Intimate partner violence is a common problem and a significant public health concern. Substance use is involved in 40% to 60% of IPV incidents. Several lines of evidence suggest that when substance use and IPV co-occur, substance use may play a facilitative role in IPV by precipitating or exacerbating violence. This article will review epidemiological, clinical and treatment research relevant to substance-abusing men with co-occurring domestic violence.
Much of the violence reported in the literature involves intimate partnerviolence (IPV) committed by men toward women, a pervasive problem in asignificant proportion of U.S.families. Roughly 1,800 instances of homicide and manslaughter between intimatepartners occurred in 1998, with more than 1,300 of these involving women asvictims (Rennison and Welchans,2000). The findings from the National Crime Victimization Survey indicate thatnearly 1 million women are victims of IPV each year (Rennisonand Welchans, 2000). Surveys of representativesamples of couples that include less severe instances of aggression (e.g.,single episodes of pushing or slapping one's partner) suggested that 8.7 millioncouples experience an incident of physical violence from within the dyad eachyear (Straus and Gelles, 1990). Additionally, asurvey of U.S.couples indicated more than one in five experienced at least one episode ofviolence during the previous year (Schafer et al., 1998).
IPV and Substance Abuse
Intimate partner violence is a major public health concern. Substance usehas been found to co-occur in 40% to 60% of IPV incidents across variousstudies (Easton et al., 2000a, 2000b; Fals-Stewart etal., in press; Moore and Stuart, 2004). Several lines of evidence suggest thatsubstance use plays a facilitative role in IPV by precipitating or exacerbatingviolence (Fals-Stewart, 2003). Several studiessuggest the promise of interventions that target substance use in men who havehistories of IPV (Fals-Stewart, 2003; Fals-Stewart et al., in press; Moore and Stuart, 2004).
It is known that many IPV episodes involve alcohol or drug consumption.Kaufman Kantor and Straus (1990) found over 20% ofmales were drinking prior to the most recent and severe act of violence. Fals-Stewart (2003) found that on days of heavy drug use,physical violence was 11 times more likely. Victims of IPV report that theoffender had been drinking or using illicit drugs (Miller, 1990; Roberts,1998). Miller (1990) reported that offenders of IPV typically use alcohol and have a dual problem with drugs. In addition, the strongrelationship between substance use and perpetration of IPV has been found inprimary health care settings (McCauley et al., 1995), family practice clinics(Oriel and Fleming, 1998), prenatal clinics (Muhajarineand D'Arcy, 1999) and rural health clinics (Van Hightower andGorton, 1998). The relationship between substance abuse and IPV has also beenobserved to be quite prevalent among individuals presenting at psychiatricsettings (Gondolf et al., 1991) and substance abusetreatment facilities (Easton et al., 2000b).
A Proximal Effects Model
Three primary conceptual models have been posited to explain the observed relationshipbetween substance use and spousal violence: 1) spurious model; 2) indirecteffects model; and 3) proximal effects model (Fals-Stewart,2003; Leonard and Quigley, 1999).
The spurious model suggests that the relationship between substance use and IPVis the result of these variables being related to other factors that influenceboth drinking and violence. For example, individuals who are young may tend tobe violent and to use drugs; thus, drug use and violence may appear directlyrelated when, in fact, they are not. Although not entirely consistent, theresults of several studies suggest that alcohol and other drug use areassociated with IPV after controlling for factors thought to be associated withboth behaviors such as age, education, socioeconomic or occupational status,and ethnicity (e.g., Leonard and Jacob, 1988; Pan et al., 1994). However, therelationship between substance use and violence remains strong even aftercontrolling for levels of general hostility (e.g., Leonard and Senchak, 1993) and normative views of aggression (Kaufman Kantor and Straus, 1990).
In the indirect effects model, substance use is viewed as being corrosive torelationship quality. Thus, long-term substance use creates an environment thatsets the stage for partner conflict and, ultimately, partner violence. Again,however, when marital satisfaction, relationship discord or other similarvariables are controlled for when examining the link between substance use andviolence, the relationship remains strong (e.g., McKenryet al., 1995).
According to this model (Fals-Stewart, 2003),individuals who consume psychoactive substances are more likely to engage inpartner violence because intoxication facilitates violence, which may bemediated through the psychopharmacologic effects of drugs on cognitiveprocessing (Chermack and Taylor, 1995) or theexpectancies associated with intoxication (Critchlow,1983). It follows from this theory that substance use should precede IPV andthe episode of violence should occur closely in time to the consumption of thedrug. Several longitudinal studies supported temporal ordering consistent withthis model. Fals-Stewart (2003) collected dailydiaries from partners with histories of IPV entering either an alcoholism ordomestic violence treatment program over a five-month period, which allowed fora detailed examination of the daily temporal relationship betweenmale-to-female aggression and drinking. The data suggested that alcohol andmale-to-female aggression were linked only on days when the drinking occurredbefore the IPV episode. The odds of severe male-to-female physical aggressionwere more than 11 times higher on days of men's drinking than on days of nodrinking. Moreover, in both samples, over 60% of all IPV episodes occurredwithin two hours of drinking by the male partner. These findings were recentlyreplicated with another sample of men entering treatment for drug abuse (Fals-Stewart et al., 2003).
Three conceptual models have been put forth to explain the relationshipbetween alcohol use and violence. Although each may have some merit and may, infact, explain part of the relationship between substance use and violence, thegreatest empirical support rests with the proximal effects model (Fals-Stewart, 2003). Hence, it is reasonable thatinterventions targeting substance use among men with histories of IPV andsubstance use may lead to reductions in partner violence.
Referral for Treatment
Currently, men convicted for IPV are referred to batterer/IPV programs(e.g., the Duluth Model). The program uses a psychoeducationstructure; actual behaviors are identified and challenged by facilitators, whomodel alternative behaviors and solutions to conflict. This approach oftentreats men with IPV in a classroom setting with 10 to 20 men in a group format.This method has the following limitations: 1) lack of structured/standardizedassessments to rule out co-occurring psychiatric or substance abuse disorders;2) lack of objective indicators to rule out current substance use (e.g., breathsamples, urine toxicology screening); 3) lack of collateral data from thevictim regarding ongoing abuse; and 4) lack of other therapeutic options formen who request additional or other treatments (e.g., individual therapy, psychiatricconsultation, parenting, couples therapy) (Babcock and LaTaillede,2000).
In addition to these limitations, there is very little empirical supportregarding the effectiveness of the Duluth Model in reducing violence orsubstance use (Babcock and LaTaillede, 2000). Infact, meta-analytic reviews of outcomes for these approaches have consistentlyfound them to be of very limited effectiveness, with effect sizes near zero(Babcock and LaTaillede, 2000). Many battererprograms do not address substance use, are highly confrontational in nature andreach far fewer individuals than substance abuse treatment programs. Hence, itis likely that focusing on IPV with men who batter within the context of asubstance abuse treatment facility may reach a comparatively larger number ofindividuals with IPV.
Standard Treatment Effects
Several studies suggest that treatment-associated reductions in substanceuse are related to reductions in violence. O'Farrell et al. (2003) examinedpartner violence in the year before and the year after individually based,outpatient alcoholism treatment for male alcoholic patients, compared with ademographically matched nonalcoholic comparison group. The results illustratedthat in the year before treatment, 56% of the alcoholic patients had beenviolent toward their female partner, four times the rate of the comparisonsample (14%).
However, in the year after treatment, violence decreased significantly to25% 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 enteringoutpatient treatment for drug abuse. During the year before treatment, theprevalence of IPV was roughly 60%, but dropped to 35% during the one-year, posttreatment follow-up period. In both studies, treatmentswere standard 12-step facilitation interventions that did not address partnerviolence (e.g., Schumacher et al., 2003). Nonetheless, participation in theprograms resulted in significant reductions in interpersonal violence,consistent with the proximal effects model. Additionally, this line of researchsuggests that tailoring or developing substance abuse treatments to addressdomestic violence-related problems (e.g., managing anger and negative moodstates) may reduce IPV, especially in the event of a substance abuse relapse.Since substance abuse treatment facilities provide a treatment venue for maleoffenders of IPV, addiction specialists and psychiatrists will play a crucial rolein the assessment of co-occurring substance abuse and IPV. In addition to usingthe DSM-IV for the Axis Isubstance-related diagnoses and the Addiction Severity Index (ASI) (McLellan et al., 1992) for diagnosing severity of substanceabuse/dependence, psychiatrists can also utilize the following diagnosticassessments to evaluate type, amount and frequency of intimate partner orfamily violence: 1) Timeline Follow-Back method (TLFB) (Fals-Stewartet al., 2000); 2) Revised Conflict Tactics Scale (CTS2) (Straus et al., 1996);and 3) State-Trait Anger Expression Inventory (STAXI) (Spielberger,1991).
Behavioral couples therapy.Several studies suggest that interventions targeting reduction in substance useand skill deficits have particular promise in this population. In particular,and highly relevant to the proposed project, behavioral couples therapy, acognitive-behavioral approach that teaches couples techniques to reduceconflict and improve relationship functioning, has been demonstrated to beeffective in several select populations (Fals-Stewartet al., 2002; O'Farrell and Fals-Stewart, 2000).Although behavioral couples therapy is effective withthese populations, it has limited application to individuals convicted ofinterpersonal violence who are referred or mandated to substance abusetreatment.
For example, behavioral couples therapy requires participation of the femalepartner and, therefore, has the following problems: 1) in many cases, thefemale partner has left the relationship and has no ongoing contact; 2) thepartner may refuse to participate in the male's treatment; 3) a male offendermay refuse to have his partner participate in his treatment because ofunwillingness to reveal the extent of his substance use; and 4) there may beimposed restraining or protective orders that limits contact between theoffender and the victim.
Cognitive-behavioraltherapy. One individual approach to substance abuse treatment withstrong empirical support and the capacity to expand to address other problemsis cognitive-behavioral therapy (CBT) (Carroll, 1998; DeRubeisand Crits-Christoph, 1998; Irvin et al., 1999). Basedon social learning theories of substance use disorders, CBT focuses on theimplementation of effective coping skills for recognizing, avoiding and copingwith situations that increase the risk of drug use and related problems.Cognitive-behavioral therapy is one of comparatively few empirically supportedtherapies that has been demonstrated to be effective across a range ofsubstance use disorders including abusers of alcohol (Morgenstern and Longabaugh, 2000; Project MATCH Research Group, 1997),marijuana (Sinha et al., 2003) and cocaine (Carrollet al., 1998; Maude-Griffin et al., 1998; McKay et al., 1997; Monti et al., 1997). Cognitive-behavioral therapy is alsowell-accepted by the clinical community and can be implemented effectively byclinicians (Morgenstern et al., 2001). Moreover, CBT has also been demonstratedto 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 asco-occurring substance abuse and depression (Dobson, 1989).
Substanceabuse-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 integratedsubstance abuse domestic violence treatment. This study assessed whether thisapproach was efficacious in decreasing alcohol use and IPV. Men (n=78; meanage=38) arrested for domestic violence within the past six months meeting DSM-IV criteria for alcohol dependencewere randomized to either 12 group sessions of integrated substance abusedomestic violence treatment, which focused both on alcohol use and IPV, or 12sessions of manual-guided group Twelve-Step Facilitation (Nowinskiet al., 1992). Twelve-Step Facilitation was chosen as the comparison conditionbecause this approach is comparative to standard treatment for this population,and would provide preliminary indication of the value of targeting alcohol usealone.
Of the participants, 49% were white, 33% were African-American, and 10% wereHispanic; 70% were employed, and 63% reported living alone. The sample's meannumber of arrests was 4.60 (standard deviation=4.2), with a mean of twoprevious domestic violence arrests. The groups were not significantly differentacross age, race, employment, education, other key demographic variables orbaseline addiction severity composite scores. However, there were significantdifferences across groups with respect to whether the participants were livingalone or with their female partners (76% in Twelve-Step Facilitation group wereliving alone versus 50% of the integrated treatment group; p<0.02).
The integrated treatment group reported using alcohol significantly fewerdays in 12 weeks of treatment. For example, the group reported 76 total daysabstinent, while the Twelve-Step Facilitation group reported a mean of 68 totaldays (p<0.03). The integratedtreatment group reported significantly more physical violence episodes atbaseline (e.g., slapping, pushing, punching, kicking and hair pulling withinthe 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 greaterreduction in the frequency of violent episodes across time for the integratedtreatment group compared to the Twelve-Step Facilitation group (p<0.094).
This is one of the first randomized, controlled studies utilizing a versionof CBT among men who have co-occurring substance use and IPV. Although thismodel shows promise, it is in its infancy stage of development and furtherinvestigation is needed with larger sample sizes and across a broader spectrumof substance abuse disorders.
Although substance use and IPV remains a public health concern, there havebeen advances in our basic understanding of how to treat men with co-occurringsubstance abuse and IPV. For example, when substance use and IPV co-occur,research suggests that substance use plays a facilitative role in IPV byprecipitating or exacerbating violence. Hence, it is important to treat thesubstance abuse disorder. We also know that standard batterer interventionprograms are not effective at decreasing IPV or substance use, and, therefore,other referrals to substance abuse or mental health treatment are needed. Weknow that behavioral couples therapy is an effectiveapproach for decreasing substance use; IPV among couples in an intactrelationship, in which both members are motivated for treatment. Alternativeapproaches that are grounded in evidenced-based practice hold promise fordevelopment of effective treatments for men with co-occurring substance abuseand IPV (Table).
Support was provided by the Donaghue Foundation (DF# 0026) and by NIDA grantsP50-DA0924 (pilot project) and K12 DA00167-11 (Clinician Scientist Award).
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