Alcohol’s Role in Violence with Partners Issues & interventions Fairbanks Alaska November 16, 2009 Larry Bennett, PhD, LCSW

2 There Is A Link... Over 50% of men in BIPs have SA issues 1 and are 8 times as likely to batter on a day in which they have been drinking 2 Half of partnered men entering SA treatment have battered in the past year 3 and are 11 times as likely to batter on a day in which they have been drinking 2 Between a quarter and half of the women receiving services for DV have SA problems 4 Between 55 and 99 percent of women who have SA issues have been victimized at some point in their life 5 and between 67 and 80 percent of women in SA treatment are DV victims 6

3 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

6 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

7 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

8 Modeling Domestic Violence

9 Some Men are Non-Violent, No Matter What Learned Inhibition-- Severe Violence Learned Inhibition Against Violence Distress Distress

10 Some Men Seem Violent, No Matter What Learned Inhibition Learned Inhibition-- Against Violence Severe Violence Distress

11 Alcohol (and Drugs) Reduces Aggression Thresholds Learned Inhibition Against Minor Violence Against Severe Violence Distress

12 Alcohol Reduces Aggression Thresholds Learned Inhibition Against Minor Violence Against Severe Violence Distress

13 More Alcohol Reduces Aggression Thresholds More Learned Inhibition Against Minor Violence Against Severe Violence Distress

14 Perspectives on the SA  DV (or DV  SA) 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 SA  DV

15 Substance Use and DV Victimization 1 N=17,348 Cohabiting Adults Age 18+ DV Rate if # Users Used Past NOT Used Per months 12 Months ________________ ________ Alcohol %4.8 % Marijuana/hashish Pain relievers PCP Hallucinogens Inhalants Cocaine Tranquilizers Sedatives Methamphetamine Heroin Crack

16 Proximal Effects Disinhibition Cognitive Disinhibition/Acute Effects Model Alcohol/Drug Intoxication Violence Alcohol/Drug Intoxication Changed Thinking Violence

17 Proximal Effects Disinhibition Cognitive Disinhibition/Acute Effects Model Alcohol/Drug Intoxication Violence Changed Thinking Violence

18 Disinhibition

19 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

20 Disinhibition

21 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

22 Alternative Explanation #1 Co-Morbidity/Co-Occurring Situations SA  DV 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

23 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

24 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

25 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

26 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?

27 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 28

Practice Issues

30 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?

31 TIP 25 Substance Abuse and Mental Health Services Administration

32 Manual of the Illinois Domestic Violence/ Substance Abuse Interdisciplinary Task Force (2 nd 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 # HHSP P 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

34 Iowa Integrated Services Project

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

36 MY ASSUMPTIONS Safety: The purpose of intervention with substance-abusing batterers is to increase the safety of victims, to hold batterers accountable, and enhance recovery of all (not to save marriages or enhance personal growth) Substance abuse (by either the victim or the offender) makes victims unsafe Battering and victimization threaten SA recovery

37 ASSUMPTIONS Responsibility & choice. The perpetrator is fully responsible for the violence; He is not provoked, triggered, or stressed into violence; He does not become violent by drinking or drugging alone; Both violence and substance use are always a choice. Violence is a vehicle. DV is a vehicle chosen to establish control over a person, persons, or a situation

38 ASSUMPTIONS Co-dependency. It is inaccurate to label battered women codependent, which is a victim-blaming term describing the socially-sanctioned roles of women in a traditional society  66% of substance abuse counselors believe battered women are co-dependent 1

39 ASSUMPTIONS People-in-society: Our society and our culture reinforce substance abuse, domestic violence, and intoxicated domestic violence. Consequently, neither substance abuse nor domestic violence may be viewed entirely at the personal level Abstinence and sobriety are neither necessary nor sufficient conditions for non-violence

40 How Effective? (briefly) Effectiveness of criminal justice system on DV Effect of batterer intervention programs on DV Effect of victim service programs on DV Effect of substance abuse treatment on SA

41 Effect of CJ on DV: Mixed 1984 Minneapolis experiment found arrest of batterers better than on-scene counseling or separation 1  Subsequent experiments find either no effect or small effects 2 Arrest increases the likelihood of DV recidivism by men with low stake in conformity (SIC = employed, married) 3 “Victimless” or “evidence-based” prosecution is not as effective at reducing future battering as letting victims have input on how/whether to prosecute 4 Coordinated, judge-centered, community collaboration has not yet been found to be effective at reducing DV 5

42 Mixed & Unintended Consequences Drug Court: Great for SA, not (yet) for DV Unintended consequences: The adverse effects of the War on Drugs on poor and minority communities  America’s shame: 5% of the world’s population and 25% of the world’s jail population

43 Effect of BIPs: Mixed Two meta-analyses of experimental and quasi-experimental BIP outcome studies concluded that BIPs are often not effective 1 or if effective, the effects are relatively small 2 Multi-site Study found that at 4 years after BIP, 90% of men had not battered in the past year 3

44 Effects of Victim Service Agencies: Mixed 1 Increased information, support (counseling, advocacy, hotline) Improved decision making (counseling, advocacy) Increased self-efficacy, coping skills (counseling) Safety (shelter)

45 Effect of SA Treatment: Mixed 20 Years of research shows treatment is effective (when delivered by qualified professionals, using empirically validated medications and therapies, applied for adequate durations and followed by monitoring and maintenance) 1 Trauma-informed treatment effective for women 2 No one path to recovery is best Long term recovery supports more critical than acute abstinence

Serial, Integrated, and Coordinated Interventions

47 Serial Interventions Substance Abuse Tx DV Program Assessment

48 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 49

50 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

51 Issues for Integrated Services Accountability & standards Reduction to the common denominator (Usually substance abuse) Finding and paying properly trained staff

52 Coordinated Services SA Tx DV Agency Case Coordination Model

53 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

55 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: $)

56 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

57 Predicting Re-assault After BIP 1 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”

58 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

59 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

60 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! 61

Substance Abuse by Victims & Survivors

63 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

64 Adverse Childhood Experiences (ACEs) Are Common among Normal People 1 Substance abuse 27% Parental sep/divorce 23 Mental illness 17 Battered mother 13 Criminal behavior 6 Household dysfunction: Abuse: Psychological 11% Physical 28 Sexual 21 Neglect: Emotional 15% Physical 10

65 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

66 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: AoD  IPV  AoD... and so on

Integrated and Coordinated Community Based Programs for Women

68 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;

69 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;

70 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

71 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

72 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! 75