Common Perspectives

A significant number of women and children seen in domestic violence agencies suffer from substance abuse problems. A study of Illinois shelters reveals that as many as 42 percent of their clients abuse alcohol or other drugs (Bennett & Lawson, 1994). There are a number of reasons for this:

• Victims may begin or increase their use of alcohol/other drugs in response to domestic violence. Alcohol/other drugs may be used to medicate the physical and emotional pain of domestic violence or to cope with the fears of being battered.

 
• Alcohol/other drug use may be encouraged or even forced by the partner as a mechanism of control. Efforts at abstinence may be sabotaged.

 
• Factors related to victimization are low self-esteem, guilt, shame, powerlessness, depression, sexual dysfunction, and relationship dysfunction. All of these provide a foundation for the development of substance abuse.

 

• Acute and chronic effects of alcohol/other drug use may prevent the victim from assessing the level of danger posed by the batterer.

 
• Under the influence, victims may feel a sense of increased power. Victims may erroneously believe in their ability to defend themselves against physical assaults, or their power to change the batterer.

 
• The abuse of alcohol/other drugs impairs judgement and thought processes so that victims may have difficulty with adequate safety planning. Alcohol/other drug use makes it more difficult for victims to leave violent relationships.

 
• Victims may be reluctant to contact police in violent situations for fear of their own arrest or referral to the Department of Children and Family Services.

• Use of alcohol/other drugs may increase involvement in other illegal activities.

 

• Victims may be denied access to shelters or other services due to substance abuse.

Response to Substance Abuse
 

Because there is a significant correlation between victimization and substance abuse, all domestic violence service providers need to address the issue of substance abuse. A formal screening for substance abuse should be included in the intake process. If victims are to remain free of violence, they should understand the impact substance abuse has on their safety.
 

Substance Abuse Screening

A substance abuse screening is an opportunity to begin discussing how substance abuse impacts safety. 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 insure that it occurs in private. Children should not be present because they may repeat what they hear.

 
• Communicate respect and trust. It is important to establish a respectful and trusting relationship. Assure victims that, except for safety concerns, anything discussed will be held in strictest confidence and will not jeopardize their ability to receive appropriate services.

 
• Observe behavior. Look for signs of alcohol or drug use.

 
• Ask questions. There are several recognized screening tools for alcohol or drug use included in the Appendix.

• Deal with denial. Denial is the most frequent response to questions about alcohol/other drug use. This is especially true for women not only because they are ashamed of their behavior, but also because they fear losing their children. When talking with a victim about alcohol/other drug use, ask open-ended questions. A victim may also find it easier to talk about their partner's use rather than their own. If this is the case, follow up with questions about the victim's use.

What should come first: domestic violence counseling or substance abuse treatment? It is not a question of either safety or sobriety first, but rather safety and sobriety, since one is less likely without the other. The presence or threat of abuse often interferes with a victim's ability to achieve abstinence. Continued use of substances interferes with safety. If screening leads you to suspect that a person has an alcohol or drug problem, refer or arrange for an on-site assessment.

Linking persons to substance abuse programs requires the domestic violence staff to:

• Be informed about treatment options/providers available in their community.

 
• Do cross-training with substance abuse programs to increase the awareness of both issues.

 
• Continue open dialogue and collaboration between agencies.

 
• Be willing to provide service options for victims who are substance dependent, whether they are in treatment or not.

 

Referral

• When referring an individual to a treatment provider for an assessment, the first concern should be safety. Will an assessment interview place the client or children at risk for further harm? What strategies can be employed to ensure safety?

 
• What assurance does the person need to follow through with the referral? Victims who have suffered from physical and/or sexual abuse and intimidation may be traumatized by the prospect of talking with a stranger about their use of illegal drugs or fear a drug test. What concerns does the person have about substance abuse treatment and how can they be addressed?

 
• What information does the person need to follow through with the referral? If the individual is referred to an off-site location, be sure the person understands where to go, who they will see, and how to get there.

 
• Another concern is what support the individual needs to keep the appointment. Is transportation or child care needed? Are there other barriers? The referral process necessitates developing a good working relationship with a treatment agency to jointly address the individual's needs.

• Victims of domestic violence should not be referred to programs that require conjoint counseling as part of substance abuse treatment.

 
• Many treatment providers do outreach; that is, they will attempt to visit the person at their home to engage them in treatment. If outreach will place the person or treatment provider staff at risk, it is important to convey that information to the provider.

When a person is referred to a substance abuse treatment provider, a counselor will use assessment techniques to characterize the problem and to develop a treatment plan. The Illinois Alcohol and Other Drug Abuse Professional Certification Association (IAODAPCA) evaluates counselor competency and grants recognition to those counselors who meet specified minimum standards. All 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.

Assessment involves five important tasks:

• Aid in diagnosis of the problem.
• Establish the severity of the problem.
• Develop a treatment plan.
• Define a baseline which can be used to evaluate an individual's progress in treatment.
• Increase the individual's motivation to attend treatment.

In some settings, urine tests may be required. For domestic violence victims who have been sexually abused, the prospect of a urine drug test may be especially threatening. Drug tests are most commonly done to monitor treatment compliance rather than as part of the assessment.

Treatment

While abstinence may be a long-term goal for addiction programs, the immediate goals are to reduce use, improve the person's ability to function and minimize the effects of abuse on health and social functioning. Matching the person with the appropriate level of care ensures that the person receives the type of treatment corresponding to the person's use and their current level of functioning. Licensed treatment agencies in Illinois use ASAM (American Society of Addiction

Medicine) criteria to determine which treatment options and level of intensity are appropriate. In developing a treatment plan, the counselor evaluates:

• •The person's level of intoxication, withdrawal potential and need for medication.
• •The person's physical health.
• •The person's emotional health and functioning.
• •The person's acceptance or resistance to treatment.
• •The potential for relapse and the recovery environment. 

 

• •Outpatient services (Level I).
• •Intensive outpatient services, a structured program offered a minimum of 9 hours per week (Level II).
• •Residential detoxification services (Level III.2).
• •Residential rehabilitation (Level III.5).
• •After-care programs.
• •Referral to support groups such as Women for Sobriety, Alcoholics Anonymous, or Narcotics Anonymous.

 

Unique confidentiality laws apply to almost all substance abuse treatment programs. The law prohibits the disclosure of any information that would identify a person as having been referred for, or having received treatment 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 it is 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.

 

Supporting Sobriety

Domestic violence agencies can support victims struggling with the issues of substance abuse in the following ways:

• •Assist staff in dealing with their own beliefs, feelings, and prejudices about substance abuse. Provide ongoing training to enable staff to recognize the characteristics of substance abuse and to make appropriate referrals.

 
• •Minimize blame and moral reprobation for use or relapse, which may further disempower the victim and empower the batterer.

 
• •Inform/advise the victim and treatment provider of the risks of conjoint couples counseling sessions.

 
• •While providing advocacy-based counseling for substance-abusing victims, help them recognize the role substance abuse plays. It can keep them tied to the abusive relationship, increase their risk of harm and impair their safety planning ability.

 
• •Assist victims by helping them find an alternate means of empowerment as replacement for the sense of power induced by substances.

 
• •Include plans for continued sobriety as part of the safety plan. Help the victim understand the ways the batterer may attempt to undermine sobriety before the victim exits the shelter or completes advocacy-based services.

 
• •Encourage and facilitate linkage with substance abuse treatment resources and abstinence-based support groups.

 
• •Remain cognizant of which local substance abuse programs and support groups provide the highest degree of physical and psychological safety for victims.