Promising Directions for Helping Chemically-Involved Battered Women
Get Safe and Sober

Theresa M. Zubretsky

Chemically-involved battered women often find themselves in the ultimate catch-22: substance use may begin or escalate as a response to the trauma of victimization, and efforts to stop using substances may precipitate abusive partners' use of increased violence. A battered woman's words about her own recovery capture the essence of the dilemma. She said, "As an alcoholic, AA and treatment saved my life; as a battered woman, it nearly killed me." Yet, despite significant correlations between domestic violence and chemical dependency and intimate links between safety and sobriety, domestic violence advocacy programs and substance abuse treatment programs are frequently ill-prepared to provide the range and depth of services needed for chemically-involved battered women to get both safe and sober. In addition, the system is no better prepared to respond to the safety-related needs of battered women whose partners are involved with substances and who seek services in substance abuse treatment programs.

The common roots shared by the domestic violence and substance abuse service systems provide a strong foundation for cooperative relationships. Long before there was a formalized movement, women were helping other women, sheltering them in their homes, in churches, and in other places of refuge. One of the strengths of the battered women's movement has been its reliance on empowerment through peer support. When women connect with other women, isolation breaks down, self-blame is challenged, their fears are normalized as reasonable and proportionate, and they become empowered with information, hope and support.

Similarly, when Bill W. started Alcoholics Anonymous (A.A.), it was with the idea that there were no better people to help alcoholics recover from addiction than alcoholics themselves. The core of the fellowship is simple and personal. Recovery begins when one alcoholic talks with another alcoholic, sharing experience, strength and hope.

However, one of the primary limitations of the recovery movement was that it originated as a response to addiction in men's lives. It wasn't until the 1980's, fifty years after A.A. was founded, that the role of substances and the limitations of traditional treatment in women's lives would be recognized. Out of this recognition grew a model for treating women's addiction based on connection, a model in which a woman's substance abuse is addressed in the context of her health and her relationship with her children, family, community and society.

The emergence of the domestic violence and substance abuse service systems subsequent to these peer support movements expanded the breadth of available assistance and created mechanisms for community education and prevention. But the trend toward professionalism in both fields has also prompted a gradual shift away from peer support to a hierarchy of power between "professional" and "client"; a shift from strength-based to deficit-based approaches. This chapter will explore the unmistakable connections between substance abuse and violence in women's lives; the strength-based models within each of the service systems that best support the goals of safety and sobriety (specifically, woman-defined advocacy [Davies, 1998], the relational model [Surrey, 1985; Finkelstein, 1996] and harm reduction [Harm Reduction Coalition, 2001]); and the resulting opportunities for enhanced coordination and collaboration between the two systems.

The Link Between Domestic Violence and Substance Abuse (1)
 

Etiology
Women who have been victims of violence have a higher risk of alcohol and other drug problems (Kilpatrick, Resnick, Saunders & Best, 1998) and frequently respond to the trauma of victimization by using alcohol or other drugs (Russell & Wilsnack, 1991; Paone, Chavkin, Willets, Friedman & Des Jarlais, 1992). Battered women often report that, in addition to medicating the emotional and physical pain of trauma, their chemical use helped to reduce or eliminate their feelings of fear and therefore became part of their day-to-day safety-related strategies (Jones & Schechter, 1992). It's therefore no surprise that battered women are disproportionately represented in chemical dependency treatment populations (Miller, 1998; Bergman, Larsson, Brismar & Klang, 1989; Covington & Kohen, 1984).

There are a number of other ways in which victimization and chemical use are often related as well. Many victims' initial or escalated use of substances is coerced or manipulated by their abusive partners, from the extreme of women being tied down and forcibly injected with drugs, to the more subtle pressure abusers place on victims to use certain drugs in social contexts to avoid personal embarrassment, or to enhance sexual satisfaction.

Battered women are at increased risk of abusing legal drugs (US Dept. of Health and Human Services, 1991) which are frequently prescribed in response to common health complaints including chronic headaches, abdominal pains, sexual dysfunction, joint pains, muscle aches, and sleep disorders (Randall, 1990). This medication not only may alleviate the presenting symptoms but may also provide relief from the emotional and physical pain of the abuse. In fact, many chemically dependent battered women are addicted to drugs that were prescribed by the health care providers from whom they sought help (Flitcraft & Stark, 1988). Further, when prescription drugs are used in combination with alcohol (a common use pattern for women), the health-related consequences can be particularly devastating and potentially lethal (Galbraith, 1991).

Increased Vulnerability to Violence and Coercion
Whatever the etiology, a battered woman's use of substances provides the abuser with yet another weapon of coercion. He may use her substance use as the excuse for his violence; he may threaten to expose her substance use to friends, family, or authorities; he may be the primary or sole supplier of the drugs, increasing her dependence on him by exploiting her dependence on drugs (Finkelstein, 1996). Chemically-involved battered women may be particularly vulnerable to sexual exploitation, either being forced into sexual activity in exchange for drugs or being prostituted by their partners as a source of income for drugs (Hart & Jans, 1997). If they are HIV positive and/or with partners who are HIV positive, victims may be threatened with infection, denied access to medication or medical attention, or threatened to have their HIV status revealed (Hart & Jans, 1997).

Barriers to Help
Chemically-involved battered women also face additional barriers to help by virtue of their substance use. They are less likely to be believed or taken seriously by others; they are more likely to be blamed for the violence (Aramburu & Leigh, 1991); they face an enormous gap in emergency shelter services that systematically deny admission to chemically-involved women; their chemical use may increase their risk of HIV, exposing them to even further discrimination in their help-seeking efforts; if mothers, they risk losing custody of their children to a system that deems them "unfit"; if pregnant, they face criminalization rather than services designed to support their recovery (Paltrow, 1998). Substance use can also compromise cognitive functioning and motor coordination, making victims less able to develop and implement safety-related strategies.

Limitations of Current Responses (2)

Despite the enormous obstacles that chemically-involved battered women face, they remain active help-seekers and surface in a wide variety of systems, including the domestic violence and substance abuse treatment systems. Unfortunately, these two service systems are often unprepared and ill-equipped to respond to women's dual needs for safety and sobriety.

Limitations of Traditional Substance Abuse Treatment
Perhaps as few as 10% of substance abuse counselors include an assessment for adult domestic violence as part of the intake process to substance abuse treatment (Bennett & Lawson, 1994). Even when domestic violence is identified, it is often assumed that treatment for the substance abuse must occur before the victimization can be addressed.

One of the concerns with the "sobriety first" approach is that it does not consider the increased risk of violence that a woman's recovery may precipitate. Batterers often are resistant to their partners' attempts to seek help of any kind, including substance abuse treatment. In response, they may sabotage the recovery process by preventing victims from attending meetings or keeping appointments, by stocking the refrigerator with beer, or by restricting access to the resources victims need to comply with their treatment plans (transportation, child care, and health insurance). Abusers may also intensify their use of violence in order to reestablish control.

Many chemically dependent battered women leave treatment in response to the increased danger or aren't able to comply with treatment demands because of the obstacles created by their partners' sabotage efforts. Others are terminated from treatment for "noncompliance" or "resistance" to treatment. Even when a battered woman is able to complete a treatment program, being revictimized is a strong predictor of relapse (Haver, 1987). The consequences of battered women's inability to successfully complete treatment are further exacerbated when treatment is leveraged or mandated by the criminal justice or child welfare systems, and can include incarceration or loss of custodial rights.

An additional concern with the "sobriety first" approach is that it fails to address the fact that battered women often rely on substances as part of their safety-related strategies. Substance-using battered women often report that the substances helped them cope with their fear and manage the daily activities of their lives in the face of ongoing abuse and danger (Minnesota Coalition for Battered Women, 1992). These are women who may be particularly resistant to engaging in a recovery process until they are confident that they can achieve genuine safety from the violence. For these women, an intervention framework that requires "sobriety first" is an approach that may be destined to fail.

Limitations of Domestic Violence Program Responses
The current rhetoric about chronology of care for chemically-involved battered women suggests a shift from "sobriety first" to "safety first." The irony of such a shift is that the domestic violence service system has historically failed to meet the safety-related needs of this population of battered women.

Chemically dependent battered women often have very limited or no access to safe shelter through the emergency domestic violence shelter network because of their addiction (Collins, et al., 1997). While admission and discharge policies must consider the safety needs of all shelter residents, policies that prohibit access by chemically dependent battered women are commonplace and cut off many women from a vital resource. In trainings conducted with domestic violence program staff from several states, a few recurring themes surface and provide insight into the persistence of non-admission policies of domestic violence programs. These include limited resources to address the complexity and demands of chemically-involved battered women (an obstacle also identified by Collins, et al., 1997); adherence to the traditional substance abuse treatment view that woman-defined responses to addiction are "enabling"; and harmful and inaccurate attitudes and beliefs about addicted women-e.g., that the chemically-involved are dangers to themselves and others; that they will be unable to comply with shelter rules; that they will be dishonest; and that they will neglect their children-attitudes frequently rooted in negative personal experiences with friends or family members who have alcohol or other drug problems (Roth, 1991).

Whether these beliefs about the chemically-involved are statistically founded or not, domestic violence programs typically determine eligibility for shelter services by assessing on the basis of an individual's presentation at time of intake. Intake counselors ask questions to determine whether any particular individual poses a safety risk to themselves or others, what their abilities are with regard to being able to participate in communal living, etc. The categorical exclusion of chemically-involved battered women from emergency shelter services is no more justifiable than the categorical exclusion of any group of women for whom there is a demonstrated-or perceived-statistical risk for undesirable or problematic behavior.

Even when domestic violence programs have admission criteria that allow chemically dependent battered women into shelter, they often do not conduct appropriate screening for substance abuse and fail even to minimally evaluate the addiction treatment needs of sheltered battered women (Bennett & Lawson, 1994). The end effect is a "don't ask, don't tell" policy. Shelter staff don't ask, and subsequently miss an opportunity to interrupt the deadly progression of women's alcohol or other drug addictions, problems that may significantly impair battered women's efforts to get safe; and battered women don't tell because they fear that to do so might jeopardize their shelter stay.

In instances in which the domestic violence program does ask and women do tell, the programs typically require a substance abuse evaluation and compliance with any subsequent treatment plan that might be recommended. The implicit expectation is often that women will proceed in linear fashion to the end goal- abstinence and recovery-an expectation no more realistic than to expect a battered woman to leave her abusive partner the first time she reaches out for help. Recovery is a process, not an event, and domestic violence responses that view relapse in a broader context- as an opportunity for intervention rather than a basis for shelter discharge- would better support chemically-involved battered women's difficult journeys toward safety and sobriety.

Lack of Connection Between the Fields
Despite the unmistakable connections between victimization and substance use, there is a notable lack of connection between the domestic violence and substance abuse treatment systems (Collins, et al., 1997). Meeting the needs of substance-using battered women, however, demands an effective working relationship between the two service systems-a relationship consistently identified as important by workers in both fields, but an undertaking fraught with multiple obstacles to cooperation (Bennett & Lawson, 1994; Levy & Brekke, 1990; Rogan, 1985; Wright, 1985). The battered women's movement is a grassroots social change movement based on a socio-political analysis of domestic violence, while the alcoholism field works from a medical model and provides treatment from a perspective that understands chemical dependency as a disease. Traditional substance abuse treatment is male-centered, de-politicized, and confrontational, whereas domestic violence advocacy is typically woman-defined, political and regards the victim as the expert of her situation. The subsequent conflicts that emerge in attempts to coordinate services to individuals affected by both problems are understandable and predictable (Collins, et al., 1997).

Domestic violence programs do refer women to chemical dependency treatment agencies more frequently than the reverse occurs, which may suggest that domestic violence programs have a greater desire to forge cooperative relationships with providers of substance abuse treatment (Bennett & Lawson, 1994). There is, however, a less charitable explanation that may account for the high referral rates by domestic violence programs. The lack of information and training on chemical dependency among domestic violence program staff and/or the existence of harmful attitudes and beliefs about chemically dependent women may deter domestic violence advocates from directly providing services to this population. The subsequent referrals may then become a way to shift primary responsibility for difficult cases to another agency or to someone else's caseload. In fact, Collins, et al. note that once victims are referred by domestic violence programs to substance abuse treatment, it is rare for those referred to receive domestic violence services simultaneously (1997).

Models for Improved Responses to Chemically-Involved Battered Women

Coordination Models
To the extent that domestic violence and substance abuse treatment programs are working together, the predominant model for cooperation is based on the goal of achieving cross-screening and cross-referral through cross-training. A common feature of this model is to develop screening tools and provide subsequent training on the appropriate use of these tools. The increased identification that results from routine screening, combined with the existing linkages between the respective service systems, enhances chemically-involved women's access to both safety-related and recovery services. In many instances, these models include the sharing of staff resources (for example, assessments conducted by a domestic violence advocate on-site in a substance abuse treatment program, or the reverse); co-facilitated women's educational or support groups; or ongoing coordinated case management.

These coordination initiatives have been successful to varying degrees, depending largely on the abilities of the domestic violence and substance abuse staff to develop and sustain a supportive and respectful relationship. The more deeply intertwined the service provision of the two fields becomes, however, the more visible the differences, and the greater the potential for friction between staff. Even when the involved staff are prepared for the inevitable conflicts and committed to working them through, conflicts between woman-defined advocacy and traditional treatment often become insurmountable. When this occurs, the relationships may simply collapse. Often, the best that can be hoped for is that staff develop a tolerance of each other, resulting in the provision of parallel services that fail to integrate important elements of the other, and ultimately limit the effectiveness of the assistance offered.

Coordination Initiatives and The Relational Model
When the substance abuse treatment program is one that provides treatment grounded in a relational or self-in-relation (Surrey, 1985) model-a model that is extremely compatible with woman-defined advocacy-coordination between the two systems is often more integrated and more effective. Relationships between the domestic violence and substance abuse program staff are more likely to flourish, enhancing trust and commitment, and ultimately facilitating women's safety and sobriety.

Just as the domestic violence field recognizes that there are myriad motivators and barriers to a woman's decision to seek help or to leave a violent partner, relational models take into account the myriad motivators and barriers to a woman's successful recovery and embrace the need for comprehensive and individualized treatment planning. The relational model expands the focus of treatment to one in which the interrelationships between a woman and the treatment program, her children, other family members, and her community become central, rather than incidental, to the treatment.

Relational models of treatment are strength-based and more likely to foster an empowering framework through which to provide assistance to women. They typically incorporate important support services into the treatment program such as women-only groups and mechanisms to promote and strengthen maternal relationships; they respond to the effects of violence and trauma as integral to women's recovery; they affirm non-traditional relationships in identifying family and friend support networks rather than relying on traditional family systems interventions that are often dangerous for battered women; and they actively promote the development of meaningful support systems (Finkelstein, 1996).

Additionally, by acknowledging the important role of socio-political influences on women's lives including sexism, racism, and poverty, relational models of intervention reject pathologizing frameworks of understanding women's victimization and addiction. Viewed through a relational model lens, domestic violence is understood as a common "disconnection" in women's lives; battered women's efforts to try to stop the violence and salvage the relationship are understood-not as pathology-but as an active strategy to maintain connection with their intimate partner. Although use of a relational model does not guarantee attention to safety-related needs, the integration of safety-planning into treatment planning within a relational model is a more natural process than it is within traditional treatment settings.

Limitations of Coordination Model
There is little question that cross-training models of coordination between the domestic violence and substance abuse fields have brought about meaningful improvements in the response to chemically-involved battered women. The availability of expert help with the development of a safety plan is a tremendous assist to a woman struggling to comply with a treatment plan that her abusive partner is intent on sabotaging; and the availability of recovery services is a similarly huge assist to women whose chemical use is interfering with their ability to get and stay safe. There is further evidence that coordination models are more effective when services are provided through complementary frameworks, rather than simply relying on cross-referrals to adequately address the needs of chemically-involved battered women.

However, while many coordinating agencies develop written Memoranda of Agreement outlining their respective responsibilities and expectations for working together, it is relatively rare for coordination efforts to be additionally supported by explicit policy development and implementation within the respective coordinating agencies. The absence of policies and procedures that institutionalize appropriate responses and the subsequent absence of accountability standards can contribute to inconsistent staff responses which, in turn, undermine the existing agreements. Further, without supporting policies, the life of these agreements is often completely dependent upon the interest of committed individuals within the respective systems. If these key staff leave their positions, the agreements often leave with them.

Another limitation of these coordination initiatives is that the substance abuse treatment programs, even when operating from within a relational context, usually provide treatment from an abstinence model framework. The pathway to recovery may be more flexible in meeting the individual needs of women, but the ultimate goal still requires abstinence. A similar limitation can exist in the provision of domestic violence services. Even when advocates support battered women in whatever choices they make and respect their rights to make those choices, they often hold on to "leaving" as the ultimate goal. For some women, however, abstinence and/or leaving may be either very distant outcomes or outcomes never realized.

Harm Reduction
Because batterers' violence and coercion often directly interfere with a battered woman's ability to achieve and sustain abstinence, harm reduction is another approach to substance abuse treatment that holds promise for working with chemically-involved battered women. Although relational models may incorporate many of the principles of harm reduction, harm reduction holds as its central goal to reduce harm; whether or not abstinence ever becomes a goal of the harm reduction process is completely contingent upon the individual. Consider a standard description of Harm Reduction:

"Harm reduction accepts, for better and for worse, that licit and illicit drug use is a part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them. . . . Understands drug use as a complex, multi-faceted phenomenon. . .and acknowledges that some ways of using drugs are clearly safer than others. . . . Establishes quality of individual and community life and well-being-not necessarily cessation of all drug use-as the criteria for successful intervention and policies. . . . Calls for non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm. . . . Affirms drug users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies that meet their actual conditions of use. . . . Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect people's vulnerability to and capacity for effectively dealing with drug-related harm. . . . Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use." (Harm Reduction Coalition, 2001)

Notice how this parallels a description of woman-defined advocacy:

"The response to domestic violence must be built on the premise that women will have the opportunity to make decisions-that she is the decision maker, the one who knows best, the one with the power. . . . [This] does not ensure that a battered woman or her children will be safe-rather, it seeks to craft the alternatives that will enhance women's safety, given the realities facing each battered woman. It is not the goal of woman-defined advocacy that women should stay in violent relationships, but when staying provides the best possible alternative, woman-defined advocacy supports a woman's decision and works with her to keep her and her children as safe as possible. Until all systems respond sympathetically and effectively for all battered women, and until batterers stop battering, the response to battered women must acknowledge these limitations and the realities of women's lives. Woman-defined advocacy is advocacy for the real-not the ideal-world and for women with real, not stereotypic, lives . . .Systemic advocacy to improve local agency and policy responses to domestic violence is an integral part of woman-defined advocacy." (Davies, 1998)

The compatibility of harm reduction and woman-defined advocacy is striking and renders the tension between "sobriety first" and "safety first" moot, since both models are rooted in meeting the individual where she's at, and beginning wherever she is willing and able to begin. Like woman-defined advocacy, the harm reduction model acknowledges the limitations of any intervention in light of the personal and systemic obstacles to the ideal goal (safety or abstinence). Both models recognize that there are risks attached to every decision an individual might make and that the individual's set of priorities and evaluation of risks may differ from that of the service provider. Both models actively engage the client in identifying and evaluating risks and benefits of different options and identifying ways to reduce risk, recognizing that the individual's perspective is, ultimately, the only one that counts. Some battered women report that they needed to get safe before they could even consider giving up their use of substances; for others, getting sober was the prerequisite to implementing safety-related strategies. Making an offer of help conditional upon an expectation that the client will follow a predetermined chronology of care or a particular path to safety or sobriety is both unrealistic and futile.

Persistent Obstacles
Harm reduction and the relational model are not only compatible with woman-defined advocacy, but are also compatible with each other and, together, hold great promise for responding to the needs of chemically-involved battered women. Comprehensive and relational models of substance abuse treatment, however, are not readily available in most communities across the country; and harm reduction has not yet gained the legitimacy within the substance abuse field that it deserves, rubbing against the grain of the more traditional abstinence models. Further, the availability of these substance abuse treatment approaches doesn't solve the problem of domestic violence programs' reluctance to expand their provision of services, especially emergency shelter, to chemically-involved battered women.

The task for domestic violence service providers in improving responses to chemically-involved battered women is, in the abstract at least, less difficult than that for the substance abuse treatment system. Domestic violence advocates need to make neither a philosophical nor a practical shift from their long-standing practice of woman-defined advocacy and safety-planning; they need only extend their emergency shelter services to this population of battered women using the same kinds of woman-centered approaches that are effective for non-chemically-involved battered women. And there is increasing urgency for them to do so.

National welfare reform law requires screening for substance abuse as part of the process for receiving assistance; and many states passed laws to also require screening for domestic violence, resulting in an increase in identification and referral of chemically-involved battered women to local domestic violence services and substance abuse treatment. Further, anecdotal reports nationwide suggest that shelter populations are changing from those largely comprised of battered women in need of safety to women with multiple distressors in addition to their need for safety, including chemical use, mental health problems, HIV, and serious mental illness.

If these anecdotal reports are accurate, the changing population may well be a result of improved systems' responses to battered women which create more and better options for safety and preclude many women's need for shelter, but which still fall short of meeting the needs of previously underserved women for whom solutions to safety are more complex. Another possibility is that the actual numbers of chemically-involved women in shelter populations is the same, but the rate of identification is increasing. Either way, domestic violence programs have an increased awareness of the prevalence of chemical dependency in the lives of battered women in shelter and an increased motivation to better meet their needs.

If one of the obstacles to domestic violence programs proactively serving the emergency shelter needs of chemically-involved women is their own set of inaccurate beliefs and negative attitudes about this population of women, then the gains to be had through training are significant. In addition, just as the substance abuse field needs the active involvement of domestic violence service providers to ensure appropriate responses, domestic violence programs need the active support of the substance abuse community. When this support is consistent with the domestic violence program philosophy and practice, the ability of domestic violence programs to respond effectively will be strengthened.

Integrated Models
There is growing support for more fully integrated models of responding to the needs of chemically-involved battered women, including top-down reform requiring substantial structural and administrative changes in funding streams and mechanisms for delivering services on a continuum of care (CSAT, 1997). Less ambitious integration calls for all needed domestic violence and substance abuse services (with the notable exception of emergency shelter) to be provided under one roof ("one-stop shopping").

Any model that seeks to minimize the burden on the person in need of services by offering them access to comprehensive assistance-whether through a continuum of care or a single port of entry- deserves serious consideration and pursuit. However, the existing service system currently lacks the necessary infrastructure to support these approaches.

The missing link in "one-stop shopping" models is that the staff implementing them often have expertise in either domestic violence or substance abuse, but not in both. Even when staff are trained by experts in the relevant field, training alone does not adequately prepare domestic violence or substance abuse program staff to deliver comprehensive services individualized to meet the diverse and complex needs of chemically-involved battered women. Often, the result is a program that doesn't fully integrate the best practices of both systems, but rather delivers services through its own primary framework of understanding, compromising either safety or sobriety in the process. Responsible and meaningful service provision demands the requisite knowledge, skills, and experience- qualifications that, at present, are more readily found within the respective service systems.

While in an ideal world, there might be comprehensive assistance for a person in need to address the multiple distressors in their lives, the truth is that our service systems are highly compartmentalized and are likely to stay that way for some time to come. While it's important to view solutions to the lack of connection between the substance abuse and domestic violence service systems from a more global perspective and to advocate for needed systemic reform, it's equally important to search for solutions in the here and now. Coordination initiatives may be the most effective and the most feasible options available within the parameters of the existing service systems in their efforts to support the needs of chemically-involved battered women. Further, based on the significant accomplishments of many coordination initiatives across the country, it is not necessarily a compromise to advocate for the effective expansion of coordination models rather than giving priority to the promotion of fully integrated models.

Coordination Initiative Project Outcomes
The potential outcomes of coordination initiatives extend far beyond cross-identification and cross-referral and greatly increase chemically-involved battered women's access to complementary assistance for both problems. Substance abuse treatment programs and domestic violence programs should consider the impact of all program components, policies, and procedures on chemically-involved battered women, including screening and intake; the development of treatment plans (in substance abuse programs); crisis intervention, counseling, case management, and client education; report and record keeping; referrals; client confidentiality; on-site safety and security; community prevention and education; and employee assistance. Evaluating and modifying existing polices and procedures to better support the needs of chemically-involved battered women not only maximizes the effectiveness of the services provided, but institutionalizes the response.

For example, many substance abuse treatment programs routinely contact partners of clients as "collateral contacts" (a mechanism by which to gather accurate information about the client's drinking and drug use). Whether a victim is being asked to provide information about her abuser's substance use or the abuser is being solicited to provide information on the victim's drug use, the potential for unintentionally colluding with the abuser and endangering the victim is great. If the program has clearly defined policies and procedures that require all staff to conduct effective and ongoing screening for domestic violence and subsequently exclude victims and abusers from serving as collateral contacts, safety for battered women can be increased.

In domestic violence shelters, there are often rules residents agree to upon admission, such as adherence to curfews or participation in particular shelter activities, that may conflict with a recovering woman's established AA meeting schedule. Some shelter programs, in the interests of "fairness," enforce these rules with residents without exception; in this case, they might encourage the woman to find a meeting that doesn't conflict with shelter requirements, justifying that it's only a short-term inconvenience, and failing to recognize the important role a "home" meeting can play in a person's recovery support system. Without interest in and a mechanism for waiving program requirements to better support women's recovery efforts, women may be forced to choose between emergency shelter and sobriety support.

Domestic violence and substance abuse treatment programs can also modify existing program components to increase the identification of chemically-involved battered women and their motivation to access help and support. For example, by integrating alcohol and other drug education into battered women's support groups-to discuss the use of alcohol/other drugs as a response to trauma; the dangers of frequent and continued use; the ways in which chemical use can interfere with battered women's abilities to implement safety strategies; the difficult challenges for women in recovery; and the benefits of recovery in women's lives-domestic violence programs can communicate a non-judgmental invitation to women who may be struggling with chemical use in private to reach out for help. (Of course, proactive efforts to identify chemical users among a population of battered women residing in shelter is recommended only in those programs that welcome chemically-involved battered women into their shelter and are prepared to respond supportively rather than punitively.) This integration of alcohol/other drug education can also sensitize non-using women to the difficulties chemical-using women face, thereby directly addressing a concern frequently voiced by domestic violence programs that more flexible admission and discharge policies for chemical-using battered women can have a negative impact on other shelter residents, particularly those who may be struggling with their own recovery and/or who have chemically-involved partners. Similarly, substance abuse treatment programs can integrate domestic violence education into family program groups, women's groups and other counseling settings to sensitize, inform and potentially link unidentified victims with safety-related assistance.

In addition to the program improvements that can be achieved through coordination initiatives, these approaches may also provide the greatest opportunity for substance abuse professionals and domestic violence advocates to develop the requisite expertise in the "other" problem which may, in turn, more fully support the successful development and implementation of integrated models. Coordination efforts pair substance abuse professionals and domestic violence advocates as equal partners, operating from a premise of respect and deference to the other's expertise in a partnership that can minimize turf battles and maximize learning. It is highly unlikely that either system holds the answer independent of the other regarding what will best help chemically-involved battered women. As coordination initiatives multiply, there will likely be a process of joint discovery that will best inform the development of future responses.

Safety Implications for Battered Women With Chemically-Involved Partners (2)

The safety implications for battered women in the substance abuse treatment system are not limited to those who are themselves chemically-involved, but also for women whose abusive partners are chemically-involved. Batterers are regularly engaged in substance abuse treatment, and victims are regularly engaged in services designed for family members of chemically-involved persons, without counselors' knowledge of or attention to the potential consequences for victim safety.

Chemically-involved Batterers
The belief that alcoholism causes domestic violence is a notion widely held both in and outside of the substance abuse field, despite a lack of information to support it. Although research indicates that among men who drink heavily, there is a higher rate of perpetrating assaults resulting in serious physical injury than exists among other men, the majority of abusive men are not high-level drinkers and the majority of men classified as high-level drinkers do not abuse their partners (Straus & Gelles, 1990).

Even for batterers who do drink, there is little evidence to suggest a clear pattern that relates the drinking to the abusive behavior. The vast majority (76 percent) of physical assaults committed by batterers who use alcohol occur in the absence of alcohol use (Kantor & Straus, 1987), and there is no evidence to suggest that alcohol use or dependence is linked to the other forms of coercive behaviors that are part of the pattern of domestic violence. Economic control, sexual violence, and intimidation, for example, are often part of a batterer's ongoing pattern of abuse, with little or no identifiable connection to his use of or dependence on alcohol.

In addition to the evidence that alcohol is neither a necessary factor nor a sufficient explanation for men's intimate violence, there is evidence that treatment for the chemical dependency does not stop the violence. Battered women with drug-dependent partners consistently report that during recovery the abuse not only continues, but often escalates, creating greater levels of danger than existed prior to their partners' abstinence. In the cases in which battered women report that the level of physical abuse decreases, they often report a corresponding increase in other forms of coercive control and abuse-the threats, manipulation and isolation intensify (Minnesota Coalition for Battered Women, 1992). In response to the increased danger, battered women may attempt to sabotage their partners' recovery efforts as a safety-related strategy. These attempts, however, are likely to be perceived by the substance abuse counselor as evidence of the need for codependency treatment rather than the need for safety-related assistance.

Impact of Codependency Treatment on Battered Women
Most often, the partners of batterers in chemical dependency treatment are directed into self-help programs such as Al-Anon or codependency groups. Like other traditional treatment responses, however, these resources were not designed to meet the needs of victims of domestic violence and often inadvertently cause harm to battered women.

The goals of Al-Anon and codependency treatment typically include helping family members of alcoholics to get "self-focused," practice emotional detachment from the substance abusers, and identify and stop their enabling or "codependent" behaviors. Group members are encouraged to define their personal boundaries, set limits on their partners' behaviors, and stop protecting their partners from the harmful consequences of the addiction. While these strategies and goals may be useful for women whose partners are not batterers, for battered women, such changes will likely result in an escalation of abuse, including physical violence.

Battered women are often very attuned to their partners' moods as a way to assess their level of danger. They focus on their partners' needs and "cover up" for them as part of their survival strategy. Battered women's behaviors are not symptomatic of some underlying "dysfunction," but are the lifesaving skills necessary to protect them and their children from further harm. When battered women are encouraged to stop these behaviors through self-focusing and detachment, they are, in essence, being asked to stop doing the things that may be keeping them and their children most safe.

The particular danger of codependency treatment for battered women, however, is grounded in a more general problem with the overall codependency framework. Both the feminist and relational model views hold that most of the characteristics ascribed to codependency (nurturing, responsibility for family, care taking, defining self in terms of one's relationships) are aspects of the traditional female gender role that itself is a byproduct of the subordination of women in a racist and sexist culture (Babcock & McKay, 1995; Collins, 1993). Codependency ignores the cultural context that gives rise to patterns of female behavior, and in so doing, transforms a socially constructed phenomenon into an individual pathology.

Codependent behaviors are explained in terms of the "dysfunctional" family and are viewed through a disease framework, labeling affected individuals as "sick" and "addicted to relationships." Codependency treatment encourages individuals to accept personal responsibility to become "healthy" which is further defined as becoming an "autonomous, individuated, separate self"(Collins, 1993). Codependency draws attention away from the effects of women's oppression in a racist and sexist world, renames the effects of that oppression as a "condition" of the oppressed, and makes women responsible for it (Hagan, 1989). To make matters worse, women are held to a standard of health that is decidedly male, ignoring the relational context in which most women are socialized to view themselves.

Need for Effective Coordination
Linkages between substance abuse and domestic violence services can facilitate the provision of accurate and complete information about available resources to battered women whose partners are chemically dependent so that they can make informed choices and set realistic expectations about the potential benefits of these different sources of help. It is critical that women understand the purposes of Al-Anon and codependency groups and the limitations of these forums as sources of accurate information regarding safety-related concerns. They should also be given access to safety-planning assistance through the local domestic violence program. Empowering women with accurate information will help them make decisions that best meet their individual needs.

Furthermore, when substance abuse programs operate from within a relational model in providing assistance to women whose partners are chemically dependent, many of the potential conflicts between the domestic violence and substance abuse service systems can be successfully avoided. Woman-defined advocacy and the relational model are feminist approaches to providing empowering assistance to women that recognize the resourcefulness, resilience, and courage that women bring to the process and that build on these strengths. When operating in tandem to respond to the needs of battered women affected by their own or their partners' substance abuse, the respective goals of the domestic violence and substance abuse service systems become mutually supportive, rather than competing, goals.

Summary

Even limited connections based on cross-referrals between the domestic violence and substance abuse treatment systems increase women's opportunities to get their safety and recovery needs met. With the emergence of new models of substance abuse treatment that are more compatible with woman-defined advocacy come even richer opportunities for the systems to work together. In fact, coordination models between the systems may be more likely to be developed and sustained when the respective systems are working from a unified philosophical and practical framework, a unification made possible through the increased availability of relational and harm reduction models of substance abuse treatment.

Multiple obstacles to cooperation between the domestic violence and substance abuse service systems have been explored in this chapter, but there are others that further complicate the landscape and impede the integration of services including the limitations of highly compartmentalized programming and staffing, limitations imposed by managed care, and funding restrictions (CSAT, 1997). Whatever the existing obstacles, both systems have a mutual responsibility to ensure that their respective responses promote victim safety and recovery from addiction. As long as there remains a disconnection between the domestic violence and substance abuse fields, battered women whose lives are affected by their own or their partners' chemical use will continue to pay the heaviest price.

Notes

  1. This section is adapted from Zubretsky, Theresa M. 1999. Adult Domestic Violence: The Alcohol/Other Drug Connection-Trainer's Manual. New York State Office for the Prevention of Domestic Violence.
  2. This section adapts from and builds upon Zubretsky, Theresa M. and Karla M. Digirolamo. 1996. "The False Connection Between Adult Domestic Violence and Alcohol." Helping Battered Women, 1st edition. Ed., Albert R. Roberts.

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