Each year, more than 500,000
non-fatal violent crimes are committed against women.1 These crimes
range from sexual assault and rape to intimate partner violence and elder
abuse. That's only a partial picture of the problem because the statistics only
reflect those crimes that are reported. Domestic violence, for example, is so
widespread that nearly one-third of all Americans know a woman who has suffered
violence from her partners.2
Many of these crimes involve
the use of alcohol or other drugs. Although some people believe that alcohol causes violence against
women, the links between the two aren't quite that simple. Just because a man
drinks doesn't mean he will commit a violent act. Conversely, not all men who
batter women also abuse alcohol. This module will examine the relationship
between alcohol and violence against women, how alcohol can increase the
chances of violence against women and how victims and perpetrators may use it
to cope with the effects of violence.
What is the relationship
between alcohol abuse and violence against women?
between the causes of a problem and "risk factors." Alcohol is not a
cause of violence but it is a risk factor for both the perpetrator and the
victim of the violence. For comparison's sake, consider the example of drinking
and driving. If a person drinks enough alcohol so his blood alcohol level is
over the legal limit, and he gets in an accident driving home from the bar,
alcohol would likely be established as a cause of the accident. The analogy is
not the same for alcohol abuse and violence. So what's the connection?
Simply stated, the presence
of alcohol - by the perpetrator or the victim - increases the chance of
violence occurring, how often it occurs and how severe it is. For example, if a
man with a short temper abuses alcohol, he may be more likely to direct his
anger at his partner when he is intoxicated. He may also go greater harm when
he has been drinking.
The use of alcohol by the
perpetrator can lead to violence, sometimes because his inhibitions and impulse
control are lessened. Women who use alcohol can also act in abusive ways, due
to similar reasons. Often a woman will use alcohol to numb her pain. When a
woman uses alcohol, however, she also puts herself at greater risk for becoming
Part of the problem with
addressing alcohol-related violence against women in the U.S. stems from
our difficulty in dealing with alcohol and drugs in society. Attempts to
prohibit alcohol use have failed, and alcohol use has become common in American
society. Unfortunately, alcohol consumption is often used to excuse harmful
behavior. For some people, getting intoxicated and abusing one's spouse is a
regular occurrence. Alcohol use is also often used as an excuse. Adding alcohol
or drug use to an already volatile situation can lead someone who is prone to
violence to commit a violent act. Impulse control can be inhibited. In some cases,
individuals may be at risk for alcohol or drug abuse and violence due to a
combination of risk factors. Difficulty coping with life or in controlling
negative feelings can contribute to both substance abuse and violence. Alcohol
may be used to:3
Experience feelings of relaxation or euphoria,
Fight or mask stress or depression,
Expand the mind by altering the perception of reality,
Numb feelings of guilt, shame, or loneliness, or
Fit in with a social crowd in order to be socially
Similarly, violence may make
a person feel better by allowing him or her to:
Release feelings of stress,
Vent anger or frustration,
Avoid painful issues,
Shift blame, or
Feel more in control.
Part II: Understanding Violence
Women of all ages can be
victims of violence. Violence against women involves the threat of force or the
actual use of force that results in or may result in injury or death, and
includes physical, sexual, emotional, psychological, and financial assault.
Perpetrators include partners, intimates, family members, and acquaintances.1
Terms used to define violence
against women include:
Intimate partner violence
Teen dating violence
Matricide (killing one's mother)
Although specific abusive
acts can occur between any two people regardless of gender, those acts do not
always have the same impact or meaning. In heterosexual relationships, the male
perpetrator tends to have more power and control in the relationship and is
usually physically stronger.2 For the purpose of this tutorial, abusers are considered
male and victims
Regardless of the type,
violent behavior is generally learned. In some cases, violence may result from
a chemical imbalance, biological disorder, or mental illness. However, absent a
physical cause, much of violent behavior is learned.
The term "violence
against women" is a broad category for offenses that include domestic
violence (or intimate partner violence), sexual assault, and rape. Health and
mental health care professionals need a clear understanding of these differences
- and their legal ramifications in their home State - in order to provide the
best support for clients.
Women are the victims of more than 2 million violent
crimes each year.13
Women of every race, nationality, and income level
experience intimate partner violence.
If every woman victimized by domestic violence last
year were to join hands in a line, that line would extend from New York to Los Angeles and back
Sixty-five percent of all reported incidents of
violence against women were from physical assault and battery.15
Nearly 30 percent of all female homicide victims are
killed by their husbands, ex-husbands, boyfriends, or partners. In
contrast, 3 percent of male homicide victims are killed by their wives,
ex-wives, or girlfriends.16
Approximately one in five female high school
students reports being physically or sexually abused by a dating partner.17
Women are six times more likely than men to be
victims of rape or sexual assault.18
Women aged 16 to 34 years experienced the highest
rates of intimate violence (dating violence), with the most frequent
occurrences between the ages of 20 and 24 years.19
Older women make up from 60 to 76 percent of those
subjected to all forms of abuse and neglect.20
In large part because of the victims' sense of shame
and fear, only 10 to 20 percent of rapes are reported.
Each year, more than 1.5
million women seek medical treatment for injuries related to abuse.21
In fact, more women are treated in emergency rooms for injuries related to
intimate partner violence than for nonmarital rapes,
muggings, and traffic accidents combined.22 Many nurses and doctors
are in an ideal position to detect abuse.
Although many battered women
seek emergency services, an even greater number see their primary doctor or OB/GYN. Twenty to 25 percent of obstetrical patients have
a history of battering. In primary care, the numbers range from 28 to 38
percent.23 Professionals should suspect the possibility of assault
or abuse when the explanation for how an injury occurred does not seem
plausible, or when there has been a delay in seeking medical help.
of Obstetrics and Gynecology (ACOG) has recommended routine screening of all
women for domestic violence. Nationally, however, doctors are inconsistent in
how often they screen and whom they screen. One study from California found that 79 percent of primary
care physicians reported they routinely screen injured patients for abuse, but
only 10 percent reported routinely screening clients at new patient visits, and
9 percent reported regularly screening them during periodic check-ups. Only 11
percent reported doing so at regular prenatal care visits.24
Lenore Walker, a pioneer in
the domestic violence field, stated in her book The Battered Woman that the injuries for
women treated in emergency rooms fall into four categories:25
Serious bleeding injuries. These include wounds that
require stitches, especially around the face or head.
Internal injuries. More specifically, these
injuries include damage or malfunctioning organs. Many women will have
damage to their kidneys, spleens, or lungs, which are punctured.
Damage to bones. The most common broken bones
are the arms, legs, and jaw. But many women also present with fractures to
their vertebrae, skull, and pelvis.
Burns. Abused women suffer from
cigarette burns to all parts of their body, but such burns are usually
seen on the abdomen and other parts not exposed on a daily basis. Burns
are also caused by hot appliances, including stoves and irons, acids, and
The clustering of violent
acts during an assault often results in multiple injury sites. Typically, these
injuries are to the face and central areas of the body rather than the
extremities.26 Abused women are 13 times more likely than other
accident victims to have injuries to their breasts, chest, and abdomen.27
The frequency with which a
woman presents to the doctor or emergency room should also raise some concerns.
A woman who comes to the emergency room at least three times with injuries has
an 80 percent chance of being a battered woman, whether or not the injuries
Injuries Needing Medical
The following common types of
injury may also indicate abuse:
Contusions, abrasions, and minor lacerations, as
well as fractures or sprains
Injuries to the neck, abdomen, breasts (especially
when pregnant), or chest
Multiple injury sites
The stress of repeatedly
living in a violent home also may cause:
Chronic pain without visible evidence
Gynecologic problems and urinary tract infections
Anxiety disorders or symptoms of depression such as:
Sleep and appetite disturbances
Abdominal and gastrointestinal
Paresthesias (unexplained numbness or
Dyspnea (difficulty breathing)
A typical chest pain
Frequent use of prescribed minor
tranquilizers or pain medications30
Although hospitals are often
the first to see abused women, studies have found that many emergency room
staff do not check for abuse or follow guidelines for referral or social
service consultation. In fact, in one study, one in four women seeking
emergency medical services were identified as having been
battered-approximately nine times the number identified by emergency service
Battered women are referred
to psychiatric staff five times more frequently than nonbattered
victims. The battered women often complain of frequent headaches, stomach
disorders, intercourse discomfort, and muscle pains, but their x-rays and lab
tests do not reveal anything. Therefore, many of the woman are labeled
"neurotic, "hypochondriac, or "a well-known patient with
multiple vague complaints." At the conclusion of a psychiatric assessment,
just one in 50 nonbattered women (2 percent) is
assigned one of these labels, compared with one in four battered women (25
Multiple emergency room
visits lead to ongoing questions focused primarily on obtaining diagnostic
information. Social problems or concerns of the woman often get interrupted or
cut off, since they do not seem relevant to diagnostic reasoning. So, the woman
is left feeling helpless, isolated, unheard, and frustrated-feelings similar to
those she experiences at home with the abusive partner. Eventually, a set of
complex problems are recognized and diagnosed as alcohol abuse, drug abuse,
depression, or a variety of other mental illnesses.33
To improve health care
response to domestic violence, the Agency for Healthcare Research and Quality
(AHRQ) developed an assessment tool hospitals can use to evaluate their
domestic violence programs.
of Alcohol Abuse and Violence on Children
Alcohol abuse, when coupled
with violence, doubles the need for denial and creates an even greater sense of
hopelessness for family members.34 Unfortunately, children at very
young ages who witness the violence and drinking suffer the repercussions. In
addition, they may be at risk of being abused.
In one survey of more than
6,000 American families, 50 percent of men who frequently assaulted their wives
also frequently abused their children.35 According to the National
Coalition against Domestic Violence, at least 3.3 million children between the
ages of 3 and 19 years are at risk of being hurt by parental violence every
Children who see violence on
television, in the movies, or in their own families or neighborhoods sometimes
try to model what they see. Millions of children each year witness or become
the victims of acts of violence against their mothers, sisters, or other female
relatives. Many come to believe that violent behavior is an acceptable way to
express anger or frustration.
Children can learn that using
physical or emotional power and control over another person can get them what
they want.36 A child often continues this pattern of abuse into
relationships in school and, when older, into dating and marriage. Children who
witness violence may allow themselves to be abused in teen and adult
relationships, believing this behavior is "normal" and to be
Children may not see the
actual violence, but they often hear the violence and see the results. From
their hiding place, they may hear their parents yelling, crying, and screaming.
They may also hear the sound of threats, physical blows, or breaking glass.
They may see the results of the abuse in torn clothing, bloody bruises on the
mother's face or body, broken furniture, or wounded animals. The children run
the risk of being injured, either intentionally by the male hurting them, or
unintentionally by trying to protect their mother.
In any case, children living
with violence can suffer lasting emotional trauma and may react with shock,
fear, and guilt.37 Witnessing violence and living with violence can
place children at risk for later alcohol problems.
What Is a
The qualities of
relationships that have been highlighted so far have not been healthy. It is
easier to recognize the unhealthy qualities in a relationship than those
qualities that are positive. If you work with any woman, you can use this
checklist to help her assess her relationships.
Is sensitive to my feelings
Respects my opinions and values
Is not overly jealous or possessive
Accepts me for who I am and does not try to change
Treats me as an equal
Is willing to discuss our problems and disagreements
Doesn't try to control my life
Does not embarrass me or put me down in front of
Is never physically rough or aggressive with me
Does not criticize how I look or dress
Listens to me and tries to understand my point of
Healthy relationships are
based on the belief that two people in a relationship are partners with equal
rights to have their needs met and equal responsibility for the success of the
partnership. Violence is not an option because it violates the rights of one
partner and jeopardizes the relationship.
Facts About Violence Against Women
Although violence against
women is drawing more attention from the media and in research, many myths
still exist. These myths can prevent women from receiving accurate, dependable
treatment and assistance. The more informed we are about violence against
women, the better able we are to help those around us with these problems. It
is important to get the myths and facts straight.
True or False?: Many women are abused in the United States.
True: Abuse of a woman occurs about every
15 seconds in the United
States. An estimated million women in America are
beaten each year by their husbands or partners.39,40
True or False?: Alcoholism and physical abuse do
not have anything in common.
False: Alcoholism and physical abuse do
share a few characteristics: (1) Both may be passed from generation to
generation, (2) both involve denying there is a problem and trying to make the
problem less important than it is, and (3) both involve isolation of the
True or False?: Violence inflicted by an
intimate partner is only a momentary loss of control. It rarely happens
more than once.
False: According to the American Medical
Association, 47 percent of men who beat their wives, girlfriends, or mothers do
so at least three times per year.43,44
True or False?: Victims of repeated violence
must have a mental illness or "are crazy" to take the abuse.
False: This mistaken idea goes back to the
belief that anyone would have to be crazy or sick to take the abuse. Most
female victims are not mentally ill, but those who are may also be abused by
their partners or intimates. There are many reasons a woman does not just leave
a violent situation, such as:
Dependence on her partner's
money or earnings
Fear, shame, guilt
Family pressure to keep the
marriage in tact
Cultural or religious reasons
Without any other place to go
Being socially isolated (abuser
keeps the woman from interacting with friends and family so that she is
emotionally dependent on him).
of violence often suffer psychological effects, such as posttraumatic stress
disorder, substance abuse, or depression.45
True or False?: Most abused women will leave
True: Most women do leave the violent
conditions, although it may take several attempts to do so. Victims who seek
and receive legal assistance at an early stage increase their chances of
obtaining the protection they need to leave their abuser. A woman may have many
reasons for waiting or she may make several attempts before leaving for good.46
Some of the reasons a victim may delay leaving include:
A sense of guilt or obligation
when the batterer expresses remorse,
Hopefulness because the batterer
is seeking treatment, or
Fear for her safety or for that
of her children.
most dangerous time for a woman is immediately after she leaves the abusive
home. Therefore, it is important for the woman to seek help in planning to
leave safely (see Safety Planning).
True or False?: Violence against women does not
happen to older or disabled women.
False: Any woman can become a victim of
A teenager or young woman (aged
12 to 24 years) may be sexually or physically assaulted or abused by a
stranger, acquaintance, romantic partner, or family member.
A woman (aged 25 to 55 years)
may be assaulted or abused by her husband or ex-husband, boyfriend,
partner, acquaintance, or stranger.
A woman who works outside the
home may be assaulted or abused by a coworker.
An older woman (55 years or
older) may be assaulted or abused by her children, husband, or
ex-husband, caregiver, or a stranger.
Older and disabled women often
are dependent on their family for support, shelter, and daily living
requirements (e.g., medicine). Abuse may be physical or it may come in the
form of neglect by the family member who is withholding assistance or
food. This type of abuse goes largely unreported.47
True or False?: Women who act or dress
provocatively ask for rape.
False: Women do not want to be raped. How a
woman dresses or acts does not give a man permission to rape her. No means no.48
True or False?: It is o.k. to force sex under
certain circumstances-they paid for the date, have had sex before, etc.
False: Paying for a date or for a gift does
not give a person the right to demand sex. Even if the woman has had sex with
the partner before, she still has the right to say no.49
True or False?: Rape is more about power and
control than sex.
True: Rape is a violent crime, brought
about by the need for power and control, not sex. Men who are misinformed about
women or sex or who can only express their feelings of weakness, pain, and rage
through sexual assault commit the most rapes.50
True or False?: Men and women are the victims of
intimate partner violence in equal numbers.
False: Women make comprise nearly 85 percent
of victims of all intimate partner violence. Twenty-two percent of all violent
acts against women were from an intimate, whereas only 3 percent of violent
acts against men were from an intimate.51
True or False?: Most of the violence against
women is actually committed by an intimate partner.
True: According to the National Institute
of Justice and the Centers for Disease Control and Prevention, 76 percent of
the women who have been raped and/or physically assaulted since age 18 were
assaulted by a current or former husband, a partner with whom they live, or a
date, compared with 18 percent of men.52
Women can be victimized and abused in many ways.
There are many physical and emotional health
problems associated with ongoing abuse.
Violence and alcohol abuse in the home affect
children in lasting ways.
There are many attainable qualities of a healthy
relationship that women should learn about.
Myths surrounding violence against women hurt many
women's chances of getting help.
Health care and mental health
care professionals have been addressing problems of alcohol abuse and violence
against women for decades (longer in the case of alcohol abuse). Only more
recently, however, have experts and researchers honed in on the importance of
looking at how the two can be linked together. By screening for alcohol abuse
in the context of domestic violence (and vice versa), professionals will be
part of the proactive process needed for prevention and treatment efforts.
Greater awareness among
professionals will not only help prevention and treatment efforts. It will also
help increase public awareness as health care professionals begin to discuss
the links between alcohol abuse and violence against women with each other and
with their patients and clients.
Characteristics of Alcohol Abuse and Domestic Violence
Alcohol abuse and domestic
violence share certain characteristics:
They both can be passed from generation to
Both involve denial and minimization of the problem.
Both may involve isolation of the perpetrator and
the victim or family.
Both revolve around power and control.1
Alcohol-abusing women and
women who have experienced domestic violence report similar experiences. Both
Isolation, shame, and guilt
Behaviors that others describe as bizarre or
Initial denial of the problem
Loss of support systems and fear of losing children
as a result of admitting their problem
Low ego strengths
A belief that the problem will just go away
Impairment of their ability to make logical
Involvement in the criminal justice system, either
as a victim or as an offender
A tendency to seek services only when in crisis
Several returns to the substance abuse or to a
relationship where battering continues before making lasting change2
Women of all ages can become
victims of physical, emotional, psychological, economic, and sexual abuse. A
woman who becomes a victim is at risk of abusing alcohol and other substances
to cope with the pain and shame. Some abusive partners force women to drink or
do drugs under the threat of further physical violence if they refuse.3
Many women are not aware that alcohol and drugs put them at risk for violence.
Destructive drinking and
violence in the home can exist before a couple gets married. Bad habits
(abusive drinking or verbal or physical abuse) are often established earlier in
life. In abusive relationships where there is also destructive drinking, the
principal issue is the need of one partner to exercise power and control over
the other.4 This need to control is also found in abusive
relationships when there is no destructive drinking.
Men who abuse their partners
at home do not often get into fights elsewhere. Abusive men need power and
control, so they focus on the person whom they see as weaker and more
vulnerable. This is usually their female partner or a child. Men abuse alcohol
in an attempt to maintain control, even though, ironically, alcohol has the
opposite effect: The man loses
control the more he drinks.
scenario illustrates this loss of control:
Jim feels stressed out (not
in control). He stops at a bar and has a few drinks with his friends. Instead
of providing the control and stability Jim wants, the alcohol impairs his
judgment and movements. When he gets home, he lashes out at his partner, which
makes him feel more out of control. Having a few drinks to calm down did not
work. This frustrating "cycle" results in Jim's feeling even worse
about himself and his situation, which increases the likelihood of further
anxiety and outbursts.
domestic violence advocates and substance abuse counselors can be hindered if
they do not realize that they share a common language.
to The Batterer
Although many men never
become violent toward their partners, some still do. Men traditionally have held
more power in the United
States and in many other countries. What is
new is the view that violence against women is not acceptable anymore. An
estimated 1.8 million men will severely assault their partner in any given
year. This includes punching, kicking, choking, and threats with or use of a
knife or gun.5
"Violence against women
will cease when men renounce the thinking and practice of dominance. We can
begin to do this on an individual basis at home, at work, and in our community.
I hope men will take the initiative and work with other men to confront sexism
and violence, not to get approval from women, but because it is the right thing
to do for women and men."
Michael Paymar, Training Coordinator, Duluth Domestic
Abuse Intervention Project,
Risk Factors For Violence
Violence against a partner
has two main purposes:
Keeping or making use of power, and
Keeping or making use of control.
Many risk factors can
increase the chance of violence in a family. A family that has many risk factors
has more of a chance of becoming violent than a family with one or two risk
Some risk factors are:
Past victim or witness of family abuse6,7
Alcohol and drug abuse
Stress outside the home (e.g., work, financial)
Poverty or problems with money
Loss (e.g., loss of a job, death, relationship)
The idea that all men have to act a certain way or
believing that all women should stay home and not work
History of abusive relationships
Mental or physical problems in the family
Isolation from others
Risk factors do not cause
violence, and they are not excuses for violence.
Characteristics of Batterers
There is no simple way to
describe a "typical" abuser. Abusers are as different from one
another as any two people may be. However, studies have shown that abusers
often have some things in common, such as feelings of low self-esteem, lack of
trust, inability to take responsibility, and family history of substance abuse.8
Other characteristics often include:
Feeling that their life is not worth anything
Having a history of alcohol or drug abuse in their
Fearing loss of control and power
Being out of touch with feelings other than anger
Believing that men must always behave in certain
ways and women in others
Acting very charming sometimes but being very angry
and mean at other times
Not trusting people
Wanting the woman all to himself
Blaming others for their actions, not assuming
responsibility for their actions
Handling stress in an unhealthy way
Believing that the male always rules the household
Having experienced violence between their parents,
or were abused by their parents, as a child
Always thinking other people are hostile
Having problems figuring out why other people act
the way they do
Other similar characteristics
among men who batter include an inability to express feelings in ways other
than anger and an unwillingness to listen to their partner's thoughts. Many
such men's behavior can also be described as unpredictable. Men who abuse fall
mostly into one of three types:9
Men who have experienced the most severe childhood physical abuse
Men who have experienced the most severe parental rejection, and
Men who have experienced less childhood trauma than the previous two.
Many people believe that men
have no control over their violent behavior. Some people think these men are
evil and lack morals. In reality, men who abuse women generally feel as if they
have no control over their violence and do not enjoy acting violently. All of
these perceptions fail to recognize the full reality in an abusive situation.
The problem with abusive men is not that they have no morals or values. The
problem is, they have learned to make poor choices that involve violent, abusive
behavior. With proper treatment and much effort, men who are abusive can learn
to make better choices and learn how to deal with others without using violence10
and Control Wheel
Not all men use all types of
abuse at all times. If there is no intervention, however, an abusive man may
inflict verbal, emotional, physical, as well as sexual abuse on a woman. The
abuse may differ in dating relationships, but whatever method a man may use, it
usually is linked to power and control. Alcohol may or may not be involved.
When it is, the risk of violence increases.
Abuse Tactics in Domestic
There are many non physical ways
that an abusive person may try to control or maintain power over his partner.
When these tactics don't work, some people may resort to physical or sexual
Nonphysical Abuse may include
using coercion and threats, intimidation, emotional abuse, using isolation,
blaming, denying, minimizing, using children, or economic abuse.11
Physical abuse includes any
of the following:
Slapping, punching, kicking, spitting, pinching.
Spanking, burning, choking, pushing.
Scratching, restraining, grabbing, biting.
Throwing objects at the victim or using or
threatening to use a weapon of any kind (knife, gun, beer bottle, stick,
ruler, belt, whip).
Forcing the victim to take drugs or large amounts of
alcohol to avoid further physical abuse.
Preventing the victim from leaving the house.
Sexual abuse occurs when the
victim's partner physically attacks sexual parts of her body (grabbing her
breasts, pinching her buttocks, or unwanted touching of any kind) or forces the
woman to perform any sexual act that she does not wish to do. Sexual abuse
occurs when the victim's partner forces sex under the following conditions:
The victim indicates "no" and her limits
are not respected.
The victim is sleeping.
The victim is drunk or high or unable to say
The victim is afraid to say "no."
Not all intimate partner
violence is physical or sexual. Abusers may use economic, emotional, or other
forms of intimidation. Women may be subject to stalking, behavior that makes
the victim afraid for her safety and which may lead to physical violence or
even murder. Stalking often occurs after a woman leaves her abuser or has him
removed from her home. Law enforcement officials and health professionals need
to be alert to stalking behaviors, including:
Following the intended victim or appearing at her
home or place of business.
Making harassing phone calls or sending unwanted
letters, cards, or flowers.
Vandalizing the victim's property.
Stay in Abusive Relationships
The response many people have
to an abusive situation is, "Why doesn't she just leave?" Women stay
in abusive relationships for many reasons, including:
She believes the abuse is her fault.
She loves the abuser and remembers that he can be a
charming and loving person.
She may have a substance abuse problem and not have
the resources to leave.
He may be her drug supplier.
She is ashamed and embarrassed.
She is afraid of what he may do to her if she
She is afraid of what he may do to the children or
animals if she leaves.
She is not familiar with the resources in the
community for getting help for abuse.
She may not know where to go if she leaves.
She may not have enough money to support herself or
her children without him.
She may be scared to tell her family (parents) since
they might make her break up with him.
She may think his jealousy is a sign of his love for
She may not have had another relationship before, so
she thinks this is the norm for all relationships.
She may feel pressured to stay in the relationship
(chiefly marriage) because of her religious or family beliefs.
She believes he will change.
She may be pregnant.
Cultural and religious
beliefs may affect the choices available to a victim, who also may be addicted
to substances. The United
States represents a true mix of cultures
from around the world. Just as people born and raised in the United States
have certain values and beliefs, families from other countries bring with them
the values and beliefs held in their country of origin.
Most studies have found that
violence during pregnancy occurs roughly in 1 in 6 pregnant women.12
Pregnant women have a 60 percent higher likelihood of being abused than
non-pregnant women.13 "Pregnancy" covers the pre-natal
months, the period immediately after delivery, as well as the 6-9 months
following delivery. Pregnancy is a unique time for intervention since women
tend to visit their health care providers more often.14 In 1995, an
estimated 72 percent of U.S. women aged 15-44 years received at least one type
of reproductive health service, including:15
have found that violence during pregnancy occurs roughly in 1 in 6 pregnant
Contraceptive counseling or prescription
Pap smears, pelvic exam, HIV test
Prenatal or postpartum care, and
Testing or treatment for vaginal, urinary tract, or
Battered women are three
times more likely than nonbattered women to be
pregnant when injured. As a result, they experience a higher likelihood of
miscarriage, separation of the placenta from the uterus, hemorrhages, fetal
fractures, low infant birth weight, and rupture of the spleen, liver, and
uterus.16 This is a particularly hard time to intervene because of
the emotional and financial ties to the partner/spouse.
Women whose pregnancies are
unintended share some risk factors with women who experience violence: younger
age, lower income, and being unmarried.17 It is estimated that
between 1990 and 1995, 31 percent of births to U.S. women aged 15-44 years were
unintended. While research shows there is a relationship between unintended
births and violence, no causal relationship has been established.18
Most data on physical
violence and pregnancy intendedness comes from the
Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing, State-based
system that conducts surveillance on maternal characteristics before pregnancy,
during, and postpartum.
One such study examined data
from 14 states and included 39,348 women who had delivered a live-born infant
within the previous 2-4 months. Eighty-six percent of the mothers were at least
20 years old, 80 percent had completed at least 12 years of education, and 68
percent were married. Twelve percent said that sometime during the 12 months
prior to delivery, the father had expressed not wanting to have a child.19
Women who experienced abuse during the 12 months prior to delivery had an
increased chance of having a child that was not intended than women who
experienced no abuse (66.3% vs. 42%).
The total incidence of abuse
during pregnancy was roughly 8 percent. Women with unintended pregnancies were
2.5 times more likely to have experienced abuse than women whose pregnancies
were planned. The maternal characteristics that were statistically significant
in relation to abuse were:20
Less than 20 years of age,
African-American descent and unmarried,
Dependence on Medicaid and living in crowded
Late entry into the prenatal system,
Lack of father's support for pregnancy, and
Smoking in the third trimester.
Assessment of domestic
violence should be a regular part of psychiatric intake and evaluation. The
stress of domestic violence may exacerbate comorbid
psychiatric disorders. Symptoms include:
Feelings of isolation and inability to cope
Suicide attempts or gestures suggesting thoughts of
Panic attacks and other anxiety symptoms
Alcohol or drug abuse
Posttraumatic stress reactions or disorder
Connection Between Alcohol Abuse and Domestic Violence
The connection between drug
and alcohol abuse and violence against women can take many forms and involves
many factors. Some men feel the need to exert power and control over a woman.
This need to control often covers feelings of inadequacy or insecurity.
alcohol abuse can play a role in violence before, during, or after an incident.
Some men turn to alcohol or
drug use to escape feelings of low-self esteem, or they use violence to gain
control. Therefore, the same need to feel powerful and in greater control is
filled in different ways. In some cases, a man could abuse alcohol or drugs and
become violent, or substance use could exacerbate violent tendencies.
Some women may feel a loss of
power and control as a result of violent victimization. They may turn to
alcohol or drugs to escape feelings of helplessness, shame, guilt, and pain.
Others may already have a drinking problem, which can put them at further risk
of becoming a victim of violence.21
If a man drinks or uses
drugs, he may force a woman to join him, threatening further violence if she
does not. In addition, some men may force women to use alcohol or drugs to
lower their resistance. Thus, drug and alcohol abuse can play a role in
violence before, during, or after an incident.
Regular alcohol abuse is one of the leading risk
factors for intimate partner violence.22
Abused women of all races report higher stress, less
support from partners, less support from others, lower self-esteem and
increased substance abuse than those women not abused.23
A national survey of female college students found
that 15 percent had been raped at some time since age 14. In 64 percent of
cases, the offender was drinking. In 53 percent, the victim was drinking.24
Attackers who abuse alcohol most frequently commit
more severe sexual assaults.25
The relationship between alcohol abuse and abuse of
women is strongest for men who already believe that male power and control
over a woman are acceptable in certain situations.26
A woman drinking alcohol is at risk for becoming the
victim of sexual assault. Many perpetrators interpret a woman's drinking
as sexual consent. This can lead to assault. Many assailants believe that
women who do not strongly resist their advances are agreeing to sex.27
Drinking by offenders and victims has been
associated with assaults occurring in less planned social situations
(e.g., bars, parties) in which the victim did not know the offender well
before the assault.28
In an abusive relationship,
whether it involves physical violence, emotional or sexual harm, or conflicts
and abuse involving money, the man generally exerts power over the woman.
Although there are heterosexual relationships in which the woman is the
aggressor, in 85 percent of cases, the man is the abuser and the woman is the
Substance abuse and violence
against women are problems that may coexist and can also exacerbate each other.
For example, both involve denial, with substance abusers and batterers blaming
their partners for their behavior. Usually, neither problem decreases until a
crisis occurs. Secrecy is often the rule, with victims of abuse wrongly blaming
themselves for their partner's substance abuse or violent behavior.30
The relationship between
alcohol abuse and domestic or dating violence is complex. Not all men who abuse
their partner drink, and many men do not become violent when they drink. A man
who drinks or uses drugs may abuse his partner when he is using and when he is not using.
This creates even more stress for abused women because there is no one simple
behavior pattern for men who abuse alcohol or other drugs.
In some abusive
relationships, the man may abuse alcohol before becoming violent toward his
partner, but not in every case. There are cases where both partners may be
abusing substances. Neither is able to stay sober without the other sabotaging
his or her efforts.
Often, when a violent man
abstains from alcohol, his violent, controlling behavior increases. As a
result, for their own safety, some women may subtly encourage the man to
continue drinking. If the woman tries to stop drinking, the man often forces
her to get drunk with him to avoid further abuse. Either way, each person's
efforts at sobriety fail.31 It is important to look for signs of an
abusive relationship. These warning signs
can help you and your client identify possible problems. Abuse is not always
physical. Simply looking for signs, such as bruises, cuts, or scars, is not
enough. There may be signs of verbal or psychological abuse as well.
Warning Signs of an Abusive
A number of warning signs are
helpful to know when you are meeting someone for the first time or are starting
The man drinks heavily. If he is rejected, he may
get angry and violent and try to force sex on you.
The man does not listen to you, ignores you, or
talks over you. This shows that he has little respect for you and might
not buy it when you say "NO." Be careful.
The man does not respect your space or personal
boundaries. You do not need to have a guy pawing all over you.
The man shows or expresses hostile feelings toward
women. The jump from hostile feelings to violent acts is a small one,
particularly when alcohol is involved.
The man does what he wants no matter what you say.
If he makes all of the decisions about where you will go or what you will
do, he probably will not respect your wishes about sex either.
The man plays on your guilt when you do not give him
what he wants. If he calls you uptight or a prude, do not let it get to
you. Remember, he just wants to have sex and does not really care about
The man acts jealous or like he "owns"
you, even when it is clear nothing is going on. This type of guy will only
get worse over time and may exhibit a bad temper as well.
The man has a very traditional, chauvinistic
attitude about male and female roles and believes "women have a
He yells or is rude to his mother or other family
members in front of you. This shows he has little respect for women or for
Cycle of Violence
The cycle of violence within
an abusive relationship is marked by specific phases. For this curriculum, the
honeymoon phase will come first, since most relationships (abusive and nonabusive) start out with both partners on their best
behavior. Here is what the cycle looks like.
At the beginning of most relationships, there is a
period of relative calm, coupled with excitement about the new partner.
Partners tend to treat one another very well.
Gifts are given, especially from the male to the
The male is loving, charming, and attentive.
The female is trusting and swept away by the
attention and love.32
Phase 2: TensionBuilding
As time goes by, the male may become a bit edgy and
He may disapprove of small things around the house
or with the woman. For example, he may expect dinner to be ready at a
certain time and get upset if it is not.
He may insist that the woman dress or act in a
Slowly, the woman begins to feel a bit tense, like
"walking on eggshells."
The man may have minor outbursts that include verbal
abuse and minor hitting or slapping.
The man may become more possessive and want to
control all of the woman's movements, financial information, and friends.
She may not be able to talk to friends or family.
She may not be able to go to work because he keeps
her up all night or forces her to drink.
Phase 3: Serious Battering
For many couples it may take a few years, but
without some intervention (counseling) the abuse will become more violent.
Where before the assaults were minor, the woman may now be badly hurt and
need to go to the hospital.
The tension leading up to the incident is strong,
and many women will speed up the cycle of violence to "get it over
During this phase, victims try to cover up bruises
to the face or body and become isolated from family and friends.
Because this first cycle may have taken a few years
to build up, most women do not realize the extent to which they have
become isolated and scared. Some women are able to reach out for help, but
many are not.
At this point, many women also get involved with
alcohol or drug abuse to numb the physical and emotional pain. They also
may feel trapped and isolated.
If children are present, they may become neglected
or abused as well.
After the severe violence, the man feels very sorry
and becomes loving again.
He promises never
to hurt the woman and tells her he loves her and that he will change.
He tells her he loves her more than anyone else
would or does.
He may tell her she made him do it.
He again gives her lots of attention, flowers, or
The woman loves him and wants to believe that he
will not hurt her again.
The abuser begins to make the woman feel guilty and
sympathetic toward him.
The abuser makes sure other people see his loving
The cycle can go around many
times. In time, the cycle of violence can speed up and the intensity of the
battering can get worse. For example, if the first cycle between the honeymoon
phase and the serious battering incident took a year, it may be only 6 months
before the next battering incident. The next may come in 3 months, and so on.
Each incident that follows may become more violent until the woman ends up in a
hospital or dead.
Role of Alcohol in the Cycle
Alcohol can affect
relationships during each phase of the cycle of violence. Remember that alcohol
does not cause violence, nor is it an excuse. But it can play a part in how men
treat their partners.
Phase 1: The "Honeymoon
Partners may drink together
on social and romantic occasions. However, alcohol is not yet the main focus.
In many cases, neither person will increase drinking.
Phase 2: The
Some men may begin to drink
more heavily and more often, especially after a stressful workday. As the
tension builds between the man and the woman, substance use may become a
problem. Drugs and alcohol can begin to play a larger role in minor violent
acts and verbal assaults.
Some women will begin to
drink or use drugs to cope with the tension and abuse. Drinking helps them numb
the pain, both physically and emotionally. While this "tension-building
phase" happens in all abusive relationships, substance use does not always
Phase 3: The Serious
A man who abuses both alcohol
and his partner may begin to depend more on alcohol to ease his feelings of
powerlessness, guilt, and stress. His tolerance to alcohol often increases so
that he needs more alcohol to achieve the same "buzz." The woman also
may begin to drink or do drugs to try to prevent further abuse.
Some violent men do not abuse
alcohol. However, men who drink too much and abuse their partners tend to use
alcohol or drugs at the time of an incident. In one study, 75 percent of female
victims reported that the man had used alcohol or drugs at the time of an
Phase 1: The Honeymoon Phase Again
If the man has been abusing
substances, he may try to cut back or stop using to prove that he is serious.
Stopping the drinking, however, will not stop the violence. In many cases,
sobriety leads to more physical and emotional abuse, as a way to relieve
anxiety. The man's sense of guilt and shame increases and the woman's sense of
shame and helplessness increases.36
In some cases, the woman
tries to remain sober but her abuser forces her to drink. This may help keep
her safe, but it ruins her effort to stay sober. She starts to accept the blame
and believes that she is the cause of both the drinking and the violence.
Depending on her level of drinking, the woman may be able to leave and seek
help. If she has an alcohol problem, she faces the challenge of getting sober
while keeping herself and her children safe.
Not all men who are dependent
on alcohol or drugs become violent. Similarly, not all violent men abuse
alcohol or drugs. In fact, even among men who abuse drugs and batter their
partners, a third of the violence happens when they are sober.37
However, substance abuse remains a major risk factor for men who become
46 percent of men who commit acts of intimate partner violence also have
substance abuse problems.
Men who have witnessed or
been a victim of violence in the home may imitate the violence they have seen.
They tend to resort to violence when they are angry or frustrated. They may not
have learned the nonviolent ways of expressing these emotions. In addition,
being physically abused as a child is a risk factor for substance abuse as an
Approximately 46 percent of
men who commit acts of intimate partner violence also have substance abuse
problems.39 Problem drinking in men increases the chance of partner
abuse eightfold. It also doubles the risk that they will kill or attempt to
kill their wives.40
Men with substance abuse
problems and a pattern of violence need to stop their violence and their
addiction. If they are treated only for the addiction, the violence will
continue. In fact, victims repeatedly report that during the their partner's
substance abuse recovery of periods of sobriety, the abuse continues. Often, it
escalades, which creates more danger than before the sobriety. When victims
report that physical violence decreases, they often report an increase in other
forms of control such as threats, manipulation, and isolation.41
Thus, men who are violent and
abuse substances need treatment for both issues simultaneously. This not only
will help ensure the safety of the victim, but will also help prevent the
abuser from relapsing. The more violent the abuser becomes when sober, the more
likely he will be to use substances again.42
The incidence of violence
against women is not new, partly because men have had more power and status in
society throughout history. What is new is the idea that violence against women
is not acceptable.
Alcohol and Domestic Violence
Some of the theories that explore
the relationship between alcohol and domestic violence include:43
Disinhibition Theory: Alcohol tends to interfere with
the part of the brain that suppresses violent behavior. Alcohol loosens a
person's inhibitions or removes the block against aggression or violent
Theory:Disinhibition occurs only at certain times, depending
on the interaction between alcohol use and a complex set of social and
psychological circumstances (e.g., at home but not in a bar).
Expectancy Theory: An individual has certain
beliefs about the effects of alcohol. For example, male perpetrators are
more likely to believe that alcohol influences the loss of temper and
impulsive behavior. They also interpret the alcohol-related sensations of
arousal (e.g., increased heart rate) as increased aggression.
Alcohol-related violence becomes a self-fulfilling prophecy.
Indirect Cause Theory: Alcohol is seen as causing
physiological, emotional, and cognitive changes that may lead to
aggressive behavior such as partner abuse.
Object Relations Theory: Humans are motivated from their
earliest moments by the need for significant relationships with objects.
Objects include people, such as the mother. Trust and security must be
fostered between mother (caregiver) and child. Inadequate nurturing can
lead to rage over unmet needs, causing the adult male to be desperate and
demanding. He has difficulty handling anger and frustration and tends to
become violent toward significant objects (partners) and society.44
These theories examine the way a child learns to accept behaviors and
attitudes based upon how he or she is raised. If a child is raised in an
environment where alcohol use and violence are norms, the child learns to
copy that behavior.45
Drinking and Family Abuse on Children
Some abused women do not
realize the effect that violence and drinking have on their children. They
might say, "We never fought in front of our son" or "My daughter
was in her room at the time, so she wouldn't know about it."
Partners of alcoholics and
abusers often minimize the impact of drinking and violence on the family.
Denial dominates the family. They learn not to feel, not to trust, and not to
talk. In addition, the children may see alcohol and violence as part of life
and adopt similar behaviors later in life.
Alcoholism, when coupled with
violence, amplifies the need for denial and creates an even greater sense of
hopelessness for family members.46 Unfortunately, children at very
young ages witness the violence and drinking and end up suffering the
repercussions. Many become victims of abuse themselves. A national survey of
more than 2,000 American families showed that between 45 and 70 percent of
children exposed to domestic violence are victims of physical abuse.47
Infants exposed to violence
also suffer. They may not develop critical attachments to their parents. They
may become "failure to thrive" babies.48 In extreme cases,
they may be injured or killed if their mother is holding them when the abuser
is violent. When substance abuse is present, mothers are not as attentive to
their babies and might neglect their basic needs for food, clothing, and
Children exposed to violence
can exhibit somatic complaints such as stomachaches, headaches, or just not
feeling well. They may also experience:
Loss of appetite or change in appetite
Sleep disturbances such as nightmares or
School problems, such as skipping school, grades
dropping, attention problems
Withdrawal or increasing isolation
Clinging to mother or siblings
Fear of the dark or of strangers
Increased violent behaviors such as kicking,
Regression, such as bedwetting, wanting a bottle,
Temper tantrums, whining, and inappropriate
responses to discipline
Role reversal, such as parenting the mother
Drug or alcohol use by teenagers
Depression and suicidal thoughts (middle and high
school children) 49,50
Whatever the behavior,
children (from grade school and up) need to be able to talk to someone whom
they can trust. The professional therapist or counselor needs to convince them
that it is normal to feel the guilt and shame felt by all children who are
raised in a violent home. Young children who have not mastered talking can
still benefit from play therapy with a trained professional.
The pattern of violence in
dating couples is similar to that experienced by couples that are married or
In both types of relationships, one partner forces
power and control over the other.
Both involve jealousy coupled with emotional and
Because 11 million drinkers are underage, alcohol
plays a large part in many teenage abusive situations. More than 60
percent of sexual assaults will involve alcohol.51 In fact, one
in four teenagers will experience sexual or nonsexual abuse by the time
they finish college. Teenagers and women in their twenties are at higher
risk of sexual abuse and verbal abuse than older women.
Although there have been many
studies on domestic violence experienced by adult women, studies on domestic
violence experienced by younger women in high school and college are just
beginning. Despite increased public awareness about drinking and abuse, many
people still do not realize that violence and problem drinking occur in younger
Dating behavior in high
school and college helps to define the relationships men and women will have as
adults. If the man in earlier relationships is violent and uses alcohol, he has
a greater chance of being violent again later in life. If a young woman
encounters violence early in her dating experience, she is more likely to
experience it again when she is older.
Relationships in high school
and college are a form of exploration and carry a sense of excitement.
Relationships allow the young woman and man to practice how to express their
emotions and feelings, but unfortunately, many young people do not have healthy
role models to emulate. Although men and women may both become victims of
abuse, the woman usually becomes the victim of more severe abuse.52
Women also tend to become violent in self-defense, not as the initial
In an unhealthy relationship,
the man has a need to show power and control. All acts, whether they are
physical, emotional, or sexual, are performed to show and keep power and
control. Most of the men who become violent in dating relationships hold very
traditional ideas about the roles of men and women. For example, the man may
believe that women need to serve men and, when married, that it is their duty
to stay home and not work outside the home.
Many teenagers and young
adults have not had healthy role models upon which to base their relationships.
Professionals working with youth can provide tools to help them see possible
warning signs of an abusive relationship. 53
Adolescence is a turbulent
time. Relationships, both romantic and with peers, add to this sense of anxiety
and confusion. If the relationship becomes violent, the young woman has not yet
had time to fully ascertain her own self-esteem and identity, something many
older women may have had time to do. Because of this, the effect of the
violence can manifest itself in different ways.
Teenage women may:
Develop eating disorders, either anorexia or bulimia
Self medicate with drugs and alcohol to numb the
pain, guilt, and shame
Develop sleep disturbances
Develop stress-related physical ailments
Become depressed or suicidal
Begin to allow their studies to slip and become
Become more isolated from friends and family54
Teen dating violence occurs
within the context of adolescent development. It affects certain developmental
aspects unique to adolescence. Therefore, it is different from violence in
adult abusive relationships.
New and mature relationships with peers of both
Social role achievement (developing a sense of who
you are within your family and peer network)
The ability to develop personal values and beliefs
Academic achievements (the ability to create and
achieve academic goals for future success)
Pregnant adolescents (aged
13-17 years) have an elevated risk of experiencing violence at the hand of
their partners than pregnant adults.55 There has not been much
research focused solely on adolescents and pregnancy, but the health
consequences of early pregnancy affect both mother and child.56
Studies have found that roughly one in eight pregnant adolescents reports being
physically abused by the father of her child in the previous 12 months. Of
these, approximately 40 percent also reported experiencing violence from
another family member or relative.57
Pregnant adolescents who are
abused by their parents have a higher risk for conditions like stress,
depression, and addiction to tobacco, alcohol, and drugs. The damage caused to
unborn children by addictive drugs and alcohol (Fetal Alcohol Effects and/or
Syndrome) has been well documented in the research. The effects of maternal
depression on newborns has not been as well researched and documented. However,
a violent environment does not lead to healthy emotional or physical
A major study that examined
the relationship between partner abuse and adolescent pregnancy found common
characteristics among the male perpetrators. These included:59
Prior police involvement
Frequent use and abuse of alcohol and illegal drugs
Women of all ages can become victims of abuse.
Victims of abuse run a higher risk of substance use than women who have
not been abused.
Alcohol abuse and domestic violence may be passed
from generation to generation. Both involve denial, and substance abusers
and batterers both blame their partners for their behavior.
Abusers use several tactics to maintain power and
control over their partners, including financial abuse, sexual abuse,
isolation, stalking, intimidation, and threatening to hurt or run away
with the children.
Several factors may stop a woman from leaving her
abuser, including fear, cultural pressures, lack of resources, isolation,
There are medical, physical, psychological, and
emotional consequences of domestic and dating violence.
Young children suffer devastating consequences from
growing up in a home where there is violence and/or substance abuse.
Contrary to popular belief,
rapists usually are not strangers. Friends or acquaintances commit nearly half
of the rapes and sexual assaults reported to police by women of all ages.1
When someone known to the victim-a date, steady boyfriend, friend, or
coworker-forces her to have sex, it is still
rape. Date rape is about power, control, and anger, not romance and passion. It
is a serious crime and a betrayal of trust that can have long-lasting emotional
In spite of the frequency of
acquaintance rape, many people continue to think of the "typical"
rape as a stranger jumping out and dragging the victim into an alley at night.
In fact, a very small percentage of rapes can actually be characterized in this
way.3 Using rapes that occur on college campuses as an example, as
many as 95 percent are committed by someone the victim knows.4
Those who believe sexual
assault is not a problem should think again. Based
on the number of reported rapes, we know that a woman over 18 years of age is
raped every minute in the United States. That comes out to
683,000 per year-and those are only the rapes that are reported. More than 80
percent of rape victims do not report the rape to police.5
The U.S. Department of
Justice describes sexual assault as a wide range of victimizations, distinct
from rape or attempted rape. These crimes include completed or attempted
attacks generally involving unwanted sexual contact between the victim and the
offender. Sexual assault may, or may not, involve force. It includes grabbing
or fondling as well as verbal threats.
CDC defines sexual assault as
a sexual act, either attempted or completed, against a victim's will. This
includes situations in which the victim is unable to consent due to age (too
young), illness, disability (e.g., unable to talk), or the influence of alcohol
or other drugs. The date rape drugs cause a woman to become unconscious, so she
cannot consent to sex or remember it after the drug wears off.
Sexual assault may involve
physical force, the threat of physical force, the use of guns or other weapons,
or pressure. Sexual assault also includes forced touching of the genitals,
anus, groin, or breast against a victim's will or choice. The perpetrator may be
a stranger, friend, family member, or intimate partner.6
Rape is forced intercourse,
including both psychological coercion and physical force. Forced sexual
intercourse includes vaginal, anal, or oral penetration by the offender. This
includes when the penetration is from a foreign object such as a bottle. The
definition includes attempted rapes, male and female victims, and heterosexual
and homosexual rape.7
Involved in Sexual Assault
Young women who are aged 16
to 24 years are at the highest risk of sexual assault.8 Roughly one
quarter of all women are sexually assaulted by the time they graduate from
college (or reach age 25). Unfortunately, most sexual assaults go unreported
because of the stigma attached to sexual assault.9
Sexual assault is especially
prevalent in high schools and on college campuses. There are several factors
that help contribute to the increased risk of sexual assault. Some of these
The strict way in which our culture stereotypes men
and women. For example, society still encourages men to be competitive and
aggressive, while teaching women to be more passive and
The increased use of alcohol for social gatherings.
Alcohol consumption is the largest risk factor for sexual assault by an
acquaintance.10 In fact, in a national study, more than 50
percent of high school seniors report drinking alcohol in the past 30
days.11 According to ColumbiaUniversity's NationalCenter on Addiction and Substance
Abuse, alcohol is involved in 90 percent of campus rapes.
Alcohol often forms the basis for social interactions on campus. There is
a positive correlation between the amount of alcohol consumed on a campus
and the incidences of sexual assault. The more alcohol there is, the more
incidences of sexual assault.
Another factor may be societal norms and lifestyle
expectations. Many men misinterpret a woman's words and actions';
"She said no, but she meant yes." Similar norms encourage sex as
a recreational activity. While women have fewer reasons to say no to sex,
there is still a double standard for men and women.
Social activities that focus
around drinking attract more publicity and attention than those that do not
have alcohol. Young women need alternatives other than "going to a
bar" to meet peers. The lifestyle that encourages bar hopping and
consuming as much alcohol as possible at one time puts women at risk for sexual
Myths of Sexual Assault
Anyone living in the United
States has been exposed to countless misconceptions about sexual assault and
rape.12,13 These myths can come from our views about interpersonal
violence, our perception of male and female sex roles, racist myths, and other
stereotypes. These beliefs blame the victim and minimize the seriousness of the
assault. Exposing these myths and replacing them with facts represent the first
steps toward changing views about sexual violence and reducing its occurrence.
Other Drugs Related to Sexual Assault and Rape
Girls in high school and
college are at the beginning of their dating experiences. Drinking can become a
popular social activity and a way of setting the mood for romance. Since
alcohol clouds a person's judgment and decreases motor skills, a woman may not
be able to make the best decisions if she has had a few drinks. She may not be
able to fend off unwanted sexual advances or escape an uncomfortable situation
before it gets out of control.14 Studies have found that when a
woman drinks on a date, she has a greater chance of being sexually assaulted by
Men in fraternities have
admitted in a survey that they are more likely to try to force a woman to have
sex with them if they have been drinking alcohol.16 They are also
more likely to give alcohol to women because they think that women who drink
are more willing to have sex. In one study, nearly 20 percent of men admitted
to giving or encouraging the use of drugs or alcohol to obtain sex.17
This is not to suggest that all fraternity members use alcohol to get sex.
However, it is a distinct possibility and women need to be cautious.
that may put a woman at risk for sexual assault include drinking in public
places, such as bars or nightclubs, and having multiple sexual partners. If a
woman takes risks, such as going to a bar or nightclub alone and drinking, she
increases her risk of becoming a victim.18 To learn more about a
lifestyle assessment tool, you can go to Pearson Assessment. The Quality of Life Inventory (QOLI)
measures life satisfaction and helps assess problems in 16 key areas of life.
In the past 10 years, three drugs
besides alcohol have been linked to an increased rate of date rape. Since high
school and college age youth are using and abusing the drugs the most, it is
not surprising that women between the ages of 16 and 24 years are the victims
of most sexual violence.19 These drugs include:
binge drink are 21 times more likely than nonbinge
drinkers to engage in unprotected sex and unplanned sexual activity.
Binge drinking is defined,
for men, as consuming five or more drinks in a row; and as four drinks in a row
for women. It is simply too much alcohol in too short a time. According to a
recent study, approximately two out of five college students are binge
drinkers.34 And of these binge drinkers (or heavy episodic
drinkers), one in five can be diagnosed with alcohol dependence (or
Since the early 1990s, the
proportion of college students who binge drink has remained roughly the same
(44 percent). However, the number of frequent binge drinkers-students who binge
three or more times in a 2-week period-has increased. Students more likely to
binge drink are white, 23 years of age or younger, and residents of a
fraternity or sorority.36
Students who binge drink are
21 times more likely than nonbinge drinkers to engage
in unprotected sex and unplanned sexual activity. Binge drinking or alcohol
abuse on college campuses triples
a woman's risk of sexual assault.37
What Professionals Can Teach
Even the best self-defense
course cannot guarantee a woman's safety. There are many things, however, that
a woman can do to decrease her risk of sexual assault. The most important thing
is to not allow alcohol or other drugs to reduce her ability to take care of
herself and make sensible decisions.38
A therapist or counselor can
try to impress the following guidelines on a young woman.
She must trust her feelings. If she feels in danger,
she probably is.
She should always be aware of her surroundings, know
her route, and stay in well-lit areas as much as possible. This includes
parking her car in well-lit areas.
After entering her car, she should drive away
immediately. She should not sit in the car and look at what she just
bought or count her money.
If she finds herself in danger, blow a whistle or
yell "FIRE" instead of "HELP" or "RAPE."39
People may be reluctant to intervene in an assault but will respond to a
more general emergency.
She should not leave a party, concert, game, or
other social occasion with someone she just met or does not know very
She should always travel in a group. Use a shuttle
service after dark. Never walk alone at night and avoid shortcuts.40
She should check out a first date or a blind date
with friends and insist on going to a public place such as a movie,
sporting event, or restaurant. She should carry money for a telephone call
and taxi, or take her own car.41
She can try to remember safety steps by thinking
Put change in her wallet for an
emergency or a ride home
Recognize the early signs of a
Examine her surroundings
Verbalize her resistance loudly
Exhibit confidence in potentially
Never assume sexual assault can
not happen to her
Travel in groups whenever
Decide on the level of intimacy she wants in a
relationship, and clearly state her limits.43
Freshmen should not allow a photo and personal
information to be published for distribution to the campus community.
Fraternities and upperclassmen have abused this type of publication to
target naive freshmen.44
If someone tries to
force her to have sex:
She should stay calm and ask herself, "How
serious about sex is this guy?" "What options do I have?"
She should think, "Is it safe to resist? Is he
armed?" If not, it is better to scream and claw and kick than to beg,
cry, or plead. This is because rape is more about power and control than
She should say "NO" with force and
certainty. She should not smile as if she is trying to protect his
feelings. Her safety and well-being are at stake here.
She should use the word rape. Often, upon hearing the word, the
attacker will realize what he is doing, and then stop and flee.
She needs to assess the situation. Can she escape?
Are there people around to help her?
She needs to find an escape route. If possible, she
should try to distract him so she can get away, first making sure he is
She should not shout "HELP." Most people
will not respond because they do not want to get involved in someone
else's business. She should shout "FIRE, which will affect people
around you as well.
She should lie if she has to. She could tell him she
has herpes, HIV, or venereal disease or anything else that he might catch.
It may deter him from following through.
Say "If you don't stop, I will consider this
Avoiding Date Rape Drugs
Pour and prepare all beverages she consumes
(alcoholic and nonalcoholic).
Not leave drinks unattended.
Keep her hand over the top of her glass or beverage
Not drink out of large, open containers, such as
Not trade or switch drinks with others.
Not drink something if it looks or tastes
Watch for signs of drug effects in friends and act
immediately on their behalf.45
What Professionals Can Teach
Avoid alcohol and other drugs that will only cloud
their judgment and understanding.
Ask themselves how sexual stereotypes affect their
attitudes and actions toward women.
Accept a woman's decision when she says
"No." Do not see it as a further challenge.
Realize that forcing a woman to have sex against her
will is rape, a violent crime.
Never be drawn into a gang rape at parties,
fraternities, or bars; try to stop them.
Do not assume to know what a woman wants.
Do not have sex with a woman who is drunk.
Do not whistle at, talk to, or look over a woman in
ways that make her feel uncomfortable.
If they feel they are getting a double message, say
so. Ask her what she wants. If she says she is not sure, assume the answer
is no and let it go.
Never voice, believe, or support the idea that a
woman wanted it.
Never think a woman owes a man sex under any
circumstances. Sexual intercourse is not payback for an expensive meal or
an evening out.46,47,48
Women can and do lie about their age. Having sex
with women under 16 with a 4 year difference in ages, is called aggravated
What Do You Do If... (For
Sexual Assault or Rape)
Your client may present with
specific circumstances involving a sexual situation. It is important that the
client get immediate medical assistance if the sexual assault happened within
the past 72 hours. Even if the sexual assault occurred more than 72 hours
before her visit, the client should think about possible testing for sexually
transmitted diseases, HIV, and/or pregnancy.
Aftermath of Rape: Victim Responses
Survivors of sexual assault
often experience traumatic
stress, a complex mix of mental, physical, and emotional responses.
They include fear, anger, pain, shock, and the shutdown of many physical
systems. Symptoms include:
Sexual assault more than
doubles the odds that the victim may resort to substance abuse after the
attack.50 The most fundamental assumptions of trust, personal
safety, and bodily integrity have been destroyed for rape victims. They must
face not only the possibility of pregnancy but also the fear that they could be
infected with HIV.
Many victims also develop
lasting symptoms of post-traumatic stress disorder (PTSD). First identified in
war veterans, PTSD causes:
Chronic numbing of physical and emotional responses
Denial of reality
Guilt and self-blame
PTSD often lasts for years.
Survivors of sexual assault may also experience depression, anxiety, and
explosive anger. They may show a general inability to maintain relationships or
to cope with everyday problems.51
Because people react to
stress in different ways, it is not possible to predict exactly how the victim
will feel after a sexual assault. It is helpful, however, to learn and
recognize some of the most common responses of sexual assault victims.52
Shock and disbelief. She may say: "I feel numb,
or "I can't believe this happened to me." She may be withdrawn
and distant from other people. She may want to forget what happened and
avoid people or situations that remind her of the assault.
Remembering what happened and
what it felt like.
She may say: "Sometimes, I can't stop thinking about it."
"It comes back out of nowhere. I feel like it's happening all over
again." She may have flashbacks and nightmares about the attack. When
she thinks about the assault, she may re-experience feelings of fear or
Intense emotions. She may say: "I feel very
sad, like I lost a part of me." "I have this intense anger that
I never felt before." Intense emotions after a sexual assault are
normal. Some people may also feel anxious or depressed.
Physical symptoms. She may say: "I've had
trouble trying to fall asleep at night." Some victims experience
headaches and stomachaches and may find it difficult to concentrate on
routine activities. She may also experience changes in her sexuality, such
as a loss of interest in sex or an avoidance of sexual situations.
Self-blame and shame. She may say: "I felt like
it was my fault. I trusted him." Because of misconceptions about
rape, some victims blame themselves, doubt their own judgments, or wonder
if they were responsible for the assault. The reactions of others, often
based on myths about rape, sometimes reinforce feelings of guilt and
shame. Some victims describe feeling dirty, devalued, and humiliated as a
result of a sexual assault.
It is important to remember
that every individual responds to trauma in her own way. The use of physical
force, display of a weapon, and injury to the victim can increase a rape
victim's chances of having PTSD symptoms. The severity of the attack will
influence the stress response to a rape. If the victim had to go to the
hospital for her injuries or undergo any medical procedures, she may be more
likely to experience ongoing stress reactions than victims who did not require medical
5 Stages of
Every person reacts
differently to sexual assault, however, in general there are five stages of
recovery, which virtually everyone will experience to some degree. It is not
unusual for different people to experience the stages in different orders or
even to repeat stages several times. As you work through these stages with your
client, she may also present with feelings of disorganization, despair, and
Stages of Recovery
Stage 1: Initial
following an assault can take on many forms. You may experience emotional as
well as physical shock, which in turn could be expressed as very controlled
and/or withdrawn, or, highly expressive, including crying, screaming or
shaking. You may or may not feel comfortable communicating these feelings to
pseudo-adjustment, this stage may find you attempting to go on with normal
routine, wanting to forget about the assault. This denial or rationalization
of what happened is an attempt to deal with inner turmoil.
involves a re-experiencing of the feelings from Stage 1, usually brought on
by the triggering of memories of the assault. Feelings of depression, anxiety
and shame increase. Other symptoms can include nightmares, flashbacks, a
sense of vulnerability, mistrust and physical complaints.
experience feelings of anger - often toward yourself, friends, significant
others, society, the legal system, all men/women, etc. With skillful support
this anger can be directed more appropriately toward the assailant.
5: Integration (Closure)
integrate the thoughts and feelings stemming from the assault into your life
experience you will begin to feel "back on track". As a result of
support, education and the passage of time, you will feel
Women of all ages, income levels, and racial-ethnic
backgrounds are sexually assaulted.
Myths about sexual assault stop many women from asking
for help and many professionals from treating them effectively.
Alcohol consumption is associated with increased
risk of sexual assault.
The drugs most related to sexual assault besides
alcohol include Rohypnol, GHB, and Ketamine.
It is important for a woman to get medical help
immediately after being sexually assaulted.
PART V: PREVENTION AND EARLY
Prevention can be defined as
an anticipatory process that prepares and supports individuals and systems in
creating and reinforcing healthy behaviors and lifestyles.
Prevention is a proactive
process. This means that we anticipate a problem and address it before it
becomes a reality. We don't wait for a problem to surface and then take action.
Ideally, health care providers incorporate prevention into regular office
visits. It could be as simple as asking patients about their alcohol
consumption or to characterize their situation at home.
Prevention also involves
connecting people and resources with innovative ideas, strategies, and
programs. It is important to create partnerships within all sectors of society
to create a holistic prevention agenda. The goal is to promote the concept of
abstaining from the use of any illegal drug, high-risk use of alcohol or other
legal drugs, and violence in the home.
The overall goal of
preventing alcohol abuse problems and violence can be achieved by empowering
individuals, families, and communities to take action. This involves helping
them develop problem-solving skills and the ability to manage difficult
situations. It also requires helping them develop skills to cope with a
situation while working to
Prevention differs from
intervention and treatment in that it is aimed at general population groups
with various levels of risk for alcohol, drug, and other alcohol-related
violence problems. Intervention and treatment are designed with a particular
person or small groups of persons in mind. The Institute of Medicine's
(IOM) program classification system is useful in understanding the differing
objectives of various interventions.
The framework of the IOM
classification system can be used to match interventions to the needs of a
targeted population.1 The three types are:
Universal programs(e.g., clinic-based health seminars, posters in
health centers or lunch rooms). These target general
population groups without making reference to those at particular risk.
All members of a community, not just specific individuals or groups,
benefit from a universal prevention effort. For women, the goal is to
prevent alcohol/drug use that would increase their chances of
programs(e.g., server interventions at
bars, screening, and brief interventions). These target
individuals who are at higher-than-average risk for substance abuse.
Targeted individuals are identified on the basis of the nature and number
of risk factors for substance use to which they may be exposed. The goal
is to prevent the development of serious problems.
programs(e.g., battered women-specific
treatment programs). These target women who are already
using or engaged in other high-risk behaviors in order to prevent chronic
alcohol use and severe problems.
Based on this framework,
several prevention and treatment strategies can be developed. The goal is to
reduce risk factors and enhance protective factors.
Abuse Prevention and Early Intervention Strategies
Information dissemination is
designed to increase knowledge and change attitudes about alcohol use and abuse
through activities such as group discussions and media campaigns. For women,
activities can focus on the correlation between alcohol use and abuse and
You can make
informational materials available in your office, community center, or waiting
The goal is to encourage
information sharing among participants and to enable them to review their own
values, lifestyles, and practices. These empower individuals to adapt their
current lifestyles to more effective and healthy approaches as needed. An
example is a seminar on a college campus that discusses myths and realities
related to alcohol, dating violence, and sexual assault.
It is important to be able to
refer people to prevention specialists, activities, and organizations that can
help them prevent alcohol abuse. Referral to a class or group can be made by
anyone who knows the appropriate referrals. Effective referral includes five
Update referral list. Keep an updated referral list
containing contacts and phone numbers.
Check credibility. Check the credibility of all
referral organizations. Ask about:
The prevention services the
The cost of the prevention
The schedule of programs and
Proximity to public
Community outreach efforts
Type of services provided
(recreation, education, etc.)
Experience dealing with special
populations, such as abused women
Requirements for appointments,
rather than walk-in service
Have the client call. Have the client make the
referral call. This will empower the client to act on his or her own
behalf instead of depending on others.
Send reminders to the client, if
Follow-up. Follow-up with the referred
person(s) to ensure that the referral appointment was kept.
You can also help educate
others. When possible, make informational materials available in your office,
community center, or waiting room.
Education programs equip
people with vital information for understanding substance misuse, violence, and
mental health problems. They also teach participants important social skills,
such as healthy coping mechanisms. Educational activities include lectures,
group discussions, audiovisuals, and question and answer sessions.
Educational approaches need
to be implemented that encourage healthy living, coping mechanisms,
assertiveness training, and self-empowerment. They also need to address issues
such as loss, fear, and isolation. Effective programs are culturally sensitive
and use a variety of teaching methods, such as exercises and discussions,
rather than lectures.
Examples of prevention
education programs include:
Direct education about safe drinking
Life skills training
Alternative activities offer
opportunities for participation in culturally and age appropriate activities to
replace, reduce, or eliminate involvement in substance use-related activities.
Women who are in abusive relationships may drink out of loneliness, shame, or
pain. Finding healthy alternatives is important, whenever possible.
The focus should be on
participatory activities that develop self-assurance and self-awareness, build
self-confidence, and facilitate healthy interactions. Examples include:
Volunteer work at a child's school
Arts programs, such as painting classes, that
Cultural activities that emphasize special holidays
and group gatherings
Sharing experiences creates a
bond, and increases the comfort level and access that a substance abuse or
violence prevention professional may not have. Peer support may be a part of an
educational activity like a workshop, as long as the participants have a chance
to dialogue with each other and develop a network.
Becoming active in
faith-based activities at a church, mosque, or synagogue helps women feel more
connected. The belief in religion and spirituality is the basis for many
self-help support groups for women in addiction programs. A supportive
community helps to create a positive and caring environment for a woman who may
be struggling with either addiction, abuse, or both.
strategies include the development of alcohol consumption guidelines for
colleges or universities.
expand community resources dedicated to preventing substance abuse and
violence. They include activities such as building community coalitions. The
need for increased services for abused women and children has resulted in the
need for additional training for service providers and impactors.
The term "impactors" refers to people in the community who can
effect change. Their involvement strengthens the community's total prevention
support system and allows for more effective delivery of services. Examples of impactors and service providers include:
Grassroots leaders and other community leaders, such
as government officials, bank presidents, and newspaper editors
Social workers, nurses, physicians, and other health
Neighbors, roommates, and friends
include environmental approaches to promote policy and system changes that
reduce risk factors and preserve or increase protective factors. Examples
Development of alcohol consumption guidelines for
colleges or universities
Cross-training of health care professionals on
issues relating to substance abuse and violence against women
Development or enhancement of programs and services
help women who have comorbid alcohol and mental
Development or enhancement of shelters that
collectively address the issues of substance abuse and violence against
Often there are barriers to
coordinating prevention and treatment efforts between the substance abuse field
and the domestic violence field. Many facets of collaboration must be addressed
in order to ensure a full community response. These include:2
Prevention programs focus on
deterring self-destructive or harmful behaviors, both to self and others, as
well as on promoting health and wellness.
Effective prevention programs
Outreach. Programs offered in office
settings generally are not well attended for a variety of reasons.
Problems include possible lack of transportation, the stigma of substance
abuse, and the shame of being a victim of abuse. Programs should be
offered in community centers, colleges, women's centers, or other
neighborhood places where a diverse group of people would be comfortable.
Interdisciplinary approaches. Service providers from several
disciplines (medical, legal, financial, social) work together to bring the
prevention message to the community. They can also help to see that the
needs of minority groups are addressed.
Age-appropriate materials. Focus on the needs and
characteristics of the population. Teenagers and young adults have
different needs than older women. Materials for youth need to be relevant
to their experiences, with colorful graphics and easy-to-understand
language. For older adults, use larger type, attractive formatting, and
ink and paper with high contrast. Ensure that all materials, where
appropriate, are translated to address non-English speaking populations.
Family/Friend involvement. Many young adults are still
connected to family. These individuals can be invaluable in reaching teens
or young adults who will not participate in prevention activities. Some
women may not be connected to family but will respond to a friend reaching
out and offering support. Neighborhoods dominated by a specific ethnic
group may facilitate this involvement. Chinatown
in San Francisco,
as well as many Hispanic neighborhoods throughout the U.S., is
Independence. Many abused women feel they have
no control over their lives and are not able to be independent. It is
important for programs to acknowledge the process of regaining
independence, confidence, and self-worth.
Growth opportunities. Educational experiences enhance
a sense of accomplishment and purpose. Learning new skills and approaches
to life problems can help women better manage life changes. Feelings of
competency, the ability to change and grow, and a sense of community
involvement are strengthened.
Commitment to healthy
Effective prevention programs dispel the stereotypes and biases commonly
associated with domestic violence and substance abuse.
Culturally sensitive approaches. Many successful programs report
that a culturally and generationally specific approach helps promote
respect. This approach allows participants to take pride in their cultural
recognition can be as relevant as cultural sensitivity. For example, asking
participants to explain more about a cultural norm is a way of giving
recognition to a particular culture. Program activities based on the
appropriate culture of participants include Native American talking circles,
African dress and dances, and Puerto Rican music.
All of these activities help
to support and acknowledge differences among participants. It is widely held
that when people have a strong sense of self that has been developed through
cultural identity, they are less likely to use alcohol or drugs to feel good or
to escape reality.
encompasses not only what we wear and how we celebrate, but also how we learn,
solve problems, value time, interact as a family, etc. It is important not to
prejudge. For example, some individuals arrive promptly for a meeting and take
a seat. Others arrive, socialize, get a cup of coffee, and eventually make it
to their seats.
Asking the right questions
can help in developing prevention strategies that value cultural diversity.
Problem identification is
needed to recognize individuals with suspected substance use problems and to
address the problems before they worsen. It may involve referring individuals
for assessment and treatment. When assessing female clients, health care
providers can help by including a routine evaluation for alcohol consumption,
home violence, and related risk factors. Using self-assessment questionnaires
and taking an alcohol and drug history are especially helpful. See Part 6 for
more information on screening. In addition, counseling women on ways to stay
safe can help them avoid turning to alcohol.
When a problem has been
identified, early intervention is needed to prevent it from getting worse. A
key issue is motivating change. Motivation is not just the responsibility of
the problem drinker. Motivation is the result of an interaction between the
drinker and others. A therapist can increase motivation for change through his
or her interactions with the person experiencing or at risk for drinking
Understanding the reasons
people stop drinking can help in motivating change. Dr. Frederic Blow at the University of Michigan has been studying motivation to
stop drinking. Results of his research revealed the following reasons people
gave for discontinuing their drinking. The total percentage of respondents may
add to more than 100 because some gave more than one reason:
Reasons To Stop
Health, 46.5 percent
Costs too much money, 10.5 percent
Did not like taste/effects, 27.6 percent
Entered Alcoholics Anonymous, 4.3 percent
Religious objections, 13.5 percent
Had treatment to stop, 2.7 percent
Objections from family/friends, 5.8 percent
Social crowd does not drink, 6.7 percent
Other, 17.6 percent3
Research shows that people
may respond quite differently to recommendations that they alter or discontinue
longstanding or previously pleasurable behaviors. Reactions depend, to a great
extent, on an individual's readiness to change.4 For example,
screening or assessment findings may confirm an individual's suspicions about
the negative effect of alcohol on personal health. He or she may immediately
commit to abstaining or begin tapering off. Another approach, giving brief one-
or two-sentence advice, requires more knowledge and experience.
For some people, an
assessment may be a revelation that must be processed over time before they can
make any changes. Still others may be unconvinced by the findings and not see
the need to change.
Most individuals experience
several stages of change in addressing an alcohol or drug problem, as indicated
in the diagram below.5 Although relapse is not formally considered a
stage, it has been included because many individuals experience relapse and
subsequently repeat the stages of change.
Categorizing individuals this
way helps predict who is most likely to succeed in making changes. It also
helps determine which interventions work best at different stages.6-8
It has been suggested that research on brief interventions for problem drinkers
should examine stages of change as a way to tailor interventions to readiness.9
Because people often move through these stages of change in cyclical patterns
over long periods, it is important to:
Evaluate the recent and past course of the
participant's movement through the stages of change.
Adjust treatment approaches to reflect the
participant's experience in trying to change.
Individualize treatment to the extent possible.
Set realistic treatment goals. Sequence and shift
goals as participants progress.
Keep in mind that much of the change takes place
outside the treatment setting. Treatment assists the participant through
certain stages of change.
Recognize the current stages of participants in
group treatment. Members can facilitate or hinder the progress of others
through role modeling and by raising appropriate or inappropriate issues
classification system can be used to match programs to the needs of a
targeted population. The three types of interventions are: Universal
programs, Selective programs, and Indicated programs.
Effective prevention programs include several
components, including outreach, age-appropriate materials, independence,
growth opportunities, culturally sensitive approaches, and commitment to
The stages of change in addressing an alcohol or
drug problem include precontemplation,
contemplation, determination, action, maintenance, and relapse.
People stop drinking for several reasons. Knowing
some of the reasons can help professionals design effective programs or
This module explores the
screening and assessment process for women and men with abuse and/or alcohol
addiction problems. There are many assessment tools that are available for
purchase. This tutorial provides those that are available to the public at no
charge, with permission from the author.
Health care professionals
treat women at every age. Most women regularly see doctors, nurses or mental
health professionals for routine check-ups, pregnancy issues, physical injury,
or mental health concerns. During these visits, health care providers have the
opportunity to do screenings and assessments for domestic abuse and sexual
assault, as well as for alcohol abuse. Many of these providers, however, never
ask questions or probe beyond the presenting problem to determine the
underlying cause of a problem.
Few people are willing to
identify themselves as victims.1 In fact, the American Medical
Association found that less than 10 percent of primary care doctors routinely
screen for domestic violence among their patients. Many never ask about alcohol
intake when examining a person for bruises or other injuries.
Clarification of Terms
For this tutorial, screening
and assessment are defined as follows:2
Screening. This is a brief procedure used
Determine the presence of a
problem (e.g., mental health disorder, substance abuse)
Substantiate that there is a
reason for concern
Identify the need for further
is done early in the process of collecting information. It may be done by a
questionnaire or checklist. Screening tools are not meant to provide a mental
health or substance abuse diagnosis. Instead, they are used to collect initial
information that will help in further assessing the problem.
Assessment. This is a more comprehensive
diagnostic and treatment planning process typically based on screening
information. A detailed assessment may take hours to complete and should
help to prepare a treatment plan. Some goals of assessment are to:3
Examine the scope and/or
severity of mental health or substance abuse problems
Identify other possible
psychosocial problems that may need to be addressed further
Provide a foundation for
Identify possible strengths of
the woman that can become part of the treatment planning process
Screening and assessment
should be done by trained professionals with experience in violence or
substance abuse issues who use specialized instruments. Health care providers
should routinely screen for alcohol and intimate partner violence. The
standardization of screening instruments among providers would also enhance the
level of screening in these areas.
Abused women report that the
one of the most important aspects of their doctor's visit was their ability to
talk about the abuse.4 Healthcare providers can screen for physical
abuse, sexual abuse
abuse by having clients fill out simple questionnaires. The Family
Violence Prevention Fund and the AmericanCollege of Obstetricians
and Gynecologists have created general screening policies for all health care
providers to use. For more information or detailed recommendations for specific
health care settings, please go to www.endabuse.org or www.acog.org.
Health care providers, social
workers, psychologists, or any other professionals working with clients are
required to follow their profession's rules for confidentiality and mandatory
exceptions to confidentiality. Professionals should explain to clients/patients
the limits to confidentiality before they begin a screening. For more legal and
confidentiality information, see Part 8.
Screening For Domestic Violence and Sexual Assault
Who should be screened
All females aged 12 years and older
Who should do the screening?
At a minimum, screening should
be done by a health care provider who:
Has been educated about the dynamics of domestic
Is familiar with the affects of the violence on the
Who is culturally competent.
This person should be trained
to introduce the subject of abuse into conversation and should know how to
intervene appropriately. Authorization to record in the patient's medical file
should be obtained by a doctor in order to assure accurate documentation.
Obviously, (and certainly in court-ordered counseling) the screener should
attempt to establish a relationship or some level of trust with the patient
before asking personal questions.
How should screening occur?
Screening for domestic
violence and sexual assault should be a regular part of a face-to-face encounter
for the health care professional. Questions need to be direct and
nonjudgmental, and the interview needs to be conducted in private. That means
relatives or friends of the patient or children over the age of two years
should be present. Patients need to know that the information is confidential,
but they should also be informed of the limits of confidentiality. Use
professional interpreters, instead of a family member or friend, whenever
When should screening occur?
As part of a routine health exam or history.
During an initial visit for a new complaint.
During every new patient meeting.
At any visit after the client has started a new
During every periodic comprehensive visit.
Where should screening occur?
Trained health care providers
should provide domestic violence screening as a routine part of patient care in
the following settings: Primary care, urgent care, OB/GYN and family planning,
mental health and inpatient care.
Domestic Violence Screening
In establishing a bond with
the client/patient, the professional must achieve his or her goals in a way
that is the least threatening or traumatic to the victim. The phrasing of the
following statements can help defuse an otherwise uncomfortable (or even
physically confrontational) atmosphere.
"Because violence is so common in many people's
lives, I've begun to ask all my patients/clients about it."
"I'm concerned that your symptoms may have been
caused by someone hurting you."
"Many of my patients/clients are involved in
abusive relationships. I don't know if this applies to you, but some are
too scared to bring it up themselves, so I now ask about it
routinely." "Do you feel safe in your relationship?"
"Statistics show lesbian women are in abusive
relationships. Does your partner ever try to hurt you?"5
Sexual Assault Screening
Many women with alcohol abuse
problems have been sexually abused as children. However, knowing how alcohol
puts a woman at risk for sexual assault, it is also important to question the
client about recent incidences of attack or abuse.6,7,8
If a client was raped or
sexually assaulted recently, it is important to know:
If the rape has occurred within the past 72 hours,
she should not shower or bathe because physical samples will help identify
the attacker or provide evidence if she decides to press charges later. A
woman's alcohol abuse does not justify sexual assault and cannot be used
as an excuse in court.
If the rape or sexual assault occurred more than 72
hours prior, the victim should still seek medical help because she should
be tested for sexually transmitted diseases, HIV, and/or pregnancy.
Further counseling is recommended to address
understandable-and natural-fears of being alone, of men and of sexual
She must not blame herself. This is the most
important thing to remember. The rape was not her fault. Neither her
behavior nor her alcohol use caused the rape; the rapist did.
Similar to domestic violence
screening, when screening for sexual assault, professionals need to establish
an environment of trust and safety. The AmericanCollege
of Obstetricians and Gynecologists (ACOG) has developed the following tool.
Screening for rape and sexual assault can be conducted by making a statement,
and asking the following questions:
"Because sexual violence
is an enormous problem for women in this country and can affect a woman's
health and well being, I now ask all my patients about exposure to violence and
about sexual assault.
Do you have someone special in your life? Someone
you're going out with?
Are you now--or have you been--sexually active?
Think about your earliest sexual experience. Did you
want this experience?
Has a friend, a date, or an acquaintance ever
pressured or forced you into sexual activities when you did not want them?
Touched you in a way that made you uncomfortable? Anyone at home? Anyone
at school? Any other adult?
Although women are never responsible for rape, there
are things they can do that may reduce their risk of sexual assault. Do
you know how to reduce your risk of sexual assault?"
Unless you are specifically
trained to counsel sexual assault victims, advise her to call the rape crisis hotline
assault coalition in her community. To find training materials and
programs, you can go to www.cdc.gov/ncipc
to access their report "Intimate Partner Violence and Sexual Assault: A
Guide to Training Materials and Programs for Health Care Providers."
Additional Statements of
If someone declines to discuss
domestic violence issues, consider whether the silence may be due to a fear of
the batterer, or to cultural, race, or gender issues that make it difficult to
talk about such personal experiences. Again, gentle, yet clearly worded
statements will achieve the best results:9
"I am concerned about your safety."
"You can talk to me about what is happening at
"I am concerned about your children's safety.
Domestic violence can harm your children."
Abused women have an
overwhelming need to feel safe. Their lives have been turned upside down and
they need to feel they can live without fear. Initially, abused women need a
safe place to sleep and store clothes and other belongings. They also need
information about available resources and options, city, county or statewide.
Some women may require medical assistance, clothing, transportation, food,
money, childcare, job training, education, and/or legal assistance.
Alcohol Abuse With Domestic Violence Clients
The previous sections
illustrated the significant links between alcohol abuse and violence against
women. Professionals who work in the field of substance abuse or in the field
of violence against women (e.g., domestic violence, dating violence, sexual
assault, rape) must understand the essential relationship between the two.
Screening for Alcohol Abuse
Alcohol abuse screening is an
opportunity to discuss how alcohol abuse affects safety. It is a preliminary
step that determines whether an alcohol problem exists. Screening for alcohol
abuse involves honest discussion with the client about her alcohol use, and
allows for observation of their behavior, and signs of use. When screening be
Ensure privacy. Children should not be present
during the interview, as they may repeat what they hear.
Communicate trust and respect. Assure victims that,
except for safety concerns, anything discussed will be held in strict
Observe behavior. Look for signs of alcohol use.
Deal with denial. Denial is the most frequent
response of women because they are often ashamed of their behavior and
they may fear losing their children. Start by asking open-ended questions
about their partner's use of alcohol, and then work into their use.
Screening Instruments for
Many instruments are
available for screening. Screening questions can be asked through an in-person
interview, a written questionnaire, a computerized questionnaire, or a
telephone interview. Any positive responses should lead to further questions
about consequences. Alcohol screening in clinical practice should be consistent
with other screening procedures in place.
In some settings, screening
instruments are given as self-report questionnaires, with instructions for the
patient to discuss the meaning of the results with his or her health care
provider. Not all patients can read well enough to complete questionnaires.
questionnaire,11 which has been validated, is one of the
most well-known, widely used alcohol screens. It consists of four questions,
which can be self-administered-even by those with low reading skills-and can be
modified to screen for use of other drugs.
The CAGE can be administered
formally or informally as part of the intake process or when alcohol problems
are suspected. Positive responses on the CAGE are for lifetime problems, not
current problems. Before administering the CAGE or any other screen, it is
important to confirm that the person does currently drink alcohol and that
positive responses relate to problems experienced recently, usually within the
The Alcohol Use
Disorders Identification Test (AUDIT) has been validated cross-culturally.
Because there are few culturally sensitive screening instruments, the AUDIT may
prove useful for identifying alcohol problems among ethnic minority groups.
Laboratory tests generally are used only to supplement screening tests.12,13
The Michigan Alcohol Screening Test (MAST)
is one of the most widely used tools for alcohol abuse. The measure is a 25-item
questionnaire designed to provide a rapid and effective screening for lifetime
alcohol-related problems and alcoholism. The MAST has been used in many
settings and with varied populations.
The Short Michigan Alcohol Screening Test (S-MAST)
The Short Michigan Alcohol
Screening Test (S-MAST)
is aimed at identifying individuals with alcohol abuse or alcoholism. This
shorter version has been adapted from the longer MAST.
Additional Alcohol Screening
In addition, instruments are
available for determining quantity and frequency of alcohol consumption. Typical
screening questions can be used to screen for alcohol use. Assessment
and followup screening questions on alcohol use
provide greater detail about drinking patterns. These questions provide greater
specificity about drinking and are not prone to underreporting errors when
patients have to report their average consumption over time. These questions
can be used to track a patient's alcohol use.
Screening For Depression and
Other Health Conditions
Screening Survey addresses a range of health issues including physical
activity, smoking, and nutrition.
Assessments For Alcohol Use
Informed clinical judgment is
essential for a sound assessment, but validated substance abuse assessment
instruments also can provide a useful structured approach for many clinicians.
They provide a convenient checklist of items that should be consistently
evaluated during the assessment.
In general, specialized
assessments are conducted by treatment program personnel or specially trained
health care providers. Structured assessment interviews are considered
desirable tools for professionals because of this perceived "quantifiability, reliability, validity, standardization,
Two structured assessments
are available: the Structured Clinical Interview for DSM-IV (SCID) and the
Diagnostic Interview Schedule (DIS) for DSM-IV. These are commercially
available products that may require special training for proper use. The SCID
is a multi-module assessment that covers:
Substance use disorders
It takes a trained clinician
approximately 30 minutes to administer the 35 SCID questions that probe for
alcohol abuse or dependence. The DIS is a highly structured interview that does
not require clinical judgment and can be used by non-clinicians. The DIS assesses
both current and past symptoms and is available in a computerized version. It
has been translated into a number of languages, including Spanish and Chinese.
Agencies that assist victims
of alcohol abuse and domestic violence whose safety will be jeopardized by the
continued use of substances need to simultaneously address sobriety and safety
issues. Ideally, an agency will provide services coordinated for domestic
violence and substance abuse. Since this is not always the case, there are some
considerations to follow when referring clients to a substance abuse provider:
Will the assessment place the client at further
What assurance does the client need to feel
comfortable in following through with the referral?
What information does the client need to follow
through with the referral? If the client is referred to an off-site
location, does she know where it is and how to get there?
Are there barriers that could prevent the client
from keeping the appointment? Does she have transportation or child care
Assessment involves five
Assistance in diagnosing of the problem.
Establishing the severity of the problem.
Developing a treatment plan.
Defining a baseline that can be used to evaluate a
client's progress in treatment.
Increasing the client's motivation to attend
A variety of methods may be
used to assess the client, including medical examinations, clinical interviews,
formal instruments and questionnaires. Areas of assessment include alcohol use,
social and family relationships, psychological functioning, legal status,
medical conditions, and employment and educational status. Urine tests may be
threatening to women who have been sexually abused and are not always necessary
for assessment. Drug tests are most commonly done to monitor treatment
Talking About Alcohol Abuse
Many therapists feel
uncomfortable talking with patients about possible alcohol abuse. How you ask
your questions is more important than what you ask. The letters in the word
"PROBE" can help you remember ways to ask questions:
Probe for related information from the
patient that may help you determine his or her risk for substance abuse.
Rephrase questions so that they are
open-ended. Be sure that your questions don't suggest how they should be
Observe behavior in addition to asking
questions. People's behavior can provide you with clues to their risk for
Be matter-of-fact and routine as you
screen. Be sure to avoid any hint of judgment in your questions.
Everyone should be screened. Inform
participants that it is your practice to do so.
There are many ways in which
domestic violence agencies can support individuals who struggle with the issues
of alcohol abuse:
Helping staff deal with their own feelings about
Minimizing blame for client's use or relapse.
Helping clients understand how current relationship
may be contributing to their alcohol problems (particularly in cases of
Helping victims find an alternative means to replace
the substance-induced sense of power clients may feel.
Including plans for continued sobriety in the safety
planning. Help the victim understand the ways an abuser might try to
jeopardize her sobriety before she leaves the shelter or has received all
of the advocacy-based services offered.
Encouraging her to find and
help her link to alcohol abuse treatment resources and abstinence-based support
groups like Alcoholics Anonymous.
Violence for Women in Alcohol Treatment
Of those women who enter
treatment for substance abuse, 75-80 percent have been victims of physical or
sexual abuse.16 This high number indicates that there is a need for
addiction counselors to know about domestic violence and sexual assault,
especially when screening and assessing a new client.
Some of the suggested
statements of support covered earlier in the curriculum can also be applicable
in this situation. Below are additional suggested statements of support:
Don't initially refer to the partner's behavior as
abusive or domestic violence. Instead, refer to it as inappropriate behavior, unsafe
behavior, or unhealthy behavior.
Be patient. Initially, a woman may not feel safe
confiding information about herself. Proceed from the least intrusive
questions to the more personal and sensitive topics.
Be careful about criticizing the partner. Battered
women may still care for their partners, become defensive, and close down
Avoid labeling a woman's survival strategies as
co-dependent. They may be her way of surviving.
When asking questions, probe
for factual details. Ask her to clarify vague answers.
How safe do you feel with your partner? How safe do
you feel when you leave here?
How does your partner try to control your alcohol
How does your partner show respect to you?
Can you tell me about a situation with your partner
when: (1) yelling and screaming occurred, (2) things were destroyed, and
(3) your partner pushed, slapped, or hit you?
Have your efforts to get clean and sober been
sabotaged by your partner?
Besides physical signs,
professionals should listen for:
Any statements that suggest her partner won't let
her do something (e.g., attend counseling, support groups, see
family/friends, go alone to appointments),
Evidence or reports of child abuse, and
Inconsistencies or evasiveness.
Domestic Violence Assessment
When determining how to
respond to domestic violence victims once they have been identified, the
professional must think carefully about the questions he or she will ask.
Professional organizations need to have protocols and policies in place that
include clinical guides for effective assessment, intervention, documentation,
and referral. It is important to remember that there are no typical victims or
abusers. Be aware of your own assumptions before questioning a client. A danger
assessment questionnaire and a risk
assessment chart are sometimes helpful in determining whether a
woman is in danger or what the danger is.
Below are several tips for
assessing the client.18
Assess the priority of safety for
Is there immediate danger? Where is the perpetrator now? Where will the
perpetrator be when the patient/client is finished?
Assess the pattern and history of
Assess the perpetrator's physical, sexual, and psychological tactics, as
well as the economic status of the client. How long has the violence been
going on? Has the perpetrator harmed the client sexually? Does the
perpetrator control the client's activities, money, or children?
Assess the connection between
domestic violence and the client's health issues. What is the impact of the abuse
on the victim's physical, emotional, and spiritual well-being? What degree
of control does the perpetrator exercise over the victim? How is the
abusive behavior affecting the victim's health?
Assess the victim's current
access to advocacy and support resources. Are there community resources
available to the client? Has the client tried to use them in the past? If
so, what happened? What additional resources (besides what you have been
offered) are available now?
Assess the patient's safety. Is
there future risk of death or significant injury? Ask about the perpetrator's
tactics: use of weapons, frequency or severity of abuse, stalking or
suicide threats, use of alcohol. If there are children, ask about their
physical safety.19 Remember, a client must realize that if she
tells the professional about child abuse or maltreatment, the professional
is mandated, by law, to reveal the abuse to legal authorities or to Child
Alcohol Abuse With Men in Treatment For Violence
The incidence of alcohol
abuse among men in batterers' programs is between 50 percent and 100 percent,
depending on the proportion of the men who were referred by the criminal
justice system.20 Batterers referred by the courts are more likely
to be substance abusers than those who are self-referred. Men who are violent
outside their families are also more likely to abuse alcohol than those men who
are only violent at home.21
Module 3 briefly addressed
risk factors for family violence and general characteristics of men who batter.
It is important to remember that alcohol does not cause battering. However, for
most batterers, alcohol abuse may:
Increase the risk that he will misinterpret his
Heighten his belief that violent behavior is due to
alcohol or drugs.
Make him think less clearly about the repercussions
of his actions.
Impair his ability to tell when a victim is injured.
Lessen the likelihood that he will benefit from
punishment, education, or treatment.
Screening for substance abuse
is a preliminary step that determines the probability of an alcohol or drug problem.
Trained workers in batterers' intervention programs should ask standardized
questions and be trained to interpret responses. Many abusers will deny the use
of alcohol and minimize the effect it may have had on the violence. As
mentioned in an earlier section, several screening tools, including the S-MAST,
are available to professionals. More helpful screening tools cover a range of typical
Professionals also need to
observe the behavior of the men in the batterers' groups. Tardiness, fatigue,
aggression, or the smell of alcohol point to the need for formal alcohol
assessment. These are some general guidelines
a program can follow to identify clients who may be affected by alcohol or
other drug use. These guidelines help establish a uniform base from which all
program staff can work. It is helpful to observe the behavior of recovering
alcoholics in the batterers' program because recovering men are often able to
identify substance patterns in others.
If screening reveals the
possibility of alcohol abuse, the batterer should be referred for formal
assessment. Some agencies may have the capability to perform assessments
in-house, while others may have to refer the client to a specialist qualified
by the State. The batterer's program should assume the role of case manager if
the client needs to be referred out to another agency. In this way, the client
does not risk falling through the cracks.
If a man is court-ordered to
attend a batterer's program, and screening has established possible alcohol
abuse, the program should communicate with his probation officer that he needs
substance abuse treatment.
It is good to remember that
safety and sobriety are related. Lack of sobriety, either in the victim or
batterer, increases the risk for further violence against the victim. Lack of
victim safety threatens the sobriety of both victim and batterer. Abstinence
and sobriety do not automatically ensure safety.23
Domestic Violence With Men in Alcohol Treatment
Domestic violence, like many
other problems that affect chemically dependent persons, traditionally has been
viewed within the substance abuse field as a manifestation of other dysfunctions
resulting from long-term use of alcohol or drugs. Many counselors believe that
once the addiction is addressed and the man remains sober, the violence will
disappear as well. This is not the case. Violence does not always stop or even
diminish when the batterer becomes abstinent, and when it does diminish, an
increase in other abusive and controlling behavior often replaces it.24
Make it clear that all men in
the substance abuse treatment program will be screened for violence. This helps
ensure victim safety if the man does not believe that the staff person was
"tipped off" by his partner. The tools to screen for domestic
violence mentioned in earlier sections apply here as well. If a professional
identifies a man as having used violence:
Immediately refer him to staff at a domestic
violence program to get him enrolled in batterer's intervention. If there
is not an integrated system within your agency, you will need to locate
the local domestic violence program.
Use separate facilities to provide services to the
batterer and his female victim. If this is not possible, try to schedule
appointments at times when the perpetrator and victim will not be in the
facility at the same time.
If the client's attendance has been court mandated,
contact the probation officer immediately.
Remember that abstinence does not always ensure that
the violence will stop.
Do not provide him with family or couples therapy.
Because many substance abuse
and domestic violence agencies have not fully integrated or coordinated their
services, it is important for a substance abuse treatment facility to train
staff to be knowledgeable about domestic violence.
Some agencies have developed
Service Organization Agreement25 or another type of
linkage agreement that establishes regular communication between substance
abuse treatment providers and local domestic violence programs. Agreements also
help to ensure proper confidentiality requirements are met and followed.
Timing for Batterer
Some substance abuse
counselors wait 90 days before enrolling a man in a batterer's intervention
program. However, violence is a powerful relapse trigger than can sabotage
recovery, especially in the early stages. There are other concerns regarding
partner abuse intervention:
Clients may be resistant to counseling and may not
appreciate the confrontational nature of batterers' groups.
Some clients may be neurologically impacted by
alcohol and drugs and may not be able to participate fully in a group
Clients may have some cognitive and educational
deficiencies, which can impact their capacity to take responsibility for
Denial is a strong component in both substance abuse
and batterer programs.
Relapse prevention seems to
work best when the client looks at batterer intervention programs as a way to
stay sober. Professionals can stress to clients that being held accountable for
a violence-free life and sobriety are linked in a number of ways:
In the Twelve Steps of AA/NA, inventory steps
emphasize that the person needs to hold himself/herself accountable by
admitting "to God, to ourselves, and to another human being the exact
nature of our wrongs." In the eighth and ninth steps, participants
are required to make a "list of persons we have harmed" and
become "ready to make direct amends to them all."26
The cognitive-behavioral approach helps men
recognize the relationship between their thoughts, feelings, and
Most religious traditions have some form of
"Golden Rule." Stress the importance of spirituality and
relationships in ways that emphasize the destructive quality of violence
Maltreatment and Abuse
Because there is established
research showing the danger parental domestic violence and substance abuse pose
to children, both kinds of treatment programs need to have policies in place to
address this issue. Even though the identified client is the adult, a child's
safety also must be considered.
Both substance abuse and
domestic violence programs are mandated to report child abuse. If there is
domestic violence in the home, the child should receive a thorough physical and
psychological assessment. When appropriate, the child also should be referred
to a support group like those run by many domestic violence programs. For more
information about child abuse and neglect, visit http://child-abuse.org or www.connectforkids.org.
Alcohol use and other
psychiatric symptoms are common in all age groups.
Data from the National
Household Survey on Drug Abuse have strengthened support for a possible link
between alcohol use and abuse and the development of other psychiatric
illnesses.27 Adults with a lifetime diagnosis of alcohol abuse or
dependence were found to have nearly three times the risk of being diagnosed
with another mental disorder.
Comorbid disorders associated with alcohol use
Antisocial personality disorder28
According to one study, older
alcohol abusers are more likely to have triple diagnoses-alcohol, depression,
and personality disorders; Younger substance abusers are more likely to be
diagnosed with schizophrenia.29 In addition, alcohol use triples the
risk of depression.30,31
Alcohol use can precipitate a
variety of mental conditions, including:
Alcohol problems often
coexist with and compound other mental disorders, primarily affective
disorders, anxiety disorders, and schizophrenia. Alcoholism can also produce
confusion and memory loss, and precipitate suicide. People with anxiety
disorders and depressive disorders have been found to abuse alcohol at higher
rates than the general population.
Reducing alcohol use often
resolves or reduces the severity of psychiatric problems.
Alcohol abuse in the presence
of a psychiatric disorder complicates treatment in a number of ways:
The co-occurrence creates interpersonal
The psychiatric problem contributes to continued
Alcohol abuse interferes with engagement in mental
The person with a dual
diagnosis is also at increased risk of social problems such as homelessness,
poverty, incarceration, and legal problems.
There are three general
linkages between substance abuse and mental health that apply to adults:
Substance abuse and mental health problems are
correlated. There is a definite relationship, but it is not clear whether
one causes the other.
Mental health issues often are risk factors for
substance abuse, such as low self-esteem, loneliness, stress, tension,
personality factors, and depression.
Many external factors are similar for both substance
abuse and mental health problems. These include sociocultural
factors, familial and genetic factors, and environmental factors.
Dual diagnosis in older
adults (55+) differs from that in younger people in the following ways:
The aging process affects the course of the
Older adults rarely use illegal drugs.
Antisocial behaviors, such as car theft, and
schizophrenia are less prevalent in older adults than in the younger
Asocial, or isolating, behavior is more commonly
seen with older adults.
Older adults, in general, tend to experience higher
rates of multiple chronic illnesses, cognitive impairments, and losses
than younger adults.
Lifestyle goals change. Older adults have more often
reached stable living conditions than young adults. Young adults tend to
move more geographically, for pleasure and business, than older adults.
Several factors place the
mental health of adults at risk:
Societal stigma toward alcoholism and mental illness
Code of silence (shame and embarrassment)
Marginalization (especially if from a minority
Danger signs that are minimized or discounted (seen
as fear, anxiety, and decreased health)
These risk factors are common
for both substance use and mental health problems. In many cases, it is almost
impossible to determine which problem presented first. It is more important to
recognize coexisting conditions. With chronic long-term use of alcohol there
may be significant irreversible cognitive damage as well as a preexisting
mental health condition.32
There are steps a woman can
take to ensure her safety in a potentially violent situation. Most will apply
directly to women who either live with or have lived with a violent partner.
However, some of these steps, can be used in other situations, such as dating
violence, acquaintance rape or sexual assault, and some forms of elder abuse.
A woman does not have control
over her partner's actions, but she does have control over how she prepares for
her safety and that of her children. The process of designing a personal safety
plan may seem overwhelming, but there are four
scenarios that will help your client determine which actions are
appropriate for her situation. These scenarios include:33
Safety During a Violent Incident
Safety for Those Who Plan to Leave
Safety in Your Own Residence
Safety On The Job
Local domestic violence or
sexual assault resources can provide more information. Tell your client always
to keep the plan in a safe place, away from her partner.
Health care or mental health professionals need to think
about specific concerns regarding domestic violence.
Screening and assessment are important first steps
when meeting with a client who may be abused or have an addiction.
Screening protocols need to be in place for
substance abuse and domestic violence clients.
Assessment of substance abuse and domestic violence
in services offered as part of both women and men's programs is crucial to
ensure the safety and sobriety of both batterer and victim.
A client may take several steps to help ensure her
safety at home or at work.
VII: DIAGNOSIS AND TREATMENT
As the modules in this course
have shown, the issues of alcohol abuse and violence against women are complex
and far-reaching. When the two issues intersect, as is frequently the case, it
creates even more challenges for the health and mental health care
professional. The challenges are especially apparent in the area of treatment.
Practitioners must often
juggle complex problems with conflicting models and goals to determine the best
course of action for a range of clients (both men and women). Just what this
"best course" is may not be obvious to even the most seasoned
practitioner. For example, should a woman with an abusive husband begin couples
therapy if it helps the man become less abusive but perpetuates an unhealthy
relationship? When is the right time for a woman to address her own addiction
problems if she is coping with post-traumatic stress disorder? What is the best
choice for an abusive man with addiction issues if the only treatment options
are separate programs across town from each other?
At the same time, few
programs address the link between alcohol abuse and violence against women,
despite research showing the connection.
Society has come a long way
since the days when wife-beating was considered a husband's prerogative or when
the only treatment for alcohol abuse was an overnight stay in the local jail.
As health and mental health professionals, researchers, and members of the
public increase their awareness of the link between alcohol abuse and violence,
program options will reflect this awareness.
Understanding the specialized
alcohol abuse treatment system can be challenging. No single definition of
treatment exists, and no standard terminology describes different dimensions
and elements of treatment. Describing a facility as providing inpatient care or
ambulatory services characterizes only one aspect: the setting.
Another challenge is that the
specialized alcohol abuse treatment system differs around the country, with
each State or city having its own peculiarities and specialties. For example:
Minnesota is well known for its array of
public and private alcoholism facilities. Most are modeled on the
fixed-length inpatient rehabilitation programs initially established by
the Hazelden Foundation and the Johnson
Institute. These organizations subscribe to a strong Alcoholics Anonymous
orientation and have varying intensities of aftercare services.
California offers a number of
community-based public sector programs based on a social model emphasizing
a 12-Step, self-help approach as a foundation for lifelong recovery.
In this module, the term
"treatment" will be limited to describing the formal programs that
serve patients with more serious alcohol and drug problems who do not respond
to brief interventions or other office-based management strategies, and those
women who face abuse issues. It is also assumed that an indepth
assessment has been conducted to establish a diagnosis and to determine the
most suitable resource for the individual's particular needs.
Treatment: Alcohol Abuse
Each individual in treatment
will have specific long- and short-term goals. However, all specialized
substance abuse treatment programs have three similar general goals:1,2
Reducing substance abuse or achieving a
Maximizing multiple aspects of life functioning
Preventing or reducing the frequency and severity of
For most people, the primary
goal of treatment is attaining and maintaining abstinence. Until the individual
accepts that abstinence is necessary, the treatment program usually tries to
minimize the effects of continuing use and abuse. This goal is achieved through
education, counseling, and self-help groups that stress:
Reducing risky behavior
Building new relationships with drug-free friends
Changing recreational activities and lifestyle patterns
Substituting substances used with less risky ones
Reducing the amount and frequency of consumption,
with a goal of convincing the client of his or her individual
responsibility for becoming abstinent.3 Total abstinence is
strongly associated with a positive long-term prognosis.
Becoming alcohol- or
drug-free, however, is only a beginning. Most people in substance abuse
treatment have multiple and complex problems in many aspects of living,
Mental health concerns
Underdeveloped or deteriorated social and vocational
Impaired performance at work or in school
Legal or financial troubles
These conditions may have
contributed to the initial development of a substance use problem or resulted from
the disorder. Treatment program staff need to assist individuals in addressing
these problems so that they can assume appropriate and responsible roles in
society. Goals include:
Maximizing physical health
Treating independent psychiatric disorders
Improving psychological functioning
Addressing marital or other family and relationship
Addressing financial and legal problems
Improving or developing necessary educational and
Many programs also help
participants explore spiritual issues and find appropriate recreational
programs are also preparing individuals for the possibility of relapse and
helping them understand and avoid dangerous "triggers" of resumed
drinking or drug use. Individuals are taught how to:
Develop contingency plans for handling stressful
Relapse prevention is
particularly important as a treatment goal in an era of shortened formal,
intensive intervention and more emphasis on aftercare following discharge.
of Alcohol Abuse Treatment
The effectiveness of
treatment for specific individuals is not always predictable. In addition,
different programs and approaches have variable rates of success. However,
evaluations of substance abuse treatment efforts are encouraging. All the
long-term studies find that "treatment works." Most
substance-dependent patients eventually stop compulsive use and have less
frequent and severe relapse episodes.4,5 Relapse is not seen as a
treatment failure, but a part of the recovery process.
The most positive effects
generally happen while the patient is actively participating in treatment.
Still, prolonged abstinence following treatment is a good predictor of
continuing success. Almost 90 percent of those who remain abstinent for 2 years
are also drug- and alcohol-free at 10 years.6
Patients who remain in
treatment for longer periods of time are also likely to achieve maximum
benefits. Duration of treatment for 3 months or longer is often a predictor of
a successful outcome.7
Individuals who have lower
levels of premorbid psychopathology and other serious
social, vocational, and legal problems are most likely to benefit from
treatment. Continuing participation in aftercare or self-help groups following
treatment also appears to be associated with success.8
The diagnosis and treatment
of addiction and alcohol abuse involves many variables. A practitioner needs to
know the type and amount of substance the person ingests. Depending on the
severity of the problem, a person can be detoxified safely on an outpatient
basis or in a non-medical setting. Others may be subject to life-threatening
withdrawal symptoms, such as grand mal seizures.9
treatment means that the individual's treatment is tailored to the specific
addiction syndrome and life situation of the patient.
Because each person presents
with different needs and history, there is no one-size-fits-all approach that
can work effectively when treating addiction. Diagnosis-driven treatment means
that the individual's treatment is tailored to the specific addiction syndrome
and life situation of the patient.10 Does the patient need to be in
an outpatient or inpatient facility? Is medical intervention necessary? Are
there other drugs that will affect the patient's withdrawal? Are there
psychiatric symptoms that will affect detoxification and sobriety? These
questions and others will need to be addressed in order to effectively treat an
Patient placement describes a
process by which a recommendation is made for placement in a specific level
(intensity) of care. Levels range from outpatient services (low intensity) to
medically managed (high intensity) inpatient services. The most commonly used patient
placement criteria are found in the American Society of Addiction
Medicine (ASAM) Patient
Placement Criteria for the Treatment of Substance-Related Disorders,
Second Edition (ASAM-PPC-2). The ASAM criteria address five major levels of
Under each type of care,
there are different levels of service intensity. The criteria evaluate six
problem areas in the process of matching a patient to a level of care:13
Acute intoxication and/or withdrawal potential
Biomedical conditions and complications
Emotional/behavioral conditions and complications
Relapse/continued use potential
Accurate and thorough written
records become essential in this diagnosis-driven approach to determine not
only what type of care is needed, but also whether treatment is necessary.
Especially in the age of HMO justification, patient evaluations that document
an objective assessment process provide justification for any treatment
DSM-IV In Clinical Diagnosis
The Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association is
the generally accepted source for assessment and diagnosis. Several clinical
interviews have been designed to help develop a DSM-IV substance use disorder
diagnosis. The Structured Clinical Interview for DSM-IV (SCID) is considered
one of the most easily incorporated into a diagnosis battery for evaluation.14,
The SCID, which can be used
to obtain Axis I and Axis II diagnoses based upon the DSM-IV criteria, is a semi-structured
interview designed for use with psychiatric, medical, or community-based normal
adults. Sections of the SCID are designed to address each of the major DSM-IV
Substance use disorders
The industry standard for a
diagnostic reference is the Diagnostic and Statistical Manual of Mental
Disorders; 4th Edition (DSM-IV). The DSM-IV
Diagnostic Criteria includes definitions for substance abuse and
Psychological Profile of Alcohol Use
In diagnosing alcohol
problems in adults, it is important to understand the person's history and
medical condition, as well as any psychosocial factors. These factors, as well
as the prognosis for treatment, vary depending on the stage of use. No one
should be deemed hopeless, but different factors affect treatment.
One category that is often
overlooked is the risky
drinker. Risky drinkers may show no signs of an alcohol-related problem at the
time of assessment, but if their rate of consumption continues to increase,
problems may arise. In older adults, risky drinking constitutes 10 to 15 drinks
per week for men, and 7 to 9 drinks per week or more than 4 drinks on any
drinking occasion for women. The Signs and
Symptoms Related to Stages of Drinking is helpful in putting
together a treatment plan, including the determination of an appropriate level
Both short- and long-term
options must be considered for women in treatment. If the woman is a victim of
intimate partner violence, short-term case management may involve details other
than alcohol abuse problems in order to keep the woman safe and alive. This is
particularly critical immediately after a woman has left her home and is most
at risk from the perpetrator's revenge.
For addiction, treatment
services can be categorized in terms of intensity, from least intense to most
On any given day, more than
700,000 people in the United
States receive alcoholism treatment in
either inpatient or outpatient facilities.16 Research in the field
continues to assess which approaches are most effective with certain
populations and in different settings.
Any professional working in
the addiction field needs to understand what alcohol withdrawal entails. The
intensity of withdrawal will depend upon the extent to which the person is
addicted and how long they have been addicted. All treatment plans address withdrawal,
which is considered a regular part of recovery.
The examples that follow are
some approaches currently used in many substance abuse treatment centers around
the country. For additional information on substance abuse treatment, go to www.samhsa.gov and click
on the Center for Substance Abuse Treatment. For a list of treatment facilities
in each State, go to www.nattc.org
and click on "treatment." The NATTC Web site also has links to other
Many forms of treatment
exist. Depending on the desired outcome, different approaches may be used.
These theoretical approaches include:
and Cognitive-Behavioral Coping-Skills Therapy
These related approaches are
based on learning theory principles that state that human behavior is largely
learned and, therefore, can be changed or adapted. The term
"behavioral" is used broadly to include any non-pharmacological
therapy for which the objective is to change behavior (e.g., to reduce alcohol
consumption). When working with addiction, one of the biggest challenges is
Internal and external risk
factors influence a person's ability to remain sober. Internal factors may
include depression, anxiety, or craving. External factors may include seeing a
bar, smelling alcohol, having relationship problems, or hearing ice click
against a glass. These cognitive
therapeutic approaches are intended to train the client to identify
those high-risk triggers and to develop alternative coping mechanisms. The
central goal of these approaches is to teach the client techniques to replace
maladaptive responses and behaviors with those that are healthier.17
Enhancement Therapy (MET)
Therapy is based on motivational and social psychology. Unlike other approaches
that guide the client step-by-step through therapy, MET's aim is to motivate
clients to use their own
resources to change behavior. This approach is largely client centered; the
client comes up with his or her own personal decision plan for change. The
therapist initially assesses the type and severity of the person's drinking and
then provides the basic structure within which the client must work.
MET differs from behavioral
approaches in that no direct advice or skill training is provided. The goal of
MET is to stop destructive drinking by helping the client to recognize
discrepancies between his or her current behavior and personal goals (rational
Relapse prevention is a type
of coping-focused psychotherapy that aims to teach recovering alcoholics coping
skills that will help them avoid relapsing back into using alcohol. The goals
helping the person identify, anticipate, avoid, or
cope with high-risk situations (for relapse);
helping the person learn how to keep one lapse from
turning into a multiple relapse situation; and
helping the person feel as if he/she is capable of
controlling his or her own behavior
Many skills are taught in a
relapse prevention class. Some of these skills include:
Learning to recognize the difference between a lapse
from a relapse (ongoing detrimental behavior)
Learning to identify stressful situations and
objects, such as a beer bottle or cigarette that can trigger a relapse
Learning how to avoid or defuse a stressful
situation once it is identified
Learning how to identify, plan, and participate in
positive and sober activities that can fill the time otherwise spent
drinking or worrying about drinking
Learning how to turn unhealthy behaviors into
Facilitation and Alcoholics Anonymous
(TSF) is a formal treatment approach that is designed to introduce clients to
and involve them in Alcoholics Anonymous (AA) or other similar 12-step
programs. AA outlines 12 consecutive steps that alcoholics must follow and
achieve during the recovery process. Some of these steps include: Admitting
they are powerless over alcohol and that their lives are "insane; making a
moral inventory of themselves; admitting the nature of their wrongs; making a
list of people they have harmed; and making amends to those people. Alcoholics
can become involved in AA before or during treatment. Individuals may
experience different levels of involvement (e.g., how often they attend AA
meetings or whether they get a sponsor).20
counselors help to guide the client through the first five steps using 12-15
brief, individualized sessions. It is based in behavioral, spiritual, and
cognitive principles that form the core of AA. The theoretical framework
follows AA's steps and traditions and includes the need to accept the belief
that willpower alone is not enough to remain sober. It also teaches that
self-centeredness must be replaced by surrender to the group conscience, and
that long-term recovery is a process of spiritual renewal. The client must actively
participate in a 12-step program and be willing to accept a higher power as the
locus of change.21
Many forms of treatment
exist. Depending on the desired outcome, and unique needs of the individual,
different approaches may be used.
For some adults, pretreatment
approaches may prove quite effective. This is especially true for late-onset
drinkers and prescription drug abusers with strong social support and no mental
health comorbidities. Followup
brief interventions and empathic support for positive change may be sufficient
for continued recovery. There is, however, a subpopulation who will need more
Despite the resistance that
some problem drinkers or drug abusers exert, treatment is worth pursuing.In determining a formal course of treatment, some
important considerations include:
Whether adequate efforts have been made to help the
client to reduce alcohol use to safe levels
Whether abstention or harm reduction is the goal of
The attitudes of staff and philosophy of the program
The availability of required modes of treatment
(e.g., detoxification, inpatient, intensive outpatient, outpatient)
The availability of aftercare or continued
As a prelude to
cognitive-behavioral therapy, a therapist might use motivational counseling.
This is a more intense process than the motivational interviewing that may take
place during a brief intervention. Motivational counseling acknowledges
differences in readiness to change and offers an approach for "meeting
people where they are."
Motivational counseling has
proven effective with adults.1 An understanding and supportive
Listens respectfully and accepts theadult's
perspective on the situation as a starting point
Helps the individual identify the negative
consequences of drinking
Helps the person shift perceptions about the impact
of drinking or drug-taking habits
Empowers the individual to generate insights about
and solutions for his or her problem
Expresses belief in and support for the adult's
capacity for change
Motivational counseling is an
intensive process that enlists patients in their own recovery by:
Avoiding confrontation (which usually results in
Accepting ambivalence about the need to change as
Inviting clients to consider alternative ways of
Placing the responsibility for change on the client
This process also can help
offset the denial, resentment, and shame invoked during an intervention.2
It falls somewhere between brief interventions and pretreatment interventions.
There are three broad
categories of cognitive-behavioral approaches: behavior modification/therapy,
self-management techniques, and cognitive-behavioral therapies. Behavior
modification applies learning and conditioning principles to modifying overt
behaviors, which are those behaviors obvious to everyone around the client.3,4
Self-management refers to teaching the client to modify his or her overt
behaviors as well as internal or covert patterns. Cognitive-behavioral therapy
involves altering covert patterns or behaviors that only the client can
techniques teach clients to identify and modify self-defeating thoughts and
beliefs.5,6 This is intended to improve mood and reduce the
probability of drinking as a method of coping, especially in the face of
relapse pressures. These pressures include negative emotional states, such as
depression, anger, and frustration; peer pressure; and interpersonal conflicts
with spouse, family, a boss, and others.
Drinking Behavior Chain
model offers an especially powerful method for targeting problems or treatment
objectives that affect drinking behavior. Together, provider and client analyze
the behavior itself, constructing a "drinking behavior chain." The
chain is composed of:
The antecedent situations, thoughts, feelings,
drinking cues, and urges that precede and initiate alcohol or drug use
The drinking or substance-abusing behavior (e.g.,
The positive and negative consequences of use for a
When exploring the latter, it
is particularly important to note the positive
consequences of use: those that maintain abusive behavior. Cognitive-behavioral
therapy is ideally suited to individuals who are slow to learn because of
residual impairment of cognitive functioning. This is because this method
breaks down information into small manageable units and repeats them until
understanding is ensured.
Researchers have developed an
instrument that can elicit by interview the individual's drinking or drug use behavior
chain.7 Immediate antecedents to drinking include feelings such as
anger, frustration, tension, anxiety, loneliness, boredom, sadness, and
depression. Circumstances and high-risk situations triggering these feelings
include marital or family conflict, physical distress, and unsafe housing
arrangements, among others.Alcohol use is often a
form of "self-medication, a means to soften the impact of unwanted change
For the patient, new
knowledge of his or her drinking chain often clarifies for the first time the
relationship between thoughts and feelings and drinking behavior. This method
provides insight into individual problems, demonstrates the links between
psychosocial and health problems and drinking, and provides the data for a rational
treatment plan and an explicit individualized prevention strategy.
Breaking drinking behavior
into the links of a drinking chain serves treatment in other ways, too. It
suggests elements of the community service network that may be helpful in
establishing an integrated case management plan to resolve antecedent
conditions (e.g., housing, financial, medical problems). Involvement from the
community may be needed beyond the treatment program.
Treatment in Group Settings
Behavioral treatment can be
used with adults individually or in groups, with the group process particularly
suited to women with abuse and addiction issues (see Group-Based
Approaches). Equipped with the knowledge of the individual's
drinking or drug abuse behavior chain, the group leader:
Begins to teach the client the skills necessary to
cope with high-risk thoughts or feelings
Teaches the person to initiate alternative behaviors
to drinking, then reinforces such attempts
Demonstrates through role-playing alternative ways
to manage high-risk situations, permitting the client to select coping
behaviors that she feels willing and able to acquire
Asks for feedback from the group and uses that
feedback to work gradually toward a workable behavioral response specific
to the individual
The behaviors are rehearsed
within the treatment program until a level of skill is acquired. The patient is
then asked to try out the behaviors in the real world as "homework."
For example, a client who has been practicing ways to overcome loneliness or
social isolation may receive a community-based assignment in which to carry out
the suggested behaviors.
After practicing, the
individual reports to the group. Then the therapist and group members provide
feedback and reinforce the individual's attempt at self-management (whether or
not the outcome was a success). This process continues until the individual
develops coping skills and brings the antecedents for abuse under self-control
or self-management. Typically, as patients learn to manage the conditions
(thoughts, feelings, situations, cues, urges) that prompt alcohol abuse,
abstinence can be maintained.
Defining drinking behavior
antecedents is also useful for determining when a client is ready for
discharge. When the individual can successfully use coping behaviors specific
to his or her drinking antecedents, the treatment team might assist the person
in gradually phasing out of the program. Discharge that takes place before the
client has acquired specific coping behaviors is almost certain to result in
relapse, probably very soon after discharge.
Studies comparing early- and
late-on set problem drinkers showed great similarity between these two groups'
antecedents to drinking and treatment outcomes.8 Another study
described a behavioral regimen that included psychoeducation,
self-management skills training, and marital therapy. Studies recommend that
treatment focus on:
Teaching skills necessary for rebuilding the social
Self-management approaches for overcoming
depression, grief, or loneliness
General problem solving9
Group experiences are
particularly helpful to women in treatment. They provide the arena for:
Giving and sharing information
Practicing skills, both new and long-unused
Testing the clients' perceptions against reality
Perhaps the most beneficial
aspect of groups for older adults is the opportunity to learn self-acceptance
through accepting others and in return being accepted. Guilt and forgiveness
are often best dealt with in groups, where people realize that others have gone
through the same struggles.
Special groups may also deal
with the particular problems of aging. The group format can help patients learn
skills for coping with many of the life changes that can put one at risk for
substance abuse, including:
Bereavement and sadness
Loss of friends, family members, social status,
occupation and sense of professional identity, hopes for the future,
ability to function
Social isolation and loneliness
Reduced self-regard or self-esteem
Family conflict and estrangement
Problems in managing leisure time/boredom
Loss of physical attractiveness (especially
important for women)
Cognitive impairment and change
Reduced coping skills
Decreased economic security or new poverty status
Therapy groups can be
effective ways to provide peer support, particularly if AA meetings are not
accessible. They focus on building new social and coping skills. They also
encourage connections with peers or others, adding to the social network.
Social contacts outside of formal meetings are usually encouraged.
Some therapy groups engage in
behavioral interaction, others in more psychodynamic therapy. Both types of
groups allow clients to test the accuracy of their interpretations of social
interactions, measure the appropriateness of their responses to others, and
learn and practice more appropriate responses. Groups provide each client with
feedback, suggestions for alternative responses, and support as the individual
tries out and practices different actions and responses.
Some people may need help in
entering the group, particularly if they are used to isolation. This help could
include individual counseling sessions in which the counselor explains how a
group works. The counselor could also answer the client's questions about
The client's entry into the
group may be eased by joining in stages, at first observing, then over time
moving into the circle. The counselor may formally introduce the new person to
the members of the group so that upon entering the group, he or she is at least
somewhat familiar with them.
Older adults grew up before
psychological terms had been integrated into everyday language. Therefore,
therapy groups for older adults should avoid the use of jargon, acronyms, and
"psychspeak." If leaders do use such terms,
they should begin by teaching the group their meanings. If a participant uses
an unfamiliar term, the leader should explain it. It may be helpful to develop
a vocabulary list on a chart and for any individual notebooks.
Similarly, many individuals
were raised not to "air their dirty laundry." Therefore, they should
never be pressured to reveal personal information in a group setting before
they are ready. Nor should patients be pressured into role-playing before they
Educational groups are an
integral part of addiction and domestic violence treatment. Patients need
information about addiction, the substances, their use, and their impact. Women
also benefit from shared information about:
The developmental tasks of each stage of life
Medical aspects of aging and addiction
The concepts and processes of cognitive-behavioral
Educational units can be
designed to teach practical skills for coping with any aspect of daily life,
such as safety, nutrition, household management, and exercise.
Some basic principles for
designing educational groups follow:
Traumatized women can receive, integrate, and recall
information better if they are given a clear statement of the goal and
purpose of the session and an outline of the content. The leader can post
this outline and refer to it during the session. The outline may also be
distributed for use in personal note taking and as an aid in review and
recall. Courses and individual sessions should be conceived as building
blocks that are added to the base of theadult's
life experience and needs. Each session should begin with a review of
previously presented materials.
Members of the group may range in educational level
from functionally illiterate to postgraduate degrees. Many women are adept
at hiding a lack of literacy skills. These individuals need to be helped
in a way that maintains their self-respect. Group leaders should choose
vocabulary carefully based on clients' communication skills.
Anonymous and Other Self-Help Groups
Many treatment programs refer
patients to Alcoholics
Anonymous (AA) and other self-help groups as part of aftercare. AA
is a grassroots peer-assistance approach that has had the greatest impact on
the treatment of chemical dependency. It addresses living without alcohol
through working a Twelve Step program.
AA requires attending
regularly scheduled meetings. This may be a problem for women who have
transportation needs, although a sponsor in the chapter may be able to assist.
Providers should warn patients
that these groups might seem confrontational and alienating. The referring
program should tell patients exactly what to expect. Group discussions may
include profanity and younger members' accounts of their antisocial behavior.
To orient clients to these
groups, the treatment program may ask that local AA groups provide an
institutional meeting as a regular part of the treatment program. Other options
are to help clients develop their own self-help groups or to facilitate the
development of independent AA groups for older adults in the area.
Avoiding future problem
drinking may depend on continuing affiliation with a recovering peer group.
Some model programs have created volunteer alumni groups to allow continued
affiliation after requirements for treatment, such as court supervision, end.
Because of current
interpersonal conflicts and the underlying feelings of shame, denial, guilt, or
anger, psychotherapy may be appropriate. It can occur in conjunction with other
treatment methods such as AA or hospital-based treatment programs. Grief
counseling can support the process of healing losses.
Individual counseling is
especially helpful to the older substance abuser in treatment's beginning
stages, but the counselor often must overcome clients' worries about privacy.
Subjects that many older adults are loath to discuss include their
relationships with their spouses, family matters and interactions, sexual
function, and economic worries.
It is essential to assure the
client that the sessions are confidential. In addition, the therapist should
conduct the sessions in a comfortable, self-contained room where the client can
be certain the conversation will not be overheard.
Older clients often respond
best to counselors who behave in a nonthreatening, supportive manner and whose
demeanor indicates that they will honor the confidentiality of the sessions.
Clients frequently describe the successful relationship in familial terms:
"It is like talking to my son, or, "It is as though she were my
sister." Older clients value spontaneity in relationships with the
counselor and other staff members. A counselor's appropriate self-disclosure
often enhances or facilitates a beneficial relationship with the patient.
Because receiving counseling
may be a new experience for the client, the provider should explain the basics
of counseling and clearly present the responsibilities of the counselor and the
client. Summarizing at the beginning of each session helps to keep the session
moving in the appropriate direction. Summarizing at the end of a session and
providing tasks to be thought about or completed before the next session help
reinforce any knowledge or insights gained. They also contribute to the older
client's feeling that he or she is making progress.
In individual sessions,
counselors can help clients prepare to participate in a therapy group, building
their understanding of how the group works and what they are expected to do.
Private sessions can also be used to clarify issues when the individual is
confused or is too embarrassed to raise a question in the group. As the client
becomes more comfortable in the group setting, the counselor may decide to
taper the number of individual counseling sessions. Likewise, the client may
prepare for discharge by reducing the frequency or length of sessions, secure
in the knowledge that more time is available if needed.
Management, Community-Linked Services, and Outreach
Case management is the
coordination and monitoring of the varied social, health, and welfare services
needed to support an adult's treatment and recovery. Case management starts at
the beginning of treatment planning and continues through aftercare. One
person, preferably a social worker or nurse, should link all staff who play a
role in the client's treatment. This person should also coordinate with other
important individuals in the client's social network.
The case/care manager
develops the treatment plan, reviews progress, and revises the treatment plan
as needed. There is a process for monitoring success in achieving the goals of
treatment. The case manager serves as an advocate, representative, and
facilitator of links to other agencies to procure services for the client.
The multiple causes of abused
and addicted women's problems require multiple linkages to community services
and agencies. The treatment program that seeks to be the sole source of all
services for its clients is likely to fail. Even in very isolated areas,
programs can strengthen their services for women through linkages to local
resources such as the faith community.
The case manager will likely
refer the client to a combination of several community resources in response to
the issues associated with the substance abuse problem. Case managers must have
strong linkages through both formal and informal arrangements with community
agencies and services such as:
Medical practitioners, particularly mental health
Medical facilities for detoxification and other
Home health agencies
Housing services for specialized housing
Public and private social services providing in-home
Faith community (e.g., churches, synagogues,
Vocational training and employment programs
Community organizations that place clients in
Legal and financial services
If a program includes
outreach services, case management may offer the best means of providing them.10,11
Case managers may, for example, initiate outreach services for homebound
clients, although it is important to maintain continuity and assign only one
case manager to an older client. If clients in a treatment program become
seriously ill or dysfunctional and temporarily require services at home, a case
manager may be the ideal staff person to broker services on their behalf. (Comprehensive
case management for substance abuse treatment is described in detail
in TIP 27.)
Not every approach will be
necessary for every client. Instead, the program leaders can individualize
treatment by choosing from this menu to meet the needs of the particular
client. Planning information comes from:
Mental status examinations
Laboratory, radiological, and psychometric tests
Social network assessments
In addition to formal
treatment, a number of other treatment approaches are useful in responding to
some substance abusers. Generally, however, they work best when they complement
the major approaches listed above.
Spiritual or religious
counseling with a clergy member, either in a group or individual setting, may
be an important adjunct to therapy for individuals who feel more comfortable
addressing their concerns in a religious context.
Substance abuse treatment
providers are moving toward a greater recognition of the role of spirituality
in recovery. Providers should not hesitate to build on the religious belief
systems of clients, when appropriate.23 From its inception, Alcoholics Anonymous has
spoken of "a higher power, and much of its effectiveness may derive from
its spiritual aspects. One caution:Adults who have
never subscribed to a religious belief system may not be ideal candidates for
spiritually oriented therapy or referral to 12-Step fellowship programs.
Rational Recovery may be a worthwhile alternative.
Spirituality is often a key
element in brief interventions. Programs that specialize in the treatment of a
particular ethnic or racial group may adopt strategies specific to that group
(e.g., the use of tribal rituals in the treatment of Native American substance
abusers). A variety of nontraditional methods for tension reduction (e.g.,
therapeutic massage, meditation, acupuncture) have been suggested as applicable
to women, although these methods remain largely untested.
Treatment: Domestic Violence and Sexual Assault
For professionals addressing
treatment needs related to violence against women, the immediate goal is to
ensure the woman's physical safety (and that of her children). In some cases, a
woman may already have prepared a safety plan in the event of a violent act by
an intimate partner. In cases of sexual assault, professionals must be trained
to make sure the woman gets the medical help she needs and takes precautions to
preserve evidence of assault if legal action is taken.
For many victims of violence,
their first contact with a mental health organization may be with a hotline,
crisis center, or emergency room, most of which provide 24-hour service to
women in need. As a first step, all mental health and health professionals -
not just those in the domestic violence field -- must be aware of the resources
in their communities. These resource include social service and other agencies
and private organizations that can address immediate needs, such as designated
"safe houses," income support, transportation, medical services, family
support, legal services, and nutrition.
However, a victim's need for
intervention services should not diminish the need for therapeutic services.
These therapeutic services must include the long-term goal of helping the
individual recover from the abuse or assault and achieve well-being. In cases
where the woman also abuses alcohol, the mental health professional must work
with the client to incorporate the goals of both sobriety and safety into her
Approaches to Treatment: Domestic Violence and Sexual Assault
Formalized treatment for
domestic violence began in the early 1970s. Through the women's movement,
treatment programs were designed, not only for the victims, but also for the
batterers. Over the years, some programs have adapted their theoretical
approaches and treatment modalities to include individual and group work. The
Domestic Violence Project in Duluth,
MN, developed a model domestic
violence program that has been widely adopted around the United States.
Many programs incorporate an
understanding of the grieving
process that abused women go through. For the victims (or survivors)
of abuse, the programs may employ the following approaches:
Consciousness-raising is not
a formal theoretical approach per
se, but counselors do provide support and education using a
combination of techniques. Most programs believe that "knowledge is
power" for the abused woman, since she is likely experiencing feelings of
isolation, confusion, and pain. Many women are victims of abuse because their
personal culture has led them to believe abuse is normal and part of any
intimate relationship. They need to re-learn basic assumptions and adopt new
ways of thinking, behaving, and coping.
Counselors often train women
using assertiveness and stress-reduction techniques to help them cope with
day-to-day matters while they sort out the relationship and try new strategies
with support. The goal is to identify a course of action, taking small steps so
the woman can feel empowered to deal with available options. Women who have
been victims of abuse need to have a focus and to engage their cognitive powers
so they can deal with their situation.
Many abused women present for
therapy with symptoms of post-traumatic stress disorder (PTSD). A woman must be
able to resolve her immediate crisis before she can begin to evaluate her
options or think about her behavior. Therapy for PTSD includes understanding
grief and loss, as well as extreme anger and rage. Many women turn that rage
inward by drinking. These women need to become better acquainted with how to
Living in chronic pain and
fear alters a person's ability to be objective and rational. These women need
support to regain their physical, spiritual, and emotional strength. Therapy
groups that focus on changing patterns and bad habits are available for those
women who have already begun to deal with the basics of abuse and are ready to
delve deeper inside themselves. These groups examine the victim's perceptions,
behaviors, and responses to people and events in her life.24
Women in Abusive Relationships
The two most widely used
treatment interventions for domestic violence are support groups and individual
counseling. Increasingly, cities are establishing centers for women that are
staffed with professionals who address both the short- and long-term needs of
abused women. These centers often are called "family crisis centers"
and the workers are "victim advocates."
In some areas, the county or
city provides services. In other areas, a nonprofit organization, such as a
local women's shelter, may offer counseling for abused women. Often, a health
care provider, such as a nurse or doctor, will recognize signs of abuse and
refer the patient to a local counseling center. Although all doctors and nurses
are not trained in domestic violence or sexual assault, many are. They can
refer the woman to community resources if she feels safe confiding her
situation to them.
Because intimate partner
violence is a difficult and complex problem, women who participate in both
individual counseling and support groups seem to do better than women who only
do one or the other. They seem to have higher self-awareness and are more
willing and able to focus on their problems and not just on the abusive
Support groups are helpful
for women who are victims of abuse because most have become isolated from
friends or family as a result of the abuse. As part of a group, each woman can
begin to understand that she is not alone and learn the steps she needs to
follow to have a safe, healthy life. Many women blame themselves. By exchanging
information and expressing their feelings with other women in similar
situations, they can benefit from belonging to a support group.
Such support groups are
attended by women only, with a facilitator to guide discussions. The absence of
men is what helps the women express themselves freely. This is especially true
for women in heterosexual abusive relationships, because the men have been
controlling. Through her experience with a support group, a woman may learn how
to trust and develop intimate relationships again.
Having the support of other
women who have faced similar experiences helps a battered woman accept the
reality of what has happened and encourages her to try to take responsibility
for what she needs to do in the future. Although some women may find a group
too threatening and choose not to return, most will find that support within
the group helps them heal.27
Most counseling centers that
handle domestic violence clients have staff trained in individual counseling.
These counselors understand the complexity of domestic violence and the
barriers a woman may face in escaping an abusive relationship. Most counselors
are also trained to understand cultural and religious beliefs that may affect a
woman's decision to leave.
Since the 1970s, domestic
violence programs have mainly employed the "feminist approach" to
counseling. With this approach, which identifies domestic violence as
gender-based power and control, the woman is seen as strong and capable, not
sick and weak. The counselor cannot tell a woman what is best for her. Only she
knows what is best, so she is encouraged to make her own individual choice to
empower herself. The counselor and client are partners thus, the therapist
offers resources and options but does not advocate a "treatment"
Women With Addiction Problems
Abused women who also have
substance abuse problems face even greater obstacles including shame, fear, and
denial. Many service systems are not equipped to meet their needs. Clearly,
there are not enough domestic violence programs to address the number of cases
involving co-occurrence of addiction and violence that require counseling.
Likewise, most addiction programs do not have a component that addresses
Because women are more
stigmatized for their substance use and abuse than men, many physicians, mental
health professionals, police, and courts are unwilling to identify abused women
as chemically dependent. This is harmful to their recovery and prevents early,
coordinated intervention.29 Almost two-thirds of women seeking
treatment for alcoholism are diagnosed with depression.30 This fact
makes it even more important that therapists have the training to assess and
treat all issues related to addiction and abuse.
Many domestic violence
shelters and programs also try to help the children, but most alcohol and drug
treatment centers do not. Women addicted to drugs or alcohol need special
services that traditionally male-based centers do not provide. These
much-needed services would include providing clients with childcare while they
are in treatment, transitional job services, and welfare/legal advocacy. Few
battered women's shelters have any 12-step programs or groups. In fact, many
battered women's shelters do not admit women who are under the influence of
alcohol or drugs.
Both short- and long-term
steps must be considered for women who require both domestic violence and
substance abuse treatment. Short-term steps for an abused woman may involve
keeping her safe and alive. After she has left her abuser, she is at the
greatest risk for harm.
The goals of domestic
violence treatment and substance abuse treatment sometimes conflict. A
shelter's primary concern is for the woman's safety; staff at a substance abuse
treatment facility, on the other hand, often are not trained to keep women
safe.31 Understandably, safety is not their first priority; sobriety
comes first. Increasingly however, more programs are beginning to realize the
need for combined services that address both domestic violence and substance
abuse. The woman's safety must take precedence over sobriety.
Group experiences are
particularly helpful for women who have both addiction and abuse issues. They
provide the arena for:
Giving and sharing information
Practicing skills, both new and long-unused
Testing the clients' perceptions against reality
There are only a handful of
programs in the United States that have worked actively to include services for
battered women who are also addicted to alcohol.32
Approaches to Treatment: Batterer's Programs
A variety of viewpoints can
underlie a treatment program's emphasis.33
Society and Culture
This theoretical framework
ascribes battering to social/cultural norms and values that endorse or tolerate
the use of violence by men against women. The feminist model of intervention
educates men concerning these norms and attempts to re-socialize them through
education. Programs emphasize equality in relationships and nonviolence.
Family-based theories about
partner violence focus mainly on the structure and social isolation of violent
families. Counseling includes issues such as communication skills, with the
goal of keeping the family together. Couples usually are seen together.
Domestic violence counselors may advise against this approach because in some
cases it is not safe for the woman to be in counseling together with the man.
These theories attribute
domestic and dating violence to biopsychosocial
factors of the individual man. Examples may include personality disorders, the
batterer's social environment during childhood, or biological predispositions
toward anger and violence.
Most batterer intervention
programs employ a combination of all three of these viewpoints. Unlike
after-care substance abuse programs, there are not many 12-step programs for
abusive men that have a provision for continued care or mentoring. Some
batterer intervention programs have begun to offer continued care after the
mandatory number of weeks is finished. They are experimenting with the idea of
mentors, similar to sponsors in 12-step programs. In this approach, a
recovering abuser (who has been out of treatment for a while) works closely
with an abuser who has just completed a treatment program.34 The
process is monitored closely by the program or shelter.
Recently, while most
batterer's programs use a combination of cognitive-behavioral and feminist
approaches, some programs have begun to try to integrate other treatment
orientations in the treatment of abusive men. In particular, the transtheoretical model,35 which views change as
progressing through a series of five stages, has been found to work well in various
Men who become violent in a
relationship need help from professionals who are trained to understand just
how serious family violence is. Some counseling centers for abused women focus
on every part of family violence, including providing legal help for the
victims, help during the crisis, and counseling for both the abuser and the
victim. Many domestic violence programs, however, do not have treatment options
for the abuser. These programs are often offered by other agencies that have
collaborative partnerships with women's programs.
programs are relatively new. Since the 1980s, both the criminal justice system
and the mental health system have begun developing and running these programs.
The main goal of batterer intervention programs is to educate men about
nonviolent options. Each man is taught alternative ways to express anger and to
recognize the consequences of his violence. Most programs for men are based on the
belief that battering is a learned behavior, not a sickness.36.
Although some men voluntarily
attend batterer treatment programs, most attend because they are forced to by
the criminal justice system. After a woman obtains a protective order, a legal
hearing is held to establish the man's guilt or innocence. If the man is found
guilty or pleads "no contest" to a domestic violence offense (or
violates a protection order), part of the court's responsibility is to assign
treatment for the abuser. Most States have requirements for treating abusive
men. In many locations, community mental health centers have taken on the role
of providing group treatment for abusive men.
Three prominent national
programs for abusive men are the Duluth Curriculum, EMERGE, and AMEND.37
In 1977, EMERGE, located in Cambridge, Massachusetts, was the first program in
the United States to develop an intervention component for male batterers. They
recognized that men also needed to be taught how to change their behaviors and
to live nonviolently. Similar to counseling for abused women, violent men seem
to improve the most when they participate in support groups with other male
Facilitated either by a
trained male counselor or a woman and male counselor together, batterer intervention
groups focus on identifying certain beliefs each man might hold (e.g., that a
man must rule the household or that a woman should only have children and never
work). The goal is to help the men see that these beliefs, when taken to the
extreme, can be unhealthy. The men in the group hold each other accountable for
violent actions (physical, sexual, or verbal) that happened in the past, as
well as those that continue today.
There is not one standard by
which support groups for violent men are run. Most programs that have
counseling for men use some combination of approaches to help the men learn new
behaviors.38 Most programs, however, are largely based upon
cognitive-restructuring and skill-building theories that emphasize:39
Knowledge of what domestic violence and abuse are,
Recognizing them in their various forms,
How domestic violence and abuse are learned
How behavior can change with perception and skill
This intervention tries to
teach each man how his thoughts affect his behavior. For example, if a man
convinces himself that his partner is cheating on him when there isn't really
any evidence, he will become angrier and angrier. Eventually, he will express
his anger with violence, because that is the only manner in which he is able to
express his feelings. Part of the therapeutic work would involve exploring why
the man feels so insecure in his relationship and to teach him other ways to
express his anger. Each man has his own triggers, and it is helpful to learn
what they are and how to control the angry response to them.
Intervention, therefore, must
be an informed combination of the therapeutic and educational approaches,
teaching and applying the information to each individual situation. A large
component of batterer's intervention programs consists of role-playing, problem
solving, stress reduction, and improving communication skills.
Men With Addictions
The options available to men
with alcohol addiction are similar to those for women. Depending on how severe
the addiction is, there are both inpatient and outpatient options available. In
both cases, men go to therapy groups and individual counseling. A large
component for men in addiction rehabilitation is attendance at 12-step meetings
such as AA or Narcotics Anonymous (NA). Most meetings are open to both men and
women, but some are gender-specific.
Abusive Men With Addictions
Abusive men who drink
excessively or take drugs need help for both problems. Even if an abusive man
abstains from alcohol or other drugs, he still is likely to become violent.
Similarly, if a man is treated only for the battering but not for the substance
abuse problem, treatment will not be effective.
For the most successful
treatment outcomes, domestic violence/battering programs should be combined
with substance abuse treatment programs.40 However, this is not
always possible, because the programs sometimes are located in different parts
of town. See Module 7 for more information about screening and assessment.
The most helpful response a
community can provide someone who is struggling with abusive behavior and/or
substance abuse is one in which health, legal, and social services are tied
together, so that the person seeking treatment is not constantly shifted from
agency to agency. Although this is not the case in most cities in the United States,
professionals in both the fields of domestic violence/sexual assault and
addiction are working to make this happen. Community support can take on various
Police or medical help
Shelters or other emergency residential facilities
Laws that protect the victim or require that the
perpetrator be removed from the home
Places where pets can be taken care of
Child protective/foster care services for children
in abusive or alcoholic homes
Advocacy and Legal
Legal steps that stop an abuser from seeing the
victim (Part 8 discusses ex parte, protective (restraining), and peace
Advocates who will explain the court system and stay
with the woman in court
Access to and custody of children
Public assistance benefits
Help with the mental health system (for co-occurring
illnesses and addiction)
Help with immigration status
Self-help support groups (for domestic violence and
12-step groups, such as Alcoholics Anonymous or Al-Anon
Self-esteem and confidence-building sessions
Counseling for trauma and PTSD
Other Supportive Services
Housing and safe accommodations
Alcohol or drug treatment
Access to community services
Access to job training or transitional work and
housing services (halfway houses)
Treatment centers use various theoretical approaches
in designing their programs for substance abuse, including
cognitive-behavioral, motivational enhancement therapy, 12-step
facilitation, and relapse prevention.
Domestic violence and sexual assault treatment
usually encompasses cognitive-behavioral, consciousness-raising
(educational), feminist understanding of power and control, and crisis
Women with addictions may receive treatment in a
variety of settings, including inpatient, outpatient and residential, as
well as self-help or support groups.
Treatment programs for addicted or physically
abusive men are also based on various theoretical approaches, including
those that focus on society or culture, family, or dysfunctions within the
Ideally, a community will offer an array of services
to assist both men and women dealing with violence, substance abuse, or
Law: Domestic Abuse and Sexual Assault
All jurisdictions in the United States
have laws designed to protect female victims of violence. In 1994, Congress
passed the 1994 Crime Bill. A part of that crime bill package, signed into law
by President Bill Clinton, was the Violence Against Women Act (VAWA). This
civil rights statute, re-authorized in 1996, strengthens many of these
protections and outlines Federal and State enforcement provisions and
penalties. VAWA strengthened prevention and prosecution of violent crimes
against women and children and made domestic violence a civil rights violation.
Thus, a victim of "crimes of violence motivated by gender" can bring
a suit for damages in civil court and ask for restitution in criminal court.
Some of the new provisions of VAWA include:1
Greater penalties for sex crimes
Funding for programs for victims of child abuse, for
the homeless, for runaways, and for street youth at risk of abuse
Funding for States to improve law enforcement,
prosecution, and services for female victims of violent crimes
Creation of a national domestic violence hotline
Denial of firearm ownership to anyone who has a
civil protection order against them
Disallowing the use of past sexual behavior or
alleged sexual predisposition as evidence against the victim in civil or
Requiring that the U.S. Postal Service protect the
confidentiality of shelters and individual abuse victims by not disclosing
addresses or other identifying information
In 2000, Congress followed up
by passing VAWA II. The Violence Against Women Act II provided for a
continuation of services, programs, and the creation of innovative practices
and procedures begun under VAWA I. In addition, VAWA II expanded the reach of
those who could be covered under its auspices to include the elderly, dating
relationships and the schools, and immigrant communities.
No consistent legal
definition of domestic violence is used in every State. Each State can decide
to include some people (e.g., married couples) and not others (e.g., dating
couples). All States have some legal protection for victims of domestic
Civil protection orders are
legally binding orders designed to prevent partner abuse. The abusive partner
is not allowed to contact the person at any place that she designates (e.g.,
home, work, school). If there are any children, their school or day care
addresses would also be a place that the abuser would not be able to go to. He
also cannot contact the person in any way. This would include by phone, fax,
email, beeper, or through another intermediary. An individual who violates such
an order may face civil contempt, misdemeanor or felony charges.
Civil protection orders are
now available to battered women in every State and the District of Columbia.2
They are available, primarily, to prevent the abuser from continuing to abuse
the victim, from having any contact with the victim, and providing the victim
and her children emergency relief. For intimate partner violence and dating
violence, each State has its own laws regarding civil protective orders (also
called restraining orders or "no contact orders") and ex parte
A woman who is victimized is
eligible for special treatment under the law, including removal of the abuser
from her home (ex parte and protective orders). Although each State may differ
slightly in terms of whom they consider "victims," generally,
eligible victims include:
a current or ex-spouse
a co-habitant (someone who has lived in the same
dwelling as a sexual partner for at least 90 days in the past 365 days)
a child (in 75 percent of States)
a person related to the abuser by blood, marriage,
a parent or stepparent who has resided with the
abuser for 90 days within the past year
a "vulnerable adult" (an adult who lacks
the physical or mental capacity to ensure her well being or to care for
daily needs) and/or
an individual with a child in common with the
abuser, such as a girlfriend
Some States also include
dating relationships. The list above is a general representation only, and is
not meant to represent any State in particular.
Each State has interpreted
the penal code to cover various acts that would be prohibited under a civil
protection order. General conduct sufficient to support the issuance of a civil
protection order includes:3
Criminal acts (such as battery, robbery, burglary,
kidnapping, reckless endangerment, and criminal trespass)
Sexual assault and marital rape
Interference with personal liberty
Interference with child custody
Assaults involving motor vehicles
Harassing behaviors, stalking
Damage to property
Some States like Rhode Island, for
example, prohibit any abuse, which they define as "attempting to cause or
causing physical harm; placing another in fear of imminent serious physical
harm; causing another to engage involuntarily in sexual relations by force,
threat of force, or duress."4Pennsylvania adds to its list acts that
inflict false imprisonment and the physical or sexual harm of children.
Two-thirds of States allow
women to file for a civil protection order pro
se-without having to hire an attorney. Most States mandate that the
courts develop special, simplified forms and instructions; provide clerical assistance
for advocates; eliminate or waive initial filing fees; and provide prompt
service and immediate access to the courts. Roughly half of the States allow
for 24-hour access for protection orders. Some offer after-hours and weekend
accessibility. In all jurisdictions except two, an abused person can obtain an
ex parte temporary order of protection-often the same day the petition was
filed. Most States also require that a court date is set within a specified
period of time, typically between 10 and 30 days.5
Nearly every State requires
that all pleadings and orders filed with the court after the domestic violence
incident must be served upon the defendant in a timely manner. Some States deem
the defendant's appearance in court and receipt of the order as sufficient.
Others require law enforcement personnel to deliver, or to make a concerted
effort to deliver, the papers directly to the partner (defendant).
Ex Parte Order
Ex Parte simply means
"one party." In this case, the petitioner (woman) goes before a Judge
to obtain short-term relief. When this is granted, the abuser (respondent) may
be ordered to:
civil protection order, a woman can receive "emergency relief" which
might include assistance in paying mortgages, childcare, car payments, or food
for the children.
Refrain from further abuse
Refrain from contacting, attempting to contact, or
harassing the victim
Refrain from entering the residence or workplace of
Vacate the residence if the two parties were
Remain away from the work, school, child care
facility, or temporary residence of the victim or home of other family
Give up temporary custody of a minor child
In most jurisdictions, the
standard of proof required for ex parte relief is good, reasonable, or probable
cause to believe that the petitioner (woman) or a member of her household is in
danger of being abused or threatened with abuse by the respondent (man).6
The time frame for ex parte orders differs from State to State, but all States
have a time limit. Some limit it to 7-10 days, others until the date of the
hearing. New Jersey
code specifies that a temporary restraining order remains in effect until the
court takes further action.7
States have all constructed
their own consequences for violating an ex parte order. California's, which has among the broadest
consequences, stipulates that:8
The court can grant the requested relief for up to 3
years without further notice to the defendant if he does not appear at the
court hearing specified on the order.
The defendant also is notified that the abused
person may obtain a more permanent restraining order when the court opens
(if the ex parte order was received after hours), and that the defendant
and abused should seek counsel promptly.
The order employed by the
State of Rhode Island
gives notice at the top of its form. It states that if a defendant violates the
order, he may be guilty of a misdemeanor and can be punished by a fine or as
much as a year in jail. He also may be ordered to attend counseling. Under the
civil protection order, a woman can receive "emergency relief" which
might include assistance in paying mortgages, childcare, car payments, or food
for the children.
In 27 States, once the notice
is served and the hearing is held, the length of the protection order is not to
exceed 1 year. In Illinois
the maximum duration is 2 years; in California
it is 3 years. State codes give the courts discretion to extend the duration of
the order, and in some States, a violation must have occurred for an extension
to be granted.
Enforcement of Orders
Although most State codes
direct that there be a system for verifying valid protection orders, some are
silent about whether an officer must verify the existence of a valid order
before taking any action to enforce it or to make an arrest. Roughly one-third
of States mandate law enforcement officers to effect warrantless arrests when
they have probable cause to believe that a person constrained by a protection
order has violated it. In more than 35 States, violation of a protection order
constitutes a misdemeanor. In some States, violation of certain provisions of
the protection order is a misdemeanor; in other States, it may only be
More than half of the States
consider a violation to be a civil contempt or misdemeanor; only 21 consider a
violation of the protection order criminal contempt. Mandatory counseling for
the batterer is often included in the sentencing after a protection order has
been violated. Some States provide a minimum jail term for violation. However,
most States give the court discretion with sentencing, including authorizing a
maximum period of imprisonment-often for 6 months or 1 year-and a maximum fine,
frequently $1,000.10 The purpose of the jail time or fine is for
civil contempt, not criminal.
The usefulness of protection
orders depends both on the specificity of the relief ordered and the
enforcement practices of the police and the courts. For orders to be effective,
they must be comprehensive and crafted in each case to the safety needs of the
victim.11 A civil or criminal court may issue protective orders,
either independently, or as part of a divorce or criminal complaint. They may
be separate from support or child custody orders.
Statutes in 47 States and the
District of Columbia
now authorize or mandate warrantless, probable cause arrest for crimes
involving domestic violence. This warrantless arrest refers to situations when
police have been called to a residence in response to a 911 call. If the
officer has probable cause to believe that any form of domestic violence has
been committed in the home, he or she has the authority to immediately arrest
Most of the State codes that
have warrantless or probable cause arrests also have a provision to notify the
victim of the availability of protection orders, shelter or other emergency
facilities, transportation, and sometimes even the right to file a criminal
The Massachusetts code may be the most extensive
example. Beyond advising victims of the right to obtain a protection order, the
"You have the right to
go to court and seek a criminal complaint for threats, assault and battery,
assault with a deadly weapon, assault with the intent to kill, or other related
offenses. If you are in need of medical treatment, you have the right to
request that an officer present drive you to the nearest hospital or otherwise
assist you in obtaining medical treatment "12
Some States permit or mandate
police officers to seize weapons used in the crime for which any probable cause
misdemeanor arrest is made.13
A woman may decide to file
criminal charges against the perpetrator after she takes care of her immediate
safety and files for a protection order. Most victim advocate centers have
attorneys available (or know some in the community) to help women work through
the legal process of filing criminal charges, which may include assault,
assault and battery, sexual assault, or assault with the intent to kill.
codes require specialized treatment programs designed especially for men who
batter their wives or partners.
Almost half of the States in
the country have adopted codes that address providing treatment or educational
services for abusive men. Most States do not fund batterer programs, instead
requiring that each man pay a nominal fee for the service.
Some States, like Arizona,
Connecticut, and California, either require pre-trial counseling, or use it as
an option for pre-trial diversion for offenders who have not previously
participated in a family violence education program or other accelerated
rehabilitation and who are charged with misdemeanors.
Most States authorizing court-ordered
intervention services do so in the civil protection order. Courts may choose
among different programs and treatment modalities available in that geographic
area. Criminal codes, however, require specialized treatment programs designed
especially for men who batter their wives or partners. WashingtonState
has the most comprehensive code regarding batterer's intervention and other
necessities for batterer programs. 14
Any crime victim can file a
civil lawsuit against a perpetrator, regardless of the outcome of any criminal
prosecution and without any criminal proceeding. In a civil case, an abuser is
called the Defendant. Unlike the criminal justice process, the civil justice
system does not attempt to determine whether the defendant is guilty or
innocent. Defendants are not put in prison. Rather, civil courts attempt to
determine whether a defendant or a third party is liable for the injuries
sustained as a result of the crime. If the defendant is found liable in this
civil process, he probably will have to pay monetary damages to the victim.15
When building a civil case,
the victim must make the effort to provide the court or an attorney the
Date and time of criminal act.
Location of events, addresses, and description of
Whether a police report was filed, and if so,
identification of the police department where the complaint was filed, the
officer or detective who took the complaint, the report number, and any
statements taken as part of an investigation.
Anyone who might have seen the crime.
Whether there was a criminal case, and if so, the
identification of the prosecutor, current status of the case, and a
description of the facts of the case.
Any available information about the perpetrator,
including name, address, social security number, any aliases, employment
information, any assets and insurance coverage, physical description, and
any identifying features.
A listing of the physical, emotional, and
psychological injuries that resulted from the assault and the cost of
Information about any property damage and how much
time and money the victim lost from her job.
The decision to press charges
is difficult but significant. As more courts and communities are forced to deal
with rape and abuse, awareness about these crimes will increase, and women can
claim the right to have these concerns taken seriously.
A woman may decide to drop
the civil charges because she does not want her personal life aired publicly.
Sometimes there might be educational, age, or economic barriers to pursuing a
case. Some women might not want family or friends to know about the rape or
assault. Some women avoid pressing charges because they fear retaliation.
However, repeat rapes are uncommon, even in cases when a rapist threatens to
return if he is reported.
Sexual Assault Bill of Rights
College campuses are working
hard to reduce and prevent rape and sexual assault. Because females aged 16 to
24 are at greatest risk for sexual assault, colleges and universities are
finding that they need to have policies in place for dealing with sexual
assault, including counseling centers for legal and emotional help. Campus
police are key to developing and implementing a working policy since the police
are usually the first on the scene.
In 1992, the Federal
government passed the "Campus Sexual Assault Victims' Bill of
Rights," which requires all colleges and universities (both public and
private) that enjoy Federal student aid to offer certain protections to sexual
assault victims, including:16
Offering the accuser and accused the same
opportunity to have others present at a hearing.
Informing both parties of the outcome of any
Informing women of their options to notify law
Notifying women of counseling services, including
on- and off-campus mental health or other student services.
Notifying women of options for changing academic and
In addition, VAWA provides
colleges and universities funding so they may offer their personnel and
students training and education in the area of drug-facilitated sexual assault.
For more information on this program, go to www.theiacp.org.
Abuse and Violence Against Women
Concern about privacy and
confidentiality, especially concerning substance abuse, is fueled by the
widespread perception that people who abuse alcohol are weak or morally
impaired. There is also a widespread stigma attached to those people who have
Aside from perceived threats
to autonomy, a person may also be concerned about the practical consequences of
admitting a substance use problem. Such patients may find it difficult or
impossible to obtain coverage for medical costs if an insurer or health
maintenance organization (HMO) learns that traumatic injuries were related to
alcohol. Relationships with a spouse, children, parents, and friends may
suffer. Adverse consequences such as these may discourage patients with
substance use problems from seeking treatment.
Federal Privacy Laws
The concern about the adverse
effects that social stigma and discrimination have on people in recovery and
how those effects might deter people from entering treatment led Congress to
pass legislation and the U.S. Department of Health and Human Services to issue
regulations protecting privacy. The law, titled "Confidentiality
of Alcohol and Drug Abuse Patient Records (42 U.S.C.
290dd-20), is contained in Volume 42 of the Code of Federal
Regulations, Part 2 (42 CFR Part 2).
of the privacy law and regulations is to decrease the risk that information
about individuals in recovery will be disseminated.
The Federal law and
regulations severely restrict communications that would reveal the actual name
of a client by "programs" providing substance use diagnosis,
treatment, or referral for treatment (42 CFR 2.11). The purpose of the privacy
law and regulations is to decrease the risk that information about individuals
in recovery will be disseminated. It is also intended to decrease the risk that
they will be subjected to discrimination and to encourage people to seek
treatment for substance use disorders.
If a health care practice or
social service organization employs someone whose primary function is to
provide substance abuse assessment or treatment, and if the practice or
organization benefits from Federal assistance, then that practice or
organization must comply with the Federal law and regulations.
The Health Insurance
Portability and Accountability Act (HIPAA) of 1996
The advent of new technology
has made additional privacy measures necessary. Federally mandated rules will
require a major overhaul of the Nation's health care information systems. The
new rules are part of the Health Insurance Portability and Accountability Act
(HIPAA) of 1996. The Department of Health and Human Services released the final
HIPAA regulations in December 2000. Health care organizations have 24 months to
comply. The rules regarding electronic transmission of information are in the Administrative
Simplification (AS) provisions of HIPAA.
HIPAA is intended to simplify
administrative and financial electronic data transactions. It also regulates
the security of electronically stored and transmitted patient health
information. The law mandates that insurance companies accept standard-format
electronic transactions and that providers who send electronic transactions do
so in the standard format.
HIPAA also includes important
and far-reaching stipulations regarding information security and patient
privacy. The HIPAA Privacy Rule (Standards for Privacy of Individually
Identifiable Health Information)17 provides the first national
standards for protecting the privacy of health information.
The Privacy Rule regulates
how certain entities, called covered entities, use and disclose certain
individually identifiable health information, called protected health
information (PHI). PHI is individually identifiable health information that is
transmitted or maintained in any form or medium (e.g., electronic, paper, or
oral), but excludes certain educational records and employment records. Among
other provisions, the Privacy Rule
gives patients more control over their health
sets boundaries on the use and release of health
establishes appropriate safeguards that the majority
of health-care providers and others must achieve to protect the privacy of
holds violators accountable with civil and criminal
penalties that can be imposed if they violate patients' privacy rights;
strikes a balance when public health
responsibilities support disclosure of certain forms of data;
enables patients to make informed choices based on
how individual health information may be used;
enables patients to find out how their information
may be used and what disclosures of their information have been made;
generally limits release of information to the
minimum reasonably needed for the purpose of the disclosure;
generally gives patients the right to obtain a copy
of their own health records and request corrections; and
empowers individuals to control certain uses and
disclosures of their health information.
The covered entities are
health-care clearinghouses, and
health-care providers who transmit health
information in electronic form in connection with certain transactions.
At DHHS, the Office for Civil
Rights (OCR) has oversight and enforcement responsibilities for the Privacy
Rule. Comprehensive guidance and OCR answers to hundreds of questions are
available at http://www.hhs.gov/ocr/hipaa.
State Privacy Laws
Even though some providers
are not subject to Federal regulations, other regulations may limit how patient
information is handled. State laws offer some protection of patient and client
medical and mental health information. Most providers and clients think of
these regulations as the "doctor-patient privilege" or "social
worker-client privilege" or "psychotherapist-patient privilege."
Strictly speaking, these
privileges are rules of evidence that govern whether a professional provider
can be asked or compelled to testify in a court case about a patient or client.
Many State laws offer wider protection. Some States have special
confidentiality laws that explicitly prohibit physicians, social workers,
psychologists, and others from divulging information about patients or clients
State professional licensing
laws often include prohibitions against sharing information. Such laws
generally prohibit licensed professionals from divulging information about
patients or clients. They also make unauthorized disclosures grounds for
disciplinary action, including license revocation.
Each State has its own set of
rules, so the scope of protection offered by State law varies widely. Whether a
communication is "privileged" or "protected" depends on a
number of factors, including:
The type of professional provider holding the
information and whether he or she is licensed or certified by the State
The context in which the information was
The context in which the information will be or was
Exceptions to any general rule protecting
How the protection is enforced
Professionals Covered by the
"Doctor-Patient" or "Therapist-Client" Privilege
Even within a
single State, the kind of protection offered may vary from profession to
Determining which professions
and which practitioners within each profession are covered depends on the State
where the professional practices. For example, California, which grants its citizens
"an inalienable right to privacy" in its Constitution, has what may
be the most extensive protections for medical and mental health information. California law protects
communications with a wide variety of professionals, such as licensed
physicians, nurses, and psychotherapists. The category of psychotherapist
includes clinical social workers, psychologists, as well as marriage and family
California law also protects many communications
with trainees practicing under the supervision of a number of these
professionals. A California
court has held that information shared by an uneducated patient with an
unlicensed professional may be privileged if the patient reasonably believes
the professional is authorized to practice medicine.19 Laws in other
States cover fewer kinds of professionals. In Missouri, for example, protection is limited
to communications with State-licensed psychologists, clinical social workers,
professional counselors, and physicians.
Depending on their
professional training and licensing, primary care physicians, physician
assistants, nurse practitioners, nurses, psychologists, social workers, and
others may be covered by State prohibitions on divulging information about
patients or clients. However, even within a single State, the kind of
protection offered may vary from profession to profession. Professional
providers should learn whether any confidentiality laws in the State where they
practice apply to their profession.
State laws vary tremendously
regarding the protection of medical information. Some States protect only the
information that a patient or client communicates to a professional in private,
in the course of the medical or mental health consultation. Information
disclosed to a clinician in the presence of a third party, such as a spouse, is
Some States, such as California, protect all
information the patient or client shares with the professional or that the
professional gains during examination.20California also protects other information
acquired by the professional about the patient's mental or physical condition,
as well as the advice the professional gives the patient. The breadth of the
protection may vary according to the clinician's profession. When California courts are
called upon to decide whether a particular communication of information is
privileged, State law requires them to presume that it is privileged.
California affords great protection to the communication that takes
place between patients and psychotherapists, a term that covers a wide range of
professions. Not only are communications by and to the patient protected, but
information communicated by a patient's intimate family members to therapists
and psychiatric personnel is as well.21 California also protects
information the patient discloses in the presence of a third party or in a
Some States protect medical
or mental health information only when that information is sought in a court
proceeding. If a professional divulges information about a patient or client in
any other setting, the law in those States will not recognize a violation of
the individual's right to privacy.
Other States protect
information in many different contexts. They may discipline professionals who
violate their patients' privacy, allow patients to sue them for damages, or
criminalize behavior that violates patients' privacy. The diversity of State
rules in this area compound the difficulty professionals face in learning which
rules apply to them.
It is the responsibility of
health and mental health professionals to be aware of State laws pertaining to
medical information and how they are applied within their profession.
Exceptions to State Laws
Protecting Medical and Mental Health Information
All States permit health,
mental health, and social service professionals to disclose information if the
patient or client consents. However, each State has different requirements
regarding consent. In some States, consent can be oral; in others, it must be
written. States that require written consent sometimes require that certain
elements be included in the consent form or that a State-mandated form be used.
Some States have different consent forms with different requirements for
Consent is not the only
exception. All States also require the reporting of certain infectious diseases
to public health authorities, and of child abuse to protective service
agencies, but they do not require counselors to report spousal abuse. Although
most States do not legally mandate reporting past spousal abuse, some substance
abuse counselors may feel compelled to report an incident to the police.
Most States require health
care professionals and mental health counselors to notify the authorities of
threats patients make to harm others. In order to avoid violating Federal
and/or State laws, a counselor may make the report without identifying the
individual as a client in a substance abuse program.22 Providers
should consult a lawyer familiar with State reporting law.
Some States permit or require
health care professionals to share information about patients with other health
care professionals without the patients' consent. However, some limit the range
of disclosure for certain diseases, such as HIV.
Most States make some
provision for communicating information to health insurance or managed care
companies. Many of the situations that physicians and social service workers
face on a daily basis, such as processing health claims or public benefit
applications, are covered by one of these exceptions. To fully understand the
"rules" regarding privacy of medical and mental health information,
professionals must also know about the exceptions to those rules, which. are
generally in the statute books, in the sections on evidence, professional
licensing, or both. The State licensing authority and professional associations
can usually help answer questions about State rules and the exceptions to those
How health care providers
should communicate with others about their clients' substance use problems is a
delicate issue. Communications with others who are concerned about the client
may confirm the provider's judgment that the client has a substance use
problem. Such communications may be useful in persuading a reluctant client
that treatment is necessary.
Before a provider gathers
information from other sources or enlists help for a patient or client
struggling with recovery, he or she should ask the client's permission to do
so. Speaking with relatives, doctors, or other health and mental health
professionals not only intrudes on clients' autonomy, but also risks their
Gathering information or
responding to questions from a spouse, parent, or other provider about a
client's problems can involve explicit or implicit disclosure about a client's
substance use problem. The provider making such a disclosure inadvertently may
be stepping on a land mine.
Making inquiries or answering
questions without client consent may seriously jeopardize the trust that the
provider and client have established. It can also undermine any attempts to
offer help. If the client feels he or she can no longer trust the provider, and
becomes angry that the provider has shown little respect for his or her
autonomy or privacy, the client may refuse to participate in any further
In some cases, the provider
has persuaded the patient or client to try outpatient treatment and knows the
director of an excellent program in the immediate area. Rather than simply
picking up the phone and letting the director know he or she has referred the
patient, the provider should consult the patient about the specific treatment
facility. Although consent to treatment may appear to be the same as consent to
referral to a particular facility, it is not.
Obtaining the patient's
consent is an important step. It demonstrates respect for the client or
patient, and protects the provider.
With the Legal System
Sometimes a health
professional must deal with the legal system. A doctor, psychologist, social
worker, or other provider may get a call from a lawyer asking about a patient
or client, especially if that client is also involved in a domestic violence
situation. A law enforcement officer may ask to review records. In some cases,
a professional may get a subpoena to testify or to produce medical records.
What should the provider do
in such cases? As in other matters of privacy and confidentiality, (1) consult
the client, (2) use common sense, and (3) seek legal advice.
Responding to Subpoenas
Subpoenas come in two
varieties. One is an order that requires a person to testify, either at a
deposition out of court, or at a trial. The other, known as a subpoena ducestecum, requires a person to appear with
the records listed in the subpoena. Depending on the State, a subpoena can be
signed by a lawyer or a judge.
client of a subpoena shows respect for his or her privacy.
Especially if your client has
experienced abuse, the first step is to call the client about whom the provider
has been asked to testify or whose records are sought and ask what the subpoena
is about. It may be that the subpoena has been issued by or on behalf of the
client's lawyer, with the client's consent. However, it is equally possible
that the subpoena has been issued by or on behalf of the lawyer for an adverse
party, such as an abusive partner. If that is the case, the best option is to
consult with the client's lawyer to find out whether the lawyer will object by
asking the court to "quash" the subpoena, or whether the provider
should simply get the client's consent to testify or turn over records.
In most instances, the provider
is not legally required to notify the client or to obtain his or her consent to
release records that have been subpoenaed. However, notifying the client of
subpoena shows respect for his or her privacy and gives him or her an
opportunity to object to the subpoena. An objection can be based on a number of
grounds, and can be raised by any party, including the person whose medical
information is sought. If a provider is covered by a State statutory privilege,
it may be possible to assert the client's privilege.
It is essential for those who
work with abused and addicted women to respect their clients' autonomy and
rights to privacy and confidentiality if they are to be effective in screening
and assessing for substance use disorders and persuading them to cut down their
use or to enter treatment. In most situations, providers can follow these
simple rules: (1) consult the client, (2) let the client decide, and (3) be
sensitive to how information is recorded or disclosed. It is only as a last
resort that the provider seek legal counsel.
Domestic violence and sexual assault laws differ
from State to State.
Women have several legal options to keep themselves
safe, including obtaining an ex parte order, protection order (restraining
order or "no contact order.")
Each State has adapted model codes for domestic
violence and sexual assault to fit their constituency and available
A woman can decide to file criminal charges and/or a
civil suit against her abuser.
All colleges and universities that use the Federal
Aid program must have procedural protections for sexual assault victims in
place on their campus.
There are Federal and State privacy and
confidentiality laws that protect men and women who have addictions and/or
who are victims of crime.
Health care professionals and counselors need to
know their State's laws concerning mandatory reporting and find ways to
work with the local legal system.
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