of abuse, including physical violence.

      Victims need accurate and complete information about the purposes of 12-step groups and co-dependency groups and the potential limitations of these forums as sources of help regarding safety-related concerns. While participation in 12-step groups may provide victims with useful information about addiction and may serve as a potential support network, victims should be given referrals to a local domestic violence service provider who is trained to assist them in addressing their safety-related needs.


  2. ABUSER ACCOUNTABILITY

    1. Routine screening for domestic violence should be conducted with all male clients to determine if they are perpetrating abuse in their intimate relationships.

      It is helpful for substance abuse treatment professionals to know if their male clients are perpetrators of domestic violence in order to effectively assist chemically dependent abusers in successful substance abuse recovery strategies and to take appropriate and allowable measures to protect the safety interests of victims.


    2. Substance abuse treatment providers should reinforce abusers' sole responsibility for their violent and coercive behavior as the issue emerges in any forum, including individual and group sessions.

      Domestic violence is behavior over which abusers have control and should never be justified, excused, or minimized. Abusers will often use alcohol and other drugs as the excuse or explanation for their violent and controlling behavior. Research, however, consistently indicates that alcohol/other drugs are neither a necessary context for domestic violence, nor is their use a sufficient explanation for the violence.


    3. If a court orders an abuser into substance abuse treatment as a response to the individual's violent and controlling behavior in an intimate relationship, the substance abuse treatment provider should respectfully refer the case back to the court with a recommendation for the imposition of appropriate criminal or civil justice sanctions.

      Perpetration of violence and coercion in an intimate relationship is not a result of chemical dependency. Substance abuse treatment providers can best support the goal of abuser accountability by refusing to accept cases in which abusers are court-ordered into substance abuse treatment as a response to their violent and controlling behavior.

      If a provider has conducted an assessment on such a client and determines that the client is indeed chemically dependent, such information can be provided back to the court. The provider should be clear, however, that chemical dependency treatment is not an appropriate response to the violence, even though it is a concurrent problem for the abuser.

      The appropriate response of the courts in dealing with abusers is to impose sentences of incarceration, probation, restitution, or fine, or some combination of these. Where available, mandated participation in a Batterers Intervention Program may be part of a coordinated sentence. Abusers should neither be referred to nor mandated to dispute mediation, mental health services, or substance abuse treatment as a response to the domestic violence. Providers in all of these systems should be referring the cases back to the court for appropriate adjudication.

    4. When a client is mandated into substance abuse treatment in response to a non-domestic violence-related offense, and subsequently identified as an abuser who is not on probation or parole for a domestic violence-related offense and/or does not have a current order of protection issued against him, substance abuse treatment providers should alert the court, parole or probation officer that domestic violence has been identified as a potential relapse issue and request that the court, parole or probation officer, when within their appropriate authority, impose sanctions related to the domestic violence.

      An abuser's success in substance abuse recovery may be related, at least in part, to his decision to stop his violent and coercive patterns of behavior in his intimate relationship. For example, some abusers rely so heavily on the availability of their alcohol/other drug use as the excuse for their coercion and violence that their success at maintaining abstinence from substances may be compromised by their continued use of violence and coercion in their intimate partnerships. Interventions designed to reinforce abusers' accountability for their violence may therefore be helpful to the success of an abuser in a substance abuse recovery program.

      Accountability for domestic violence is possible only when there is an ability to impose swift, consistent, and meaningful sanctions for the abusive behavior, a role that rests primarily, if not exclusively, with the criminal and civil justice systems. When a substance abuse treatment provider has an opportunity (without violating confidentiality) to inform the appropriate criminal or civil justice authority that a mandated client is a perpetrator of domestic violence and to make a concurrent recommendation that such authority make appropriate mandated referrals and/or set relevant conditions of supervision, the provider should do so.


    5. In the case of a victim's partner coming on-site, substance abuse treatment providers should activate appropriate in-house security measures. If the abuser refuses to leave, and/or engages in acts that threaten the safety of staff or clients, and/or that violate an existing order of protection, the police should be called. Substance abuse treatment providers should consider the input of the victim in developing a response plan but also maintain a responsibility to respond quickly to the safety-related needs of staff and other clients.

    6. Substance abuse treatment providers who have a legal duty to warn, should take appropriate steps to protect the intended victim when they have direct knowledge of a client's intent to do harm to that intended victim.

      Abusers' threats should be taken very seriously and responded to swiftly and consistently. When there is firsthand knowledge of an abuser's threat to do harm, the victim and the police should be notified immediately, and the victim should be provided the local domestic violence service program hotline number and offered assistance with safety planning.


  3. SYSTEMS' RESPONSIBILITY

    1. Training on the relationship between domestic violence and alcohol/other drug use and addiction should be required for all substance abuse counselors, supervisors, and clinical directors.

      All substance abuse providers should be trained on the issue of domestic violence. The training should include an understanding of the dynamics of domestic violence, assessment tools, appropriate interview and intervention skills, and an adequate understanding of domestic violence resources, as outlined in the Guiding Principles, 3.a. In addition, substance abuse treatment providers should receive training on the relationship between domestic violence and the development of alcohol/other drug problems in women, the use of alcohol/other drug use as an excuse for abusers' coercive and violent behavior, the ways in which abusers use alcohol/other drug use as a mechanism of control, and strategies for intervention that promote victim safety, abuser accountability, and recovery from addictions. Training should be thorough and ongoing.

    2. With the appropriate releases of information, substance abuse treatment providers should coordinate case management for chemically addicted men who batter with probation, parole, law enforcement, the courts, and Batterers Intervention Programs, as appropriate. Coordinated efforts are of particular importance to effectively reinforce abuser accountability. If a substance abuse treatment program has responsibility for a component of a domestic violence offender's sentence and becomes aware of a violation of any term of the sentence, or any new domestic violence offense, the substance abuse treatment provider should report the violation to the sentencing court or Probation Department.

    3. With the appropriate releases of information, case management for chemically addicted victims should be coordinated, as appropriate, with domestic violence service programs, and the health care, mental health, child welfare, and legal systems.

      Case management and coordination is key to the success of victims in developing and implementing effective safety plans. It is essential that involved systems work together to ensure that substance abuse treatment and intervention goals support victims' attempts to be safe.


    4. Accurate information on domestic violence should be included in alcohol/ other drug education and prevention efforts.

      The community, including its young people, needs to know that alcohol/other drug use does not cause domestic violence, and will therefore not be accepted as an excuse for such behavior. Accountability for violence needs to be reinforced at every opportunity.

(24) Select Committee on Aging, House of Representatives. Alcohol Abuse and Misuse Among the Elderly. Washington, CD: Government Printing Office, 1992.

(25) Abrams, R., and Alexsopoulues, G. Substance Abuse in The Elderly: Alcohol and Prescription Drugs. Hospital and Community Psychiatry (38) 12, 1286, 1987.

(26) American Medical Association, Report of the Council on Scientific Affairs: Alcohol, Drugs and Family Violence, A-93, 1993.

(27) Minnesota Coalition for Battered Women, Safety First: Battered Women Surviving Violence When Alcohol and Drugs Are Involved, 1992.