Alcohol s Role in Violence with Partners Issues

Alcohol’s Role in Violence with Partners Issues & interventions Fairbanks Alaska November 16, 2009 Larry Bennett, Ph. D, LCSW larrywbennett@yahoo. com

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 2

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 3

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

. . . Or Not

• 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. • 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 6

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 7

Modeling Domestic Violence 8

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

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

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

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

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

Perspectives on the SA DV (or DV SA) Relationship • The previous slides illustrate a proximal model or cognitive explanation of how alcohol (not drugs) may cause DV 1 § 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 14

Substance Use and DV Victimization 1 N=17, 348 Cohabiting Adults Age 18+ # Users Per 1000 ____ Alcohol 707 DV Rate if Used Past 12 months ____ 6. 7 % DV Rate if NOT Used 12 Months ____ 4. 8 % Marijuana/hashish Pain relievers 86 35 16. 2 16. 8 5. 2 5. 7 PCP Hallucinogens Inhalants Cocaine Tranquilizers Sedatives Methamphetamine 1 14 4 19 16 3 6 21. 7 22. 2 22. 4 22. 9 25. 6 26. 0 6. 1 5. 9 6. 1 5. 8 5. 9 5. 1 6. 0 1 5 35. 0 36. 8 6. 1 6. 0 Heroin Crack 15

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

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

Disinhibition 18

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 19

Disinhibition 20

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 21

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 men with antisocial personality disorder don’t batter men with high levels of hostility don’t batter substance abusers don’t batter 22

Alternative Explanation #2: Men’s Need for Power • Alcohol aggression relationship is conditional upon individual power needs 1 Power Needs SA • Alcohol is an “instrument of intimate DV 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 23

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 24

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 25

Alternative Explanation #5: Expectancy • Expectations for the effects of alcohol or drug use: sexier, stronger, social, aggressive 1 • Time out and cultural expectancy • The balanced placebo experiment • Male-specific? 2 3 26

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 27

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

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? 30

TIP 25 Substance Abuse and Mental Health Services Administration www. ncbi. nlm. nih. gov/books/bv. fcgi? rid=hstat 5. chapter. 46 712 31

Manual of the Illinois Domestic Violence/ Substance Abuse Interdisciplinary Task Force (2 nd Edition, 185 pp. ) www. dhs. state. il. us/page. aspx? item =38441 32

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 233200400566 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 907 -586 -3650 www. andvsa. org

Iowa Integrate Services Project www. ispia. org/index. php 34

Trauma-informed Services for Wome With Co-occurring Substance Use/ Mental Health Disorders and Victims of Violence (SAMHSA) www. prainc. com/wcdvs/pdfs/Creating. Trauma. Services 35

Serial, Integrated, and Coordinated Interventions

Serial Interventions DV Program Assessment Substance Abuse Tx 47

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 48

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

Integrated Services SA Agency Integrated: Distinct Programs & Staff (eg: mental health agency with both AOD and BIP) DV SADV Agency & Staff Integrated: Distinct Programs (eg: substance abuse agency with in-house BIP) Theoretically Integrated: Program built on common foundation (eg: Power Model, DBT, Trauma Theory) 50

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

Coordinated Services SA Tx DV Agency Case Coordination Model 52

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 53

Integrated and Coordinated Community Based Programs for Batterers

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: $) 55

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 56

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” 57

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 -3 x/week) intervention for prior/severe offenders for first month • Victim support 58

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 59

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 • ADA/Dawn Farm (Michigan) 4 3 § Accountability/Recovery model • Behavioral Couples Therapy (Harvard) 5 § No discussion of domestic violence at all 60

THANK YOU! 61

Substance Abuse by Victims & Survivors

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 63

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

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 65

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: Ao. D IPV Ao. D. . . and so on 66

Integrated and Coordinated Community Based Programs for Women

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; 68

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; 69

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 70

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 retriggered/aggravated by the services provided and by the setting • Committed to supporting the healing process while ensuring no more harm is done 71

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 72

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 wellbeing, too

THANK YOU! 75