Several studies suggest that treatment-associated reductions in substance use are related to reductions in violence. O'Farrell et al. (2003) examined partner violence in the year before and the year after individually based, outpatient alcohol(Drug information on alcohol)ism treatment for male alcoholic patients, compared with a demographically matched nonalcoholic comparison group. The results illustrated that in the year before treatment, 56% of the alcoholic patients had been violent toward their female partner, four times the rate of the comparison sample (14%).
However, in the year after treatment, violence decreased significantly to 25% of the alcoholic sample but remained higher than the comparison group.
In a parallel study, Fals-Stewart et al. (2003) examined partner violence among a sample of married or cohabiting men entering outpatient treatment for drug abuse. During the year before treatment, the prevalence of IPV was roughly 60%, but dropped to 35% during the one-year, posttreatment follow-up period. In both studies, treatments were standard 12-step facilitation interventions that did not address partner violence (e.g., Schumacher et al., 2003). Nonetheless, participation in the programs resulted in significant reductions in interpersonal violence, consistent with the proximal effects model. Additionally, this line of research suggests that tailoring or developing substance abuse treatments to address domestic violence-related problems (e.g., managing anger and negative mood states) may reduce IPV, especially in the event of a substance abuse relapse. Since substance abuse treatment facilities provide a treatment venue for male offenders of IPV, addiction specialists and psychiatrists will play a crucial role in the assessment of co-occurring substance abuse and IPV. In addition to using the DSM-IV for the Axis I substance-related diagnoses and the Addiction Severity Index (ASI) (McLellan et al., 1992) for diagnosing severity of substance abuse/dependence, psychiatrists can also utilize the following diagnostic assessments to evaluate type, amount and frequency of intimate partner or family violence: 1) Timeline Follow-Back method (TLFB) (Fals-Stewart et al., 2000); 2) Revised Conflict Tactics Scale (CTS2) (Straus et al., 1996); and 3) State-Trait Anger Expression Inventory (STAXI) (Spielberger, 1991).Evidenced-Based Therapies
Behavioral couples therapy. Several studies suggest that interventions targeting reduction in substance use and skill deficits have particular promise in this population. In particular, and highly relevant to the proposed project, behavioral couples therapy, a cognitive-behavioral approach that teaches couples techniques to reduce conflict and improve relationship functioning, has been demonstrated to be effective in several select populations (Fals-Stewart et al., 2002; O'Farrell and Fals-Stewart, 2000). Although behavioral couples therapy is effective with these populations, it has limited application to individuals convicted of interpersonal violence who are referred or mandated to substance abuse treatment.
For example, behavioral couples therapy requires participation of the female partner and, therefore, has the following problems: 1) in many cases, the female partner has left the relationship and has no ongoing contact; 2) the partner may refuse to participate in the male's treatment; 3) a male offender may refuse to have his partner participate in his treatment because of unwillingness to reveal the extent of his substance use; and 4) there may be imposed restraining or protective orders that limits contact between the offender and the victim.
Cognitive-behavioral therapy. One individual approach to substance abuse treatment with strong empirical support and the capacity to expand to address other problems is cognitive-behavioral therapy (CBT) (Carroll, 1998; DeRubeis and Crits-Christoph, 1998; Irvin et al., 1999). Based on social learning theories of substance use disorders, CBT focuses on the implementation of effective coping skills for recognizing, avoiding and coping with situations that increase the risk of drug use and related problems. Cognitive-behavioral therapy is one of comparatively few empirically supported therapies that has been demonstrated to be effective across a range of substance use disorders including abusers of alcohol (Morgenstern and Longabaugh, 2000; Project MATCH Research Group, 1997), marijuana (Sinha et al., 2003) and cocaine (Carroll et al., 1998; Maude-Griffin et al., 1998; McKay et al., 1997; Monti et al., 1997). Cognitive-behavioral therapy is also well-accepted by the clinical community and can be implemented effectively by clinicians (Morgenstern et al., 2001). Moreover, CBT has also been demonstrated to be effective for a range of other behavioral and mental health disorders (DeRubeis and Crits-Christoph, 1998) and can easily be adapted to address multiple problems such as co-occurring substance abuse and depression (Dobson, 1989).
Substance abuse-domestic violence treatment. In a recent preliminary study, CBT was tailored to treat men with co-occurring alcohol dependence and IPV (Easton et al., unpublished data). This treatment model is called an integrated substance abuse domestic violence treatment. This study assessed whether this approach was efficacious in decreasing alcohol use and IPV. Men (n=78; mean age=38) arrested for domestic violence within the past six months meeting DSM-IV criteria for alcohol dependence were randomized to either 12 group sessions of integrated substance abuse domestic violence treatment, which focused both on alcohol use and IPV, or 12 sessions of manual-guided group Twelve-Step Facilitation (Nowinski et al., 1992). Twelve-Step Facilitation was chosen as the comparison condition because this approach is comparative to standard treatment for this population, and would provide preliminary indication of the value of targeting alcohol use alone.
Of the participants, 49% were white, 33% were African-American, and 10% were Hispanic; 70% were employed, and 63% reported living alone. The sample's mean number of arrests was 4.60 (standard deviation=4.2), with a mean of two previous domestic violence arrests. The groups were not significantly different across age, race, employment, education, other key demographic variables or baseline addiction severity composite scores. However, there were significant differences across groups with respect to whether the participants were living alone or with their female partners (76% in Twelve-Step Facilitation group were living alone versus 50% of the integrated treatment group; p<0.02).
The integrated treatment group reported using alcohol significantly fewer days in 12 weeks of treatment. For example, the group reported 76 total days abstinent, while the Twelve-Step Facilitation group reported a mean of 68 total days (p<0.03). The integrated treatment group reported significantly more physical violence episodes at baseline (e.g., slapping, pushing, punching, kicking and hair pulling within the past 30 days) (37.9%) as compared to the Twelve-Step Facilitation group (6.9%) (p<0.005). Repeated measures ANOVA (analysis of variance) indicated a trend for a greater reduction in the frequency of violent episodes across time for the integrated treatment group compared to the Twelve-Step Facilitation group (p<0.094).
This is one of the first randomized, controlled studies utilizing a version of CBT among men who have co-occurring substance use and IPV. Although this model shows promise, it is in its infancy stage of development and further investigation is needed with larger sample sizes and across a broader spectrum of substance abuse disorders.Conclusions
Although substance use and IPV remains a public health concern, there have been advances in our basic understanding of how to treat men with co-occurring substance abuse and IPV. For example, when substance use and IPV co-occur, research suggests that substance use plays a facilitative role in IPV by precipitating or exacerbating violence. Hence, it is important to treat the substance abuse disorder. We also know that standard batterer intervention programs are not effective at decreasing IPV or substance use, and, therefore, other referrals to substance abuse or mental health treatment are needed. We know that behavioral couples therapy is an effective approach for decreasing substance use; IPV among couples in an intact relationship, in which both members are motivated for treatment. Alternative approaches that are grounded in evidenced-based practice hold promise for development of effective treatments for men with co-occurring substance abuse and IPV (Table).Acknowledgements
Support was provided by the Donaghue Foundation (DF# 0026) and by NIDA grants P50-DA0924 (pilot project) and K12 DA00167-11 (Clinician Scientist Award).