Several studies have found that a majority of women seeking services from domestic violence advocacy programs and substance abuse treatment agencies have experienced both issues, and are best viewed as substance abusing battered women. How­ever, there have been few attempts to integrate services for women with dual issues across the two agencies (Bennett & Lawson, 1994). The purpose of this article is to discuss the needs of substance abusing battered women, the challenges to this population being able to access mainstream services and a dynamic project that has enhanced collaboration between substance abuse treatment agencies and domestic violence programs.

 

 

Substance abusing battered women’s safety and sobriety are linked. It is difficult for women to achieve or maintain sobriety if they are not safe from domestic violence and, conversely, it is difficult for them to be safe if they are not sober (Bland, 2001). Therefore, optimally effective services for substance abusing battered women would address both problems simultaneously and conjointly (Jones, Atkinson, Rindels, Downs & Ziemann, 2008; Bland, 2001). Based on these needs, there have been a number of recommendations for ways in which domestic violence advocacy programs and substance abuse treatment agencies can provide integrated services for women that address both problems (Center for Substance Abuse Treatment (CSAT), 1997; O’Brien, et al., 2002).

 

Ashley, Marsden and Brady (2003) cited recent research demonstrating that women and men differ in substance abuse etiology and access to treatment, and yet few treatment programs offer specialized services for women. In particular, based on the connections between women’s experiences of domestic violence and substance abuse problems, domestic violence advocacy services need to be integrated into treatment for women with substance abuse, and substance abuse treatment agencies need to provide outreach services to domestic violence programs.

 

Historically, however, few domestic violence programs and substance abuse treatment agencies have collaborated to provide integrated services for substance abusing battered women, creating a large gap between domestic violence services and substance abuse treatment (Bland, 2001; Downs, 2001; Bennett & Lawson, 1994). To close this gap, it is necessary to explore the barriers that have existed between these two fields.

 

Domestic violence programs base interventions on the use of empowerment and the women’s right to choose which services she needs. Domestic violence advocates believe that women are the experts on safety, including which interventions are safe, and under which circumstances.  They see their role as helping support women in making choices that maximize their safety. Con­versely, substance abuse treatment providers view addiction as an illness, and it is the treatment provider, not the client, who is viewed as the expert on sobriety. While best practices in substance abuse treatment are expanding to include treatment modalities such as motivational interviewing and brief solution-focused therapy, many treatment providers still use treatment modalities that are primarily based on the medi­cal model. Assessment language (e.g. substance use “disorder”) is based on the need to diagnose, treat and secure insurance payment for services. While domestic violence advocates find it imperative to believe and accept a woman’s story of abuse, substance abuse treatment providers often take into account the tendency of clients to minimize the amount of alcohol and other drugs they use and may question their stories when substances are involved.

 

Another difference in philosophy is the substance abuse treatment agency’s view of male clients. Domestic violence program advocates often view males through the lens of perpetrating domestic violence. Substance abuse treatment staff may have difficulty hearing about the terrorism and severe violence that their male clients have perpetrated, and integrating this view into the services they provide for men.

 

The concept of codependence also can be a barrier for collaboration between domestic violence and substance abuse treatment services. Domestic violence advocates may view this concept with suspicion because of the potential to equate codependence with “victim blaming.” Codependence was developed as a means to account for the non-addicted partner’s (usually woman’s) compliance with demands based on the addicted partner’s (usually man’s) alcohol-related behavior. However, when domestic violence is present, the woman labeled as codependent could be in serious physical danger if she does not cooperate with her addicted partner’s behaviors. Women have learned that compliance with an abusive partner can be an excellent self-protection strategy (Downs, Rindels & Atkinson, 2007). As such, domestic violence advocates often see the term “codependent” as a failure to recognize the strengths of the battered woman, and may hesitate to collaborate with substance abuse treatment agencies or even in some cases, to refer clients to services for fear that they will be penalized for making choices to maximize their safety from the abusive partner.

 

Another barrier is that both providers may fail to recognize domestic violence and substance abuse as separate and distinct issues. Most substance abuse treatment staff have not been educated in the dynamics of domestic violence, nor have they been trained in how to intervene with women who have experienced domestic violence (Van Wormer & Davis, 2003). They may assume or expect that when alcohol and drug use stops, that the violence will stop. At the same time, domestic violence advocates are typically not educated in the dynamics of substance abuse or the different ways in which substance abuse has an impact on women (Campbell, Raja & Grining, 1999; Danis & Lockhart, 2003). This can lead to the assumption that, if the threat of abuse from her partner is reduced, the woman will stop abusing alcohol and drugs. Both providers try to address the issues of abuse and violence, when discovered, with the tools in their toolbox. The toolbox simply lacks an appropriate diagram of the co-occurring problem, specifically, the way that substance use and domestic violence are often intertwined in the lives of the women they serve.

 

Based on the lack of knowledge of the cross-problem, agency philosophies might clash with clients’ needs. For example, substance abuse treatment staff may decide that a substance-abusing battered woman must leave the abusive partner, without understanding the difficulties (e.g., leaving with children) or the dangers (e.g., stalking, increase in abuse) therein. Domestic violence ­program staff may not understand the strength of the addiction or difficulties in achieving sobriety, not go into this issue any deeper with her, fail to understand why she continues to use while she is in the shelter, and then fail to understand that this may be the reason why the substance abusing battered woman leaves the shelter after only a day or two.

 

In both cases, the woman most likely knows more about the strength of her addiction than the domestic violence program advocate and more about her experiences of abuse than the substance abuse treatment staff. The substance abusing battered woman knows the withdrawal symptoms she will experience if she cannot continue using. Women may decide, for example, not to go to shelter because of the strength of their addiction and the belief that they cannot obtain alcohol, tobacco or illegal drugs while there. The substance abusing battered woman also knows how safe substance abuse treatment procedures are—for example, whether it is safe to leave the children with the abusive partner while she attends an evening group session. To provide best practices to substance abusing battered women, the process of intervention must be client-driven.

 

Each field of service has its own philosophy based on what is viewed as the primary needs of the client. This philos­ophy becomes the lens through which each field views clients. However, in viewing the client through only the lens with which they are familiar, they may miss other points of view. These philosophical differences may contribute to inter-agency conflict and constitute barriers to collaboration. In this case, substance abusing battered women may be caught in the middle, and be expected themselves to integrate treatment and interventions across these two disparate fields of service.

 

Substance abusing battered women must try to cope with addiction, an abusive partner, their partner’s addictions, threats from the Department of Human Services to remove children, threats from the abusive partner that he will take the children and additional service needs such as prenatal care, child care, housing, education and job training as well (Ashley, et al., 2003). Trying to get services from two different agencies without a partner’s knowledge, as that would decrease the safety for both the woman and her children, is likely to be beyond her capabilities. Under these circumstances, the failure of agencies to collaborate to provide for the needs of substance abusing battered women is unacceptable. Instead, discrepancies at many levels must be reconciled and synthesized into an integrated service approach before innovative interventions can be developed.

 

 

Goals of the Integrative Services Project. The Integrative Services Project (ISP) of the University of Northern Iowa received a series of grants from the United States Depart­ment of Justice Office on Violence Against Women. The ISP team consists of domestic violence advocates, substance abuse treatment counselors and a professor of social work. The Project began by interviewing 225 women in treatment for substance abuse and 222 women in domestic violence programs (Jones, et al., 2008). Of women in the substance abuse treatment sample, 67 percent had experienced physical violence, and 93 percent psychological abuse, in the six months prior to entering treatment. Of women in the domestic violence program sample, 26 percent had a lifetime diagnosis of alcohol dependence based on the International Classification of Diseases Version 10 (World Health Organization, 1997), and 39 percent, while not ­technically ­meeting the criteria for alcohol dependence, did report problems with alcohol, drugs or both. Based on the needs identified above, the goals of the Project included: 1) enhance substance abuse treatment staff knowledge regarding women client’s experiences of partner physical violence and psychological abuse; 2) enhance domestic violence staff knowledge regarding women’s substance abuse problems; and 3) based on this education, work with staff in both agencies to enhance collaboration and develop integrated services for substance abusing battered women. Since 2001, there have been nine sites—eight with one domestic violence and one substance abuse treatment program, and one in which the domestic violence program collaborated with two substance abuse treatment programs—which have worked with ISP to inte­grate services for substance abusing battered women in their programs.

 

Collaboration with the agencies. We have found four key activities necessary to develop optimal collaboration be­tween the partnered agencies.

First, form planning committees consisting of from three to five staff (both direct service and management staff) from both agencies. Over time, relationships among planning committee members comprise the core of inter-agency collaboration; help overcome the inter-agency philosophical barriers to collaboration; and help sustain the project.

 

Second, create equity. To balance the power differences between domestic violence programs and substance abuse treatment agencies, an equal number of meetings are held at both agencies, and ISP facilitators ensure that the needs of both agencies are represented during the discussions.

 

Third, maximize the number of staff educated. We have found that involvement of 75 percent of staff in the education programs changes agency culture; helps overcome the inter-agency philosophical barriers to collaboration; and enhances services for substance abusing battered women at both domestic violence advocacy program and substance abuse treatment agencies.

 

Fourth, develop integrated services with staff from both agencies. Partici­pation of staff from both groups to deliver services to substance abusing battered women enhances inter-agency collaboration.

 

The ISP team adopted a strengths perspective, encouraging the collaborating agencies to respect their differences and embrace them as strengths, as we would encourage them to look for the strengths in the women they serve. For example, we encouraged domestic violence program staff to recognize the strength that substance abuse treatment staff have in focusing on women’s accountability for their substance use, a key component of achieving recovery and a common treatment perspective. Conversely, we encouraged substance abuse treatment staff to recognize that although women’s substance use could be a way for her to cope with an abusive relationship, she is not accountable for the abuse, which is an essential perspective and strength of domestic violence advocacy. We encouraged all staff to embrace both views of accountability and integrate them into their service provision.

 

In addition, through this process, the ISP team and the agencies discovered several similarities between the two fields of domestic violence and substance abuse services for women:

 

1. Both fields have a history of advocacy for their clients and began at the grassroots level.

2. Both populations—the individuals who became addicted to alcohol and women who experienced domestic violence—came together to create powerful and practical solutions (i.e., Alcoholics Anonymous and the battered women’s movement).

3. Both populations are stigmatized. Abused women are frequently viewed as having ‘done something’ to deserve the abuse, while those who are addicted are viewed as ‘choosing irresponsibly’ to use alcohol or drugs without others understanding the power of the addiction.

4. Staff members in both fields have experienced the issue of ‘reflected stigma’, themselves having been stigmatized because of their jobs.

Educational and training programs. In the beginning, collaboration meetings with the agencies involved the ISP team requesting that each field of service provide a list of topics in that field that they wanted staff in the other field to understand, as well as topics in the other field they wanted to understand for themselves. ISP staff planned to facilitate those trainings, using the topics decided by the agencies. During the first series of meetings, ISP staff met separately with each agency to facilitate accessing topics that were potentially divisive. After the list of topics became comprehensive, ISP staff met jointly with the domestic violence and substance abuse treatment staff at each site to discuss the list of topics and finalize content for the educational and training programs.

 

As discussions proceeded, it became apparent that the educational and training programs themselves could become vehicles for building collaborative relationships. At one site, one of the domestic violence program staff suggested that doing the basic trainings herself, as opposed to having ISP staff conduct the trainings, would create better collaboration. Based on this suggestion, the ISP team adopted and implemented the idea of staff from both agencies developing and delivering their own educational and training programs to staff from the other collaborating agency. Agencies at both sites were initially concerned about the increase in staff time expected by ISP; however, over time staff at both agencies came to believe that successful staff buy-in for the integrative work would require more active participation by staff from both agencies. In addition, agency team members were willing to plan as well as be trainers for the other agency. This model has now been adopted at all project sites with a major improvement to the project.

 

There was much greater involvement of the collaborating agencies in the development of the education and training programs than originally planned. As discussions on the trainings proceeded, relationship building between the collaborating agencies became at least as important as the content of the educational and training programs. Based on these discussions, ISP staff eventually proposed two-tier training: basic and joint training. Agency staff would themselves deliver eight hours of basic training to staff from the other collaborating agency. Basic training meant topics specific to one field of service. For example domestic violence advocacy program staff covered history of the domestic ­violence movement, services offered by the domestic violence agency, dynamics of abusive relationships, etc. Substance abuse treatment staff covered the history of substance abuse services, services offered by the substance abuse treatment agency, the bio-chemical nature of addiction, etc. Building on this basic training, ISP staff would then provide 11 hours of joint training on combined domestic violence and substance abuse issues, for presentation to staff from both collaborating agencies. The basic training would begin the relationship building process, and the joint training would continue that process.

As we proceeded, pairs of agencies at each site developed topics for the educational program pertinent to their site based on local need. In addition, ISP staff identified several technical ongoing assistance topics (e.g., assessment tools). The educational programs qualified for continuing education units (CEUs) for substance abuse, nursing, mental health and social work, both to reflect the value of the training and to increase participation from agency staff.

 

Development of integrated services and changes in existing practices. After the delivery of the basic education programs and during the delivery of the joint education programs, ISP and the collaborating agencies continued to discuss the development of integrated services and changes in existing services. At the level of client services, a new integrated service developed by one of the project sites is a weekly group for women in aftercare and extended outpatient treatment, designed specifically for women who have experienced both substance abuse and domestic violence. It focuses on maintaining recovery by addressing issues of safety and sobriety and is co-facilitated by a domestic violence advocate and substance abuse treatment counselor.

 

There have also been changes in existing practices at the level of systems integration. At one site, a staff person from the domestic violence program visits the substance abuse treatment agency monthly to provide information regarding domestic violence and available services, and a staff person from the substance abuse treatment program goes to the shelter monthly to provide information to staff regarding substance abuse and treatment. At another, substance abuse treatment staff co-presented with domestic violence program staff at a state conference. In general, substance abuse treatment staff reported becoming more aware of no-contact orders; more likely to ask women if they feel safe before allowing partners in for family work; and becoming more comfortable screening for and identifying domestic violence. Domestic violence advocacy program staff reported having more positive attitudes toward and understanding of the needs of substance abusing battered women, as well as a greater comfort level referring women to treatment.

 

 

The ISP is an ever-adapting model that changes with each new site and each new collaboration. While much work has been done on working with people with past trauma and how that affects their substance use, ISP staff and all of their partner agencies are working with women who are in the middle of their trauma at the hands of their abusers, while at the same time in the middle of their struggles with addiction. The voices of substance abusing women and the providers who serve them—both substance abuse and domestic violence workers—must continue to shape our collaborations.

 

 

The authors thank the agencies who allowed us access to their clients and, especially, the women who shared their stories with us. This project was supported under award number 2001-DD-BX-0086 from the Office on Violence Against Women, United States Depart­ment of Justice. Points of view in this manuscript are those of the authors and do not necessarily represent the official position of the United States Depart­ment of Justice.

 

Kim Adelia Leff, LMSW was a Graduate Assistant and Domestic Violence Specialist on the Integrative Services Project from November 2001 until February 2004. We would like to acknowledge her significant contributions to this project.

 

Connie S. Wood, MSW was the Program Manager on the Integrative Services Project from October 2004 through August 2006. Our friend and colleague Connie Wood developed ovarian cancer and died in January 2007. We would like to acknowledge posthumously her significant contributions to this project.

 

Barb Rindels holds the highest certification for domestic violence and sexual assault, and has been a domestic violence advocate since 1992, providing client services such as advocacy in domestic violence, advocacy in sexual assault, crisis counseling and legal advocacy to obtain no contact orders. She has participated in several trainings for volunteers and community agencies’ staff, recruited and supervised new volunteers, developed and coordinated a court watch program, and facilitated domestic violence and sexual assault groups. She is co-founder of the Integrated Service Project and currently works as an advo.

 

William R. Downs, PhD is a professor in the Department of Social Work at the University of Northern Iowa. He has 23 years of research experience in the areas of women’s experiences of violence and their alcohol and drug problems, and has published 37 peer-reviewed articles and six book chapters. He is co-founder of the Integrated Services Project, and has served on the boards of three victim service agencies.

 

Christine Atkinson, LISW, LADC is a substance abuse specialist for the Integrated Service Project in addition to providing therapy in her private practice in northeast Iowa. She has more than 20 years experience in the substance abuse and mental health fields, and created the first program to addressmental health and substance abuse in persons with brain injuries. She has co-authored professional journal articles and continues to work with the team and agencies on education and collaborative efforts to integrate services for substance abusing battered women.

 

Kelly Ziemann joined the Integrated Services Project in early 2007 as a domestic violence specialist. She has 10 years experience as a domestic violence advocate, and her areas of interest include financial advocacy, legal advocacy, shelter advocacy, systems advocacy, working with underserved populations, particularly with GLBT survivors and community education. She is also the Housing and Economic Justice Coordinator at the Iowa Coalition Against Domestic Violence.

 

Megan B. Jones, LISW, CADC has worked in the human service field for eight years, primarily in the fields of domestic violence, substance abuse and mental health. In addition working as a substance abuse specialist for the Integrated Services Project, she also is certified as a substance abuse professional through the U.S. Department of Transportation, and is a counselor at the Cornell College Counseling Center.

 

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