Substance Abuse and Partner Violence: The Case for Couples Therapy - Juniper Publishers

 

Addiction & Rehabilitation Medicine - Juniper Publishers

Abstract

Intimate partner violence continues to be a profound public health concern, with 25% of women and 10% of men report experiencing intimate partner violence in their lifetime. Many cases of intimate partner violence go undetected and untreated, however, identifying different ways of conceptualizing violence and alternative modalities of treatment may provide clinicians with the opportunity to intervene at higher rates. Given the men admitted to treatment for substance misuse problem report high rates of partner violence, this setting may provide an important point of contact for identification and treatment. Research using Behavioral Couples Therapy address non-severe forms of violence within a substance abuse treatment setting with promising outcomes. Future research is needed to identify the best technique to manage more severe forms of violence and in which settings.

Keywords: Clinical psychology; Substance abuse; Intimate partner violence; Behavioral therapy; Couples therapy

Abbreviations: IPV: Intimate partner violence; BCT-SUD: Behavioral Couples Therapy for Substance Use Disorders; SAMHSA; Substance Abuse and Mental Health Services Administration

Introduction

Intimate partner violence (IPV) remains a tremendous public health concern which transcends age, gender, ethnicity, and social standing [1]. National surveys of couples reveal 25% of women and 10% of men are victims of intimate partner violence [2]. As alarming as these statistics seem, they pale in comparison to rates of partner violence reported among men admitted into substance abuse treatment [3]. As these cases often go undetected and untreated, the challenge for clinicians and researchers alike is to identify different ways of conceptualizing violence and consider alternative modalities of treatment.

What is IPV?

A challenge when investigating partner aggression has been the lack of consensus on the definition. Intimate partner violence and family violence, including the threat of violence, can be conceptualized as violence that occurs between the partners of a romantic relationship [4]. A number of theories have been proposed to explain IPV including feminist, family violence, and psychopathology. The feminist perspective understands IPV through the historical traditions of male dominance and is largely concerned with power and control [5,6]. The feminist perspective states violence and aggression are indicators of social power, and that IPV is a result of disparity in the perceived equality of the genders [7]. According to family violence theory, familial stressors may foster a conflictual environment, in which violence is used as a method of conflict resolution [8]. Finally, the psychopathology perspective emphasizes individual problems, including emotional deregulation, personality disorders, and early life experiences [7]. In fact, 80-90% of male-female IPV cases involve and assaulter with a personality disorder, compared to the 10-15% of individuals in the general population with a personality disorder [7].

It is important to note that IPV is often conceptualized as a homogenous phenomenon, when in fact, it encompasses a wide range of physically aggressive behaviors which may differ along dimensions such as:

a. Type and severity of aggression.

b. Frequency.

c. Emotional and physical impact [7].

In an effort to more accurately capture types of partner aggression, Johnson [9] developed a control-base typology, describing three types of IPV that appear to be conceptually and etiologically distinct. Intimate Terrorism, is characterized by severe male-to-female physical aggression (e.g., punching, threatening with weapons), with less severe female-to-male violence occurring during these episodes as a form of self-defense (i.e., Violent Resistance). In cases of Intimate Terrorism, female partners are at an increased risk of physical injury and there is a heightened fear of the male partner. In this case, the goal of the aggressor is to exert power and control over the partner. Violent Resistance typically occurs in response to a partner’s violent and controlling behavior (e.g., Intimate Terrorism); this type is violent but not used as a form of control and may be best thought of as defensive responding. Situational Couple Violence is characterized by bidirectional partner aggression, which is mild to moderate in severity and is the result of an escalation in conflict. Situational Couple Violence is a method used to exert power or control, nor is it used to instill fear. Situational Couple Violence is likely to be akin to violence reported among substance misusing clients, whereas Intimate Terrorism more closely resembles the violence found in clinical samples.

Treatment Options

Treatment-as-usual: standard substance abuse treatment

One option for identifying IPV involves training staff to identify and assess for partner violence and refer those patients to domestic violence intervention programs (i.e., coordinated response approach). Given the prevalence of IPV among men entering substance abuse treatment, these programs may be an important point for identification and referral. However, research indicates substance abuse treatment providers rarely make referrals to batterers treatment due to the lack of formal assessment of IPV during intake and treatment and/or use of inadequate measures [10]. Consequently, the lack of formal IPV screening during intake and treatment results in these issues going undetected and inappropriately addressed. Given the link between substance use and violence, it is plausible that engagement in substance abuse treatment and decreased substance use may result in reduced partner aggression. However, substance abuse clients have high rates of relapse, and so this decrease in partner aggression may be contingent on the client’s ability to remain abstinent-thus, this approach is inherently flawed. Moreover, referral to domestic violence treatment programs (i.e., batterers’ treatment) presents two important challenges:

a. Existing research suggests that clients rarely followthrough and engage with domestic violence prevention programs and those that do, tend to drop out prematurely.

b. The evidence for the effectiveness of batterers’ programs in reducing partner violence has been mixed [11]. These programs tend to be tailored to the most severe forms of violence and do not take the different forms of IPV into account [11]. As a result, domestic violence treatment is not suitable or a good fit for many offenders.

Behavioral couples therapy for alcoholism and substance abuse: effects on IPV

Partner-involved conjoint therapies are among the most controversial treatment approaches. Critics argue that addressing IPV in a relational context will place female victims in the role of having to manage their partner’s violent behavior [12]. Critics also argue that conjoint approaches encourage honest and open disclosure, which, in turn, could lead to conflict in therapy sessions that could escalate to violence outside of therapy. However, given the interactional and bidirectional nature of some types of violence, carefully screened and controlled partner-involved treatments may have advantages for couples who engage in non-severe forms of IPV [13].

Couples therapy may allow for a more effective conceptualization of the IPV, as treatment focuses on violence reduction, encouraging partners to discuss emotionallycharged topics, and fostering adaptive communication [13]. Partner aggression often occurs in the context of disagreements between partners and is often mutual and bidirectional [13]. This escalation in conflict frequently results in a vicious cycle, in which one behavior serves to reinforce the other in a continuous feedback loop. Thus, addressing the reciprocal nature of violence may provide an opportunity to alter the interaction patterns that precede it and learn healthier ways of resolving conflict. Because relationship distress is a powerful predictor of partner aggression [13], improvements in relationship functioning should reduce the likelihood of IPV.

Behavioral couples therapy for alcoholism and substance abuse: effects on IPV

Behavioral Couples Therapy for Substance Use Disorders (BCT-SUD) is a conjoint treatment for alcohol and drug abuse with extensive empirical support for its clinical and cost effectiveness. According to “Substance abuse treatment and family therapy” [14] the US government regulatory panel, titled Substance Abuse and Mental Health Services Administration (SAMHSA), recognizes BCT-SUD as an evidence-based treatment. The focus of BCT is twofold:

a. Improve relationship functioning.

b. Reduce or eliminate substance abuse.

BCT-SUD posits that problems within the relationship can serve as a trigger for substance use and that problematic substance use negatively impacts relationship functioning. As a result, the couple is caught in a cycle in which each problem serves as both the antecedent and consequence, and continuously reinforces the other. Partners engaged in BCTSUD are taught communication and conflict resolution skills for managing emotional disagreements and conflict (for a review, see Fals-Stewart et al. [15]). Nonsubstance-abusing partners are also taught skills to increase safety when faced with a situation where a relapse to drugs, violence, or both are likely. It is important to note that BCT does not rely on abstinence as the mechanism of action for nonviolence; thus, BCT is designed to decrease IPV even in the event a relapse occurs.

Several noncontrolled studies have examined the effects of BCT on IPV prevalence and frequency among alcohol and drugabusing men and their nonsubstance-abusing female partners [16,17] and reported up to a 60% decrease in IPV prevalence in the year following treatment compared to baseline levels. O’Farrell and Fals-Stewart [18-20] collected a sample of drugabusing couples with and without a history of IPV and found that significantly smaller proportion of drug-abusing couples who received BCT reported episodes of IPV compared to those who participated assigned to a treatment-as-usual condition.

Conclusion

Partner violence remains a tremendous public health concern. Given the rates of IPV reported among men admitted to treatment for substance misuse problem, this setting may serve as an important point of contact for identification and treatment. The results of the studies listed above reveal the promise BCT holds as an intervention to address non-severe forms of violence within a substance abuse treatment setting. However, additional research is needed to determine how best to manage more severe forms of violence and in which settings.

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