Alcohol’s Role in Violence with Partners Issues & interventions

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

2. There Is A Link . . . • Over 50% of men in BIPs have SA issues1and are 8 times as likely to batter on a day in which they have been drinking2 • Half of partnered men entering SA treatment have battered in the past year3 and are 11 times as likely to batter on a day in which they have been drinking2 • Between a quarter and half of the women receiving services for DV have SA problems4 • Between 55 and 99 percent of women who have SA issues have been victimized at some point in their life5 and between 67 and 80 percent of women in SA treatment are DV victims6

3. There is a link . . . But What Is The Link? • Most men not drinking or drugging when they batter 1 • Most (80%) heavy drinkers don’t batter 1 • The apparent correlation between SA and DV fits only a sub-group of people.2 • When male-dominant attitudes are controlled, relationship between SA and DV lessens, suggesting both SA and attitudes toward gender are important in preventing DV 3

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

5. . . . Or Not

6. Human aggression is over-determined: there are “Many roads to Rome” • Alcohol/drugs use (intoxication) is a road • Alcohol/drug abuse/dependency is a road • Male power/control motivation is a road • Weak impulse control is a road • etc. etc. • None of these are usually the stand-alone causes of violence • Impulsive violence may share paths in the brain with psychoactive substances, the orbito-frontal portion of the pre-frontal cortex 1

7. Modeling Inhibition & Distress * Learned Inhibition Against Violence * The Bar * All the things acting against your using physical aggression * Distress * All outside and inside pressures * An instigation, and its’ meaning to you

8. Modeling Domestic Violence

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

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

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

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

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

14. Perspectives on the SADV (or DVSA) Relationship • The previous slides illustrate a proximal model 1or cognitiveexplanation of how alcohol (not drugs) may cause DV • Sometimes called Disinhibition • Proximal model doesn’t work in all (or even most) cases of SA, and neither does any other explanation • After presenting a summary of data supporting a proximal model, I will present alternative ways of explaining SADV

15. Substance Use and DV Victimization1N=17,348Cohabiting Adults Age 18+ DV Rate if DV Rate if # Users Used Past NOT Used Per 1000 12 months 12 Months ________ ________ ________ Alcohol 707 6.7 % 4.8 % Marijuana/hashish 86 16.2 5.2 Pain relievers 35 16.8 5.7 PCP 1 21.7 6.1 Hallucinogens 14 21.7 5.9 Inhalants 4 22.2 6.1 Cocaine 19 22.4 5.8 Tranquilizers 16 22.9 5.9 Sedatives 3 25.6 5.1 Methamphetamine 6 26.0 6.0 Heroin 1 35.0 6.1 Crack 5 36.8 6.0

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

17. Proximal Effects • Disinhibition • Cognitive Disinhibition/Acute Effects Model Alcohol/DrugIntoxication Violence Changed Thinking Violence

18. Disinhibition

19. Laboratory ResearchBlood Alcohol  Cognitive distortion • Perceive. Aggression depends on drinker perceiving his target as aggressive • Misperceive. Aggression more likely at high BAL--drinker more likely misperceives her behavior as aggressive, abandoning, or overwhelming • Red-out.At high BAL, drinker is less likely to have empathy or mercy for his victim

20. Disinhibition

21. The Proximal Model Suggests: • Alcohol & drugs (moderated by personality orientation, beliefs about violence, and skills) increase the risk of violence • Violence can be prevented by lowering cognitive distortion, raising inhibitions to violence, and in those for whom alcohol/drug acts in some way to increase aggression, reduce consumption (risk/harm reduction) or remove the alcohol/drug(abstinence) • Problem: The effects of alcohol on aggression are not only due to its’ biochemical effects on the brain

22. Alternative Explanation #1Co-Morbidity/Co-Occurring Situations • SADV linked to • Personality characteristics such as hostility 1 • Co-occurring disorders such as antisocial personality disorder 2 • Co-occurring situations such as social class 3 • More co-occurring disorders/situations  greater likelihood of DV • But Keep In Mind: • Most poor men don’t batter • Most men with antisocial personality disorder don’t batter • Most men with high levels of hostility don’t batter • Most substance abusers don’t batter

23. Alternative Explanation #2: Men’s Need for Power • Alcohol  aggression relationship is conditional upon individual power needs 1 • Alcohol is an “instrument of intimate domination” 2 • Power motivation origins in early personal experiences, social interactions, class, or ethnicity • The relationship between power and abuse is usually gendered and reinforced in culture Power Needs SA DV

24. Alternative Explanation #3:The Situation • DV may occur during the process of obtaining and using substances, not from the substances per se • Particularly relevant when illegal drugs are involved 1 • DV is more severe when drugs other than alcohol are involved,2 not due to the drug itself but due to the situation in which the drug is used and the lifestyle of the users 3 • Conflict over drinking cited in half DV episodes recalled by both perpetrator and victim 4

25. Alternative Explanation #4:Culturally-based Excuses • In many cultures SA serves as time out from responsibility during which the user can engage in exceptional behavior and later disavow the behavior as caused by the substance rather than the self 1 • “It wasn’t me (Baby, Judge, Doc, Officer); it was the alcohol.” • U.S. courts no longer accept drunkenness as a reason for criminal behavior • The reverse is true for victims, however; her use of alcohol and drugs increases the degree criminal justice professionals believe she is responsible for her own victimization 2

26. Alternative Explanation #5:Expectancy • Expectations for the effects of alcohol or drug use: sexier, stronger, social, aggressive 1 • Time out and cultural expectancy2 • The balanced placebo experiment 3 • Male-specific?

27. The Controlling Effect of Drunkenness • Robin Room: “Alcohol is an instrument of intimate domination” 1 • Drunkenness serves to control partner behavior by increasing unpredictability, and therefore, fear • Frequency of drunkenness almost quadruples the likelihood of victim fear, even after controlling for the amount alcohol used, class, race, marital status, and levels of prior abuse 2

28. Summary: Batterers • The way that A/D use and abuse increases the risk for DV is complex and different for every person and sometimes different for each event • Removing the substance (abstinence) is likely to reduce DV in only a minority of cases

29. Practice Issues

30. The Issues • If a man (or woman) is arrested for DV, or seeks help as a victim of DV, whose job is it to detect substance abuse? Under what policy? In what way? • If substance abuse by a batterer or victim is detected, what happens next, and who decides? What is the policy? • If a man or woman is arrested for alcohol or drugs, or is in treatment for alcohol or drugs, whose job is it to detect DV? Under what policy? In what way? • If DV is detected, what happens next, and who decides? • Most importantly: Assuming all the necessary services/sanctions/treatment are not provided by the same entity, how do multiple entities work to support victim safety and substance abuse recovery?

31. TIP 25 Substance Abuse and Mental Health Services Administration www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.46712

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

33. Getting Safe and Sober: Real Tools You Can Use A Teaching Kit For Use With Women Who Are Coping with Substance Abuse, Interpersonal Violence and Trauma (Available in English and Spanish) This project was supported by the Office of Women’s Health Region X Grant # HHSP233200400566P and by Grant #’s 2003-MU-BX-0029, 2004-MU-AX-0029 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions and recommendations expressed here are those of the presenters and authors and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women or the Office of Women’s Health. Principal Authors : Patricia J. Bland , M.A. CCDC CDP and Debi Edmund, M.A. L.P.C. For more information contact: Alaska Network on Domestic Violence and Sexual Assault 907-586-3650 www.andvsa.org Resource Manual

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

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

36. Serial, Integrated, and Coordinated Interventions

37. Serial Interventions DV Program Assessment Substance Abuse Tx

38. Problems with Serial Interventions for Offenders • Offender rarely shows up at second service • Offender is acculturated in the primary problem • Only works with a high level of case management, highly trained staff at primary service, and assertive P.O.s • Current best practice: NO SERIAL INTERVENTIONS EXCEPT DETOX

39. Problems with Serial Interventions for Victims • Reinforces DV staff failure to recognize addiction as a brain disease • Do we turn away diabetics who use insulin? Obese women who over-eat? What’s the difference? • SA victim usually involved with SA perp • Refusal to engage SA victim decreases her opportunity for sobriety and increases her opportunity for injury • DV program refusal does not increase the chances she will enter SA treatment

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

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

42. Coordinated Services SA Tx DV Agency Case Coordination Model

43. Issues with Coordinated Services for Offenders • Confidentiality, sharing information (e.g. HIPPA) • Cost, compared to integrated programs • Time commitment for intensive treatments • Cognitive impairment in early recovery may interfere

44. Integrated and Coordinated Community Based Programs for Batterers

45. Not Much Yet • Integrated and coordinated services for batterers not as well developed as services for victims • Substance abuse treatment agencies have taken the lead (often for the wrong reason: $)

46. Good Ideas (Maybe) But Risky Business for Batterers • Self help • Couples counseling • Anger management • Anything with “Compassion” or “Forgiveness” in title • Men’s growth groups • Psychotherapy • Pastoral/faith-based programs • Confrontational approaches

47. Predicting Re-assault After BIP1 • Predicting re-assault at intake • History of severe partner abuse • History of non-DV arrest • Severe mental disorder • Predicting re-assault during the program • Women’s feeling of safety • Drunkenness • Almost all re-assaulters “get away with it”

48. Program Recommendations • Existing programs adequate w/ changes • Rapid (pre-trial?) intake to program • Ongoing monitoring of substance use, emotional/psychiatric problems, re-offense • Intensive (2-3x/week) intervention for prior/severe offenders for first month • Victim support

49. System Recommendations • Periodic court review (DV Court) • Assertive case management & risk review • Support & safety planning with female partners • Coordinated Community Response • “Swift and certain” response to re-assault, dropout, and non-compliance

50. Some Integration Attempts • Dade County FL1 • Integrated Domestic Violence Model • Duluth-based • Yale 2 • Substance Abuse Treatment Unit’s Substance Abuse–Domestic Violence • 10-session CBT model • U. Maryland MET Clinical Trial 3 • ADA/Dawn Farm (Michigan) 4 • Accountability/Recovery model • Behavioral Couples Therapy (Harvard)5 • No discussion of domestic violence at all