This chapter presents an overview of those issues likely to affect survivors of domestic violence seeking treatment for substance abuse. Its purpose is to help substance abuse treatment providers understand the impact of this experience on the treatment and recovery process and appreciate the differences in approach between the fields of substance abuse and domestic violence as they affect the survivor, so that treatment programs can respond more appropriately to this client group. The primary focus of substance abuse treatment services is to initiate the recovery process and reinforce the skills needed to stay sober or abstinent, while domestic violence programs seek to interrupt the cycle of violence and help the survivor client access the information and resources she needs to increase her safety and to develop and implement a safety plan. Holistic care is impossible if a treatment provider cannot understand the profound effect of domestic violence on a survivor.
The battered woman lives in a war zone: She rarely knows what will trigger an abusive episode, and often there is little, if any, warning of its approach. She spends a great deal of time and energy trying to read subtle signs and cues in her partner's behavior and moods in order to avoid potential violence, but she is not always successful. Financial constraints and fear that the batterer will act on his threats to harm family members or continually harass, stalk, and possibly kill her often inhibit victims from leaving
(Rodriguez et al., 1996). If the batterer is also the victim's drug supplier, that further complicates the situation. Assuming all these issues can be resolved, the effects of continual abuse and verbal degradation can be so inherently damaging to self-esteem that the survivor may believe that she is incapable of "making it" on her own.
When a client presents for substance abuse treatment and informs staff that she is a victim of domestic violence, treatment providers should focus on
Ensuring her safety: Whether a client is entering inpatient or outpatient treatment, the immediate physical safety of her environment must be the chief concern. If inpatient, security measures should be intensified; if outpatient, a safety plan (which may include immediate referral to a domestic violence or battered women's shelter) should be developed. In both cases, staff should be cautioned about the importance of vigilantly guarding against breaches in confidentiality.
Validating and believing her, and assuring her that she is believed: Reinforcement of the counselor's belief of a survivor's victimization is a critical component of ongoing emotional support. Affirming the survivor's experience helps empower her to participate in immediate problem solving and longer term treatment planning.
Identifying her options: Treatment providers should ask the survivor to identify her options, share information that would expand her set of available options, explore with her the risks associated with each option, and support her in devising a safety plan.
These three goals remain important for a survivor throughout treatment. Other needs that must be addressed immediately are
Stabilizing detoxification (including withdrawal symptoms, if any).
Evaluating and treating any health concerns, including pregnancy. The latter is especially important for a survivor client because batterers often intensify their abuse when they learn their partner is pregnant
(Hayes and Emshoff, 1993;
Stark et al., 1981). Injuries should be documented for any future legal proceedings that might occur.
Attending to immediate emotional and psychological symptoms that may interfere with the initiation of treatment, such as acute anxiety and depression.
Once survivor clients' physical safety and symptoms have been addressed, treatment providers can obtain the information necessary to design a treatment plan.
A number of issues unique to domestic violence survivors must be considered by substance abuse treatment providers who work with these clients. Chief among these is the need to uncover the extent of the client's history of domestic violence. The survivor client's current substance abuse problems must be placed in the context of whatever violence and abuse she may have experienced throughout her life, both within her current family and in her family of origin. Childhood sexual abuse has been associated with a higher risk for "revictimization" later in life
(Browne and Finkelhor, 1986).
(See Chapter 4 for a discussion on how to elicit information regarding domestic violence.)
Studies have found a higher incidence of substance abuse among women who were victims of childhood sexual abuse and sexual assault
(Ryan and Popour, 1983;
Reed, 1985). Data suggest that substance abuse often begins at an early age and may become part of a self-destructive coping style that is sometimes seen in incest victims
(Harrison et al., 1989;
Conte and Berliner, 1988;
Briere, 1989). It is not unusual for the abuser to foster the child's initiation into alcohol and drugs in order to make the child more compliant.
A discussion of substance abuse in the client's history should cover her current use, her treatment history, and alcohol or other drug use in her family of origin. In addition, patterns and frequency of alcohol or other drug use by her batterer are key to understanding the relationship of substance abuse to the violence.
Substance abuse counselors should be aware that survivors often are reluctant to disclose the extent of violence in their lives. Often a survivor's denial that violence occurs is so pervasive that it has become an integral element of her psyche. And, especially if violence existed in her family of origin, she may simply consider it a normal part of an intimate relationship.
At the same time, it is important to recognize that many survivors consciously keep the fact or extent of their battering concealed for good reasons, such as fear for themselves, their children, or other family members. When a battered woman leaves her abuser, her chances of being killed increase significantly
(Wilson, 1989;
Casanave and Zahn, 1986;
Rasche, 1993;
Dutton-Douglas and Dionne, 1991). Furthermore, the batterer may be the primary source of income, so his incarceration could leave her destitute
(Rodriguez et al., 1996). Instruments for uncovering domestic violence appear in
Appendix C.
Treatment providers can best serve clients by establishing strong linkages to domestic violence referral and intervention services and by employing staff who are thoroughly familiar with local and State laws regarding domestic violence and with the unique needs of the domestic violence survivors. Ideally, counselors should be able to refer to those services and staff members when domestic violence is suspected and call on them for consultation as needed. If a client denies a history of domestic abuse but the treatment provider still suspects it is possible, additional attempts to discuss it with the client should be made and documented. Once the client has entered treatment, a treatment plan that includes guarantees of safety (see
Appendix D) and a relapse prevention plan should be developed. Considerations specific to domestic violence survivors should be integrated into each phase of the treatment plan.
In the early stages of the survivor's treatment, the substance abuse counselor should help her develop a long-term safety plan either by referring the client to or employing domestic violence service providers. If substance abuse counselors have been well trained in this area, they can work with clients to develop such a plan as part of intake.
One of the purposes of screening is to assess the degree to which the survivor is in physical danger. Screening for this purpose should be conducted early in the treatment process. However, domestic violence and safety issues do not always arise in the early stages of treatment of these clients. Thus substance abuse treatment providers are wise to be prepared to develop a safety plan whenever the need becomes known or acknowledged.
(See Chapter 4 on screening and assessment for a discussion on assessing danger and lethality and
Appendix C for an example of a danger assessment instrument). In this regard, it is also important to remember that the client's sobriety may threaten the batterer's sense of control. In response, he may attempt to sabotage her recovery or increase the violence and threats in order to reestablish control. It is important to address this issue in treatment and to help the client minimize her risk of harm so that she can continue to comply with her treatment plan. In addition, although involving the family in counseling is usually a precept of successful substance abuse treatment, couples and family therapy may be dangerous for domestic violence survivors and should be undertaken cautiously, if at all.
It is also important for the substance abuse provider to assess the degree to which an addicted client's drug problem is tied to the abusive partner: Her batterer may be her supplier. A survivor client who relies on a batterer to obtain or administer drugs may have a difficult time remaining in treatment or avoiding the batterer. A batterer who understands his partner's addiction may simply wait for the victim to resurface. The treatment provider should be alert to the possibility that a survivor client may sabotage both her treatment and her safety in the service of her addiction.
Domestic violence survivors often present with acute injuries and long-term sequelae of battering as well as the physical health problems more commonly associated with substance abuse (e.g., skin abscesses and hepatitis). Cuts and bruises from domestic violence tend to be on the face, head, neck, breasts, and abdomen
(Randall, 1990). The body map in the Abuse Assessment Screen
(see Appendix C) can help identify these injuries. Abdominal pain, sleeping and eating disorders, recurrent vaginal infections, and chronic headaches are also common among survivors
(American Medical Association, 1992;
Beebe, 1991;
Stark et al., 1981;
Randall, 1990). While it may be necessary to attend to pressing legal and financial concerns before chronic health problems can be addressed, medical staff should be available to assess the client's most immediate physical, emotional, and mental health needs.
When a woman presents for treatment with obvious signs of or complaints about physical battering or sexual abuse, staff should consider enlisting a forensic expert to help the survivor client obtain proper medical documentation of her injuries. Forensic medicine programs have been employed successfully in pediatric populations
(Corey Handy et al., 1996), and are now being expanded to include adult victims of abuse. Forensic examiners are medicolegal experts (e.g., nurses, emergency room physicians, and forensic pathologists) specially trained to evaluate, document, and interpret injuries for legal purposes
(Corey Handy et al., 1995). They can assess whether an injury is consistent with events as described by the victim or perpetrator client, information especially valuable when the victim is unable to accurately recount the circumstances surrounding her injuries because she was using alcohol or other drugs at the time of the assault. Forensic examiners frequently are called to testify in court and may be viewed as a valuable asset in any court proceeding relating to the assault
(Corey Handy et al., 1995).
Other health concerns that need attention early in treatment include screening and care for pregnancy, HIV infection, and other sexually transmitted diseases (STDs). Battered women are at extraordinarily high risk for STDs because they are frequently unable to negotiate the practice of safe sex with their partners and are often subjected to forced, unprotected sex. They also may have been forced by their partners to share needles. Not only do STDs and pregnancy require immediate medical attention, but they can also be triggers for more battering.
One of the coping mechanisms used by many survivors is the repression of physical sensations, including physical pain. Often the survivor's awareness of physical pain and discomfort resurfaces only when the traumatic effects of the abuse have been relieved. An increase in a client's somatic symptoms is also common as emotional issues surrounding her victimization begin to emerge. Such a newfound awareness can be confusing and frightening for the survivor, and it is important to ensure that this awareness is addressed both in her medical care and through psychotherapeutic counseling.
A key aspect of treatment for substance abuse is encouraging the client to assume responsibility for her addiction. For a survivor client, it is critical at the same time to dispel the notion that she is responsible for her partner's behavior. She is only responsible for her own behavior.
The survivor client must realize that she does not and cannot control her partner's behavior, no matter what he says. Treatment should help move her toward becoming an autonomous individual who is not at the mercy of external circumstances. Concrete steps to ensure her safety or, if she decides to leave the batterer, to set up a new life will do more toward this end than anything else. As she frees herself from the violence, she will feel more independent. A counselor can help reinforce the client's view of herself as capable and competent by eliciting information about her efforts to address the violence, even if they were unsuccessful. A counselor can point out that her efforts reflect determination, creativity, resourcefulness, and resilience, many of the same qualities that will equip her to take responsibility for her substance abuse.
Poorly developed decisionmaking skills is a problem for many substance abusers. When a client is a battered woman, that inadequacy may be compounded by the domestic abuse
(American Medical Association, 1993). For some battered women, every aspect of their lives has been controlled by the batterer, and a "wrong" decision (as perceived by the batterer) may have served as another excuse to batter her. The paralyzing effect of being battered for making independent decisions must be overcome as the survivor begins to exercise choices without fear of reprisal. Thus one of the first steps in the process of empowering the survivor client is to help her develop, strengthen, focus, or validate her decisionmaking skills.
For a proportion of domestic violence survivors, decisionmaking is a new skill that must be acquired for the first time rather than a lost skill that must be relearned. Exploring her own wants, needs, and feelings, although an unfamiliar and sometimes uncomfortable process, can be a stepping stone to making larger and longer term decisions. It is important for the treatment provider to avoid underestimating the importance to the survivor of making even seemingly mundane decisions, such as what to wear or when to eat.
Like most substance abusers, the survivor client must examine those areas of her life that will either support or undermine her recovery. Like others in treatment, she must disengage from drug-using friends, and she will need support as she begins the task of making new social contacts who support her recovery.
Reevaluating relationships with partners who support and encourage drinking or drug-taking is another therapeutic task for those undergoing substance abuse treatment. In a pattern that parallels the experience of many survivors of domestic violence, female substance abusers are often introduced to and supplied with drugs by male partners. Among the myriad reasons for continuing use are to maintain a relationship, to please a partner, or to share a common activity. Since safety poses such a serious problem for survivor clients, reevaluating ties to her significant other in the context of her goals for recovery requires careful consideration. For many of these women, recovery will not be possible without separation from their partners -- a reality that may be extremely difficult for them to acknowledge, accept, and translate into action. Furthermore, because of the toll that the battering has taken on many survivor clients' belief in their ability to make decisions, they are likely to need additional help in evaluating and identifying sources of stress in their relationships. Despite the time and effort involved in working through this issue, however, it is not uncommon for survivor clients to change their views about which relationships feel safe as they begin to make choices that support recovery.
When working with some survivor clients, substance abuse treatment providers may have to discard traditional notions about the wisdom of making major life decisions, such as moving, early in the course of treatment. For a domestic violence survivor who fears being pursued by a batterer, relocation to another community may be a priority. As part of treatment, the stress of uprooting herself and her children and the accompanying risk of relapse must be weighed against safety issues. Should a client decide to move, every effort should be made to refer her to appropriate resources and supportive services within the new community.
Posttraumatic stress disorder (PTSD) is a psychiatric diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
(American Psychiatric Association, 1994). The first diagnostic criteria are being "exposed to a traumatic event in which . . . (1) the person experienced, witnessed, or was confronted with an event or events that included actual or threatened death or serious injury, or a threat to the physical integrity of self or others [and] (2) the person's response involved intense fear, helplessness, or horror"
(American Psychiatric Association, 1994, pp. 427-428). Other criteria include recurrent nightmares, difficulty sleeping, flashbacks, hypervigilance, and increased startle responses -- symptoms shared by many battered women
(Walker, 1991;
Douglas, 1987;
Follingstad et al., 1991;
Woods and Campbell, 1993). One study of 77 battered women in a shelter found that 84.4 percent of them met the PTSD criteria in the DSM-IV
(Kemp et al., 1991). Though the DSM-IV states that the disorder is "more commonly seen in association with an interpersonal stressor (e.g., childhood sexual or physical abuse, domestic battering, being taken hostage, incarceration as a prisoner of war or in a concentration camp, torture)" (p. 425), some domestic violence support workers have been reluctant to acknowledge PTSD among survivor clients. Their fear is that thus labeling the victim moves the onus for the violence from the abuser to the victim and provides another excuse for the batterer's behavior (e.g., "she's crazy"). A treatment provider, however, must be aware of the possibility that a survivor may be suffering PTSD and must make the appropriate referral.
Many survivor clients also suffered abuse as children
(Browne and Finkelhor, 1986). Emotional and psychological trauma from childhood abuse is often repressed and may surface once the client is in a safe setting, such as an inpatient substance abuse treatment facility. The emergence of this memory can be an overwhelming experience, and treatment providers should not attempt to address it before the survivor is ready or if program staff are unprepared to handle the results. If the issue surfaces in a group setting, the substance abuse counselor should allow the survivor client to express her emotions initially. Thereafter, however, a client should be referred if possible to a therapist with special training in treating victims of childhood abuse.
Recovering substance abusers are trained to deal with relapse triggers -- events or circumstances that produce cravings and predispose them to resume their use of alcohol or other drugs. A potential trigger for relapse can be something as seemingly benign as walking through a neighborhood where the recovering individual once purchased drugs. A domestic violence survivor is vulnerable to an additional set of triggers -- situations or experiences that may unexpectedly cause her to feel the fear and victimization she experienced when being battered. Such life event triggers may cause the client to relapse and should be addressed directly by counselor and client. Examples of life event triggers are sensory stimuli (sights, sounds, smells); the close physical proximity of certain people, particularly men; or situations that trigger unpleasant memories (such as witnessing a couple arguing). They also include stressful situations that evoke trauma responses and recreate the sense of victimization
(Craine et al., 1988). Such triggers may push these feelings to the surface many years later, after the survivor is out of the abusive relationship; some disappear over time, but others may always be present to some degree. Counselors should help patients identify these stressful situations and rehearse alternative responses, just as they should for substance use triggers.
Survivors of domestic violence usually experience strong emotional reactions when they stop abusing alcohol or other drugs, which may have been a form of self-medication. They may be flooded by formerly repressed emotions and physical sensations. Abstaining from substance abuse, which often helps a survivor repress her responses, may also eradicate her ability to psychologically dissociate (distance herself emotionally so she does not "experience" feelings) from what was happening during the abuse. This dissociation may have provided her with an effective coping mechanism that allowed her to function on a day-to-day basis, despite the abuse. Its elimination may give rise to somatic symptoms, such as headaches or backaches, as formerly blocked physical sensations and experiences reenter her awareness.
Another issue for the survivor upon becoming abstinent may be the freeing of time and energy formerly spent procuring alcohol or other drugs, leaving her feeling empty or directionless and with too much time to dwell on her life situation. Other problems may surface as well. In the Panel's experience, eating disorders as well as other kinds of obsessive-compulsive behavior tend to reemerge after substance abuse ceases. Treatment providers should be alert to this possibility and prepared to refer survivor clients for specialized help (such as a local eating disorders program or chapter of Overeaters Anonymous).
Paradoxically, the very concept of "safety" may itself seem "unsafe" to a survivor of domestic violence. As one survivor expressed it, "The minute you (think you) are safe, you are not safe." For these clients, feeling safe from the perpetrator, even if he is dead or incarcerated, is equated with letting one's guard down and making oneself vulnerable to attack. Survivors tend to be hypervigilant and are accustomed to always being on guard. The substance abuse treatment provider needs to understand and respect the domestic violence survivor's concept of and need for safety. Helping a client rebuild a more appropriate general level of trust is an important long-term therapeutic goal.
For some survivors, anxiety, depression, suicidal thoughts, and sleep disorders are severe enough to require medication during their treatment for substance abuse. In such cases, it is of utmost importance to strike a balance between the need for medication and the avoidance of relapse. On the one hand, the recurrence of the physical and emotional sequelae of abuse may tip a survivor into emotional trauma; on the other hand, however, the client may risk relapse with the possible misuse or abuse of the medication. Physicians should weigh carefully the risks and benefits of prescribing drugs to battered women for symptom relief. For battered women who use or are dependent on alcohol or other drugs, the drug may affect their awareness, cognitive reasoning, or motor coordination, which can, in turn, reduce their ability to protect themselves from future incidents of physical abuse. A thorough medical and psychological assessment should be conducted by a trained clinician experienced in addiction medicine before any psychoactive medications are prescribed. As with other medicated substance abusers, regular monitoring and reassessment of symptoms are essential.
Practical concerns overwhelm many survivors of domestic violence after they become abstinent. These include resolution of legal problems, housing, transportation, employment or supported vocational training, and child care, among others. Linkages with other programs and agencies become extremely important in meeting these clients' needs.
(See Chapter 6 for a discussion of the importance of forming collaborative relationships.) In addition, there are some special concerns that merit particular attention when working with survivor clients. "Welfare to Work," "Workfare," and other initiatives designed to rapidly move welfare recipients into employment may prove especially problematic for these clients. Both Panel members and reviewers described the inordinate pressure survivors experience when they are compelled to accept several new responsibilities at the same time.
Panel members recommended developing, if possible, a schedule for the graduated assumption of responsibilities. Field Reviewers concurred and observed that providers should plan on providing extra support during this crucial postabstinence period.
In addition, survivor clients are likely to need education or reeducation about meeting sexual needs without drugs or alcohol. Referral to or staff training by experts in this area is recommended to ensure that this topic is approached sensitively. In addition, classes in healthy nutrition are a useful adjunct to treatment for survivor clients as for other substance abusers.
Although a strong family or friendship support system can be invaluable to substance abusers as they reenter the mainstream from the drug culture, the domestic violence survivor who is recovering from substance abuse may find it especially hard to reestablish ties, make new friends, or, in some cases, build a completely new life for herself. Social isolation is common among domestic violence survivors, as batterers curtail their victims' contacts with friends and family members. While a survivor client will likely need help and advice about creating a new nondrug, nonviolent social milieu, treatment providers should be careful not to make decisions for her, but rather support her in finding new activities and pastimes. Many women who are victims of domestic violence are surprised to discover that they have a continuum of choices, especially in social situations: The idea of enjoying a party without getting intoxicated, for example, may not have occurred to a survivor in the past.
Parenting is an issue for many substance abusers but may be a special challenge for survivor clients. The time spent in treatment initially may provide a respite from the concerns of parenting for many mothers, and the resumption of child care may be a source of additional stress. Some children become extremely needy after separation from their mother, and their demands could trigger a relapse or provoke an episode of violent behavior on her part.
An additional stressor may be the fact that some children are not supportive of their mother's choices. For example, they may not like her decision to separate from her abusive partner. They may pressure her, become depressed, act out, and try to coerce her into going home. This can create extreme conflict as the survivor client struggles to act in the best interests of her children. To further complicate the situation, it is not uncommon for older children (particularly boys) to ally with the batterer and become verbally or physically abusive to their mother.
To handle these issues effectively, a postabstinent domestic violence survivor may need to learn new parenting skills that take into account the realities of her status as a domestic violence survivor. These clients and their children commonly have a great deal of suppressed rage; handling frustration and anger is a crucial life skill that must be addressed directly in treatment. If treatment providers have not been trained in anger management and violence prevention, survivor clients should be referred to domestic violence support programs for these services.
Discussing the realities of everyday living and plans for the future that may increase the client's chances of a successful recovery is essential to the design of an effective treatment plan. Treatment providers should explore with the client her plans for future education and employment and should have information available about a variety of options. Through linkages with other agencies, the treatment provider can also help the client develop realistic plans for addressing any legal issues that may be unresolved and are interfering with recovery.
Domestic violence survivors who are newly abstinent may feel overwhelmed by pressures inherent in the responsibilities just described. For many, harassment and threats from their partners will be a continuing concern, and custody disputes and divorce hearings may further complicate their lives. All of these factors are potential triggers for relapse to which the provider should remain attuned. However, as a number of Field Reviewers pointed out, revictimization by their abusive partners poses the greatest risk of relapse for battered women. Whether these women remain in the relationship or not, the likelihood of revictimization is great -- domestic violence is a highly recidivistic crime
(Zawitz et al., 1993;
Browne, 1993). Careful attention to recurring episodes of violence is essential to working with survivor clients to prevent relapse and, if relapse does occur, to minimizing its negative effects.
Children of domestic violence survivors have special problems and needs that may not be readily apparent to the substance abuse treatment provider. Often this is because the more obvious, acute needs of the mother tend to eclipse those of her children. Children's issues must be addressed; if ignored, they can become antecedents to more severe problems, such as conduct disorders or oppositional defiant disorders.
Children of survivor clients typically display strong feelings of grief and loss, abandonment, betrayal, rage, and guilt. Older children also may have feelings of shame. Some indications that such feelings may be developing into serious problems for the child include
The child of a survivor may have his or her own, less apparent triggers for emotional trauma that may be quite different from the mother's. Children's triggers generally have to do with abandonment and separation issues, particularly if the children have been in foster care. Possible problem behaviors include the child's becoming overly clinging and needy upon reuniting with the mother, being fearful of a separation from her again, and acting out with hostility and violence to gain attention.
Children of survivors may also become "parentified," trying to be "perfect." Often this is the result of the child's feelings that he or she is somehow to blame for a parent's anger and subsequent violence. These children may also become extremely protective of their mothers. Other children may have somatic complaints, such as hives, headaches, stomachaches, or other unexplained aches or pains.
Children's responses to family violence vary according to individual temperaments and their age at the time the violence occurred. Posttraumatic symptoms, including sleeplessness and agitation, are common among children who experience violence within the family home
(Pynoos, 1993). Some young children exposed to domestic violence may demonstrate regression in toileting behaviors and emotional distress
(Arroyo and Eth, 1995). Developmental delays and language disorders also have been linked to parental domestic violence
(Kurtz, 1994;
Arroyo and Eth, 1995). Some school-aged children become more aggressive and anxious and lose ground academically
(Pynoos et al., 1987).
Adolescents who have observed their fathers abusing their mothers exhibit high levels of aggression and acting out, anxiety, learning difficulties in school, revenge seeking, and truancy. Children who witness or experience domestic violence are at increased risk of adopting these same strategies in their interactions with their partners and children
(Bell, 1995;
Kalmuss, 1984). They may also become hypervigilant to the point of immobility or, in extreme cases, catatonia.
Some substance abuse programs allow children to accompany the mother to the facility where she receives services. Depending on the program's resources, children can be assessed at that time, treated onsite with counseling groups that coincide with adult sessions, or referred to a qualified children's treatment or counseling program for concerns such as
Ideally, substance abuse treatment programs will establish collaborative relationships with children's programs available through public and private, nonprofit, family service mental health and developmental assessment agencies.
In many areas, these programs provide sophisticated case management services that access respite care, home aid, and parenting skills training that are beyond the scope of most substance abuse treatment programs.
Collaboration with such specialized programs would free substance abuse counselors to concentrate on providing treatment to their survivor clients.
The family services case manager would assume responsibility for making linkages with the myriad institutions that affect the mother through the child, including
The school system
The health care system
Social services and employment programs
The child welfare system
The criminal justice and civil court system
Other community-based agencies (including family preservation and support).
Some survivor clients may be or will become involved with children's protective services (CPS) agencies because their children have been or are being abused and neglected. Since many battered women fear that CPS will take their children from them, they may resist efforts to involve CPS, and some will undermine their treatment to do so.
Treatment providers must adhere to the laws in their States regarding mandated reporting of child abuse and neglect even though clients may perceive those actions as a betrayal of trust. One way to minimize problems is to discuss reporting requirements and the procedures the treatment program follows prior to treatment. Providers should also establish working relationships with CPS to ensure an appropriate and best-case response to the family situation and the child's protection.
The substance abuse counselor is involved with the children -- directly or indirectly -- through the mother. A key responsibility, then, is to understand how to interact with and support the mother in her parenting role.
Substance abuse treatment counselors must understand that the mother may be involved with multiple agencies, all of which make demands on her limited time and energy. To help her focus on her abstinence, treatment providers should
Help the mother identify and coordinate the various services she needs via external case management services or, if unavailable, by acting as an advocate on her behalf.
Support her efforts to participate in and take advantage of these services.
Listen empathetically as she voices her frustration about the difficulties of meeting the demands made by the various agencies and service programs with which she is involved.
Help her clarify the sometimes mixed messages she receives from these agencies, each of which tends to consider its "problem area" a priority (and, as a corollary, ensure that the substance abuse program's messages do not contribute to her confusion and frustration).
Serve as an intermediary and advocate when other agency providers ask her to do more than is reasonable given her progress in treatment (e.g., resume custody before she is prepared to take on responsibility for her children or begin working while still striving to maintain abstinence).
Treatment providers also can assist survivor clients by inviting staff from domestic violence agencies such as Homebuilders and from CPS, jobs training agencies, and other organizations involved with domestic violence survivors to the substance abuse program so they can better understand the treatment and recovery process. Substance abuse treatment counselors also should request cross-training in domestic violence support as well as in-service training on the mission and operation of those agencies that come in contact with survivor clients.
As the chapter makes clear, survivors of domestic violence present unique substance abuse treatment challenges. Because domestic violence can be so psychologically damaging, particularly if it has been sustained since a client's childhood, a treatment provider should refer to domestic violence experts whenever possible. The treatment provider must also be careful not to unintentionally place the survivor client in danger by making inappropriate recommendations.
Central to the discussion of survivors' issues is the overarching need for informed, ongoing collaboration with the agencies that can help the survivor rebuild her life. Substance abuse treatment providers should try to facilitate this collaboration to the greatest extent possible. Treatment outcomes are substantially improved when interventions encompass all the relevant areas of a client's life, services are coordinated, inconsistent messages and expectations are reduced, and the effects of both domestic violence and substance abuse are well understood by all those interacting with the survivor client.
Judy, a white high school graduate in her late 20s, is a recovering substance abuser and a survivor of domestic violence. Her story is typical of the many problems and circumstances faced by women who enter both the domestic violence support and substance abuse treatment systems.
She was molested by her uncle from the age of 3 until she was 10; the molestation included vaginal penetration. Like many victims of sexual abuse, Judy was threatened by her abuser and never disclosed the abuse. On one occasion, her mother asked whether her uncle had ever touched her, and she replied, "No, he does nice things for me."
At age 15, she became sexually active with her 23-year-old boyfriend, Alex. Alex and she began using marijuana. When she was 18, she started using cocaine with Alex, who was now occasionally slapping her and forcing her to have sex.
At that time, she also discovered that she was pregnant. She decided to have the baby but received only sporadic prenatal care. During her pregnancy, both Judy and Alex used cocaine and marijuana and drank alcohol. The infant, a girl named Candace, was born at full term but was small for her gestational age. Alex left Judy soon thereafter, and she and Candace moved in with a new boyfriend, Billy. He used drugs and was both extremely possessive and violent. He intimidated Judy and sometimes threatened to kill her, Candace, and himself.
When Candace was 3, Judy, then 21, became pregnant again. Billy did not welcome the pregnancy and began hitting her in the abdomen and breasts when he was angry. Judy received no prenatal care during her second pregnancy and delivered a preterm, small-for-gestational-age baby whom she named Patricia. Neither Judy nor her baby was screened for drugs or HIV before or immediately after the birth.
By the time Patricia was born, Judy's drug use had escalated to include crack and increasing amounts of alcohol. Despite her mounting problems, Judy recognized that her new baby was a poor feeder. Judy was frightened enough to keep a 6-week postdelivery pediatric visit during which Patricia was diagnosed as "failing to thrive." At the same visit, 3-year-old Candace was weighed and found to be only in the 10th percentile of weight for her age.
Two weeks later, Judy and Billy were arrested on drug charges -- Judy for possession and Billy for dealing. She received probation, and she and her children moved in with her mother, Vivian. Billy was incarcerated, and Judy was required by the court to participate in substance abuse treatment.
In a group therapy session in her substance abuse treatment program, Judy acknowledged her history of family violence, childhood sexual abuse, and battering. Her case manager in this program wanted her to join another group of childhood incest survivors, but Judy felt ashamed and did not want to discuss the incest further. She began attending treatment sessions sporadically and, after 2 months, dropped out. In the meantime, tension developed between Judy and Vivian. Judy felt that her mother cared more for her granddaughters than she had about Judy when she was a child. Now that Judy had acknowledged her history of sexual abuse, she found herself blaming her mother for "allowing" it to happen. She also was jealous because she felt that Vivian was a better mother to Patricia and Candace than she was.
After a series of violent fights with her mother, Judy moved out and got a minimum-wage job, leaving her children with Vivian.
Around this time, Judy met Cody, a drug dealer. Cody moved in with her, but their relationship was characterized by frequent arguing and mutual battering. Judy's work habits became erratic; she often had bruises and sprains that she refused to discuss when her concerned coworkers questioned her about them. Although she saw her children infrequently, she would call late at night when she was high and criticize Vivian for keeping her children from her.
Meanwhile, under Vivian's care, Candace gained weight but exhibited a language delay. Her preschool teacher called Vivian repeatedly about Candace's problem behavior and acting out; she was having trouble paying attention in school, was defiant to her teachers, and was domineering with her peers. The school also reported that Candace had language problems and that she frequently cried for her mother.
Meanwhile, Vivian had quit her job in order to care for her grandchildren and was receiving Aid to Families with Dependent Children (AFDC). At this time, Vivian's health began to deteriorate, and she asked for help with Candace and Patricia. When a social worker began to talk about sending the children to a foster home, Judy was scared into action. Developmental evaluations were recommended for both children, and Judy took them to those appointments. Both children were found to have marginal developmental problems, possibly due to Judy's drug use during pregnancy. In response to the psychologist's advice, Judy enrolled Candace in a developmentally more appropriate preschool program that required parental involvement. Judy participated in this program with her daughter and resumed treatment.
For a brief time, Judy's life appeared to stabilize. Although she had not finished her substance abuse treatment program, she and Cody were both working, and she continued to receive negative screens for drugs (although she was still using occasionally). At the next CPS hearing, the children were returned to Judy's custody with the stipulation that she participate in parenting classes as well as continue in treatment.
Once her two children moved in with her and Cody, the situation began to deteriorate. Cody could not tolerate the children, and his episodes of violent behavior increased. He put his fist through the wall and kicked the door down. He became increasingly angry at Judy's frequent absences as a result of "all this kid stuff" (parenting classes and Candace's preschool program). He began to "spank" the children or grab them roughly by their arms when he wanted their attention. They showed up at their respective day care and preschool programs with bruises, which were attributed to "accidents." No one at the day care or preschool programs was aware of Judy's history or her disclosures of childhood abuse and battering in the treatment program.
Cody's violence continued to escalate and, increasingly, was directed at the children. While Judy was concerned about his hitting and yelling at the children, she didn't know what to do about it. She was feeling overwhelmed by her job, the parenting classes, her meetings with social services workers and her probation officer, and her child care responsibilities. In time, however, she began intervening when Cody yelled at or hit the children, deliberately provoking him in order to divert his attention away from the children and onto herself. The neighbors called 911 frequently, but the police never found any substantial evidence of violence.
A year passed with no improvement. The children continued to attend school, but Judy appeared only sporadically at her parenting classes and the preschool program. She was now beginning to suspect that Cody was sexually abusing 5-year-old Candace. She had begun to notice the same kinds of behavior in her daughter that she remembered in herself when she was sexually abused at that age. One day she asked Candace whether Cody had ever touched her in certain ways. Candace replied, "No, he is always nice to me." Judy remembered using almost identical words to her own mother years before and was certain that her daughter was being victimized in the same way. All the rage from her own abuse by her uncle erupted. She verbally and physically confronted Cody, and a battle ensued, which Candace witnessed. (Later this episode became a major treatment issue for the child, who believed that the violence in her household was her fault.)
Both Judy and Cody sustained injuries in their fight. Candace ran next door with her little sister, screaming about "all the blood." The neighbors called the police; Judy and Cody were both taken to the hospital, and the children were taken to a CPS emergency shelter. Judy and Cody were arrested for disturbing the peace and for possessing drug paraphernalia. Cody was charged with first degree (later reduced to third degree) assault, for which he eventually received a suspended sentence.
In the hospital, a social worker referred Judy and the children to a program for domestic violence survivors. After she was treated and released from the hospital, Judy stayed overnight in jail. The next day she was given a court appearance date, and a domestic violence advocate arranged transportation to the domestic violence program for her and her children. Program staff also assisted Judy in obtaining a restraining order against Cody and accompanied her to court to obtain it. When Candace and Patricia were reunited with their mother in the domestic violence facility, they clung to her, crying. Over the ensuing days, they experienced nightmares.
Despite the minor drug charge, the domestic violence program agreed to accept Judy because her drug screens were negative; the program had no knowledge of Judy's substance abuse treatment history. During intake, staff explained the program's drug use policy: If Judy used while in the program, her choices were to leave the facility or participate in treatment. The domestic violence program advocates did not think Judy was using drugs at the time of her admission and did not believe that she would use during her stay.
One day, Judy returned to the domestic violence program intoxicated, and a joint fell out of her purse. The program staff members saw and reported it to CPS. CPS then took away her children and again sent them to live with their grandmother. Judy's choices were now to either get substance abuse treatment or leave the facility. She entered a 1-year residential treatment program and was assigned to a counselor who was not only a recovering addict but a survivor of domestic abuse and with whom Judy felt an immediate rapport. The counselor and Judy together developed a treatment plan that took Judy's concerns and goals as well as the needs of her children into account. Although they agreed that intensive outpatient treatment would have been preferable, she had no place to stay where she would have been safe from Cody. She could not stay at the domestic violence program for that long, and Cody knew where her mother lived. Without a safe haven, her recovery and her life would have been in jeopardy, so Judy and her counselor decided on residential treatment. The counselor walked her through the admissions process.
Judy has been in recovery for 2 years, and her mother -- who was encouraged to participate in family sessions -- is supportive. Judy goes to work every day and has begun to date an older, recovering alcoholic she met at an AA meeting. He is more established and sees her children regularly. Vivian has again quit her job and is receiving AFDC. Cody is receiving substance abuse treatment and counseling for domestic violence, which were conditions of his suspended sentence. Another condition is that he remain in treatment and make no attempt to contact Judy or the children. The children are seen on a daily basis in the domestic violence program. But because the program can provide only supportive care and play activities, the children have been referred to a local agency with special supportive and mental health services for children.
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