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Much of the violence reported in the literature involves intimate partner violence (IPV) committed by men toward women, a pervasive problem in a significant proportion of U.S. families. Roughly 1,800 instances of homicide and manslaughter between intimate partners occurred in 1998, with more than 1,300 of these involving women as victims. The findings from the National Crime Victimization Survey indicate that nearly 1 million women are victims of IPV each year. Surveys of representative samples of couples that include less severe instances of aggression (e.g., single episodes of pushing or slapping one's partner) suggested that 8.7 million couples experience an incident of physical violence from within the dyad each year. Additionally, a survey of U.S. couples indicated more than one in five experienced at least one episode of violence during the previous year.

IPV and Substance Abuse

Intimate partner violence is a major public health concern. Substance use has been found to co-occur in 40% to 60% of IPV incidents across various studies. Several lines of evidence suggest that substance use plays a facilitative role in IPV by precipitating or exacerbating violence. Several studies suggest the promise of interventions that target substance use in men who have histories of IPV.

It is known that many IPV episodes involve alcohol or drug consumption. Research found that over 20% of males were drinking prior to the most recent and severe act of violence. It was also found that on days of heavy drug use, physical violence was 11 times more likely. Victims of IPV report that the offender had been drinking or using illicit drugs. It was reported that offenders of IPV typically use alcohol and have a dual problem with drugs. In addition, the strong relationship between substance use and perpetration of IPV has been found in primary health care settings, family practice clinics, prenatal clinics and rural health clinics. The relationship between substance abuse and IPV has also been observed to be quite prevalent among individuals presenting at psychiatric settings and substance abuse treatment facilities.

A Proximal Effects Model

Three primary conceptual models have been posited to explain the observed relationship between substance use and spousal violence:

1) spurious model;
2) indirect effects model; and
3) proximal effects model.

The spurious model suggests that the relationship between substance use and IPV is the result of these variables being related to other factors that influence both drinking and violence. For example, individuals who are young may tend to be violent and to use drugs; thus, drug use and violence may appear directly related when, in fact, they are not. Although not entirely consistent, the results of several studies suggest that alcohol and other drug use are associated with IPV after controlling for factors thought to be associated with both behaviours such as age, education, socioeconomic or occupational status, and ethnicity. However, the relationship between substance use and violence remains strong even after controlling for levels of general hostility and normative views of aggression.

In the indirect effects model, substance 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. Again, however, when marital satisfaction, relationship discord or other similar variables are controlled for when examining the link between substance use and violence, the relationship remains strong.

Individuals who consume psychoactive substances are more likely to engage in partner violence because intoxication facilitates violence, which may be mediated through the psychopharmacologic effects of drugs on cognitive processing or the expectancies associated with intoxication. It follows from this theory that substance use should precede IPV and the episode of violence should occur closely in time to the consumption of the drug. Several longitudinal studies supported temporal ordering consistent with this model. Daily diaries were collected from partners with histories of IPV entering either an alcoholism or domestic violence treatment program over a five-month period, which allowed for a detailed examination of the daily temporal relationship between male-to-female aggression and drinking. The data suggested that alcohol and male-to-female aggression were linked only on days when the drinking occurred before the IPV episode. The odds of severe male-to-female physical aggression were more than 11 times higher on days of men's drinking than on days of no drinking. Moreover, in both samples, over 60% of all IPV episodes occurred within two hours of drinking by the male partner. These findings were recently replicated with another sample of men entering treatment for drug abuse.

Three conceptual models have been put forth to explain the relationship between alcohol use and violence. Although each may have some merit and may, in fact, explain part of the relationship between substance use and violence, the greatest empirical support rests with the proximal effects model. Hence, it is reasonable that interventions targeting substance use among men with histories of IPV and substance use may lead to reductions in partner violence.

Referral for Treatment

Currently, men convicted for IPV are referred to batterer/IPV programs. The program uses a psychoeducation structure; actual behaviours are identified and challenged by facilitators, who model alternative behaviours and solutions to conflict. This approach often treats 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/standardized assessments to rule out co-occurring psychiatric or substance abuse disorders;

2) lack of objective indicators to rule out current substance use (e.g., breath samples, urine toxicology screening);

3) lack of collateral data from the victim regarding ongoing abuse; and

4) lack of other therapeutic options for men who request additional or other treatments (e.g., individual therapy, psychiatric consultation, parenting, couples therapy).

In addition to these limitations, there is very little empirical support regarding the effectiveness of the above research in reducing violence or substance use. In fact, meta-analytic reviews of outcomes for these approaches have consistently found them to be of very limited effectiveness, with effect sizes near zero. Many batterer programs do not address substance use, are highly confrontational in nature and reach far fewer individuals than substance abuse treatment programs. Hence, it is likely that focusing on IPV with men who batter within the context of a substance abuse treatment facility may reach a comparatively larger number of individuals with IPV.

Standard Treatment Effects

Several studies suggest that treatment-associated reductions in substance use are related to reductions in violence. Partner violence in the year before and the year after individually based, outpatient alcoholism 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.

A parallel study 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. 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) 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);

2) Revised Conflict Tactics Scale (CTS2); and 3) State-Trait Anger Expression Inventory (STAXI).

Evidenced-Based Therapies

Behavioural 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, behavioural couples therapy, a cognitive-behavioural approach that teaches couples techniques to reduce conflict and improve relationship functioning, has been demonstrated to be effective in several select populations. Although behavioural 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, behavioural 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-behavioural therapy. One individual approach to substance abuse treatment with strong empirical support and the capacity to expand to address other problems is cognitive-behavioural therapy (CBT). 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-behavioural 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, marijuana and cocaine. Cognitive-behavioural therapy is also well-accepted by the clinical community and can be implemented effectively by clinicians. Moreover, CBT has also been demonstrated to be effective for a range of other behavioural and mental health disorders and can easily be adapted to address multiple problems such as co-occurring substance abuse and depression.

Substance abuse-domestic violence treatment. In a recent preliminary study, CBT was tailored to treat men with co-occurring alcohol dependence and IPV. 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. 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).

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. 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%). 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.

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 behavioural 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). ... by Caroline J. Easton, Ph.D.