Treating Substance Abuse and Intimate Partner Violence: Implications for addiction Professionals

By Cheryl Kennedy, LMSW, Keith Klostermann, PhD, NCC, Christie Gorman, MA, CASAC, & William Fals-Stewart, PhD

As counselors in substance abuse treatment programs begin using evidence-based marital and family-based interventions with their clients, they frequently encounter one of the most emotionally charged public health issues of our time: intimate partner violence (IPV).

Unfortunately, the prevalence of partner aggression among married or cohabiting substance-abusing clients is alarmingly high. For married or cohabiting clients entering treatment for alcoholism, the proportion reporting at least one episode of IPV in the previous year has ranged from 40-60 percent across several studies, which is 4-6 times higher than observed in national samples (e.g., Fals-Stewart, 2003; O’Farrell & Murphy, 1995).

Consequently, as a team that has treated more than 1,500 drug- and alcohol-abusing couples in our research protocols and clinical practices over the last decade, we are all too familiar with the complexities of dealing with physical aggression between partners and, regrettably, have had to address this issue with great regularity.

In this article, we define the types of IPV, explore the relationship between substance use and IPV, and offer recommendations for assessing and treating IPV among clients entering treatment for substance abuse.

What is IPV?

Although often treated and discussed as a unitary, homogeneous phenomenon, physical aggression between intimate partners varies greatly along such dimensions as (a) the type and severity of aggression (e.g., a push versus an injury-inducing beating); (b) frequency (e.g., a single push versus repeated pushing over an extended time frame); and (c) emotional and physical impact (i.e., aggression which induces fear; O’Leary, 2002).

Johnson (1995) captures these distinctions in his description of two types of IPV that appear to be conceptually and etiologically different. One type, patriarchal terrorism, is characterized by severe male-to-female physical aggression (e.g., punching, threatening with weapons), with less severe female-to-male violence occurring in these episodes primarily as self-defense.

For the female partner, patriarchal terrorism is marked by a high likelihood of physical injury and increased fear of the male partner. The distinctive feature of this severe type of IPV is that the aggression serves the purpose of dominating and controlling the partner.

The second type of IPV, referred to as common couple violence, is characterized by more bidirectional partner aggression that is mild to moderate in severity. Common couple violence is less likely to cause fear in or endanger the female partner and is also less likely to be used as a form of control. Moreover, common couple violence, as the name implies, is far more typical than patriarchal terrorism.

How common is IPV?

Although historically viewed as a private family matter, IPV has come out from behind closed doors and been recognized as a pervasive societal problem for more than 20 years. Estimates of physical aggression between partners vary widely, depending on the definition of violence used and the context in which it is measured.

For example, according to the Department of Justice, roughly 1,500 instances of homicide and manslaughter between intimate partners occur annually, with more than 1,200 of these involving women as victims (Bureau of Justice Statistics, 1998a). Nearly a quarter million emergency room visits in the U.S. each year involve a victim of intimate partner violence.

The findings of the National Crime Victim Survey (NCVS), which is a survey of the victimization experiences of a nationally representative sample of the U.S. population, indicate there are nearly one million female victims of IPV each year. In fact, surveys of representative samples of couples suggest that each year, one out of every eight husbands engages in physical aggressive behavior, which includes less severe instances of aggression (e.g., single episodes of pushing or slapping), against their wives (Bureau of Justice Statistics, 1998b).

Although not widely reported (or at least not emphasized), female-to-male physical aggression is also common, occurring in proportions that are equal to or slightly higher than men (e.g., Archer, 2000). However, the consequences of male-to-female physical aggression appear to be greater on the female partners (Cascardi, Langhinrichsen, & Vivian, 1992), and on children in the home (e.g., Margolin, 1998), than female-to-male violence.

Substance use and IPV

Research shows that a large proportion of IPV episodes involve alcohol or other drug consumption by either the male partner, the female partner, or both. In the NCVS (BJS, 1998b), more than half of the victims of IPV reported that the perpetrator had been drinking. Among prisoners convicted of murdering an intimate partner, 45 percent reported that they were drinking at the time of the incident, with an average blood alcohol concentration of three times the legal limit.

In addition, the strong relationship between alcohol use and perpetration of IPV has been found in primary health care settings (McCauley et al., 1995), family practice clinics (Oriel & Fleming, 1998), prenatal clinics (Muhajarine & D’Arcy, 1999), and rural health clinics (Van Hightower & Gorton, 1998).

Research examining the link between use of drugs other than alcohol and IPV is not as well developed. However, several recent studies reveal associations between use of certain drugs and partner aggression similar to those found with alcohol. In a study by Brookoff and colleagues (1997), 92 percent of partners who engaged in IPV used alcohol or other drugs on days of the episode.

Relatedly, in a survey of substance abuse treatment providers, it was estimated that nearly half of substance-abusing men engaged in IPV in their relationships (Bennett & Lawson, 1994); comparable proportions of IPV among men entering substance abuse treatment have also been reported in other investigations (e.g., Easton, Swan, & Sinha, 2000; Fals-Stewart, Birchler, & O’Farrell, 1996).

Cause or excuse?

Given these robust findings, the association between substance use and IPV is no longer in dispute. Yet the causal or facilitative role of intoxication in episodes of IPV remains a source of much controversy. A very commonly held and regularly stated axiom in the domestic violence literature is that “drinking is not a cause of partner aggression, it is an excuse” (e.g., Miller & Welford, 1997).

Conversely, many researchers examining factors associated with the occurence of IPV have concluded that intoxication is one of many causal factors in the occurrence of IPV (e.g., Leonard, 2002). This debate is not merely an academic exercise; if intoxication is causally implicated in IPV, it would follow that interventions that are successful in reducing substance use could also reduce partner violence. Thus, a fundamental question is, “Does intoxication play a causal role in IPV?”

Evidence supporting the causal role of intoxication in IPV

The results of the investigations briefly reviewed above indicate there is a fairly strong association between substance use and partner aggression, but such an association does not, in and of itself, prove that substance use has a causal role in IPV episodes. Although it is now beyond reasonable debate that substance use is very often part of the situational context in which IPV occurs, several different explanations have been put forth to explain this co-occurrence (Leonard & Quigley, 1999).

In the spurious model, the relationship between substance use and IPV is viewed as a consequence of these variables being related to other factors that influence both behaviors. For example, individuals who are young may have a tendency to be violent and also have a tendency to drink; thus, drinking and violence may appear to be directly related when, in fact, they are not.

Although findings in different investigations have not been entirely consistent, the results of numerous studies indicate substance use is associated with partner violence after factors that are thought to be associated with both behaviors are controlled, such as age, education, socioeconomic or occupational status, and race (e.g., Leonard et al., 1985; Pan, Neidig, & O’Leary, 1994).

In the indirect effects model, alcohol and other drug use is viewed as being corrosive to relationship quality. Thus, long-term substance use creates an environment that sets the stage for partner conflict and, ultimately, partner violence.

However, when marital satisfaction, relationship discord, or other similar variables are controlled when examining the alcohol-partner violence link, the relationship remains strong (e.g., Fals-Stewart, 2003; McKenry, Julian, & Gavazzi, 1995).

According to the proximal effects model, intoxication is viewed as one of several potential causal agents of IPV. Therefore, individuals who drink or use other intoxicating substances are more likely to engage in partner violence because intoxication facilitates violence.

The model predicts that substance use precedes episodes of IPV and, moreover, episodes of violence occur close in time to the consumption of alcohol or other drugs (i.e., when the perpetrator is intoxicated). One of the key arguments against this model is that studies have failed to demonstrate the temporal precedence of alcohol or other drug use in episodes of IPV, a necessary condition for substance use to be considered causal.

A more recent study (Fals-Stewart, 2003) of alcohol use and IPV has, through the collection of detailed diaries of men entering either an alcoholism or domestic violence treatment program and their female partners, established that IPV episodes tend to occur close in time to drinking and drug use. Moreover, more than 60 percent of all episodes occurred within 2 hours of drinking by the male partner.

Although each model may have merit and may, in fact, serve to explain some part of the relationship between substance use and partner violence, the greatest empirical support rests with the proximal effects model. This is not to suggest that drug or alcohol use are the only causal factors; however, conceptualizing intoxication as a causal factor in IPV has important treatment implications.

IPV and substance abuse: Assessment

Given the strong link between substance use and IPV, coupled with the prevalence of partner violence among alcoholic and drug-abusing clients entering treatment, counselors in substance abuse treatment programs, whether they are aware of it or not, are almost certainly encountering clients who have engaged in physical aggression toward their partners. Importantly, its discovery may not only occur in the context and course of partner-involved therapies; it is also exposed in comprehensive intake assessments of married or cohabiting clients entering substance abuse treatment (Schumacher, Fals-Stewart, & Leonard, 2003).

Individuals entering alcoholism or drug abuse treatment are often not assessed for IPV or, if they are, the assessments themselves are inadequate; consequently, a substantial proportion of clients who engage in IPV are not identified (Schumacher, Fals-Stewart, & Leonard, 2003).

Thus, substance abuse treatment programs need to assess for the presence of IPV among their married or cohabiting clients. Several options for assessing IPV are available. The revised version of the Conflict Tactics Scale (CTS-2; Straus et al., 1996) is the most commonly used IPV measure and evaluates not only physical aggression between partners, but also partners’ use of negotiation, sexual coercion, psychological aggression, as well as the occurrence of injury. It is comparatively brief and easily understood by clients.

Although more labor intensive and time consuming, the Timeline Followback Spousal Violence Interview (TLFB-SV; Fals-Stewart, Birchler, & Kelley, 2003a) is a calendar-based interview that provides not only information about the prevalence and frequency of physical aggression between partners, but also allows for examination of temporal patterns and the co-occurrence of other behaviors that may also be coded on the calendars (e.g., drinking or drug use). Many other options are also available (for a review, see Feindler, Rathus, & Silver, 2003). Given this information, not assessing for IPV is no longer defensible. Furthermore, while identification of IPV is necessary, it is not sufficient.

IPV and substance abuse treatment: Behavioral Couples Therapy

Once IPV is identified among alcoholic or drug-abusing clients entering treatment, addressing the substance use problem effectively is critical. While standard substance abuse treatment does appear to reduce the re-occurrence of IPV significantly, we believe it is not sufficient as a stand-alone treatment for IPV because the observed positive effects on IPV rely primarily on abstinence, an outcome that many substance-abusing clients fail to reach.

Given the fairly high relapse rates typically reported for clients after substance abuse treatment, coupled with the many-fold increase in the likelihood of IPV on days of alcohol or other drug use after standard treatment for alcoholism and drug abuse (e.g., Fals-Stewart, 2003; Fals-Stewart et al., 2003b), standard substance abuse treatment should be viewed as a necessary, but not sufficient, intervention for clients seeking help for alcoholism or drug abuse who have also engaged in IPV.

We recommend that providers use partner-based interventions, particularly Behavioral Couples Therapy (BCT), for the majority of substance-abusing clients who have engaged in IPV prior to program entry. BCT is more effective in reducing or eliminating substance use than standard individual-based treatments; from that outcome alone, we would expect BCT to be more effective than standard substance abuse treatment in reducing partner aggression.

Moreover, BCT does not appear to rely exclusively on abstinence for its positive effects on IPV. Partners are taught skills to reduce the likelihood of IPV even when drinking or drug use has occurred; this is a fundamental advantage of partner-involved IPV interventions for partner violent substance-abusing clients and their partners.

Similar to the clinical themes that are part of conjoint interventions for IPV (e.g., anger management, communication and problem-solving skill development, and relationship enhancement), partners participating in BCT for substance abuse agree not to engage in “angry touching,” receive communication skills and problem solving training, and participate in relationship enhancement exercises.

Relationship exercises include Catch Your Partner Doing Something Nice, which has each partner notice and acknowledge something positive that his or her partner did that day, and Caring Days, which have each partner plan a special activity for their significant other to show caring.

Communication skills (e.g., mirroring, validating, Positive Specific Requests) and problem-solving training helps to improve communication and increase understanding and support to help deal with daily life stressors. In addition, BCT also stresses dyadic support for abstinence and has been shown to be very effective in reducing or eliminating substance use which, as highlighted earlier, is strongly associated with IPV.

For example, couples are asked to perform a daily Abstinence Trust Discussion in which the substance-abusing partner states that he or she has not used alcohol or drugs on that day and expresses appreciation for the support that he or she has been given by his or her partner. The nonsubstance-abusing partner then states his or her support to the substance-abusing partner for remaining free of alcohol and drugs and expresses a willingness to help out in any way that he or she can to maintain abstinence.

Furthermore, in the course of BCT, nonsubstance-abusing partners are taught certain coping skills to increase safety when faced with a situation where the likelihood of IPV is increased. In particular, emphasis is placed on engaging in behaviors that reduce the likelihood of aggression when a partner is intoxicated (e.g., leaving the situation, calling a Time-Out, avoiding discussions about conflictual and emotionally laden topics with an intoxicated partner).

These interventions are designed to reduce partner violence in couples even when relapse occurs (i.e., BCT does not rely exclusively on abstinence as the mechanism of action for nonviolence). Thus, we would expect to observe important differences in the likelihood of IPV on days of drinking or drug use among clients with a history of IPV who receive individual treatment for substance abuse versus those clients who receive couples therapy.

However, conjoint therapies, including BCT for substance abuse, are contraindicated for couples in which partners engage in severe forms of IPV. In the course of separate interviews, we collect information from partners in violent couples to ascertain the degree, severity, and impact of IPV in the relationship. Our exclusion criteria for BCT with partner-violent couples are consistent with and were drawn from exclusion criteria used by other researchers who have used conjoint therapy among partner-violent couples.

These criteria include one or both partners reporting: (a) fear of injury or death from their significant other; (b) threats and/or being harmed with a gun, knife or other weapon; (c) fear of participating in couples therapy; (d) a desire to leave the relationship, in whole or part, due to degree and severity of partner aggression; or (e) severe violence (resulting in injury and/or hospitalization) has occurred within the past two years. However, it is important to emphasize that we have rarely excluded couples on these grounds; as noted earlier, less than five percent of couples who have participated in our research or clinical practices have been excluded for these reasons.

We also believe that, for clients who engage in patriarchal terrorism, concerns about accountability and safety must override efforts at rehabilitation. On the rare occasions when we have encountered this form of IPV among clients we have evaluated, we do not use partner-involved therapies of any kind for any purpose with such clients.

Rather, we recommend that participation in a batterers program be included as part of the formal treatment plan developed in the substance abuse treatment program. In turn, if these clients do not attend the batterer treatment programs, as outlined in their treatment plans, we recommend discharge from the substance abuse treatment program for failing to follow treatment guidelines and notify the referral source (e.g., probation department, judge).

Several investigations have supported the efficacy of BCT as a treatment for substance-abusing couples with a history of IPV. Fals-Stewart (2004) found that during the year after treatment, on days of male partner drinking, the likelihood of male-to-female physical aggression was lower for couples who received BCT compared to the couples who received individual-based alcoholism treatment for the male partner only or a psychoeducation program for both partners.

In a recent study, O’Farrell and colleagues (2004) examined partner violence before and after BCT for 303 married or cohabiting male alcoholic clients, and used a demographically matched nonalcoholic comparison sample. In the year before BCT, 60 percent of alcoholic clients had been violent toward their female partners, five times the comparison sample rate of 12 percent.

In the year after BCT, violence decreased significantly to 24 percent of the alcoholic sample but remained higher than the comparison group. Among remitted alcoholics after BCT, violence prevalence of 12 percent was identical to the comparison sample and less than half the rate among relapsed clients (30 percent). Results for the second year after BCT yielded similar findings to those found for the first year outcomes.

Thus, partner violence decreased after BCT, and clinically significant violence reductions occurred for clients who ceased drinking after BCT. Attending more scheduled BCT sessions and using BCT-targeted behaviors more during and after treatment were related to less drinking and less violence after BCT, suggesting that skills couples learn in BCT may promote both abstinence and reductions in IPV.

Fals-Stewart and colleagues (2002) examined changes in IPV among 80 married or cohabiting drug-abusing clients and their nonsubstance-abusing female partners. Although nearly half of the couples in each condition reported male-to-female physical aggression during the year before treatment, the number reporting violence in the year after treatment was significantly lower for BCT (17 percent) than for individual treatment for the male partner only (42 percent). BCT may reduce violence better than individual treatment because BCT reduces drug use, drinking, and relationship problems to a greater extent than individual treatment.

Closing reflection

With the established link between substance abuse and incidents of IPV, substance abuse treatment providers are in a unique and optimal position to have the opportunity to work together with couples to encourage and maintain abstinence and reduce the likelihood of IPV occurring in these relationships. We strongly recommend the use of BCT with substance-abusing individuals and their partners who enter substance abuse treatment, as BCT has been shown to result in reduced substance use and reduced episodes of IPV.

Ultimately, finding and implementing the most effective intervention and treatment methods will lead to the greatest level of safety for clients, their partners, and their families — which is everyone’s goal.

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Cheryl Kennedy, LMSW is a Project Director at the Research Institute on Addictions, The University at Buffalo, SUNY. Her primary project role is to develop various mediums for disseminating BCT-related materials and research findings. She is also actively involved in community disaster preparedness efforts in Buffalo, NY.

Keith Klostermann, PhD, NCC is a board certified counselor and Project Director at the Research Institute on Addictions, The University at Buffalo, SUNY. Dr. Klostermann’s work focuses on marital and family therapy with drug- and alcohol-abusing patients.

Christie Gorman, MA, CASAC is a Project Assistant at The University at Buffalo, SUNY. Her research interests include drug and alcohol treatment, comorbid anxiety disorders and alcohol use, and research-to-
practice collaborations.

William Fals-Stewart, PhD is a Senior Research Scientist at the Research Institute on Addictions, The University at Buffalo, SUNY. Dr. Fals-Stewart’s internationally recognized work focuses on marital/family therapy with drug- and alcohol-abusing patients.

Acknowledgement
We wish to thank Cynthia A. Stappenbeck, MA and Cassandra Hoebbel, EdM, of the Research Institute on Addictions, Buffalo, NY for their insightful comments on an earlier version of this article.

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This article is published in Counselor,The Magazine for Addiction Professionals, February 2005, v.6, n.1, pp.28-34