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dependent on tranquilizers, sedatives, stimulants, and painkillers and are morelikely to abuse alcohol (Stark and Flitcraft, 1988a). Other evidence of theconnection between substance abuse and family violence includes the followingdata: About 40 percent of children from violent homes believe that theirfathers had a drinking problem and that they were more abusive whendrinking (Roy, 1988).Childhood physical abuse is associated with later substance abuse byyouth (Dembo et al., 1987).Fifty percent of batterers are believed to have had "addiction" problems(Faller, 1988).Substance abuse by one parent increases the likelihood that thesubstance-abusing parent will be unable to protect children if the otherparent is violent (Reed, 1991).A study conducted by the Department of Justice of murder in familiesfound that more than half of defendants accused of murdering theirspouses -- as well as almost half of the victims -- had been drinkingalcohol at the time of the incident (Bureau of Justice Statistics, 1994).Teachers have reported a need for protective services three timesmore often for children who are being raised by someone with anaddiction than for other children (Hayes and Emshoff, 1993).Alcoholic women are more likely to report a history of childhoodphysical and emotional abuse than are nonalcoholic women(Covington and Kohen, 1984; Miller et al., 1993; Rohsenow et al.,1988; Hein and Scheier, 1996).Women in recovery are likely to have a history of violent trauma andare at high risk of being diagnosed with posttraumatic stress disorder(Fullilove et al., 1993).The Societal ContextClearly, substance abuse is associated with domestic violence, but it is notthe only factor. As discussed above, witnessing or experiencing family violenceduring childhood is a risk factor as is a history of childhood aggression. Anotherfactor that must be acknowledged is societal norms that indirectly excuseviolence against women (tacit support for punishing unfaithful wives, for example,or stereotyped views of women as obedient or compliant) (Kantor and Straus,1987; Reed, 1991; Bennett, 1995; Flanzer, 1990).The overt or covert sexism that contributes to domestic violence alsobears on connections between violence and substance abuse. Manifestations ofthat sexism vary across social classes and cultural groups: Some groups more 1998-2001 DLC, LLC5

Substance Abuse Treatment and Domestic Violence – Batterersthan others accept domestic violence or intoxication as a way of dealing withfrustration or venting anger. Though they range from subtle to blatant, sexistassumptions persist and are reflected by society's different responses todomestic violence and substance abuse among men and among women.For example, substance abuse treatment providers have observed thatsociety tolerates a man's use of alcohol and other drugs more readily than awoman's. They note that batterers often blame a woman they have victimized forthe violence, either implicitly or explicitly, and other people, including police,judges, and juries, often accept this argument. Research suggests thatintoxicated victims are more likely to be blamed than sober victims and thataggression toward an inebriated victim is considered more acceptable thanaggression toward a sober one (Aramburu and Leigh, 1991). At least one otherresearch team (Downs et al., 1993) argues that sexist attitudes may in factcontribute to the alcoholism of some women. "The alcoholic woman," they write,"may internalize previous negative stigmatization and subsequently use alcoholto cope with negative feelings resulting from the stigma. Conversely, the partnermay use the woman's drinking as a rationale to label her negatively" (p. 131).Attitudes toward rape are another example of how this rationalizationworks. Even when alcohol or other drugs are not involved, women victimsfrequently are assumed to have provoked their rapists by the way they behavedor dressed. This widely accepted misperception is often internalized andaccounts for the guilt and shame that many rape victims experience. Notsurprisingly, some victims of rape and other violence report using alcohol andother drugs to "self-medicate" or anesthetize themselves to the pain of theirsituations.The Connection Between Substance Abuse and DomesticViolenceThough experts agree there is a connection between the two behaviors,its precise nature remains unclear. One researcher writes, "Probably the largestcontributing factor to domestic violence is alcohol. All major theorists point to theexcessive use of alcohol as a key element in the dynamics of wife beating.However, it is not clear whether a man is violent because he is drunk or whetherhe drinks to reduce his inhibitions against his violent behavior" (Labell, 1979, p.264).Another expert (Bennett, 1995) observes that[I]f substance abuse affects woman abuse, it does so either directly bydisinhibiting normal sanctions against violence or by effecting changes in6

thinking, physiology, emotion, motivation to reduce tension, or motivationto increase interpersonal power (Graham, 1980). Despite its popularity,the disinhibition model of alcohol aggression is often discredited becauseof experiments that have found expectation of intoxication a betterpredictor of aggression than intoxication itself (Lang et al., 1975).Analternative to disinhibition, is 'learned disinhibition,' or expectancy of adrug and violence relationship Drug and alcohol use occur in a culturalcontext in which behavior can be attributed to 'I was loaded' (MacAndrewand Edgerton, 1969). (p. 761)Within this theoretical framework, the societal view of substance abusersas morally weak and controlled by alcohol or other drugs actually serves somebatterers: Rather than taking responsibility for their actions, they can blame theirviolent acts on the substance(s) they are abusing. Although drugs or alcohol mayindeed be a trigger for violence, the belief that the violence will stop once thedrinking or drug use stops is usually not borne out. The use of alcohol or otherdrugs may increase the likelihood that a batterer will commit an act of domesticviolence -- because it reduces inhibitions and distorts perceptions, becausealcohol is often used as an excuse for violence, and because both alcohol abuseand domestic violence tend to follow parallel escalating patterns -- but it does notfully explain the behavior (Pernanen, 1991; Leonard and Jacob, 1987; Steele andJosephs, 1990). The fact remains that nondrinking men also attack their partners,and for some individuals, alcohol actually inhibits violent behavior (Coleman andStraus, 1983).Batterers often turn to substances of abuse for their numbing effects.Batterers who are survivors of childhood abuse also frequently say that they usedrugs and alcohol to block the pain and to avoid confronting that memory. It is aself-perpetuating cycle: Panel members report that batterers say they feel freefrom their guilt and others' disapproval when they are high.The Impact of Violence on Substance Abuse TreatmentThough it cannot be said that substance abuse "causes" domesticviolence, the fact remains that substance abuse treatment programs seesubstantial numbers of batterers and victims among their patient populations andincreasingly are compelled to deal with issues related to abuse (Flanzer, 1993).As substance abuse treatment programs have grown more sophisticated,the treatment offered patients has become more comprehensive and moreeffective. Questions about vocational, educational, and housing status; coexistingmental disorders; and presence of human immunodeficiency virus (HIV) and 1998-2001 DLC, LLC7

Substance Abuse Treatment and Domestic Violence – Batterersother infectious diseases are routinely raised during the assessment process.Treatment providers now recognize the importance of addressing issues thataffect clients' patterns of substance abuse (and vice versa) so that these issuesdo not undermine their recovery. Today, mounting evidence about the variedassociations between domestic violence and substance abuse attests to theneed to add violent behavior and victimization to the list of problems that shouldbe explored and addressed during treatment. Based on their clinical experience,members of the Consensus Panel who developed the TIP which this training isbased upon conclude that failure to address domestic violence issues interfereswith treatment effectiveness and contributes to relapse.Practitioners in both fields must be attuned to the connections betweenthe two problems. By sharing knowledge, substance abuse treatment providersand domestic violence workers can understand the complexity of the problem,address their own misperceptions and prejudices, and better serve individualclients -- as well as lay the foundation for a coordinated community response.Building bridges between the fields requires an understanding of the way eachproblem can interfere with the resolution of the other and of the barriers posed bythe two fields' differing program priorities, terminology, and philosophy.Barriers To Addressing Domestic Violence in the TreatmentSettingBattering, victimization, and treatment effectivenessBattering and victimization undermine substance abuse treatment in bothdirect and indirect ways. Members of the Consensus Panel which created theoriginal TIP document report that a substance-abusing woman often finds thather abusive partner becomes angry or threatened when she seeks help, and hisviolence or threats of violence may push her to drop out of treatment. Panelmembers have also seen a violent partner sabotage a woman's treatment byappearing at the program and threatening physical harm unless she leaves withhim or by bullying or manipulating her to use alcohol or other drugs with him.Another variation on this theme occurs when a woman manages to continue intreatment, a violent episode occurs, and, as part of "making up," is persuaded totake alcohol or other drugs. Although these patterns occur in nonviolentrelationships as well, the threats of physical harm, withholding of financialsupport, or abuse directed toward children can lead survivors to resort to usingsubstances to buffer their distress. For this reason, recovery from a substanceuse disorder may not be possible unless client survivors improve their selfesteem, sense of competence, and ability to make sound decisions. Survivorsmust get to the point where they can recognize and take advantage of their8

options and alternatives before they can replace their substance use with positivecoping strategies.When batterers enter treatment, their partners also may subvert theirefforts to achieve sobriety. Some batterers are less violent and easier to handlewhen they are drunk or high. If a batterer is more violent when sober orabstinent, his partner may encourage drinking or taking drugs. "Enabling" isactually a safety measure in these cases. Another complicating factor is somewomen's perception that they are responsible for their partners' substanceabuse, a perception that often is reinforced by their partners, friends, and family.In the same way that they hold themselves culpable for their battering, thosewomen believe that their "bad" behavior prompts their partners' use of alcohol orother drugs, a position that abusers exploit to rationalize their continuedsubstance abuse.Program priorities, terminology, and philosophyThe problems of substance abuse and domestic violence intersect indestructive ways; furthermore, differences in priorities, terminology, andphilosophy have hampered collaboration between providers in the two fields. Forsubstance abuse, attaining abstinence is a key goal; for domestic violenceprograms, ensuring survivors' safety is of paramount concern. While both goalsare valid, the reality is that they may be difficult to balance. The problem forsubstance abuse and domestic violence staff then lies in the perception that onegoal invariably must be selected to the exclusion of the other for a program topreserve its identity and thereby carry out its mission.A heightened awareness of the two problems, however, reveals thatprograms can forego an "either/or approach," shift priorities to accommodate aclient's situation, and still retain program identity and orientation. Adjustingpriorities on a case-by-case basis does not undermine a particular program'sphilosophy; instead it recognizes the need for flexibility in responding to individualclient needs.Other features of substance abuse treatment that have posed problemsfor domestic violence programs and have inhibited collaboration between the twofields are the largely male clientele, the emphasis on family involvement, and theuse of confrontational group therapy. Some domestic violence professionalsworry that the male orientation in many substance abuse treatment programsmakes these programs irrelevant to the realities of women's lives, insensitive totheir needs, and inapplicable to the issue of domestic violence. They also believethat enlisting the help of family members and significant others in the treatmentprocess can, in the case of violent partners, endanger the survivor. 1998-2001 DLC, LLC9

Substance Abuse Treatment and Domestic Violence – BatterersAlthough there is some validity to these characterizations (as well as tothe claim that domestic violence staff are uninformed and naive about substanceabusers and the manipulative behaviors they sometimes employ), education,communication, and cross-training can help to overcome barriers betweensubstance treatment and domestic violence programs. Increased understandingwithin both disciplines will equip practitioners to address the particular problemsof substance abusers who are victims or perpetrators of domestic violence.A New Way of ThinkingThe disagreements between experts in the fields of substance abuse anddomestic violence can inhibit the exchange of essential information to thedetriment of the client's recovery. This DLC represents an initial effort to bridgethat gap. In the chapters that follow, experts in the respective arenas share theirunderstanding about the impact of domestic violence on batterers. In addition,this DLC provides suggestions for screening and assessing for past and currentexperience with domestic violence, offers ideas for intervening with survivor andperpetrator clients, and summarizes legal and ethical issues that substanceabuse providers should consider when working with this population. In addition topresenting guidelines to improve client outcomes, the information included in thisdocument is intended to begin a dialogue between domestic violence andsubstance abuse treatment staff about the larger issue of systemic reform.Currently, domestic violence and substance abuse treatment function as parallelprograms within the overall social services system.In the short term, the ideas presented in this DLC should enhance theresponses of both programs to the problems of domestic violence survivors andbatterers who are also substance abusers. However, to effect lasting change andreduce morbidity, people working in both fields must accept the fact that the twoproblems often exist together, must recognize the importance of a holistictreatment approach, must be willing to set aside concerns about "turf," and mustlearn to collaborate effectively on the client's behalf. Impediments to systemicreform are scattered throughout substance abuse and domestic violenceprograms and in the public and private funding organizations supporting them.The insistence on identifying a single problem as primary or the need to conceala problem in order to receive services can complicate admission to treatment,interfere with the development of appropriate treatment plans, and ultimatelyderail progress.10

Chapter 2 -- Batterers: An OverviewThere are myriad reasons why substance abuse counselors shouldaddress the domestic violence of clients who batter their partners. Experts haveobserved that the violent behavior of a batterer client can interfere with histreatment for substance abuse, and conversely, his substance abuse caninterfere with interventions aimed at changing his violent behavior (Bennett,1995). Clients who are incarcerated, for example, or accused of assault ormurder have limited access to substance abuse treatment. Practitioners haveobserved that for those clients in treatment, battering may precipitate relapse andthwart the process of true recovery, which includes "adopting a lifestyle thatenhances one's emotional and spiritual health, a goal that cannot be achieved ifbattering continues" (Zubretsky and Digirolamo, 1996, p. 225).Use of psychoactive substances, on the other hand, may interfere with aclient's capacity to make a safe and sane choice against violence by impairinghis ability to accurately "perceive, integrate, and process information" aboutanother's behavior toward him (Bennett, 1995, p. 761). Intoxication appears toincrease the likelihood that a batterer may misinterpret or distort a partner'sremarks, demeanor, or actions by "blunting whatever cognitive regulators theabuser possesses" (Stosny, 1995, p. 36). While abstinence from drugs andalcohol does not alter battering behavior, substance abuse problems negativelyaffect a batterer's capacity to change and increase the chance that violence willoccur (Tolman and Bennett, 1990; Bennett, 1995).Both battering and substance abuse result in harm to the client andothers. Responding to a client's penchant for violent behavior is as vital asresponding to his depression or to the array of other conditions that may impedeprogress in treatment and interfere with recovery.Perspectives on Substance Abuse and The Batterer ClientAlthough domestic violence occurs in the absence of substance abuse,there is a statistical association between the two problems. Alcohol use has beenimplicated in more than 50 percent of cases involving violent behavior (Roy,1982). Research by Kantor and Straus suggested that approximately 40 percentof male batterers were heavy or binge drinkers (Kantor and Straus, 1987). Arecent study found that more than half of defendants accused of murdering theirspouses had been drinking alcohol at the time (Bureau of Justice, 1994). Anotherstudy of incarcerated batterers found that 39 percent reported a history ofalcoholism and 22 percent reported a history of other drug addiction. A total of 50 1998-2001 DLC, LLC11

Substance Abuse Treatment and Domestic Violence – Battererspercent self-reported current addiction; however, this figure rose to 89 percentwhen the researchers examined court documents.

The Premier Source for Addiction Information and Continuing Education on the World Wide Web. This Distance Learning Course (DLC) was developed for the Distance Learning Center for Addiction Studies (DLCAS) by Vic Shaw, MTh. It is based on work from the Treatment Improvement Protocal (TIP) #25 - Substance Abuse