alcohol abuse

Alcohol Abuse and Violence Against Women

(6 hours)

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?

Professionals differentiate 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 a victim.

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,
  • Enhance performance,
  • 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 accepted.

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 Against Women

Introduction

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:

  • Rape
  • Sexual assault
  • Sexual abuse
  • Intimate partner violence
  • Domestic violence
  • Family violence
  • Spouse abuse
  • Battering
  • Marital rape
  • Teen dating violence
  • Matricide (killing one's mother)
  • Elder abuse
  • Homicide

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 female.

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.

Definitions

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.

Statistics on Violence Against Women

  • 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 again.14
  • 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.

Health Consequences

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.

The American College 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 scalding liquids.

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 require stitches.28

Injuries Needing Medical Attention

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
  • Chronic injuries29

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
    • Fatigue
    • Sexual disturbances
    • Chronic headaches
    • Abdominal and gastrointestinal complaints
    • Palpitations
    • Dizziness
    • Paresthesias (unexplained numbness or prickly sensations)
    • 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 staff.31

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 percent).32

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.

The Effects 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 year.

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 expected.

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 Healthy Relationship?

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.

My partner...

  • Is sensitive to my feelings
  • Respects my opinions and values
  • Trusts me
  • Is not overly jealous or possessive
  • Accepts me for who I am and does not try to change me
  • 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 others
  • 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 view38

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.

Myths and 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.

  1. 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 3 to 4 million women in America are beaten each year by their husbands or partners.39,40

  1. 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 family.41,42

  1. 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

  1. 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
    • Children,
    • 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).

Victims of violence often suffer psychological effects, such as posttraumatic stress disorder, substance abuse, or depression.45

  1. True or False?: Most abused women will leave their abuser.

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.

The 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).

  1. True or False?: Violence against women does not happen to older or disabled women.

False: Any woman can become a victim of violence.

    • 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
  1. 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

  1. 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

  1. 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

  1. 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

  1. 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

Summary

  • 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.

 

Introduction

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.

Common Characteristics of Alcohol Abuse and Domestic Violence

Alcohol abuse and domestic violence share certain characteristics:

  • They both can be passed from generation to generation.
  • 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 may demonstrate:

  • Isolation, shame, and guilt
  • Behaviors that others describe as bizarre or dysfunctional
  • Traumatization
  • Initial denial of the problem
  • Loss of support systems and fear of losing children as a result of admitting their problem
  • Low ego strengths
  • A belief that the problem will just go away
  • Impairment of their ability to make logical decisions
  • 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.

The following 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.

Communication between domestic violence advocates and substance abuse counselors can be hindered if they do not realize that they share a common language.

Introduction 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:

  1. Keeping or making use of power, and
  2. 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 factors.

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)
  • Family trouble
  • 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
  • Pregnancy

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 family
  • 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

Type 1: Men who have experienced the most severe childhood physical abuse

Type 2: Men who have experienced the most severe parental rejection, and

Type 3: 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

The Power 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 Violence

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 abuse.

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 "no."
  • 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.

Why Women 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 leaves.
  • 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 her.
  • 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.

Violence During Pregnancy

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

Most studies have found that violence during pregnancy occurs roughly in 1 in 6 pregnant women.

  • Contraceptive counseling or prescription
  • Pap smears, pelvic exam, HIV test
  • Sterilization, abortion
  • Prenatal or postpartum care, and
  • Testing or treatment for vaginal, urinary tract, or pelvic infection

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 conditions,
  • Late entry into the prenatal system,
  • Lack of father's support for pregnancy, and
  • Smoking in the third trimester.

Mental Health/Psychiatric Symptoms

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 suicide
  • Depression
  • Panic attacks and other anxiety symptoms
  • Alcohol or drug abuse
  • Posttraumatic stress reactions or disorder

The 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.

Drug and 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.

Alcohol-Related Violence Statistics

  • 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

Patterns of Relationship Violence

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 victim.29

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 Dating Relationship

A number of warning signs are helpful to know when you are meeting someone for the first time or are starting to date.

  • 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 your feelings.
  • 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 certain place."
  • 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 you. 60

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.

Phase 1: "Honeymoon"

  • 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 female.
  • The male is loving, charming, and attentive.
  • The female is trusting and swept away by the attention and love.32

Phase 2: Tension Building

  • As time goes by, the male may become a bit edgy and irritable.
  • 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 certain way.
  • 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 with."33
  • 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.

Phase 1: "Honeymoon" Again

  • 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 candy.
  • 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 behavior.

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 of Violence

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 Phase"

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 "Tension-Building Phase."

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 occur.34

Phase 3: The Serious Battering Phase

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 assault.35

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.

Alcohol and Abusive Men

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 violent.

Approximately 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 adult.38

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.

Theories of 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 behavior.
  • Selective Disinhibition 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
  • Social Learning/Deviance Disavowal Theory: 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

Effects of 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 safety.

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 restlessness
  • 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, scratching, fighting
  • Regression, such as bedwetting, wanting a bottle, thumb sucking
  • 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.

Alcohol and Dating Violence

The pattern of violence in dating couples is similar to that experienced by couples that are married or living together:

  • In both types of relationships, one partner forces power and control over the other.
  • Both involve jealousy coupled with emotional and physical abuse.
  • 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 relationships.

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 aggressor.

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 distracted
  • 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.

Developmental aspects include:

  • New and mature relationships with peers of both sexes
  • Emotional independence
  • 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)

Adolescent Pregnancy

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 development.58

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
  • Prior legal problems due to alcohol or drugs
  • Depression and anger/hostility
  • Inappropriate expectations regarding relationships

Summary

  • 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, and age.
  • 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.

Introduction

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 consequences.2

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

Sexual Assault

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

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

Factors 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 factors include:

  • 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 non-confrontational.
  • 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 Columbia University's National Center 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 assault.

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.

Alcohol and Other Drugs Related to Sexual Assault and Rape

Alcohol

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 the man.15

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.

Lifestyle characteristics 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.

Other Drugs

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 Drinking and Sexual Assault

Students who 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 alcoholism).35

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

Strategies for Prevention

What Professionals Can Teach Young Women

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 well.
  • 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 "P.R.E.V.E.N.T.":
    • Put change in her wallet for an emergency or a ride home
    • Recognize the early signs of a potential assault
    • Examine her surroundings carefully
    • Verbalize her resistance loudly
    • Exhibit confidence in potentially threatening situations
    • Never assume sexual assault can not happen to her
    • Travel in groups whenever possible42
  • 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 about sex.
  • 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 not armed.
  • 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 rape."

Avoiding Date Rape Drugs

She should:

  • 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 container.
  • Not drink out of large, open containers, such as punch bowls.
  • Not trade or switch drinks with others.
  • Not drink something if it looks or tastes "different."
  • Watch for signs of drug effects in friends and act immediately on their behalf.45

What Professionals Can Teach Young Men

  • 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 sexual abuse.49

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.

The 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:

  • Chronic headaches
  • Fatigue
  • Sleep disturbances
  • Recurrent nausea
  • Nightmares
  • Decreased appetite
  • Eating disorders
  • Menstrual pain
  • Suicide attempts

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.

Post-Traumatic Stress Disorder

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
  • Nightmares
  • Flashbacks

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 powerlessness.
  • 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 interventions.53

5 Stages of Recovery

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 fear.54,55

Stages of Recovery

Stage 1: Initial Shock

Shock 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 others.

Stage 2: Denial

Also called 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.

Stage 3: Reactivation

This stage 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.

Stage 4: Anger

You may 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.

State 5: Integration (Closure)

As you 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

 

Summary

  • 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 INTERVENTION

Introduction to Prevention

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 Framework

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 victimization.
  • Selective 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.
  • Indicated 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.

Alcohol Abuse Prevention and Early Intervention Strategies

Information Dissemination

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 victimization.

You can make informational materials available in your office, community center, or waiting room.

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 steps:

  • 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 organization provides
    • The cost of the prevention services
    • The schedule of programs and office hours
    • Accessibility
    • Proximity to public transportation
    • Languages spoken
    • 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 appropriate.
  • 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.

Prevention Education

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:

  • Wellness programs
  • Safety seminars
  • Direct education about safe drinking
  • Life skills training

Alternative Activities

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 promote creativity
  • Cultural activities that emphasize special holidays and group gatherings

Peer Support

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.

Faith-Based Activities

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.

Community-Based Strategies

Community-based strategies include the development of alcohol consumption guidelines for colleges or universities.

Community-based strategies 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:

  • Shelter staff
  • Educators
  • Grassroots leaders and other community leaders, such as government officials, bank presidents, and newspaper editors
  • Social workers, nurses, physicians, and other health care providers
  • Family members
  • Neighbors, roommates, and friends
  • Faith/spiritual leaders

Community-based strategies include environmental approaches to promote policy and system changes that reduce risk factors and preserve or increase protective factors. Examples include:

  • 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 health problems
  • Development or enhancement of shelters that collectively address the issues of substance abuse and violence against women

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

Aspects of Effective Prevention Programs

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 include:

  • 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 very close-knit.
  • 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 relationships. 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 heritage.

Cultural Awareness

Sometimes, 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.

Cultural diversity 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.

Early Intervention

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.

Motivating Change

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 problems.

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 Drinking

  • 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

Summary

  • The Institute of Medicine's 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 healthy relationships.
  • 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 treatments.

Introduction

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 to:
    1. Determine the presence of a problem (e.g., mental health disorder, substance abuse)
    2. Substantiate that there is a reason for concern
    3. Identify the need for further evaluation

Screening 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
    1. Examine the scope and/or severity of mental health or substance abuse problems
    2. Identify other possible psychosocial problems that may need to be addressed further
    3. Provide a foundation for treatment
    4. 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 and psychological abuse by having clients fill out simple questionnaires. The Family Violence Prevention Fund and the American College 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.

General Screening For Domestic Violence and Sexual Assault

Who should be screened routinely?

  • 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:

  1. Has been educated about the dynamics of domestic violence,
  2. Is familiar with the affects of the violence on the victims, and
  3. 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 that no 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 possible.

When should screening occur?

  1. As part of a routine health exam or history.
  2. During an initial visit for a new complaint.
  3. During every new patient meeting.
  4. At any visit after the client has started a new intimate relationship.
  5. 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 Statements

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 problems.
  • 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.

Supportive Statements

Similar to domestic violence screening, when screening for sexual assault, professionals need to establish an environment of trust and safety. The American College 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.

  1. Do you have someone special in your life? Someone you're going out with?
  2. Are you now--or have you been--sexually active?
  3. Think about your earliest sexual experience. Did you want this experience?
  4. 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?
  5. 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 or sexual 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 Support

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 home."
  • "I am concerned about your children's safety. Domestic violence can harm your children."
  • "Domestic violence is a crime."

It is also important to remember that a woman's pregnancy puts her at additional risk for abuse at home. For more information about domestic violence and pregnancy, go to the Centers for Disease Control's site: http://www.cdc.gov/reproductivehealth/wh_violence.htm. There are many assessment tools available to those professionals working with teenagers and dating violence. A few of them test acceptance of couple violence, gender stereotyping, and attitudes toward women.

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.

Addressing 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 sure to:10

  • 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 confidence.
  • Observe behavior. Look for signs of alcohol use.
  • Ask questions.
  • 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 Alcohol Use

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.

CAGE

The CAGE 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 past year.

AUDIT

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)

The 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 Tools

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

Although two or more positive responses are indicative of an alcohol problem, a positive response to any one of the questions should prompt further exploration. The Goldberg Depression Questionnaire and The Center for Epidemiological Studies Depression Scale can help supplement alcohol screening to determine whether depression is also present.

The Health 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, and recordability."14

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
  • Psychotic disorders
  • Mood disorders
  • Anxiety disorders
  • Somatoform disorders
  • Eating disorders
  • Adjustment disorders
  • Personality 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 risk?
  • 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 needs?

Assessment involves five important tasks:15

  • 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 treatment.

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 compliance.

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:

P:

Probe for related information from the patient that may help you determine his or her risk for substance abuse.

R:

Rephrase questions so that they are open-ended. Be sure that your questions don't suggest how they should be answered.

O:

Observe behavior in addition to asking questions. People's behavior can provide you with clues to their risk for substance abuse.

B:

Be matter-of-fact and routine as you screen. Be sure to avoid any hint of judgment in your questions.

E:

Everyone should be screened. Inform participants that it is your practice to do so.

Supporting Sobriety

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 substance abuse.
  • 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 couples).
  • 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.

Assessing 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.

Interview Tips

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 the conversation.
  • 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.

Domestic Violence Screening

There are many questions you can ask a woman to begin screening for evidence of domestic abuse. One tool is the Psychological Maltreatment of Women Inventory. Other questions you may ask include:17

  • What happens when you argue with your partner?
  • How safe do you feel with your partner? How safe do you feel when you leave here?
  • How does your partner try to control your alcohol use?
  • 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 Tips

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 the victim. 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 the abuse. 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 Protection Services.

In addition, professionals who are treating women with alcohol abuse need to screen for domestic violence and sexual assault.

Addressing 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 partner's behavior.
  • 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.

Alcohol Screening

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, and CAGE are available to professionals. More helpful screening tools cover a range of typical screening questions.22

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.

Alcohol Assessment

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

Addressing 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

Abuse Screening

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 a Qualified Service Organization Agreement 25 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 Intervention/Relapse Prevention

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 setting.
  • Clients may have some cognitive and educational deficiencies, which can impact their capacity to take responsibility for the violence.
  • 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 behaviors.
  • 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 and addiction.

Child 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.

Psychiatric Comorbidities

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 include:

  • Anxiety disorders
  • Affective illness
  • Cognitive impairment
  • Schizophrenia
  • 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

Dual Diagnosis

Alcohol use can precipitate a variety of mental conditions, including:

  • Cognitive disorders
  • Depressive disorders (major depression, bipolar disorder, etc.)
  • Anxiety disorders
  • Schizophrenic disorders and other psychoses
  • Personality disorders (e.g., borderline, histrionic, narcissistic)

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 difficulties.
  • The psychiatric problem contributes to continued substance abuse.
  • Alcohol abuse interferes with engagement in mental health treatment.

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 condition.
  • Older adults rarely use illegal drugs.
  • Antisocial behaviors, such as car theft, and schizophrenia are less prevalent in older adults than in the younger population.
  • 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)
  • Denial
  • Powerlessness
  • Marginalization (especially if from a minority group)
  • 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

Safety Planning

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

  1. Safety During a Violent Incident
  2. Safety for Those Who Plan to Leave
  3. Safety in Your Own Residence
  4. 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.

Summary

  • 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.

PART VII: DIAGNOSIS AND TREATMENT

Introduction

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?

Treatment providers working in the fields of addiction, domestic violence and sexual assault have similar goals of helping clients become self-sufficient and healthy. In addition, there are common concepts between the addiction and domestic violence fields.

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.

Definitions of Treatment

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.

Goals of 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 substance-free life
  • Maximizing multiple aspects of life functioning
  • Preventing or reducing the frequency and severity of relapse

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, including:

  • Medical issues
  • Mental health concerns
  • Disrupted relationships
  • Underdeveloped or deteriorated social and vocational skills
  • 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 issues
  • Addressing financial and legal problems
  • Improving or developing necessary educational and vocational skills

Many programs also help participants explore spiritual issues and find appropriate recreational activities.

Increasingly, treatment 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:

  • Recognize cues;
  • Handle cravings;
  • Develop contingency plans for handling stressful situations; and
  • Handle "slips."

Relapse prevention is particularly important as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.

Effectiveness 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

Diagnosis-Driven Treatment (Alcohol Abuse)

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

Diagnosis-driven 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 addicted client.

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 care:11,12

  • Hospital
  • Non-hospital
  • Inpatient
  • Day treatment
  • Outpatient

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

  1. Acute intoxication and/or withdrawal potential
  2. Biomedical conditions and complications
  3. Emotional/behavioral conditions and complications
  4. Treatment acceptance/resistance
  5. Relapse/continued use potential
  6. Recovery/living environment

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 recommendations.

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, 15

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 syndromes:

  • Anxiety disorders
  • Affective disorders
  • Psychotic disorders
  • 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 substance dependance.

Medical 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 of treatment.

Levels of Treatment Services

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 intense:

Theoretical Approaches: Alcohol Treatment

Every facility designs their programs based on theoretical approaches accepted in the field. Some of the most widely used include:

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 addiction-related sites.

Many forms of treatment exist. Depending on the desired outcome, different approaches may be used. These theoretical approaches include:

Cognitive-Behavioral 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 preventing relapse.

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

Motivational Enhancement Therapy (MET)

Motivational Enhancement 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 self-interest).18

Relapse Prevention

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 include:

  1. helping the person identify, anticipate, avoid, or cope with high-risk situations (for relapse);
  2. helping the person learn how to keep one lapse from turning into a multiple relapse situation; and
  3. 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 healthier behaviors.19

Twelve-Step Facilitation and Alcoholics Anonymous

Twelve-Step Facilitation (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

Twelve-Step Facilitation 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

Treatment Modalities

Many forms of treatment exist. Depending on the desired outcome, and unique needs of the individual, different approaches may be used.

Types of formal specialized treatment include:22

Formal Specialized Treatment

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 intensive treatment.

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 treatment
  • 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 involvement

Types of treatment include:

Cognitive-Behavioral Approaches

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 counselor:

  • 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 labels
  • Avoiding confrontation (which usually results in greater defensiveness)
  • Accepting ambivalence about the need to change as normal
  • Inviting clients to consider alternative ways of solving problems
  • 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.

Types of Cognitive-Behavioral Approaches

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 observe.

Cognitive-behavioral 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.

The Drinking Behavior Chain

The cognitive-behavioral 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., pattern, style)
  • The positive and negative consequences of use for a given individual

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 and feelings.

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.

Behavioral 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.

Posttreatment Issues

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 support network
  • Self-management approaches for overcoming depression, grief, or loneliness
  • General problem solving9

Group-Based Approaches

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)
  • Physical distress
  • Insomnia
  • Sensory deficits
  • Reduced mobility
  • Cognitive impairment and change
  • Impaired self-care
  • Reduced coping skills
  • Decreased economic security or new poverty status
  • Dislocation
Therapy Groups

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 confidentiality.

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 are ready.

Educational Groups

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
  • Support systems
  • Medical aspects of aging and addiction
  • The concepts and processes of cognitive-behavioral techniques

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.
Alcoholics 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.

Individual Counseling

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.

Case 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 providers
  • Medical facilities for detoxification and other services
  • Home health agencies
  • Housing services for specialized housing
  • Public and private social services providing in-home support
  • Faith community (e.g., churches, synagogues, mosques, temples)
  • Transportation services
  • Social activities
  • Vocational training and employment programs
  • Community organizations that place clients in volunteer work
  • 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:

  • Interviews
  • Mental status examinations
  • Physical examinations
  • Laboratory, radiological, and psychometric tests
  • Social network assessments

Other Approaches

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.

Goals of 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 treatment plan.

Theoretical 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 and Cognitive-Behavioral Therapy

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.

Crisis Intervention

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 handle anger.

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

Treatment for Women

Helping 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 partner.25,26

Support Groups

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

Individual Counseling

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" path.28

Helping 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 violence issues.

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:

  1. Giving and sharing information
  2. Practicing skills, both new and long-unused
  3. 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

Theoretical 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.

The Family

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.

The Individual

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 situations.

Treatment for Men

Helping Abusive Men

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.

Batterer intervention 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 abusers.

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 behaviors, and
  • How behavior can change with perception and skill building.

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.

Helping 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.

Helping 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.

Community Services

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 forms, including:41

Crisis Intervention

  • Police or medical help
  • Crisis hotlines
  • Shelters or other emergency residential facilities
  • Medical services
  • Emergency in-patient addiction treatment facilities
  • Transportation networks
  • 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 Assistance

  • Legal steps that stop an abuser from seeing the victim (Part 8 discusses ex parte, protective (restraining), and peace orders.)
  • Advocates who will explain the court system and stay with the woman in court
  • Access to and custody of children
  • Property matters
  • Financial support
  • Public assistance benefits
  • Help with the mental health system (for co-occurring illnesses and addiction)
  • Help with immigration status

Emotional Support

  • Self-help support groups (for domestic violence and sexual assault)
  • 12-step groups, such as Alcoholics Anonymous or Al-Anon
  • Assertiveness training
  • Self-esteem and confidence-building sessions
  • Counseling for trauma and PTSD
  • Parenting courses

Other Supportive Services

  • Housing and safe accommodations
  • Alcohol or drug treatment
  • Child care
  • Access to community services
  • Access to job training or transitional work and housing services (halfway houses)

Summary

  • 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 intervention.
  • 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 individual.
  • Ideally, a community will offer an array of services to assist both men and women dealing with violence, substance abuse, or both.

Federal 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 criminal court
  • 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.

For additional information about VAWA, go to www.megalaw.com, www.ojp.usdoj.gov/vawo or www.firstgov.com.

Legal Remedies Within States

Civil Protection Orders

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 violence.

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 orders.

Local domestic violence or victim assistance centers can provide information regarding the laws in your State. To locate your State's resources or local coalitions against domestic violence, you can go to www.ndvh.org or www.vaw.umn.edu/FinalDocuments/FFCMatrfin.htm.

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, or adoption
  • 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.

Prohibited Behavior

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
  • Emotional abuse
  • 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."4 Pennsylvania 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:

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.

  • Refrain from further abuse
  • Refrain from contacting, attempting to contact, or harassing the victim
  • Refrain from entering the residence or workplace of the victim
  • Vacate the residence if the two parties were cohabitating
  • Remain away from the work, school, child care facility, or temporary residence of the victim or home of other family members
  • 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 and Wisconsin, the maximum duration is 2 years; in California and Hawaii, 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 contempt.9

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.

Police Arrests

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 the perpetrator.

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 complaint.

The Massachusetts code may be the most extensive example. Beyond advising victims of the right to obtain a protection order, the code states:

"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.

Batterer Intervention Services

Criminal 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. Washington State has the most comprehensive code regarding batterer's intervention and other necessities for batterer programs. 14

Filing a Civil Lawsuit

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 following facts:

  • Date and time of criminal act.
  • Location of events, addresses, and description of premises.
  • 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 anticipated treatment.
  • 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.

Campus 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 disciplinary proceeding.
  • Informing women of their options to notify law enforcement.
  • Notifying women of counseling services, including on- and off-campus mental health or other student services.
  • Notifying women of options for changing academic and living situations.

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.

Privacy and Confidentiality

Alcohol 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 been abused.

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).

The purpose 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.

In addition to complying with laws and regulations, programs must implement special rules for handling information about patients who may have substance abuse problems. For more information on the Federal law and regulations, see the Center for Substance Abuse Treatment's TIP 8, Intensive Outpatient Treatment for Alcohol and Other Drug Abuse and TAP 13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment. Exemption from the Federal rules, as with HIV-related cases, does not mean that providers can handle information about their clients' substance use problems haphazardly. Because of the potential for damage, providers should always handle such information with great care.

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 information;
  • sets boundaries on the use and release of health records;
  • establishes appropriate safeguards that the majority of health-care providers and others must achieve to protect the privacy of health information;
  • 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 plans,
  • 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. 18

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 without consent.

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:

  1. The type of professional provider holding the information and whether he or she is licensed or certified by the State
  2. The context in which the information was communicated
  3. The context in which the information will be or was disclosed
  4. Exceptions to any general rule protecting information
  5. 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 profession.

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 counselors.

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 Protections

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 not protected.

Some States, such as California, protect all information the patient or client shares with the professional or that the professional gains during examination.20 California 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 group setting.

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 particular diseases.

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 rules.

Communicating With Others

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 privacy.

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 discussions.

Making Referrals

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.

Communicating 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 duces tecum, 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.

Notifying the 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.

Summary

  • 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 resources.
  • 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.

References PART I

1.     Rennison, C.M., Ph.D. (2003). Intimate partner violence, 1993-2001. Publication No. NCJ 197838. Washington, DC: U.S. Department of Justice.

2.     Rennison, C.M., and Welchans, S. (2000). Intimate partner violence. Publication No. NCJ 178247. Washington, DC: U.S. Department of Justice.

3.     American Medical Association, (1999). Substance Abuse. Chicago: Author.

References PART II

1.        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2001). Intimate partner violence fact sheet. Atlanta: Author. [Available online at http://www.cdc.gov/ncipc/factsheets/ipvfacts.htm]

2.        Tjaden, P., & Thoennes, N. (1998, November). Prevalence, incidence, and consequences of violence against women: Findings from the national violence against women survey. National Institute of Justice and the Centers for Disease Control and Prevention: Research in Brief. Washington, D.C.: U.S Department of Justice, Office of Justice Programs.

3.        National Center for Injury Prevention and Control. Intimate partner violence fact sheet.

4.        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2001). Sexual violence. In Injury fact book 2001-2002. Available online at http://www.cdc.gov/ncipc/fact_book/24_Sexual_Violence.htm] Atlanta: Author.

5.        Domestic Abuse Project Advocates and the Minnesota Coalition for Battered Women. (1999). Safety first: Battered women surviving violence when alcohol and drugs are involved. St. Paul, MN: Minnesota Coalition for Battered Women.

6.        Tjaden, P., & Thoennes, N.

7.        National Center for Injury Prevention and Control. Injury fact book.

8.        Centers for Disease Control and Prevention, National Center for Injury Prevention & Control. (2000). Rape fact sheet. Atlanta: Author.

9.        Trauma Foundation, San Francisco General Hospital. (1998). Alcohol and rape/sexual assault: Fact sheet.

10.     Domestic Abuse Project Advocates and the Minnesota Coalition for Battered Women.

11.     Bureau of Justice Statistics. (1997). National crime victimization survey. Washington, DC: U.S. Department of Justice, Office of Justice Programs.

12.     Domestic violence quiz. (2000). New York: Safe Horizon.

13.     Bureau of Justice Statistics, National crime victimization survey.

14.     Domestic violence quiz.

15.     Bureau of Justice Statistics. (May, 2000). Intimate partner violence. Washington, DC: U.S. Department of Justice.

16.     Maryland Network Against Domestic Violence.

17.     Tjaden, P., & Thoennes, N. (1998).

18.     Bureau of Justice Statistics, (May, 2000).

19.     Ibid.

20.     Administration on Aging. (1998, September). The national elder abuse incidence study, Final Report. Washington, DC: Author. Available online at http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/ABuseReport_Full.pdf

21.     Jones, A. (1994). Next time she'll be dead: Battering and how to stop it. Boston: Beacon Press.

22.     Violence against women: Relevance for medical practitioners. (1992, June 17). American Medical Association Council on Scientific Affairs, Journal of the American Medical Association, 267(23), 3184-3189.

23.     Rath, G. D., Jarratt, L. G., & Leonardson, G. (1989). Rate of domestic violence against adult women by male partners. Journal of the American Board of Family Practice 1989, 2.

24.     Moore, M. (1999, November/December). Reproductive health and intimate partner violence. Family Planning Perspectives, 31.

25.     Walker, L. (1979). The battered woman. New York: Harper and Row.

26.     Wilson, K. J. (1997). When violence begins at home. Salt Lake City: Publishers Press.

27.     Browne, A. (1987). When battered women kill. New York: The Free Press.

28.     Stark, E. & Flitcraft, A. (1991). Spouse Abuse. In J. M. Last (Ed.), Maxcy-Rosenau: Public health and preventive medicine. New York: Apleton-Century-Crofts.

29.     Bennett, L., & Lawson, M. (1994). Barriers to cooperation between domestic violence and substance abuse programs. Families in Society: Journal of Contemporary Human Services, 75, 277-286.

30.     Ibid.

31.     Stark, E. & Flitcraft, A., Spouse Abuse.

32.     Stark, E. & Flitcraft, A. (1996). Women at risk: Domestic violence and women's health. Thousand Oaks, CA: Sage Publications.

33.     Waitzkin, H. (1985). Information giving in medical care. Journal of Health and Social Behavior, 26.

34.     Black, C. (1981). It will never happen to me. New York: Ballantine Boooks.

35.     Straus, M. A., and Gelles, R. J. (1990). Physical violence in American families. New Brunswick, NJ: Transaction Books.

36.     Family Violence Prevention Fund (1999). The effects of domestic violence on children. San Francisco: [available online at < http://www.endabuse.org >]

37.     Wilson, K. J. (1997). When violence begins at home. Salt Lake City: Publishers Press.

38.     Family Violence Prevention Fund (2000). What men can do to help stop violence. San Francisco: Available online at http://www.endabuse.org.

39.     American Bar Association Commission on Domestic Violence. (1999). Statistics. Available online at http://www.abanet.org/domviol/stats.html

40.     National Clearinghouse for the Defense of Battered Women. (1995). Statistics Packet, 3rd Edition (pp. 108-112). Philadelphia: Author.

41.     American Bar Association Commission on Domestic Violence.

42.     National Clearinghouse for the Defense of Battered Women.

43.     American Bar Association Commission on Domestic Violence.

44.     National Clearinghouse for the Defense of Battered Women.

45.     Dutton, M.A. (1994). The dynamics of domestic violence: Understanding the response from battered women. Florida Bar Journal, 68(9), 24.

46.     Maryland Network Against Domestic Violence. (1999). Domestic violence and the workplace curriculum. Bowie, MD.

47.     Administration on Aging. (1998 September).

48.     Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2000).

49.     Center for Substance Abuse Prevention. (1993). AOD-Related violence prevention workshop: Tools for planning in your community. Available online at http://p2001.health.org/SI01/Si01ttl.htm Rockville, MD: Author.

50.     Ibid.

51.     U.S. Department of Justice, Office of Justice Programs. (2001). Bureau of Justice Statistics Bulletin. National crime victimization survey. Washington, DC: Author.

52.     Centers for Disease Control and Prevention's National Center for Injury Prevention and Control. (2001).

References PART III

1.     Domestic Violence/Substance Abuse Interdisciplinary Task Force of the Illinois Department of Human Services (2000, July). Safety and sobriety: Best practices in domestic violence and substance abuse.

2.     Hutchison, I. W. (1999). Alcohol, fear, and woman abuse. Sex Roles 40, 893-920.

3.     The National Council of Jewish Women (2000). The truth about dating violence.

4.     Centers for Disease Control and Prevention's National Center for Injury Prevention and Control. (2000). Male batterers. Retrieved March 4,2003.

5.     Center for Substance Abuse Treatment.

6.     National Center for Injury Prevention and Control, Male Batterers.

7.     Eyler, A. E. & Cohen, M. (1999, December). Case studies in partner violence. American Family Physician, 60(9), 2569-76.

8.     My Sister's Place. (2000). Characteristics of a batterer. Washington, DC: Author. Available at http://www.mysistersplacedc.org/batterer.asp

9.     Jacobson, N. S. & Gottman, J. M. (1998, March-April). Anatomy of a violent relationship. Psychology Today.

10.   National Center for Injury Prevention and Control, Intimate partner violence fact sheet.

11.   Tjaden, P. & Thoennes, N. (1998). Stalking in America: Findings from the national violence against women survey. Washington, DC: U.S. Department of Justice, National Institute of Justice.

12.   National Center for Health Statistics, Centers for Disease Control and Prevention. (2000 February 12). News Release.

13.   Gazmararian, J. A., Petersen, R., Spitz, A. M. et. al. (2000). Violence and reproductive health: Current knowledge and future research directions. Maternal and Child Health Journal, 4.

14.   American Medical Association Council on Scientific Affairs.

15.   Gazmararian, J. A. et. al.

16.   Abma, J., Chandra, A., Mosher W. et. al. (1997). Fertility, family planning and women's health: New data from the 1995 National Survey on Family Growth. National Center for Health Statistics, Vital Health Statistics, 23(19).

17.   Goodwin, M. M., Gazmararian, J. A., Johnson, C. H. et. al. (2000). Pregnancy intendedness and physical abuse around the time of pregnancy: Findings from the pregnancy risk assessment monitoring system, 1996-1997. Maternal and Child Health Journal, 4.

18.   Ibid.

19.   Moore, M.

20.   Black, C. (1981). It will never happen to me. New York: Ballantine Books.

21.   Bennet, L. (1997). Substance abuse and woman abuse by male partners. Chicago: University of Illinois. Available online at http://www.vaw.umn.edu/finaldocuments/Vawnet/substanc.htm.

22.   Curry, M. A. (1999). The interrelationship between abuse, substance use and psychosocial stress during pregnancy. American Journal of Maternal Child Nursing 24(4), 211.

23.   Bureau of Justice Statistics. (2001, October). National violence against women survey. Washington, DC: U.S. Department of Justice.

24.   Abbey, A., Zawacki, T., Buck, P. O., et al. (2001). Alcohol and sexual assault. Alcohol Research and Health, 25(1), 43-51.

25.   U.S. Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA)'s National Clearinghouse for Alcohol and Drug Information (NCADI). (1995 Spring). Making the link: Domestic violence & alcohol and other drugs. NCADI Inventory Number ML001.

26.   Ullman, S. A., Karabatsos, G., and Koss, M .P. (1999). Alcohol and sexual aggression in a national sample of college men. Psychology of Women Quarterly, 23, 673-689.

27.   Wechsler, H., Lee, J. E., Kuo, M., & Lee, H. (2000, March). College binge drinking in the 1990s: A continuing problem. Journal of American College Health 48(5),199-210.

28.   Bureau of Justice Statistics.

29.   Center for Substance Abuse Treatment. (1997). Substance abuse treatment and domestic violence. Treatment Improvement Protocol 25, Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 97-3163. Washington, DC: U.S. Government Printing Office.

30.   Leonard, K. E.

31.   Wilson, K. J.

32.   Seymour, A., & Rynearson, E. K. (2000). Chapter 7: Substance abuse and victimization. In A. Seymour, M. Murray, J. Sigmon, M. Hook, C. Edmunds, M. Gadboury et al. (Eds.), 2000 National victim assistance academy. Washington, DC: U.S. Department of Justice, Office of Violence and Crime. Available at http://www.ojp.usdoj.gov/ovc/assist/nvaa2000/academy/G-7-SUB.htm

33.   Saltzman, L. E., Fanslow, J. L., McMahon, P. M., Shelley, G. A. (1999). Intimate partner violence surveillance. Atlanta, GA: Centers for Disease Control and Prevention's National Center for Injury Prevention and Control.

34.   Centers for Disease Control and Prevention's National Center for Injury Prevention and Control. (2000). Dating violence fact sheet.

35.   Mahoney, P. (1998 July). The wife rape information page. Center for Research on Women. Wellesley Centers for Women. Wellesley, MA. Available online at http://www.wellesley.edu/WCW/projects/mrape.html

36.   Tjaden, P. & Thoennes, N. (1998). Stalking in America: Findings from the national violence against women survey. Washington, DC: U.S. Department of Justice, National Institute of Justice.

37.   U.S. Department of Justice, Office of Justice Programs. (2001). Stalking and domestic violence: Report to Congress. Washington, DC: Author.

38.   American Medical Association. (2001). Diagnosis and clinical findings in domestic violence. Chicago: Author.

39.   Black, C. (1981). It will never happen to me. New York: Ballantine Books.

40.   Behrman, R. E. (Ed.) (1999, Winter). Domestic violence and children. The Future of Children, 9(3). The David and Lucile Packard Foundation. Available online at http://www.futureofchildren.org

41.   Newton, C. J. (2001 February) Domestic violence: An overview. FindCounseling.com Mental Health Journal. Available at http://www.findcounseling.com/journal/

42.   Bushman, B. (1997). Effects of alcohol on human aggression: Validity of proposed explanations. In Galanter, M.. (Ed.). Recent Developments in Alcoholism, Volume 13: Alcoholism and Violence. New York: Plenum Press.

43.   Claes, J. A., & Rosenthal, D. M. (1990). Men who batter women: A study in power. Journal of Family Violence, 5(3), 215-224.

44.   Straus, M. A., & Gelles, R. J. (1990). Physical violence in American families. New Brunswick, NJ: Transaction Books.

45.   Black, C.

46.   Behrman, R.E. (Ed.).

47.   Newton, C. J.

48.   Wilson, K. J.

49.   Center for Substance Abuse Treatment.

50.   Centers for Disease Control and Prevention's National Center for Injury Prevention and Control. Dating violence fact sheet.

51.   Molidor, C., Tolman, R. M., & Kober, J. (2000). Gender and contextual factors in adolescent dating violence. The Prevention Researcher, February 2000, 1-12.

52.   VAWnet (Violence Against Women), a project of the National Resource Center on Domestic Violence. (2001). Warning signs of an abusive relationship. Minnesota : Author. Available on http://www.vaw.umn.edu.

53.   Ibid.

54.   Boston, MA Department of Education. (1997). Guidelines to school districts on addressing teen dating violence. Boston, MA: Author.

55.   Gazmararian, J.A., Adams, M.M., Saltzman, L.E. et. al. The relationship between pregnancy intendedness and physical violence in mothers and newborns. The PRAMS Working Group. Obstetric Gynecology, 85(6), 1995.

56.   Fact Sheet of the Program on Women, Health and Development. Domestic violence during pregnancy. Pan-American Health Organization, November 2000.

57.   Wiemann, C.M., Agurcia, C.A., Berenson, A.B. et. al. Pregnant adolescents: Experiences and behaviors associated with physical assault by an intimate partner. Maternal and Child Health, v. 4, 2000.

58.   Abuse of pregnant women and adverse birth outcome. Journal of the American Medical Association 267, 1992.

59.   Wiemann, C.M., Agurcia, C.A., Berenson, A.B. et. al. Pregnant adolescents: Experiences and behaviors associated with physical assault by an intimate partner. Maternal and Child Health, v. 4, 2000.

60.   Source: National Resource Center on Domestic Violence, VAWnet (Violence Against Women net), Minnesota, www.vaw.umn.edu, 2001.

References PART IV

1.        Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2001). Sexual violence. In Injury fact book 2001-2002. Available online at http://www.cdc.gov/ncipc/fact_book/24_Sexual_Violence.htm] Atlanta: Author.

2.        Empower Program. (2000). Social control, verbal abuse, and violence among teenagers. Washington, DC.

3.        3. State of Texas (2001). Texas Commission on Law Enforcement officer standards & education.

4.        Centers for Disease Control & Prevention. (2001).

5.        Centers for Disease Control and Prevention, National Center for Injury Prevention & Control. (2000). Rape fact sheet. Atlanta: Author.

6.        Centers for Disease Control & Prevention. (2000).

7.        Empower Program.

8.        Silverman, J.G., Raj, A., Mucci., L.A. & Hathaway, J.E. (2001, August). Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. Journal of the American Medical Association, 286(5).

9.        Centers for Disease Control and Prevention.

10.     Trauma Foundation, San Francisco General Hospital. (1998). Alcohol and rape/sexual assault: Fact sheet.

11.     OMalley, P. M., Johnston, L. D., et. al. (1998). Alcohol use among adolescents. Alcohol Health & Research World, 22, 85-94.

12.     Sexual Assault Crisis Center, Knoxville, TN. (2001). Myths and facts about rape.

13.     State of Texas. (2001).

14.     Testa, M., & Parks, K. A. (1996). The role of womens alcohol consumption in sexual victimization. Aggression and Violent Behavior 3(1), 217-234.

15.     Trauma Foundation, San Francisco General Hospital. (1998).

16.     Fromme, K., & Wendel, J. (1995). Beliefs about the effects of alcohol on involvement in coercive and consenting sexual activities. Journal of Applied Social Psychology, 25(23).

17.     Ibid.

18.     Testa, M., & Parks, K. A. (1996).

19.     Office of National Drug Control Policy. (2001). Drug facts: Club drugs.

20.     California State University Fresno, Department of Biology. (2000). What is Rohypnol?

21.     Drug Early Warning System (DEWS), University of Maryland. (2000). Club drugs: From rave to the grave.

22.     National Institutes of Health, National Institute on Drug Abuse (NIDA). (2000). Club drugs. INFOFAX.

23.     Card, D. (2001, Fall). College campus: No safe haven. National Council of Jewish Women Journal, Fall 2001, pp. 20-21.

24.     U.S. Department of Justice, Drug Enforcement Agency. (2001). Flunitrazepam (Rohypnol).

25.     NIDA, INFOFAX. (2000).

26.     National Institute on Drug Abuse. (2001). Conference highlights increasing GHB abuse. NIDA Notes, 16, 2.

27.     NIDA, INFOFAX. (2000).

28.     Office of National Drug Control Policy. (2001). Drug facts: Club drugs.

29.     NIDA, INFOFAX. (2000).

30.     Office of National Drug Control Policy. (2001).

31.     Drug Early Warning System (DEWS), University of Maryland. (2000).

32.     Office of National Drug Control Policy. (2001).

33.     NIDA, INFOFAX. (2000).

34.     Harvard School of Public Health College of Alcohol Study (CAS); CDC National College Health Risk Behavior Study (2000).

35.     Knight, J. R., Wechsler, H., et al. (2000, May). Alcohol abuse and dependence among U.S. college students. Journal of Studies on Alcohol, 63:3, 263-270.

36.     Wechsler, H., Lee. J. E., Kuo, M., Lee, H. (2000, March). College binge drinking in the 1990s: A continuing problem. Journal of American College Health, 48(5), 199-210.

37.     American Medical Association, STOPCollegeBingeing.com. (2001). Frequently asked questions about college binge drinking.

38.     National Crime Prevention Council. (2000). Rape is a crime of violence, not an act of passion.

39.     Sexual Assault Crisis Center, Knoxville, TN. (2001).

40.     Security On Campus, Inc. (2001). Victim assistance.

41.     National Crime Prevention Council. (2000). Date rape is a power trip.

42.     Project SISTER Sexual Assault Crisis & Prevention Services, Claremont, CA, (2001).

43.     Rape, Abuse, Incest National Network. (2001). What can I do to reduce my risk of sexual assault? www.rainn.org

44.     Security On Campus, Inc. (2001).

45.     Card, D. (2001).

46.     National Crime Prevention Council. (2000).

47.     Sexual Assault Center, Baltimore, MD. Date rape: Risk reduction.

48.     Adapted from Oklahoma Coalition Against Domestic Violence and Sexual Assault, Rape Awareness List for Nice Guys. (2001).

49.     U.S. Federal Code: Title 18, Section 2241 (Aggravated Sexual Abuse).

50.     Trauma Foundation, San Francisco General Hospital. (1998).

51.     State of Texas. (2001).

52.     Rape Treatment Center, UCLA Medical Center, Santa Monica, CA. (2000).

53.     Marmar, C. R., Foy, D., Kagan, B., & Pynoos, R. S. (1994). An integrated approach for treating posttraumatic stress. In R.S. Pynoos (Ed.), Posttraumatic stress disorder: A clinical review. Lutherville, MD: Sidran Press.

54.     Matsakis, A. (1996). I can't get over it: A handbook for trauma survivors. Oakland, CA: New Harbinger Publications.

55.     National Coalition Against Sexual Assault.

References PART V

1.        Kumpfer, K. L., Alexander, J. F., McDonald, L., et al. (1998). Family-focused substance abuse prevention: What has been learned from other fields. In R. S. Ashery, E. B. Robertson, and K. L. Kumpfer (Eds.), Drug abuse prevention through family interactions. NIDA Research Monograph 177. NIH Publication No. 97-4135. Rockville, MD: National Institute on Drug Abuse.

2.        Center for Substance Abuse Treatment (1997). Substance abuse treatment and domestic violence. Treatment Improvement Protocol 25, Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 97-3163. Washington, DC: Government Printing Office.

3.        Blow, F.C. (2000). unpublished research.

4.        Prochaska, J. O., DiClemente, C. C., and Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114.

5.        Prochaska, J., and DiClemente, C. (1986). Toward a comprehensive model of change. In W. R. Miller and N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 3-27). New York: Plenum Press.

6.        DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., et al. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295-304.

7.        Prochaska, J. O., and DiClemente, C. C. (1985). Processes and stages of change in smoking, weight control, and psychological distress. In S. Schiffman and T. Wills (Eds.), Coping and substance abuse (pp. 319-345). New York: Academic Press.

8.        Velicer, W. F., Prochaska, J. O., Rossi, J. S., et al. (1992). Assessing outcome in smoking cessation studies. Psychological Bulletin, 111(1), 23-41.

9.        Hodgson, R., and Rollnick, S. (1992). How brief intervention works: Representative cases as viewed by the health advisors. In T. F. Babor and M. Grant (Eds.), Project on identification and management of alcohol-related problems: Report on phase II. A randomized clinical trial of brief interventions in primary health care (pp. 221-232). Geneva, Switzerland: World Health Organization.

References PART VI

1.     Family Violence Prevention Fund. (2001). Preventing domestic violence: Clinical guidelines on routine screening. San Francisco: Author. Available at http://endabuse.org/programs/healthcare/files/screpol.pdf

2.     The National GAINS Center (2003). Policy Research Associates. Available at http://gainscenter.samhsa.gov.

3.     Ibid.

4.     Hamberger, L.K., Ambuel, B., Marbella, A., Donze, J. (1998) Physician interaction with battered women: the women's perspective. Archives of Family Medicine, 7(6), 575-82.

5.     Ibid.

6.     Adapted from Rape101.com. (2001). How do you help a survivor of sexual assault?

7.     Adapted from Oklahoma Coalition Against Domestic Violence and Sexual Assault. (2001). How to avoid date rape. Oklahoma City, OK: Author. Available at www.ocadvsa.org/teens.htm

8.     National Center for Injury Prevention and Control. (2000). Rape [Fact Sheet]. Atlanta, GA: Centers for Disease Control and Prevention.

9.     American Bar Association, Commission on Domestic Violence. (2001). Multidisciplinary responses to domestic violence. Washington, DC: Author. Available at www.abanet.org/domviol/mrdv/home.html

10.   Domestic Violence/Substance Abuse Interdisciplinary Task Force of the Illinois Department of Human Services (2000, July). Safety and sobriety: Best practices in domestic violence and substance abuse.

11.   Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. JAMA, 252(14),1905-7.

12.   Babor, T.F., de la Fuenta, J.R., Saunders, J., Grant, M. (1992). AUDIT: The alcohol use disorders identification test: guidelines for its use in primary health care. Geneva, Switzerland: World Health Organization.

13.   Beresford, T.P., Blow, F.C.. Hill, E., Singer, K.. and Lucey, M.R. (1990). Comparison of CAGE questionnaire and computer-assisted laboratory profiles in screening for covert alcoholism. Lancet, 336(8713), 482-5.

14.   Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington, DC: National Academy Press.

15.   Domestic Violence/Substance Abuse Interdisciplinary Task Force. (2000, July).

16.   Gordon, S.M. (2002). Women and addiction: Gender issues in abuse and treatment. Wernersville, PA: Caron Foundation.

17.   Domestic Violence/Substance Abuse Interdisciplinary Task Force. (2000, July).

18.   American Medical Association. (2001). Diagnostic and treatment guidelines on domestic violence. Chicago: Author.

19.   Ibid.

20.   Fazzone, P.A.; Holton, J.K., and Reed, B.G. (1997). Substance abuse treatment and domestic violence. Treatment improvement protocol series 25. (DHHS Publication No. SMA 97-3163). Rockville, MD: Center for Substance Abuse Treatment.

21.   Domestic Violence/Substance Abuse Interdisciplinary Task Force. (2000, July).

22.   Ibid.

23.   Ibid.

24.   Ibid.

25.   Center for Substance Abuse Treatment. (1997).

26.   Alcoholics Anonymous. (2001). The recovery program. New York, NY: Author. Available at www.aa.org. (Click on AA Fact File).

27.   Ibid.

28.   Speer, D.C., and Bates, K. (1992). Comorbid mental and substance disorders among older psychiatric patients. Journal of American Geriatric Societ. 40(9), 886-90.

29.   Golding, J.M., Burnam, M.A., Benjamin, B., Wells, KB. (1993). Risk factors for secondary depression among mexican americans and non-hispanic whites. Alcohol use, alcohol dependence, and reasons for drinking. Journal of Nervous and Mental Disease, 181(3), 166-175.

30.   Swendsen, J.D., Merikangas, K.R., Canino, G.J., Kessler, R.C., Rubio-Stipec, M., Angst, J. (1998).The comorbidity of alcoholism with anxiety and depressive disorders in four geographic communities. Comprehensive Psychiatry, 39(4), 176-84.

31.   Fisher, P.E., and Bradshaw, D. (1995). Dual diagnosis and the older adult: An education strategy for health care providers and older adults. Vancouver, BC: Seniors Well Aware Program Society.

32.   National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. (2001). Frequently asked questions on alcohol abuse and alcoholism. Bethesda, MD: Author. Available online at www.niaaa.nih.gov/faq/faq.htm

33.   American Bar Association.

References PART VII Subsection

1.     Miller, W.R., and Rollnick, S. Motivational Interviewing. New York: Guilford Press, 1991.

2.     Ibid.

3.     Powers, R.B., and Osborne, J.G. Fundamentals of Behavior. New York: West Publishing Co., 1976.

4.     Spiegler, M.D., and Guevremont, D.C. Contemporary Behavior Therapy. Pacific Grove, CA: Brooks/Cole, 1993.

5.     Dobson, K.S., ed. Handbook of Cognitive-Behavioral Therapies. New York: Guilford Press, 1988.

6.     Scott, J.; Williams, J.M.G.; and Beck, A. Cognitive Therapy in Clinical Practice: An Illustrative Casebook. London, UK: Routledge, 1989.

7.     Dupree, L., and Schonfeld, L. Assessment and Treatment Planning for Alcohol Abusers: A Curriculum Manual. FMHI Publication Series, Number 109. Tampa: Florida Mental Health Institute, University of South Florida, 1986.

8.     Schonfeld, L., and Dupree, L.W. Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol 1991, 52:587-592.

9.     Schonfeld, L., and Dupree, L. Older problem drinkers: Long-term and late-life onset abusers: What triggers their drinking? Aging 1990, 361:5-9.

10.   Graham, K.; Saunders, S.J.; Flower, M.C.; et al. Addictions Treatment for Older Adults: Evaluation of an Innovative Client-Centered Approach. New York: Haworth Press, 1995.

11.   Fredriksen, K.I. North of Market: Older women's alcohol outreach program. Gerontologist 1992, 32:270-272.

References PART VII

1.     Schuckit, M.A. (1994). Goals of treatment. In: Galanter, M., and Kleber, H.D. (Eds.) The American Psychiatric Press Textbook of Substance Abuse Treatment. Washington, DC: American Psychiatric Press, pp. 3-10.

2.     American Psychiatric Association. (1995). Practice guidelines for treatment of patients with substance use disorders: Alcohol, cocaine, opioids. Washington, DC: American Psychiatric Association.

3.     Ibid.

4.     Ibid.

5.     Landry, M.J. (1996). Overview of addiction treatment effectiveness. (SMA) 96-3081. Rockville, MD: Substance Abuse and Mental Health Services Administration.

6.     American Psychiatric Association.

7.     Gerstein, D.R., and Harwood, H.J. (Eds.) (1990). Institute of Medicine. Treating Drug Problems. Washington, DC: National Academy Press.

8.     American Psychiatric Association.

9.     Smith, D.E. and Seymour, R.B. (2001). Clinicians guide to substance abuse. Maidenhead, Berkshire, England: McGraw Hill, Medical Publishing Division.

10.   Ibid.

11.   Ibid.

12.   Gastfriend, D.R., Baker, S.L., Najavits L.M. et. al. (1998). Assessment instruments. In: A.W. Graham, T.K. Schultz, and B.B. Wilford, (Eds.), Principles of addiction medicine. Chevy Chase, MD: American Society of Addiction Medicine.

13.   Smith, D.E. and Seymour, R.B. (2001).

14.   Ibid.

15.   First, M., Gibbon, M., Spitzer, R., and Williams, J. (1996). Users guide for the structured clinical interview for DSM-IV Axis I disorders, research version. New York: Biometrics Research Department, New York State Psychiatric Institute.

16.   Fuller, R.K. and Hiller-Sturmhofel, S. (1999). Alcoholism treatment in the United States: An overview. Alcohol Research & Health, Vol. 23(2), 69-77.

17.   Longabaugh, R. and Morgenstern, J. (1999). Cognitive-behavioral coping-skills therapy for alcohol dependence: Current status and future directions. Alcohol Research & Health, 23(2) 78-85.

18.   Miller, W.R. (2000). Motivational enhancement therapy: Description of counseling approach. In: Approaches to drug abuse counseling. Bethesda, MD: National Institutes of Health, National Institute on Drug Abuse.

19.   Larimer, M.E., Palmer, R.S., and Marlatt, G.A. (1999). Relapse prevention: An overview of Marlatts cognitive-behavioral model. Alcohol Research & Health, 23(2), 151-160.

20.   Fuller, R.K, and Hiller-Sturmhofel, S. (1999).

21.   Nowinski, J. (2000). Twelve-Step Facilitation. In: Approaches to Drug Abuse Counseling.Bethesda, MD: National Institutes of Health, National Institute on Drug Abuse.

22.   Center for Substance Abuse Treatment. (1994). Practical Approaches in the treatment of women who abuse alcohol and other drugs. Rockville, MD: Dept. of Health and Human Services, Public Health Service.

23.   39. The National Center on Addiction and Substance Abuse at Columbia University (CASA). (November 2001). So help me god: Substance abuse, religion and spirituality. New York: Author.

24.   Roth, P. (Ed.) (1991). Alcohol and drugs are womens issues: A review of the issues, Vol. I. Metuchen, NJ: Scarecrow Press.

25.   The National Clearinghouse for Alcohol and Drug Information. (1997). Substance abuse treatment and domestic violence, TIP 25. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

26.   National Coalition Against Domestic Violence. (2001). Getting help: Support. Denver, CO: Author. Available at www.ncadv.org

27.   NiCarthy, G., Marriam, K. and Coffman, S. (1984). Talking it out: A guide to groups for abused women. Seattle, WA: Seal Press.

28.   Pence, E. (1987). In our best interest: A process for personal and social change. Duluth, MN: Minnesota Program Development, Inc.

29.   Wilson, K.J., (1997). When violence begins at home: A comprehensive guide to understanding and ending domestic violence. Utah: Publishers Press.

30.   Hazelden Foundation. (2000). Womens alcohol and other drug use. Center City, Minnesota: Author.

31.   The National Clearinghouse for Alcohol and Drug Information. (1997).

32.   Office of Victims of Crime, National Victim Assistance Academy Curriculum (2000). Substance abuse and victimization, (Chpt. 7). Rockville, MD: Author.

33.   National Center for Injury Prevention and Control. (2000).

34.   The National Clearinghouse for Alcohol and Drug Information. (1997).

35.   Lawson, D.M. (2003). Incidence, explanations, and treatment of partner violence. Journal of Counseling and Development, (81)19-32.

36.   EMERGE. (1999). Batterer intervention program. Cambridge, MA: Author. Available at http://emergedv.com.

37.   National Institute of Justice. (July 1998). Research in action: Batterer programs: What criminal justice agencies need to know (pp. 1-12). Washington, D.C.: United States Department of Justice

38.   National Center for Injury Prevention and Control. (2000). Male batterers [electronic fact sheet]. Washington, D.C.: Centers for Disease Control and Prevention.

39.   Rosenbaum, A. and Maiuro, R.D., (1989) Eclectic approaches in working with men who batter. In Treating men who batter: Theory, practice, and programs. New York: Springer.

40.   Ibid.

41.   Ibid.

References: Part VIII

1.     The National Clearinghouse for Alcohol and Drug Information. (1997). Substance abuse treatment and domestic violence, TIP 25. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.

2.     National Council of Juvenile and Family Court Judges. (1992). Model code on domestic and family violence. Reno, NV: Conrad Hilton Foundation.

3.     The National Clearninghouse for Alcohol and Drug Information.

4.     Rhode Island General Law 15-15-1: Domestic Relations: Domestic Abuse Prevention.

5.     Finn, P., and Colson, S. (1990). Civil protection orders: legislation, current court practice and enforcement. Issues and Practices in Criminal Justice. Washington, D.C.: National Institute of Justice.

6.     Carter, J. (1992). Domestic violence cases in civil court cases: A national model for judicial education. San Francisco: The Family Violence Prevention Fund.

7.     N.J. Stat. Ann. 2C:25-28(m).

8.     California Civil Procedural Code 546(b).

9.     National Council of Juvenile and Family Court Judges (1992).

10.   Finn, P., and Colson, S. (1990).

11.   National Council of Juvenile and Family Court Judges (1992).

12.   Mass. Ann. Laws ch. 209A 6(4)

13.   National Council of Juvenile and Family Court Judges (1992).

14.   Washington Rev. Code Ann. 26.50(150). For more detail, see Hart, B. Accountability: Program Standards for Batterer Intervention Services, Harrisburg, PA: PCADV, 1992.

15.   National Center for Victims of Crime. (2000). Information for victims. Washington, D.C.: The National Crime Victim Bar Association.

16.   Security On Campus, Inc. (2001). Victim assistance: Campus sexual assault victims bill of rights. King of Prussia, PA: Author.

17.   Office for Civil Rights. Department of Health & Human Services. Title 45, Code of Federal Regulations Parts (160 and 164). Available at www.dhhs.gov/ocr/combinedregtext.pdf.

18.   Office for Civil Rights. OCR guidance explaining significant aspects of the privacy rule (2002). Department of Health & Human Services. Available at www.hhs.gov/ocr/hipaa.

19.   Luhdorff v. The Superior Court of Tulare County, 166 CA3d 485, 212 Cal. Rptr. 516 (5th District, 1985).

20.   Section 451 of the California Evidence Code codifies the doctor-patient privilege. See Grosslight v. Superior Court of Los Angeles, 72 Cal. App. 3d 502, 140 Cal. Rptr. 278 (1977), in which the court held that information communicated by the parents of a minor psychiatric patient to her doctor and his secretary was privileged, even though the parents were being sued by someone the child injured on the theory that the parents knew their child was a danger to others.

21.   Ibid.

22.   The National Clearinghouse for Alcohol and Drug Information. (1997).