Alcohol’s Role in Violence with Partners Issues & interventions

Alcohol’s Role in Violence with Partners

Issues & interventions

Fairbanks Alaska

November 16, 2009

Larry Bennett, PhD, LCSW

larrywbennett@yahoo.com

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There Is A Link . . . • Over 50% of men in BIPs have SA issues1 and are 8

times as likely to batter on a day in which they have been drinking2

• Half of partnered men entering SA treatment have battered in the past year3 and are 11 times as likely to batter on a day in which they have been drinking2

• Between a quarter and half of the women receiving services for DV have SA problems4

• Between 55 and 99 percent of women who have SA issues have been victimized at some point in their life5 and between 67 and 80 percent of women in SA treatment are DV victims6

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There is a link . . . But What Is The Link?

• Most men not drinking or drugging when they batter 1

• Most (80%) heavy drinkers don’t batter 1

• The apparent correlation between SA and DV fits only a sub-group of people.2

When male-dominant attitudes are controlled, relationship between SA and DV lessens, suggesting both SA and attitudes toward gender are important in preventing DV 3

The DV (Y) and Alcohol (X) Relationship is Obvious . . .

. . . Or Not

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• Human aggression is over-determined: there are “Many roads to Rome” Alcohol/drugs use (intoxication) is a road Alcohol/drug abuse/dependency is a road Male power/control motivation is a road Weak impulse control is a road etc. etc.

• None of these are usually the stand-alone causes of violence

• Impulsive violence may share paths in the brain with psychoactive substances, the orbito-frontal portion of the pre-frontal cortex 1

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Modeling Inhibition & Distress* Learned Inhibition Against Violence* The Bar * All the things acting against your

using physical aggression

* Distress * All outside and inside pressures* An instigation, and its’ meaning to

you

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Modeling Domestic Violence

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Some Men are Non-Violent, No Matter What

Learned Inhibition--Severe Violence

Learned Inhibition Against Violence

Distress Distress

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Some Men Seem Violent, No Matter What

Learned Inhibition Learned Inhibition--

Against Violence Severe Violence

Distress Distress

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Alcohol (and Drugs) Reduces Aggression Thresholds

Learned Inhibition Learned Inhibition Against Minor Violence Against Severe

Violence

Distress Distress

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Alcohol Reduces Aggression Thresholds

Learned Inhibition Learned Inhibition Against Minor Violence Against Severe

Violence

Distress Distress

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More Alcohol Reduces Aggression Thresholds More

Learned Inhibition Learned Inhibition Against Minor Violence Against Severe

Violence

Distress Distress

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Perspectives on the SADV (or DVSA) Relationship

• The previous slides illustrate a proximal model 1 or cognitive explanation of how alcohol (not drugs) may cause DV Sometimes called Disinhibition

• Proximal model doesn’t work in all (or even most) cases of SA, and neither does any other explanation

• After presenting a summary of data supporting a proximal model, I will present alternative ways of explaining SADV

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Substance Use and DV Victimization1 N=17,348 Cohabiting Adults Age 18+

DV Rate if DV Rate if # Users Used Past NOT

Used Per 1000 12 months 12 Months________ ________ ________

Alcohol 707 6.7 % 4.8 %

Marijuana/hashish 86 16.2 5.2Pain relievers 35 16.8 5.7

PCP 1 21.7 6.1Hallucinogens 14 21.7 5.9Inhalants 4 22.2 6.1Cocaine 19 22.4 5.8Tranquilizers 16 22.9 5.9Sedatives 3 25.6 5.1Methamphetamine 6 26.0 6.0

Heroin 1 35.0 6.1Crack 5 36.8 6.0

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Proximal Effects

• Disinhibition

• Cognitive Disinhibition/Acute Effects Model

Alcohol/Drug Intoxication

Violence

Alcohol/Drug Intoxication

ChangedThinking

Violence

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Proximal Effects

• Disinhibition

• Cognitive Disinhibition/Acute Effects Model

Alcohol/Drug Intoxication

Violence

ChangedThinking

Violence

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Disinhibition

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Laboratory Research Blood Alcohol Cognitive distortion

• Perceive. Aggression depends on drinker perceiving his target as aggressive

• Misperceive. Aggression more likely at high BAL--drinker more likely misperceives her behavior as aggressive, abandoning, or overwhelming

• Red-out. At high BAL, drinker is less likely to have empathy or mercy for his victim

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Disinhibition

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The Proximal Model Suggests:• Alcohol & drugs (moderated by personality

orientation, beliefs about violence, and skills) increase the risk of violence

• Violence can be prevented by lowering cognitive distortion, raising inhibitions to violence, and in those for whom alcohol/drug acts in some way to increase aggression, reduce consumption (risk/harm reduction) or remove the alcohol/drug (abstinence)

• Problem: The effects of alcohol on aggression are not only due to its’ biochemical effects on the brain

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Alternative Explanation #1Co-Morbidity/Co-Occurring

Situations• SADV linked to

Personality characteristics such as hostility 1

Co-occurring disorders such as antisocial personality disorder 2

Co-occurring situations such as social class 3

• More co-occurring disorders/situations greater likelihood of DV

• But Keep In Mind: Most poor men don’t batter Most men with antisocial personality disorder don’t

batter Most men with high levels of hostility don’t batter Most substance abusers don’t batter

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Alternative Explanation #2: Men’s Need for Power

• Alcohol aggression relationship is conditional upon individual power needs 1

• Alcohol is an “instrument of intimate domination” 2

• Power motivation origins in early personal experiences, social interactions, class, or ethnicity

• The relationship between power and abuse is usually gendered and reinforced in culture

SAPower Needs

DV

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Alternative Explanation #3:The Situation

• DV may occur during the process of obtaining and using substances, not from the substances per se Particularly relevant when illegal drugs are

involved 1

DV is more severe when drugs other than alcohol are involved,2 not due to the drug itself but due to the situation in which the drug is used and the lifestyle of the users 3

• Conflict over drinking cited in half DV episodes recalled by both perpetrator and victim 4

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Alternative Explanation #4:Culturally-based Excuses

• In many cultures SA serves as time out from responsibility during which the user can engage in exceptional behavior and later disavow the behavior as caused by the substance rather than the self 1

“It wasn’t me (Baby, Judge, Doc, Officer); it was the alcohol.”

• U.S. courts no longer accept drunkenness as a reason for criminal behavior The reverse is true for victims, however; her

use of alcohol and drugs increases the degree criminal justice professionals believe she is responsible for her own victimization 2

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Alternative Explanation #5:Expectancy

• Expectations for the effects of alcohol or drug use: sexier, stronger, social, aggressive 1

• Time out and cultural expectancy 2

• The balanced placebo experiment 3 • Male-specific?

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The Controlling Effect of Drunkenness

• Robin Room: “Alcohol is an instrument of intimate domination” 1

• Drunkenness serves to control partner behavior by increasing unpredictability, and therefore, fear Frequency of drunkenness almost quadruples the

likelihood of victim fear, even after controlling for the amount alcohol used, class, race, marital status, and levels of prior abuse 2

Summary: Batterers

• The way that A/D use and abuse increases the risk for DV is complex and different for every person and sometimes different for each event

• Removing the substance (abstinence) is likely to reduce DV in only a minority of cases

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Practice Issues

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The Issues• If a man (or woman) is arrested for DV, or seeks

help as a victim of DV, whose job is it to detect substance abuse? Under what policy? In what way?

• If substance abuse by a batterer or victim is detected, what happens next, and who decides? What is the policy?

• If a man or woman is arrested for alcohol or drugs, or is in treatment for alcohol or drugs, whose job is it to detect DV? Under what policy? In what way?

• If DV is detected, what happens next, and who decides?

• Most importantly: Assuming all the necessary services/sanctions/treatment are not provided by the same entity, how do multiple entities work to support victim safety and substance abuse recovery?

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www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.46712

TIP 25

SubstanceAbuse andMental Health Services Administration

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www.dhs.state.il.us/page.aspx?item=38441

Manual of the IllinoisDomestic Violence/Substance Abuse Interdisciplinary Task Force (2nd Edition, 185 pp.)

Resource Manual

Getting Safe and Sober: Real Tools You Can Use A Teaching Kit For Use With Women Who Are Coping with Substance Abuse, Interpersonal Violence and Trauma (Available in English and Spanish)

This project was supported by the Office of Women’s Health Region X Grant # HHSP233200400566P and by Grant #’s 2003-MU-BX-0029, 2004-MU-AX-0029 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions and recommendations expressed here are those of the presenters and authors and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women or the Office of Women’s Health. Principal Authors : Patricia J. Bland , M.A. CCDC CDP and Debi Edmund, M.A. L.P.C.

For more information contact:Alaska Network on Domestic Violence and Sexual Assault

907-586-3650 www.andvsa.org

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www.ispia.org/index.php

IowaIntegratedServicesProject

35www.prainc.com/wcdvs/pdfs/CreatingTraumaServices.pdf

Trauma-informed Services for Women With Co-occurringSubstance Use/ Mental Health Disorders and Victims of Violence(SAMHSA)

Serial, Integrated, and Coordinated Interventions

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Serial Interventions

Substance Abuse Tx

DVProgram

Assessment

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Problems with Serial Interventions for Offenders

• Offender rarely shows up at second service

• Offender is acculturated in the primary problem

• Only works with a high level of case management, highly trained staff at primary service, and assertive P.O.s

• Current best practice: NO SERIAL INTERVENTIONS EXCEPT DETOX

Problems with Serial Interventions for Victims

• Reinforces DV staff failure to recognize addiction as a brain disease Do we turn away diabetics who use insulin? Obese

women who over-eat? What’s the difference?

• SA victim usually involved with SA perp• Refusal to engage SA victim decreases her

opportunity for sobriety and increases her opportunity for injury

• DV program refusal does not increase the chances she will enter SA treatment

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Integrated Services

Theoretically Integrated: Program built on common foundation (eg: Power Model, DBT,

Trauma Theory)

DV

Agency Integrated: Distinct Programs & Staff(eg: mental health agency with both AOD and BIP)

SA

Agency & Staff Integrated: Distinct Programs(eg: substance abuse agency with

in-house BIP)

SA

DV

SADV

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Issues for Integrated Services

• Accountability & standards• Reduction to the common

denominator (Usually substance abuse)

• Finding and paying properly trained staff

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Coordinated Services

SA Tx DV Agency

Case Coordination Model

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Issues with Coordinated Services for Offenders

• Confidentiality, sharing information (e.g. HIPPA)

• Cost, compared to integrated programs• Time commitment for intensive

treatments• Cognitive impairment in early recovery

may interfere

Integrated and Coordinated Community Based Programs for

Batterers

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Not Much Yet

• Integrated and coordinated services for batterers not as well developed as services for victims

• Substance abuse treatment agencies have taken the lead (often for the wrong reason: $)

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Good Ideas (Maybe) But Risky Business for Batterers

• Self help • Couples counseling• Anger management• Anything with “Compassion” or

“Forgiveness” in title • Men’s growth groups• Psychotherapy• Pastoral/faith-based programs• Confrontational approaches

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Predicting Re-assault After BIP1

• Predicting re-assault at intake History of severe partner abuse History of non-DV arrest Severe mental disorder

• Predicting re-assault during the program

Women’s feeling of safety Drunkenness

• Almost all re-assaulters “get away with it”

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Program Recommendations

• Existing programs adequate w/ changes

• Rapid (pre-trial?) intake to program• Ongoing monitoring of substance use,

emotional/psychiatric problems, re-offense

• Intensive (2-3x/week) intervention for prior/severe offenders for first month

• Victim support

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System Recommendations

• Periodic court review (DV Court)• Assertive case management & risk

review• Support & safety planning with female

partners• Coordinated Community Response• “Swift and certain” response to re-

assault, dropout, and non-compliance

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Some Integration Attempts

• Dade County FL 1

Integrated Domestic Violence Model Duluth-based

• Yale 2

Substance Abuse Treatment Unit’s Substance Abuse–Domestic Violence

10-session CBT model• U. Maryland MET Clinical Trial 3

• ADA/Dawn Farm (Michigan) 4

Accountability/Recovery model • Behavioral Couples Therapy (Harvard) 5

No discussion of domestic violence at all

THANK YOU!

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Substance Abuse by Victims & Survivors

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Trauma

• Strong relationship between the amount of childhood trauma and adult SA Women significantly more likely than men to

initiate substance abuse to reduce the effects of trauma 1

• No evidence that SA causal in women’s victimization by partners, but substance abuse and dependency plays a substantial role keeping women unsafe by: Impairing her ability to leave her batterer Reducing her ability to protect herself and her

children If illegal drugs, putting her in more harm’s way 2

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Adverse Childhood Experiences (ACEs)Are Common among Normal People 1

Substance abuse 27%Parental sep/divorce 23Mental illness 17Battered mother 13Criminal behavior 6

Household dysfunction:

Abuse: Psychological 11% Physical 28 Sexual 21

Neglect: Emotional 15% Physical 10

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Harm Facing Battered Women Using Drugs 1

• Effects of SA prevent her from accurately assessing the level of danger posed by her perpetrator

• Erroneously believes she can defend herself against physical assaults

• Impairs cognition making safety planning more difficult

• Reluctant to seek assistance or contact police for fear of arrest, deportation or referral to a child protection agency

• Compulsive use/withdrawal symptoms make it difficult for SA victims to access shelter, advocacy, or other forms of help

• A recovering woman may find the stress of securing safety leads to relapse

• If she is using or has used in the past, she may not be believed

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Explaining Co-Occurrence in Victims: The Trauma Cycle

Substance abuse may increase the risk of victimization through numerous paths (vulnerability hypothesis)

Impairing judgement Increasing financial dependency Exposing women to violent men who also abuse substances Separation violence Response to retaliation

Women’s risk for alcohol and drug abuse is increased by victimization (self-medication hypothesis)

Cyclic relationship: AoDIPVAoD . . . and so on

Integrated and Coordinated Community Based Programs for

Women

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Coodination/Integration Recommendations of the Women’s Co-Occurring

Disorders and Violence Study (WCDVS) 1

1. Coordinating bodies required for information exchange, coordinating service, needs assessment, and reducing service barriers;

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WCDVS (cont’d)

2. Cross-training or co-training staff, which needs to be ongoing due to frequent staff turnover;

3. Memoranda of Understanding (MOU) to permit agencies to share information, facilitate referrals, and coordinate services;

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WCDVS (cont’d)

4. Policy Work aimed at education of officials;5. Co-location of services, including IPV

agencies providing groups at SA agencies or SA staff doing assessments at IPV agencies;

6. Central Intake to allow an individual to complete one application for services at different agencies – one-stop shopping

7. Integrating consumers, survivors, and recovering (C/S/R) women into every level of the process while avoiding hierarchies with professionals

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Characteristics of Trauma-informed Care 1

• Providers stop asking What’s wrong with you? and start asking What happened to you?

Focus on wellness rather than sickness

• Understand that trauma can be re-triggered/aggravated by the services provided and by the setting

• Committed to supporting the healing process while ensuring no more harm is done

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Organizational Shifts are Needed• Organizational shift from a

traditional “top-down” environment to one that is based on collaboration with consumers and survivors

• Non-hierarchal programs led by the consumer or survivor, and supported by the service provider/professional

Avoid Revictimizing

• People do not choose to develop substance use disorders any more than they pick out batterers

• Think before speaking...how would you like to be spoken to?• Remember to offer respect, not

rescue; options, not orders, safe treatment rather than re-victimization

Validate• You did not deserve this and neither do

your children• I’m so glad you found a way to survive.

Drinking or drugging can kill pain for a while but there are safer ways of coping that can cause you less grief

• You deserve a lot of credit for finding the strength to talk about this

• Addressing the drinking/DV may help you get safer/sober; your health and safety can improve your children’s safety and well-being, too

THANK YOU!

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